Small Towns are Ripe for Team Training

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by Jennifer Bayersdorfer, MHA[br]
System Director, Clinical Effectiveness & Quality[br]
Providence Health & Services
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I grew up in a small rural town in northwest Wisconsin. It was the kind of town where an unplanned visit to the emergency department is followed by three calls from people who spotted your car at the hospital, where the police chief has morning coffee with your dad, and your science teacher lives three doors down. This may sound familiar to the nearly 1.6 million Washington residents who are living in small cities and rural areas. [br][br]
Most days I look back on these small-town intimacies with great fondness, the more stifling aspects rendered fuzzy by the lens of time. But romanticisms aside, our rural communities face unique pressures, especially in the delivery of health care. According to the American Hospital Association, these challenges include workforce shortages, aging facilities, poor access to capital, and low margins. And while the relationship between patient and caregiver is sacred everywhere, it is especially precious in these communities when patients are neighbors, friends and family members.[br][br]
The fragile nature of these relationships was demonstrated several years ago at one critical access hospital in a neighboring state. Over the course of 18 months, three separate and devastating adverse events occurred on the OB unit. These events left three families shattered and the caregivers at this hospital rocked to their core. Not one degree of separation existed between the care team and the affected family members. The phenomenon we know as “second victim” is amplified in small towns, and in this case left these caregivers wondering how they could continue facing their neighbors.[br][br]
In this case, the team had ample opportunity to examine the root causes behind the three events. They observed a common thread across all: breakdowns in teamwork and team coordination. Issues ranged from ineffective communication to insufficient trust and respect. They were ready for anything that would help and, as luck would have it, a solution appeared in the form of TeamSTEPPS, a teamwork approach developed by the Department of Defense and Agency for Healthcare Research & Quality (AHRQ).[br][br]
TeamSTEPPS is an evidence-based teamwork system to improve communication and teamwork skills among healthcare professionals. It offers a flexible framework and comprehensive set of tools, and a growing body of research supports its effectiveness in improving teamwork across a variety of settings and applications.[br][br]
Given the fallout it was experiencing from litigation surrounding the aforementioned events, this hospital felt its level of readiness warranted assistance in beginning its TeamSTEPPS journey, and engaged a consulting firm to help get started. While they found this beneficial (in this case, it was funded through the hospital’s foundation, and they would recommend it for those who can afford the expense), TeamSTEPPS tools and training are freely available and more typically hospitals implement without assistance. [br][br]
The hospital began gradually with two departments: OB and surgery. Within six months, significant differences were discernible in the quality of teamwork, especially in the Family Birth Center. This strong initial progress led to a reaffirmation of commitment and a spread of the tools and techniques to the rest of the hospital. Efforts were made to integrate TeamSTEPPS into everything they did, from the organization’s strategic plan to performance expectations and staff meeting agendas. Whenever a particular improvement opportunity was identified, the care teams would revisit their arsenal of TeamSTEPPS tools and apply a tool specific to the problem and quickly correct course. It took another two years to spread to every department in the hospital, and this year they are spreading to their clinics. [br][br]
The results have been excellent, with significant improvements in their Safety Attitude Questionnaire scores for safety climate, teamwork climate and job satisfaction. Staff and leaders report recognizable differences in the organization’s culture and ability to come together quickly to solve problems. [br][br]
Rural health is a critical dimension of the overall Washington state healthcare landscape. While our state ranks at the national median for proportion of residents living in small cities and rural areas, it ranks in the top quartile for number of critical access hospitals, at 48 hospitals in 2014 . This disparity illustrates the broad dispersion of Washington’s rural population over its geographic footprint. It also represents the large number of communities able to relate closely to this story and gain insights from the lessons they’ve learned. [br][br]
I believe critical access hospitals in general may be well-positioned to adopt Team STEPPS with great success. These hospitals have a number of unique qualities that can give their efforts a boost:

• Patient safety is personal. People tackle problems with a different mindset when those closest to them may be the ones to benefit from the solution.
• Team member familiarity can be leveraged. Familiarity among team members across department lines is more likely to exist in a small hospital and can be leveraged to serve as a foundation for strengthening teamwork through TeamSTEPPS.
• Interdependency breeds necessity. All healthcare teams are highly interdependent, but in smaller hospitals where resources are scarce and people are juggling multiple roles, teamwork is all the more essential. Recognition of this interdependence can lead to greater buy-in to the program.
• Small size is an asset. TeamSTEPPS training can be more quickly deployed when a smaller number of caregivers are involved.
• Scarce resources can be an advantage. The most successful TeamSTEPPS implementations are those where the caregivers involved in daily operations and patient care are the ones promoting and teaching the tools. It gets woven into the daily fabric of teamwork. While resources like clinical educators or quality specialists may allow a facility to move more quickly, they won’t necessarily lead to a more effective implementation.

I don’t want to minimize the challenges of implementing TeamSTEPPS. It’s a cultural transformation that will not happen overnight. It is hard work and a continuous improvement journey. It requires the passionate engagement of caregivers at the front line, and the committed support of leaders at the top. And the advantages for small hospitals I’ve listed could just as easily become disadvantages if not managed properly. At a minimum, the clear benefits outlined in the research demand a review by all of our hospital leaders. As representatives of their communities, boards should educate themselves as well and demand action from management when teamwork and communication deficits are evident.[br][br]
Washington is especially fortunate to have one of the only six TeamSTEPPS regional training centers right in our backyard at the University of Washington’s Institute for Simulation and Interprofessional Studies (ISIS). Regularly scheduled master trainer courses are offered at ISIS for teams of three or more. These classes are free, though participants are responsible for their travel expenses.[br][br]
If you are reading this from a small hospital, I hope you are feeling encouraged to explore a Team STEPPS journey. A wealth of resources are available on the Team STEPPS portal to get you started. If you would like to learn more from the hospital I mentioned earlier, please reach out to me and I will be happy to make that connection.
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