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VHA National Center for Patient Safety

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Clinical Team Training

Clinical Team Training (CTT) program offers an opportunity for clinicians to improve patient safety and job satisfaction by facilitating clear and timely communication through collaborative teamwork in the clinical workplace.

Principles of aviation’s Crew Resource Management (CRM) are introduced in a clinical context to model specific applications in the healthcare environment.

CTT requires a coordinated, multi-disciplinary approach with top leadership engagement and support. On-site training with integrated simulation, conducted by experienced faculty from the National Center for Patient Safety, is followed by coaching and monitoring of unit-based performance outcomes over twelve months.

Recurrent training is conducted one year from the date of initial learning session and is critical to re-enforcing key CRM concepts in the program.

The fundamental paradigm of CTT is that front-line clinicians are taught specific CRM behaviors to manage human error before patients are harmed. Human errors are trapped before they reach the patient through effective teamwork, communication, and higher levels of team situational awareness.

To schedule a CTT learning session at your Veterans Department facility contact:
Gary L. Sculli MSN, ATP
Director of Clinical Training Programs
VHA National Center for Patient Safety 

More About the Program

Culture of Safety

Concept: Culture of Safety, Error Management, and “Fault Tolerance” 

  • Although the primary goal is to avoid errors, methods and countermeasures need to be developed and implemented to mitigate the effects of errors when they occur.
  • “Fault Tolerance” mechanisms are applied to insure that healthcare systems continue to function to provide safe patient care.
  • Clinicians look beyond their own actions to examine vulnerabilities that exist within the system.  Vulnerabilities are identified in a clinical context and countermeasure behaviors are highlighted which serve to manage errors and avoid or reduce patient harm.

Concept: Standardization of a Patient Care Process

  • Standardization allows clinicians to know and execute learned procedures in compliance with facility policies and procedures.
  • Standardization reduces cognitive load on attention and working memory.
  • Standardization can be used to optimize performance and SA during patient care activities, procedures, and team handoffs.

Leader Behaviors

Concept: Leadership and Team Building

  • Leadership encourages open communication and inquiry from other team members, especially when patient safety is in question.
  • Leaders implement specific strategies and behaviors that facilitate teamwork and the open, timely exchange of relevant clinical information among staff.

Effective Followership

Concept: Effective Followership – Assertive Inquiry and Advocacy

  • Effective Followership is an active role that requires critical thinking and an ability to directly and promptly communicate concerns about patient safety.
  • Effective followers practice assertive inquiry (investigating patient care decisions) and assertive advocacy (promoting the best course of action for patient care) regardless of hierarchy in the organization.
  • Strategies of Effective Followership are pivotal in formulating assertive statements and to resolve conflicts about patient care decisions.
  • Specific, tangible, and useful communication tools are taught and practiced during CTT simulations.
For more information about Effective Followership, please see the 2015 article by Sculli, et al. entitled "Effective Followership: A Standardized Algorithm to Resolve Clinical Conflicts and Improve Teamwork" in the Journal of Healthcare Risk Management.

Situational Awareness Countermeasures

Concept: Situational Awareness (SA) Countermeasures

  • The major elements of SA include the clinicians’ ability to:
    • Perceive what is occurring in the environment
    • Prioritize and attach meaning to form a clinical picture
    • Synthesize the information into an expected outcome.
  • SA is expressed as being “high” when associated with decision-making that is both sound and safe:
    • High SA is required when clinical practice occurs in a complex, dynamic, and safety sensitive environment.
    • Clinicians preserve higher levels of SA by implementing processes such as actively monitoring team members for the effects of task saturation and fatigue, along with the use of tools like checklists and briefings.
    • High SA is a precursor to decision-making.
  • Safety culture is enhanced when clinicians understand the factors in their environment that threaten SA, recognize SA is at risk, and implement plans to maintain SA.
  • Specific countermeasures to manage threats to SA are taught, which can improve team decision making. 

Concept: Workload Management

  • Leadership is an integral part of effective workload management.
  • Workload management encompasses effective task division by team leaders, especially during critical or acute situations.   
  • Workload management includes knowing and utilizing “all available resources” to complete necessary patient care tasks.

Concept: Reduce Distractions during Critical Tasks – “Sterile Cockpit” rule 

  • Specific changes in team communication are designed to reduce interruptions and distractions during critical tasks or during specific time periods. The prescribed changes that are implemented protect clinicians and to prohibit behaviors that divert attention from safety-sensitive tasks.

Concept: Fatigue Awareness

  • Fatigue reduces SA and threatens clinical performance and decision-making.
  • Clinicians discuss fatigue awareness in unit briefings, monitor each other for signs of fatigue, and implement operational countermeasures to manage its effects.

Concept: Verifying Actions and Inputs 

  • Clinicians use redundancy and “double checks” with another staff member to verify critical actions and inputs such as administering high-risk medications, programming infusion pumps, and changing ventilator settings.

Briefings and Checklists

Concept: Briefings 

  • Briefings enhance teamwork and communication as well as support team SA. Leaders use structured briefings to communicate pertinent patient information, team behavioral expectations, goals, and areas for focused patient assessment.
  • Briefing creates an opportunity to have controlled team discussion, to clarify questions, and address concerns with the members of the team.
  • Briefings are advocated for use in procedure settings as well as patient care areas.
    • Briefings are used prior to an invasive procedure or treatment.
    • Briefings can occur within disciplines or between disciplines, e.g. nursing and medical staff. 
    • Briefings are initiated by leaders in nursing, medical, or other healthcare teams. 

Concept: Debriefings 

  • Debriefings are structured discussions facilitated by a team leader for the purposes of reviewing individual and team performance in an open, blame-free, non-punitive environment.
  • Debriefing serves to identify areas where the team performed well along with opportunities for improvement, serves to build teamwork, facilitate communication, and elevate SA for future challenges.
  • Debriefings are utilized following routine patient care and emergent or adverse events.

Concept: Checklists 

  • A checklist is a tool used to support memory and to verify that critical steps are not missed as a result of distractions or interruptions.  
  • Teams learn to develop and implement usable checklists based on the nature of the tasks being supported.  Clear and specific differences in checklist usability and construction are highlighted.

High-fidelity Simulation

Concept: Recurrent Training and Competency Practice with Simulation

  • Recurrent training is an opportunity for professionals to revisit important policies and standard operating procedures at specified intervals.
  • Competency practice with simulation of real events allows professionals to practice and perfect responses to infrequent clinical situations in a safe environment.
  • A recurrent training and competency practice model allows dedicated time for professionals to immerse themselves in training that takes place in an appropriate learning environment away from the clinical unit.
  • CTT Recurrent training and competency practice with simulation occurs one year from the initial training.