LaMothe TeamSTEPPS Transcript

Welcome to the Indiana University School of Nursing Interprofessional Education and Collaborative Practice in Education Podcast Series. This podcast series was supported by grant funding from the Health Resources and Services Administration under the U.S. Department of Health and Human Services. The goal of this podcast series is to provide ideas and information to individuals interested in implementing interprofessional education or collaborative practice initiatives in their practice or educational setting.

For this podcast, we will talking with Julie LaMothe, the project manager for the HRSA grant. Julie was involved in every aspect of the grant and the objectives, but she joined us to discuss her experience working with the primary care centers around Indiana to enhance interprofessional collaborative practice and teamwork. This is part 1 of a two-part podcast, which starts with Julie discussing the use of TeamSTEPPS in the primary care setting. While part 2 focuses on the use of a snorkel activity and coaching calls. We started our conversation with a description of the grant project.

[LaMothe] We have a grant, a 3-year grant. Um, that we've been working with. In this grant, we were to enhance interprofessional collaborative practice in the primary care setting and in the acute care setting. And one of the tools that uses teamwork as its base is, is called Team Strategies and Tools to Enhance Performance and Patient Safety, and it's called TeamSTEPPS for short. And, it's based on 30 years of research, developed by the Department of Defense and the AHRQ and it is based on four teachable, learnable skills, which include communication, leading teams, situational monitoring, and mutual support. And, then these effect team outcomes as far as performance, attitudes, and knowledge. And, we felt that, um, since there was success in the acute care setting based on previous research that this could be implemented in the primary care setting because the tools are adaptable to any setting. The tools are available on the AHRQ site and you can download all of the tools. You can download videos. You can even now be trained to teach Team... to be a master trainer all online. Now, originally we, there were a group of three of us that went to training at one of their sites, and we had a two and a half day training on the TeamSTEPPS model, and then I had additional training in the primary care setting at their headquarters in Chicago because we were part of the group that was going out to implement in the primary care setting, um, so we were the initial cohort group that did the implementing.

So the way we implemented in the primary care setting is that since a lot of these primary care centers are further away, we had videos and worksheets for them to work on, and we did some phone calls and they would watch the videos of TeamSTEPPS and discuss the questions that were on kinda the worksheet and then I would call them. And, this was a three-week process, and we talk about the different tools, and how they can apply those tools to their to their setting. So, we did that for three weeks and then did face to face training, in which they were actually able to practice the use of the tools to their settings. So, um TeamSTEPPS is a lot about story-telling and applying the use of the tools to the setting that you would like to... to use them in.

[CPDLL] The primary care centers included in this project were located around the state of Indiana.

[LaMothe] Some of the sites were rural, some were urban, but they were all in medically underserved areas. They were all community health centers that were patient-centered medical homes so they had to qualify for that, but we had both the urban and the rural centers.

[CPDLL] Julie shared with me a little bit more about the structure of the teams and their work at the sites.

[LaMothe] So, in each of the primary care sites we worked with a multi-disciplinary team that consisted of a physician or an NP, a medical assistant, a mental health provider, our community worker, and RNs. There may have been one or two MAs or or one or two RNs, and we used their collective input from all the members. We initially did a SWOT analysis, which is a strength and opportunities analysis of their facility, and we also did an activity called "snorkel," which looks at areas where they were having difficulty or something they wanted to work on. And, they identified a center improvement project that was based on a population they worked with so many of them picked diabetes. One center chose hypertension. Another center had pediatric asthma as their population that they were work with. We provided them TeamSTEPPS training to these groups, and we applied it to their..these tools to the population and to the project improvement they wanted.

[CPDLL] It seemed to me that the TeamSTEPPS strategies were pretty straightforward but need to be integrated into the processes of a site. I asked Julie for some examples of how they were used.

