KAISER PERMANENTE

FONTANA - ONTARIO MEDICAL

CENTERS

TeamSTEPPS Journey

August 3, 2016

Kathy Christmas, RN, MSN, CPHRM – Director Risk Management & Patient Safety Bonnie Dean, RN - Project Manager, Risk Management & Patient Safety Joan Wheeler, RN - Project Manager, Risk Management & Patient Safety Shawn Winnick, MD - Physician Champion TeamSTEPPS

On the road to ZERO

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“Two Medical Centers, One Promise”

Service

Quality

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About Kaiser Permanente

Founded in 1945, Kaiser Permanente is a non-profit

health care organization serving more than 9.1 million

members in the US.

Kaiser Permanente has three entities:

Kaiser Foundation Health Plan

Kaiser Foundation Hospitals

SCPMG Permanente Medical Group

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Our Mission - Our Vision

Mission

Kaiser Permanente exists to provide high-quality,

affordable health care services and to improve the

health of our members and the communities we serve.

Vision

We are trusted partners in total health, collaborating

with people to help them thrive and creating

communities that are among the healthiest in the

nation.

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Our Integrated System

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Our Structure

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Fontana Medical Center

Since 1943, Kaiser Permanente has served

Fontana and the surrounding community with

quality care and service

Staff Beds 314

52 bed Emergency Department.

ED patients volume 2015 - 96,860

ED Non member visit volume - over 36%

Monthly ED volumes – 7600 +/month

700 + Physicians

1,100 Nurses

Specialty services: Neurosurgery,

Cardiovascular Surgery, Robotics, Level III

NICU, Pediatrics and PICU

Teaching facility: Internal & Family

Medicine Residency Programs & support

local residency programs

Southern California membership - 4,116,600

Service area membership - over 545,900

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Ontario Medical Center

Ontario Medical Center opened November 1, 2011.

176 licensed beds

37 bed Emergency Department

ED patients volume 2015 - 54,962

Non-member ED volume - 21%

Monthly ED volumes – 4361 +/month

Ambulatory Surgery Center on campus

700+ Physicians

557 Nurses

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Situation: 2015 SCAL Kaiser

Initiative

Developed Southern California strategy

Developed Infrastructure

Targeted Patient and Workplace Safety departments

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Preparation, Implementation and Sustainability

Step 1

Preparation

Simulation And Human Factors Education

Operations Committee

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Preparation, Implementation and Sustainability

Simulation And Human Factors Education

Operations Committee

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Preparation, Implementation and Sustainability

Simulation And Human Factors Education

Operations Committee

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SCAL Safety Structure through SAHFE

Regional SAHFE Steering Committee

Co-Leads: Jim Defontes

Rachel Mueller

Regional SAHFE Operations Committee

Co-Leads: Vu Nguyen,

Kathryn Schaivonne

Perinatal

Local SAHFE Operations Meetings

Physician Lead:

RM PS Lead:

Nursing Ed (amb/inpt) Lead:

Ambulatory

K

E

Y

Newly added Department

Local SAHFE Meetings

“Historical” Departments

Regional Structure

Monthly Meeting to Discuss Safety

Topic and current CSAs and events

from PSHC

Representation from Simulation,

Nursing Ed, Physician Ed and

every Med Center

Each of these areas has SME representation and reports out on Programs

Dx Imaging

Interventional Radiology

Perioperative

Emergency Department

Procedural Areas

Patient Advisory Team

Med Surg

Workplace Safety

Physician Education

Nursing Education

ICU / PICU / NICU

Each of these areas report into local SAHFE Operation Meetings

Simulation And Human Factors Education

Operations Committee

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Situation: 2015

Our medical center goal is to have zero significant

events by 2020.

Currently not at zero with opportunities identified in key areas

of the hospital and outpatient departments

Failure to speak up identified

Learning Climate (Staff Safety Survey) results

identified issues with Speaking Up

Minimal Patient Safety Training

Decline in Critical Events Training

National & SCAL KP support for TeamSTEPPS

On the Road to Zero

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Background: 2nd Quarter 2015

Three members of our Risk/Patient Safety Team

attended TeamSTEPPS training

In April, 2015 Patient Safety/Risk Management

Department identified TeamSTEPPS as a tool to

improve team performance & to enhance patient safety

Provided overview of TeamSTEPPS to Leadership:

Quality and Medical Executive Committees

3 OR leaders attended UCLA TeamSTEPPS Master

Training

In June, conducted 3.5 hour TeamSTEPPS course to

125 staff, physicians & leaders.

