Oderberg, Jane
Ross, Sarah
Severance, Jennifer
Agena, Valerie


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PURPOSE Skilled nursing facilities (SNF) have an increasingly frailer and more dependent patient population with a high risk of re-hospitalization from preventable adverse events. Developing a culture of safety is a core component to clinician and staff behaviors that affect safety, quality, and patient outcomes, although little is known about improving patient safety in long term care settings. With a goal of improving the safety culture and quality of care provided in SNF settings, UNTHSC Center for Geriatrics developed and implemented the evidence-based interprofessional Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) to address falls risk reduction at skilled nursing facilities in Fort Worth, Texas. METHODS We administered the Agency for Healthcare Research and Quality (AHRQ) Nursing Home Survey on Patient Safety Culture Brookdale Broadway Plaza (n=36), the Stayton (n=26) between August and October 2017. Survey results across twelve composites of patient safety culture were used to inform the development and delivery of a TeamSTEPPS Long Term Care 2.0 training series focused on falls risk reduction. The first training session delivered in October 2017 for direct care staff (n=47) provided an overview of the TeamSTEPPS model and communication tools, and an introduction to falls risk reduction in long term care settings. A second session for direct care staff (n=37) delivered in December and January provided additional training in TeamSTEPPS strategies and development of a communication tool to aid in fall risk reduction. Initial evaluation of knowledge and skills of trainees included a Likert scale survey. RESULTS Survey analysis identified that most staff believed their residents were safe in their facility (89% Brookdale,91% Stayton,82%Trinity) and they would recommend their facility to others (76% Brookdale; 80% Stayton). The lack of communication regarding residents (Brookdale 60%; Stayton 48%) was prevalent in both facilities and most direct care staff felt they were not considered members of the care team (61% Brookdale; 50% Stayton). Initial evaluation of TeamSTEPPS training showed that a majority (92-100%) were highly confident they could describe objectives related to the TeamSTEPPS program and falls awareness and prevention. As a result of the training, an action plan and communication tool was developed with input from the trainees to ensure continuity of care, improve communication, and decrease falls. Using a Plan-Do-Study-Act continuous improvement cycle, this checklist will be implemented by designated facility personnel. A post evaluation using the patient safety culture survey will be administered. CONCLUSIONS The implementation of TeamSTEPPS at SNF facilities demonstrated benefits to staff in improving their quality of care and ability to work collaboratively for the good of the patients. We anticipate that SNF will utilize TeamSTEPPS principles to develop, implement and sustain effective patient safety interventions.