[LaMothe] I can give you an example. So, several, there were several of the centers, um, used huddles. And huddles are also part of the patient-centered medical home, which is a designation that each of these primary care centers would like to get. And, huddles, um, are usually formed in the morning prior to the work day to kind of get the lay of the land and to plan out the day. Not all centers were using these huddles because due to barriers about time and lack of coordination and different communication styles, and you have to have buy-in. So, not everyone in the group understood the importance of doing these huddles because they take some time. They can take anywhere from 5 to 10 minutes, but they do, um, get everybody on the same page so that everybody knows what the day is going to look like and, for the population, like the diabetic population we were working with. Several referrals of these diabetic patients were getting lost and were not getting to the coaches that needed to coach them and to give them what they needed as for their education. So, it improved the process, so we finally got buy-in, but it took several coaching calls to reinforce and to find out, and so if the champion wasn't there that week, if she was on vacation, or he was on vacation, then the huddles wouldn't happen. So then we, we had to troubleshoot, and say, ok, well, who would be the secondary person if this person wasn't there that could organize the huddle. We just needed that reinforcement through the coaching calls.

[CPDLL] I asked Julie about how long it took to get the process started at the sites.

{LaMothe] It all depended on the site, but it took a few phone calls to really get things moving and to establish who that champion would be. So, I would say we would do these calls every two weeks, so I would say within a month we were hoping to have those huddles in place and happening, but it does take a while for change to occur, and that's one thing we didn't expect to happen but what, but we also had some nice surprises that came out in that they um, with the huddles and with the handovers they came up with other ideas that used the tools so they would find uses for the new tools and we'd, and they, in one center they want to expand into other teams into other other multi-disciplinary teams and we have buy-in from the head of the center who is the CEO of the center. So, that was very important.

[CPDLL] Another example was a site that included mental health workers and case managers on their team to improve communication between the disciplines.

[LaMothe] Because they were using the tools of mutual respect, mutual support, which are all tools in TeamSPECK, uh, TeamSTEPPS, it helped the relationship and the cohesiveness of the group. And, it, um, uh, I really felt that these multi-disciplinary groups really formed a nice bond and they worked well together, they communicated well together, and it improved the quality and safety of their care because they were talking to each other, and it also increased the efficiency because then things were not repeated.

[CPDLL] One site coordinated diabetic group visits in which a group of patients would come see their providers at the same time, which resulted in a supportive structure that the patients really appreciated.

[LaMothe] They stated that these patients and these group visits liked it so much that they became a cohesive group. And, when the group visits ended, they were very sad. And, so they are restarting the group as it, and they want to be a part of that, and I thought that was outstanding because it's very difficult to get these, in rural communities to get these patients to come in for visits. And they were sad that they weren't able to come back to these group visits. So they were getting a lot of support, and it was through their communication and the way they set up these group visits.

[CPDLL] The grant team collected data from the care teams throughout the process to see the perceived changes in particular areas, which showed signs of improvement from the start of the projects to the end.

[LaMothe]  Well, we did do a surveys. One was a safety organizing scale, which set a culture of safety. We did that at baseline, 6 months, and 12 months, and we also looked at care decisions, collaborative care decisions. Another survey, and both of those surveys showed an increase in communication and collaboration. And an increased mindfulness so the scores did increase; they, some of the teams started off very high so they didn't have much room to go but we did see.. we did not see a decline in any of the scales. But, we did see an increase. And, that was important. These teams do change over time because there is turnover in the facilities so it wasn't always only the same group, but in some of the centers where there was less turnover, we saw even more success because it was the same group that worked that worked together. But, I feel like this use of the TeamSTEPPS gave, tools, with the coaching really improved just the communication and the follow-through of patient information. So, I feel like patient information got to the right source; there was just more streamlined, more efficiency with the visit. They felt like the visits were going better. They felt like they knew the patients better, so when the patients would come in they in, they felt like the whole team knew the patients, not just the physician or nurse practitioner, which I thought was important for the connection for the patient. The appreciation of one another's roles I think was also an improvement. I think they appreciated what each could bring to the table. So, everybody had a collective voice. And, I thought that was also a big benefit of working with these groups in providing the tools to do that.

[CPDLL] The groups also found that the tools related to mutual support really helped them talk through conflict or uncomfortable conversations in a purposeful and instructive way as opposed to destructive.

When I asked about lessons learned, Julie had a number of recommendations for other groups who were looking to do this type of work.