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Background: 3rd Quarter 2015

July & August – 6 additional physicians and leaders

attended UCLA TeamSTEPPS Master Training

course

August/September – Trained Ontario & Fontana

Rapid Response Teams on TeamSTEPPS (3.5 hour

class)

September – Fontana ICU Charge Nurses – 3.5 hour

TeamSTEPPS Course

Completed TeamSTEPPS Training Plan:

Departments

Reporting Culture UOR-

O 1st Q16 Red = 0-1

Yellow = 2 - 5

Green = 6 or more

Near Misses 1st

Q16

Red = 0

Yellow = 1 - 3

Green = 4 or more

Learning Culture -

2014

Red = <74

Yellow = 74 - 83

Green = >83

Human

Factors Trng CETT

SE 2014-2015

Red = 2 or more

Yellow = 1

Green = 0

Untimely Reviews- July

15 (11 day report)

Red = 6 or more

Yellow = 2 - 5

Green = 0 - 1

1 0 69% 0 0

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Background: 4th Quarter 2015

October – Highly Reliable Surgical Team

TeamSTEPPS Offsite

> 500 physicians, staff & managers attended

OR, Interventional Radiology and L&D

Focus on Debriefing

Launch of CETT training

November – Planning for 2016, Memorandum Of

Understanding Submitted

December – 10 physicians, managers, educators &

staff completed TeamSTEPPS Train the Trainer

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Background: 1st Quarter 2016

Conducted Mutual Support Training in Radiology

March – 12 managers, educators & staff completed

Train the Trainer

Held Patient Safety Fair

Launched Simulation Committee

NICU/L&D conducted Mutual Support Training

Launched Monthly TeamSTEPPS Messaging in Staff

Meeting Template

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Background: 2nd Quarter 2016

Simulation & Human Factors Education Committee

Established Steering Committee

Selected Physician Lead

Development Team Charter

Identified membership

Developing Simulation Lab Strategy

OR & OVASC TeamSTEPPS Training

Launched Critical Events Training in Emergency

Department

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Background: 3rd Quarter 2016

Simulation & Human Factors Education Committee

Establish monthly meeting

Launched Critical Events Training in Interventional Radiology

TeamSTEPPS training for Unit Based Teams Co-Chairs

TeamSTEPPS Train the Trainer class

CETT Training the Trainer class for Educators

Update Plan

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Assessment:

Have we made an impact?

Increased team training

Significantly improved Speak Up scores

on Staff Survey

Decrease in significant events

Identified challenges in linking training to

outcomes

Difficulty in defining metrics prior to training

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Assessment: Impact on Surgical

Departments

Time out

Introduction of Debriefing

Hardwiring debriefing results

Introduction of CETT training

All specialties involved

Scenarios based on actual events or issues

Reduction of significant events

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Assessment: Impact on Rapid

Response Teams

Introduced proactive rounding with coaching

Introduced debriefing after each event & satisfaction

surveys

Reduced Code Blues outside the ICU in 2016

Track days between Codes Outside ICU in Daily Operations

Briefings

Increase in staff satisfaction

Proactive rounds

Happy Staff

Debriefing

Less Codes

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Assessment: Impact on Radiology

& Emergency Departments

Radiology - Goals

Improve Speak up culture

Improved Consistency of Time Out processes

Reduced events

Emergency Department - Goals

Increase comfort & competency with Pediatric Emergencies

Improve Speak up culture

Establish Debriefing of Code Blue Events

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Recommendations: Lessons

Learned

Leadership buy-in (Top down, Bottom up)

Communication strategy

Link with events

Link with quality & patient / staff safety goals

Expectations for trainersg

Logistics:

Planning

Goals

Metrics

Meeting management

Follow up

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Questions

? ?

? ?

? ? ? ?

? ?

Finding

the

way