Craig Bunnell, MD, MPH, MBA
Chief Medical Officer
Dana-Farber Cancer Institute
Boston, MA
Changing Culture for Good:
Disseminating and Sustaining Team Training in Outpatient Oncology Across an Academic Medical
Center and Community Satellites
Disclosure
I have no conflicts of interest to declare.
3
To provide expert,
compassionate care to children
and adults with cancer while
advancing the understanding,
diagnosis, treatment, cure, and
prevention of cancer and related
diseases.
DFCI Mission
Background• Multiple studies have found that 75% of errors occur because of
deficiencies in communication and coordination of patient care.
• Failures in coordination and communication have been associated with:• higher risk for error• increased mortality• longer hospital lengths of stay• higher staff turnover
• Poor communication and misunderstandings contribute to a culture of blame, isolationism, and lack of trust.
Background
Joint Commission Sentinel Event Statistics
Background
• The Institutes of Medicine and The Joint Commission have recommended implementation of team training techniques
• Such techniques have been applied successfully in various “contained” inpatient settings (e.g. ICU, ER, OR, L&D, etc.) but never in an outpatient or oncology setting.
The Science of Teamwork
• Based on 30 years of research (military, aviation, nuclear industries, more recently medicine)
• Defines a team
• Mitigates issues of hierarchy
• Identifies necessary skills for optimum team performance
• Relies on robust systems to support implementation of tools and agreements
• Involves culture change
Team Training Concepts (Crew Resource Management)
• Research for Army Aviation showed teamwork saved lives
• 5 Principles of CRM
• Asking for relevant information
• Offering relevant information
• Communicating and confirming proposed actions
• Advocacy
• Conflict resolution
What’s in it for us ?
Reduced ErrorReduced risk of harm
Decreased litigation exposureDouble check Better systems
Improved Quality of Life
Fewer distractions Less anxiety
Skills for organization Improved Work Environment Improved Work Relationships Decreased finger pointing
Decreased conflict Mutual trust
Improved Efficiency Fewer errorsFewer pages
Decreased wait timesFewer emails
Improved Patient Care
POTENTIAL
BENEFITS
Why Team Training in Outpatient Oncology?
• Chemotherapy process: most high risk/high volume activity in a cancer center (>150,000 infusion visits/yr)
• Treatment regimens complex, involving multiple drugs; standard and investigational (342 clinical trials)
• Treatment plans can be changed based on lab results
• Clinical team often separated by geography, making direct communication challenging
• Occurrence reports and ‘near miss’ data demonstrated opportunity to improve safety
The Intervention• Baseline data collection: staff surveys, safety reports
• Engage Leadership: kickoff meeting
• Observations, interviews with clinical staff
• “Train the Trainer” session and determine “pain points”
• Process Meetings: develop agreements, tools, system changes
• Train ALL staff
• “Go Live”
• Post-data collection
Strategy for Change• Mandate from Executive Leadership and Board of
Trustees
• Clinical leaders teach and lead
• Use performance data, actual ‘near-miss’ scenarios
• “Train the Trainer” methodology
• Project support: outside consultation, project manager
• Continuous measurement and feedback
• Refresher courses, trainings, video for new staff
• Learning Collaborative: to sustain/spread best practices
Dana Farber Cancer Institute - Team Training Dissemination: Initiation to Implementation
July 2008
Oct.2008
Jan.2009
April2009
July 2009
Oct. 2009
Jan.2010
April 2010
July 2010
Oct. 2010
Jan.2011
April2011
July 2011
Oct2011
Jan 2012
April 2012
Hematologic Malignancies (HEO)
Breast Oncology (BOC) Institute Pilot
Benign Hematology (HSC)
Neuro-Oncology (NOC)
Gynecologic Oncology (GYN)
Sarcoma Oncology (SAC)
Milford Regional Medical Center
South Shore Hospital
Gastrointestinal Oncology (GCC)
Head & Neck Oncology (HNO)
Melanoma (MEL)
Cutaneous Oncology (CUC)
Londonderry
Pediatric Oncology
Genitourinary Oncology (GUC)
Thoracic Oncology (TOP)
Planning Phase
Implementation Phase
Faulkner Hospital
Inpatient
Metrics
• Patient arrival to infusion area with no chemotherapy orders
• # of change orders not communicated
• Staff perceptions of teamwork, communication, safety and respectful practice environment
• Patient perception of teamwork (Press-Ganey)
• Wasted drug related to communication failures within team
Breast Oncology: Post-Implementation Unlinked Appt.