[LaMothe] Why I think you, um, you need to start with a goal in mind, an aim statement of what you are trying to achieve, and, uh, not to bite off too much, like if you want to do the huddles then I would just work with the huddles until you have that down. If you want to work with a communication system like SBAR, which is Situation, Background, Assessment, and Response, you want to, you would just work with that. I would work with one tool at a time and reinforce that and not try to take on much. And, don't expect things to change overnight. You need a champion, uh, in the facility, especially in the primary care setting where you do have a lot of turnover. If you have a champion there that really believes in the tools and believes the the ideas or whatever you, whatever the aim is, that you're trying to achieve that is monumental -- because then you create change teams with that lead and these change teams then can train other teams. Because, other teams will see how successful you are.

[CPDLL] The nurses often emerged as the team champions and Julie told me a little bit about what their role was a champion as well as some additional support from management that that also helped the teams along in the process.

[LaMothe] The way that they championed it, this, was that they were always on the phone calls when we were there. If there were barriers, they would work around those barriers, and they'd find solutions to work around. They were committed to making things work. They were just committed. They spoke with the chief stakeholders. They promoted the work. And, one particular nurse did a project and a poster and presented it to the board. She was so excited about it. And, this is one of the centers that is going to spread TeamSTEPPS throughout the whole center because of her work.

One place, um, the CEO was kinda pushing it, and felt it was very important and because of that support and also the support of the Chief Financial Officer in the group that really drove it. And this was just a group that was very innovative and creative and they wanted to increase the efficiency. And, they were always open to ideas, and I think that because they were open to it, the others, the people that worked there were open to learning. 

[CPDLL] These champions were self-selected and emerged on their own according to Julie as opposed to being asked or instructed to serve in the lead role by a manager. She felt this was really was strength in the role because those who emerged as champions were very committed to the center and the work of the team.

One thing to keep in mind is that these tools have been used quite a bit in acute care such as an operating room or medical-surgical units. In these types of units, there's also a specific focus in terms of the types of patients or the type of care being provided versus a big more variety in the types of patients and needs in the primary care setting where patients come and go throughout the day and may return again in a short period of time or not for months or even ever.

[LaMothe] I would just say the teams are different. It's broader. The scale is broader than in primary care setting. You're seeing patients that are coming in and out. You're not with the patients the whole time if you're on a unit. You're caring for them so it can be reinforced. It's just such a different setting. That's why with TeamSTEPPS, if you go to the TeamSTEPPS site, they do have videos that are adapted to the primary care setting. And, they have TeamSTEPPS videos adapted to the acute care. And, they're very different because the settings are so different. There's a different pace. There's different activities in the acute care. You may have emergency type situations that you don't see in the primary care setting.

[CPDLL] I asked Julie to describe her thoughts about the most important impacts of using TeamSTEPPS and other interprofessional collaboration tools at the primary care centers.

[LaMothe] Well, the impact, I think, with the use of TeamSTEPPS in the primary care setting or in the acute care setting is that you're getting your teams to work well together to improve handovers and patient care. The efficiency of care is improved as the team works together and their shared knowledge and respect of their roles and responsibilities. The process of the diabetic group as its improved when we worked with them due to the morning huddles because of these improved handoffs to the diabetic coach and asthma care of the children improved with the phone calls after the visits. In all cases, the process improved the care provided.

[CPDLL] Ideally, the outcome of an initiative like this is to see improvements in efficiency overall and a decrease in healthcare costs as patients would visit the emergency room less and return to their primary care center for routine visits.

Julie shared with us some final thoughts about her observations regarding what can help other sites be successful in testing out these types of initiatives.

[LaMothe] Well, I would recommend that these primary cares, any primary care centers be open to learning TeamSTEPPS. They do have free training; they require three people from the team to come to the training or you can do the online training and I would recommend that the centers train everyone in TeamSTEPPS and that you have a champion that reinforces this. I think that the coaching calls are very effective because they enforce and also help the group to manage and to troubleshoot the the barriers that they come up against in these primary care settings.

[CPDLL] I'd like to thank Julie LaMothe for speaking with me for this podcast and would like to thank you for taking the time to listen and learn more about the work that's being done at the IU School of Nursing.

Check out part 2 of this podcast in which I interviewed Betsy Lee. Part 2 focuses on the same primary care activities but describes the snorkel process and coaching calls that were used. Make sure to check out our other podcasts and continuing education offerings at cenurse.iu.edu