This is the second in a series of profiles on the 2012 Samuel J. Heyman Service to America Medal finalists. The awards, presented by the nonprofit Partnership for Public Service, recognize outstanding federal employees whose important, behind-the-scenes work is advancing the health, safety and well-being of Americans and are among the most prestigious honors given to civil servants. This profile features Citizen Services Medal finalists Heidi King, director of the Patient Safety Solutions Center, TRICARE Management Activity at the Department of Defense, and James Battles, social science analyst at the Agency for Healthcare Research and Quality, Department of Health and Human Services.
Every year, tens of thousands of patients die or are harmed by preventable medical errors such as pharmaceutical prescription mistakes, hospital acquired infections and surgical missteps. Breakdowns in communication among doctors, nurses and other care providers are a leading cause of these tragic errors.
Heidi King of the Department of Defense (DOD) Patient Safety Program and James Battles of the Agency for Healthcare Research and Quality (AHRQ) set out to do something about this troubling crisis, developing a health-care provider training system known as TeamSTEPPS that has become the gold standard for eliminating preventable medical harm. In developing the program, they assessed the evidence on which behaviors, skills and principles make delivering health-care safer.
“We believe thousands of lives have been saved and countless more medical encounters have been vastly improved as a result of their efforts,” said Dr. Joshi Maulik, senior vice president of the American Hospital Association.
King and Battles launched their partnership eight years ago, pulling together more than 100 independent experts to develop strategies, tools and a training system for professionals who work not only in high-stress situations-such as surgical suites, emergency departments and intensive care units-but also in ambulatory care settings, including physicians’ offices.
The principles are based on research from teams working in high-risk environments, such as aviation, nuclear power and the military, where the consequences of errors are great. The training teaches medical teams about human factors that contribute to errors, such as team members giving too much deference to someone with a higher-rank, even when they’re about to make a mistake.
After DOD combat medical support units in Iraq implemented the system in 2008, the rate of communication-related errors decreased 65%, medication and transfusion errors plummeted 85% and lives of critically injured soldiers being transported were saved.
“It provides mechanisms for everyone to step up and say, ‘something’s not right,’” said Dr. Donald W. Robinson, director of the DOD Patient Safety Program. “It really is cultural development.”
Teams are taught four skill sets: leadership, mutual support, situation monitoring and communication.
If, for example, a surgeon is about to amputate the wrong limb, “we make sure anyone who has information is comfortable saying something and will speak up, even if he or she is the lowest-paid person in the room, even if the doctor is the top surgeon in the world,” Battles said.
King and Battles established a national training infrastructure, including 11 centers across the country, through which more than 6,200 health care professionals have become master trainers and instructors who return to their health care systems to lead implementation of the program.
The curriculum, available free online, includes assessment, planning, training, implementation and sustainment phases.
“We saw a real need for an immediate solution,” said King. “Patients were losing their lives due to medical errors, and the harm was preventable. The program has now taken off like wildfire.”
By the end of 2011, TeamSTEPPS or the Team Strategies and Tools to Enhance Performance and Patient Safety program, was in use in all 50 states, reaching an estimated 25% of the more than 5,700 U.S. hospitals. It also has been employed in over 80% of DOD healthcare facilities worldwide.
“For programs to work, we really need the buy-in of service leadership,” said Dr. Jack W. Smith from the Office of the Assistant Secretary of Defense for Health Affairs. “The fact that this is so widely accepted across services speaks to the value of the program.”
When 625 new slots for trainers recently became available, the openings were filled within three weeks, Battles said. There is a waiting listing from more than 200 institutions.
Most importantly, evidence shows the program has an impact. For example, after DOD combat medical support units in Iraq implemented the system in 2008, the rate of communication-related errors decreased 65%, medication and transfusion errors plummeted 85% and lives of critically injured soldiers being transported were saved. In a program to reduce infections caused from catheters that included TeamSTEPPS participants, instances of bloodstream infections were dramatically lowered.
The reach of the program has been growing steadily. It has been adopted as a quality and safety improvement tool by the Centers for Medicare and Medicaid Services, included in the educational curriculum of the World Health Organization and made part of a public-private partnership launched by the Obama administration to improve the quality, safety and affordability of health care.
“We are seeing an increase in patient involvement in their care, effective communication among clinical teams, safe handoffs of patients between providers, and all staff speaking up when there is a concern or question,” said King.
Thousands of trainees have reported substantial gains in teamwork skills and confidence, said Robinson.
“Ms. King and Dr. Battles masterfully co-led a public service campaign that touches the lives of thousands,” said Robinson. “With determination, humility and inspiration, they are changing the face of health care, one team at a time.