Featured Case Study: Denver Hospital Uses AHRQ’s TeamSTEPPS Training To Enhance Teamwork

Porter Adventist Hospital, a 368-bed facility in Denver, Colorado, has used AHRQ’s TeamSTEPPS® patient safety training program to improve workflow between perioperative and intensive care units. TeamSTEPPS was used to enhance communication among physicians and develop a handoff tool particular to head and neck surgery patients. Program improvements reduced annual preventable harm events from 191 to 127 over a three-year period, and no adverse events occurred during that time. Access the case study.

Denver Hospital Uses AHRQ’s TeamSTEPPS Training To Enhance Teamwork

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Patient Safety

August 2016

Porter Adventist Hospital, a 368-bed facility in Denver, Colorado, has used AHRQ’s TeamSTEPPS® patient safety training program to improve workflow between perioperative and intensive care units (ICU). As a result of the training, the 123 participants’ perceptions of the hospital’s teamwork improved in several areas, with a marked improvement in the “mutual support” category.

Developed by AHRQ and the Department of Defense, TeamSTEPPS is an evidence-based system to improve communication and teamwork skills among health care professionals to boost patient care and safety.

Following a sentinel event—an unexpected occurrence involving death or serious physical or psychological injury—at Porter Adventist, the head and neck surgeons at the hospital wanted to improve patient safety by limiting patient handoffs in post-operative care. They implemented a new workflow that removed the intermediary step of sending patients to the post-anesthesia care unit following surgery and began sending patients directly to the ICU instead.

"With head and neck surgery patients, their airway is critical," said Belinda Shaw, D.N.P., R.N., associate chief nursing officer at Porter Adventist. "The surgeons consider ICU nurses experts in airway management."

Dr. Shaw saw the change in workflow as an opportunity to use TeamSTEPPS to enhance communication among physicians and develop a handoff tool particular to head and neck surgery patients. The staff developed communication tools that included posting signs at a patient’s bedside to notify staff about surgical anatomy changes, provide emergency airway information, and list physician contact information.

Emergency airway supplies are now readily available in customized "buddy boxes" in patient rooms. Carts with specialized equipment to access difficult airways are located in key hospital departments. The perioperative and ICU teams also created a specialized head and neck handoff report.

Program improvements reduced annual preventable harm events from 191 to 127 over a three-year period, according to Dr. Shaw. In addition, no adverse events occurred during that time.

After the changes were implemented, participants completed the TeamSTEPPS Teamwork Perceptions Questionnaire, a survey assessing health professionals’ perceptions of teamwork within an organization and group-level team skills and behaviors. The chart below reflects results of a survey showing that, following TeamSTEPPS training, more staff either strongly agreed or agreed that they worked in an environment of mutual support.

Following TeamSTEPPS training, more participants either strongly agreed or agreed that they worked in an environment of mutual support.

The success of TeamSTEPPS in enhancing teamwork during a strategic change in workflow laid the foundation for expansion throughout the hospital system.

Impact Case Study Identifier:

2016-11

AHRQ Product(s): TeamSTEPPS®

Topics(s): Patient Safety

Geographic Location: Colorado

Implementer: Porter Adventist Hospital

Date: 08/18/2016

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Page last reviewed August 2016