In the 1970s, after investigators reported that more than 70 percent of air crashes involved human error, the aviation community worked with psychologists to develop a training protocol to improve teamwork, decision-making and safety.
Since then, that core training has been adapted for use in other professions, including the military, firefighting and medicine.
Now, health professionals in Connecticut have taken those basic lessons and drafted a training protocol for yet another high-risk setting: Nursing homes. The authors of the program, called TeamSTEPPS for Long-Term Care, say the simple training can save lives and money. They plan to pilot the program in Connecticut in the fall and promote it nationally.
“This is the first time we have an evidence-based team training for long-term care,” said Ann Spenard, vice president of operations for Qualidigm, Connecticut’s Medicare quality improvement organization, which developed the nursing home protocol.
“We know communication is a major issue in errors – that people tend to work in silos,” she said. “We think if we can help to change that culture, there’s an opportunity to improve patient safety in nursing homes.”
The nursing home training, which emphasizes a team approach and shared responsibility for care, is a spinoff of a similar program that has been widely used in hospitals, in Connecticut and nationally. Preliminary data from evaluations of the hospital program shows that the training can lead to a reduction in errors such as adverse drug reactions, which dropped from a rate of 30 to 18 per 1,000 patient days in some hospitals studied.
Hospitals that adopted the program also saw declines in the length of patient stays in the ICU — down from a mean of 2.2 days to 1.1 days; nursing turnover in the operating room, which declined by 16 percent; and errors in medication reconciliation at patient discharge, which were reduced from 47 percent to 11 percent.
About half of the state’s hospitals have received some training in the protocol, Spenard said. At Griffin Hospital in Derby, 18 of the hospital’s units, including the operating room, the childbirth center and the ICU, have adopted TeamSTEPPS, and the new approach is paying off, said Kathleen Martin, Griffin’s vice president of patient safety and care improvement.
Many departments have morning “huddles” to discuss care plans, and operating room teams take a “time-out” before they start a procedure to verify the correct patient, correct procedure and correct site of the surgery.
In health care, “everyone tends to be on their own planes,” Martin said. “We’re trying to standardize how we communicate – to develop a common language throughout the house . . . It’s also about empowering staff to speak up when they have a concern.”
TeamSTEPPS, originally developed by the Department of Defense and the Agency for Healthcare Research and Quality (AHRQ), has been adopted in a variety of settings, including military combat-support hospitals and universities. The training clarifies roles, encourages cross-monitoring by staff, and lays out strategies to ensure that employees at every level can communicate concerns effectively.
Spenard noted that because lower-level staff shoulder considerable responsibility in nursing homes, a strictly hierarchical approach can be dangerous. Under TeamSTEPPS, a nurse’s aide who notices a lapse in care, for example, would be directed to report that problem up the chain, under a “two-challenge rule” that encourages workers to voice a concern at least twice, to make sure it is acknowledged. Employees also are empowered to “stop the line” of care if they see a safety breach.
In one case that Martin recounted, at Griffin’s childbirth center, a nurse who noticed a lapse during a delivery was reluctant to communicate the problem to the physician because the patient’s husband was in the room. So the hospital developed certain “code words” that childbirth staff can use to convey concerns without worrying patients and family members, Martin said.
“We tweak the training as we need to. It’s a strategy that can be adapted,” she said.
Besides reducing risks, the training program can save money by reducing staff turnover and clarifying responsibilities, Spenard and Qualidigm President Timothy Elwell said. Those issues are important in long-term care settings.
“The main thrust of this is to improve patient safety, but there are some clear derivative benefits, in terms of costs,” Elwell said.
TeamSTEPPS is the latest of many attempts to try to reduce medical errors in high-risk settings. The defense department’s patient safety program came up with the training in 2006, in response to a landmark report by the Institute of Medicine in 1999 that found that almost 100,000 deaths a year were caused by preventable medical errors. Qualidigm and Abt Associates, Inc., worked with AHRQ for two years on the long-term care version.
In Connecticut, nursing homes are most often cited for lapses in care that lead to patient injury, such as pressure ulcers, lack of fall-prevention strategies and mistakes in medication or treatment. At least five citations in the past year have involved residents choking to death on food, in some cases because of negligent supervision by staff.
Spenard said Qualidigm is hoping to identify a Connecticut nursing home willing to pilot the new program in the fall. The program also is available nationwide to any long-term care facilities that want to be trained. (For program details click here.)
“It’s worked in hospitals – it could be used in assisted living and other continuing care communities,” Spenard said.
“We’re going to start to beat the drum and get the word out.”
It’s not reassuring that the program is announced without participants. Given the large numbers of citations in CT nursing homes, and all the errors and lapses in care that are not tracked and reported, a program like this could be significant. Unfortunately as described at the Center for Medicare Advocacy website, voluntary programs rarely produce significant change. The initiative to reduce dangerous antipsychotic drugs in nursing homes has yet to result in any significant changes either. Without the recognition of regulators, politicians and the public, that change is needed across the board with greater enforcement efforts, programs like this may just remain good untried ideas. What we can’t see in these kinds of discussions is actual experience of elders. They deserve to be free of suffering and have peaceful deaths which is not necessarily the status quo.