Unlinked Appointments - % of Total Patient Scheduled, Pre and Post Email Reminder, 2009
70%
87%
95%
74%
91% 90% 89%
82%
90% 92%
81%
89%
82%85%
89%
98% 98% 100%96% 96% 98% 99%
94% 96% 98% 98% 98% 96%99%
96%
0%
20%
40%
60%
80%
100%
120%
3/9 3/16 3/23 3/30 4/6 4/13 4/20 4/27 5/4 5/11 5/18 5/25 6/1 6/8 6/15
% t
o t
arg
et
% pts with orders (48hrs prior to appt) % pts with orders prior to patient arrival (after email reminder)
Availability of chemotherapy orders for unlinked visits increased from 70% to 97% and has been sustained
Breast Oncology: Reported Near Miss Events
1115 12
62
4
0
5
10
15
20
Pre TrainingAug-08 - Feb-09
Post TrainingMar-09 - Sept-09
Follow-UpMar-10 - Sept-10
Num
ber o
f Rep
orts
Breast Oncology - Safety ReportsPre and Post Team Training, 1-Year Follow-up
Unrelated to Team Training Related to Team Training
Main Campus: Reported Near Miss Events
Pre Training Post Training 1 Year Follow-up0
25
50
75
100
125
150
143
108
138
12
6
5
Unrelated to Team Training Related to Team Training
Nu
mb
er o
f R
epor
ts
DFCI Main Campus- Safety Reports Pre and Post Team Training, 1-Year Follow-up
Patient’s Perception of Teamwork: Satellite vs. Main Campus
Oct
-09
Dec-0
9
Feb-1
0
Apr-1
0
Jun-
10
Aug-1
0
Oct
-10
Dec-1
0
Feb-1
1
Apr-1
1
Jun-
11
Aug-1
1
Oct
-11
Dec-1
1
Feb-1
2
Apr-1
2
Jun-
12
Aug-1
2
Oct
-12
Dec-1
290.0
92.0
94.0
96.0
98.0
100.0
96.9
94.1
Press-Ganey: "Degree to which staff worked together to care for you"
satellite campuses Linear (satellite campuses)main campus Linear (main campus)
Pa
tien
t Sa
tisfa
ctio
n S
core
Team Training (TT)Survey Questions
MD, NP, PAn = 120
Infusion RNsn = 122
Support Staff
n = 230
Definitely/Probably
Has TT improved patient safety? 71% 79% 79%
Has TT improved the efficiency of patient care? 63% 72% 75%
Has TT improved the quality of patient care? 71% 72% 78%
Has TT helped staff to treat one another more respectfully? 67% 77% 67%
Has TT improved relationships among members of the care team? 61% 77% 70%
Has TT made it easier for you to ask others for help? 52% 74% 68%
Has TT made it easier for you to express your concerns to other members of the care team? 55% 77% 65%
Staff Perception of Teamwork
Chemotherapy Order Intervention Data
Pre Team Training Post Team Training
Random Sampling n = 1850 n = 1951
Order Changes Not Communicated
51 (2.76%)
34 (1.74%)
Lessons Learned: Critical Strategies for Dissemination and Sustainability• Support from Leadership: - Board of Trustee participation - Engagement of Executive Leadership
- Early engagement of day-to-day leadership- Patient involvement
• Engage the Front-line in Development, Planning, Implementation- Train-the-trainer- Implementation--balance universal change with flexibility
• System/infrastructure redesign to support changes/agreements
• Execute, Measure and Refine - Metrics
- Continuous feedback on team performance - Training plan for new employees - Periodic refresher course/iterative refinements
- Acknowledge/Share Best Practices
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