TeamSTEPPS新视点:照护合作很重要

2017-06-02 谢燕 译 肖明朝公众号

10年前,美国医疗保健研究与质量局在美国国防部的协助下,发布了“加强绩效与患者安全的团队策略与工具”。

10年前,美国医疗保健研究与质量局(AHRQ)在美国国防部(DoD) 的协助下,发布了“加强绩效与患者安全的团队策略与工具”(Strategies & Tools to Enhance Performance & Patient Safety,TeamSTEPPS)。该工具作为美国卫生保健领域团队训练的国家标准。早在2006年,卫生专业人员还不能明确TeamSTEPPS的价值。但从这以后,全球成千上万人员接受了该项目的培训,并由此开展了一系列关于卫生保健团队功能、提高照护合作的方式、团队合作与临床进程及结果的关系等研究。目前,团队合作在提供安全、优质的服务和团队培训中毫无疑问起着非常重要的作用。

本文主要分享了10个关于卫生保健团队培训项目的观点。这些观点的提出主要基于研究人员参与TeamSTEPPS项目的实施和每年的TeamSTEPPS年会。TeamSTEPPS年会从2006年的30位参会者已经发展到2016年的600位。最后,研究人员将TeamSTEPPS应用于临床,并针对如何通过更好的团队工作提升患者安全进行研究。

视点1 患者安全,照护质量和照护合作密切相关

当10年前发起TeamSTEPPS时,质疑者要求提供证明TeamSTEPPS有效的证据。尽管TeamSTEPPS是经过循证研究的,但相关研究主要是在卫生保健以外的领域进行,关于TeamSTEPPS与改善临床进程和患者预后之间关系的研究也非常缺乏。

2006年以后,关于团队合作与患者安全之间关系的研究迅速增加。最近的一篇关于卫生保健团队培训的meta分析(129个相关研究)表明, TeamSTEPPS、参与型学习、培训转化和组织效果密切相关。一项10年的研究也表明,TeamSTEPPS能提升对患者的照护服务。

视点2 未来10年需要解决文化的变革

虽然TeamSTEPPS的推进已经取得了很大的进展,但是在不同的临床环境中持续应用TeamSTEPPS工具,将团队合作原则整合到提供服务和日常工作实践中等许多问题还有待解决。即使是10年后,组织机构依然面临组织变革的问题,TeamSTEPPS仍然是卫生保健专业人员团队合作提供服务的重要工具。2006年以来,参与TeamSTEPPS团队拓展培训的人员认识有了很大的提高,但对于怎样持续推进组织文化变革还知之甚少。

视点3 医学专业教育应包含团队训练

以往的跨学科教育和将团队概念嵌入医学院校教育并没有使团队合作热起来,直到最近才开始改变。10年前,杜克大学和北卡罗莱纳大学尝试运用TeamSTEPPS元素和模拟训练为护生和医学生开设了一天的培训课程。同时,撰写了一篇介绍怎样将TeamSTEPPS植入医学教育的文章。从那之后,跨学科教育得到了长足发展。新的医学院校普遍都开设有跨学科课程教育,并且大部分的院校不管新老都开始应用模拟场景的教学方式。跨学科教育被认为是提升照护合作和增进患者安全的基础。尽管TeamSTEPPS已经开展起来,但要去改变业已形成的行为比从一开始就学习正确的行为要困难许多。

视点4 医疗改革创造新的机会

医疗改革将质量提高到非常重要的地位。服务质量、患者预后、患者满意度和资源使用等对医疗费用支付的影响日益增加。虽然团队合作的质量在新的费用支付模式中没有被直接评价,但毫无疑问,它与许多患者预后密切相关。这种情况将会改变。在这种形式下,通过开发测量优质服务的方法,来验证团队合作的重要性以及将评价团队合作作为医院和医疗费用支付评审标准的一部分等研究将应运而生。这种评价也应该被应用到模拟场景训练中。

视点5 TeamSTEPPS没有界限

在发起美国实施TeamSTEPPS时,一批澳大利亚的研究和专业人员接受了培训。这些人员在澳大利亚西南部地区推广应用TeamSTEPPS并获得了巨大的成功。随后,非洲、亚洲、欧洲、南美洲和中东地区都取得了同样的成功。2015年,TeamSTEPPS 被世界卫生创新峰会(World Innovation Summit for Health)评为八大全球创新之一,不仅在短时间内成功推广,而且有形成果广泛。致力于TeamSTEPPS的全球推广,特别是医疗保健体制和文化存在巨大差异的国家中推广。尽管存在这些差异,但TeamSTEPPS的核心工具和策略,包括信念、人员、执行情况是可以跨越文化的,对提高服务协作质量的需求是一致的。

视点6 通过模拟场景,大力发展TeamSTEPPS

过去10年,科学技术的进步和模拟场景教学的发展也助推了TeamSTEPPS的推广。模拟病人已经被广泛应用于教学、技能培训和再次认证等方面。模拟场景教学对于培训团队应用TeamSTEPPS工具和策略至关重要。在团队合作的背景下,模拟场景的设计、采取哪些措施和反馈方式的重要性远大于模拟的逼真度。目前,已经有3个区域的国家级TeamSTEPPS培训中心将不同层次的模拟场景整合到TeamSTEPPS研究生培训课程中。这些课程包含高保真和低保真模拟,学员在练习中应用TeamSTEPPS,其他人员观察学员的表现并提供技术方面的反馈等。10年之前,这些都是不可能的。现在模拟、场景设计的进步和团队合作测量方法已经成为TeamSTEPPS的重要补充。

视点7 医生是团队工作的倡导者

早期,TeamSTEPPS被认为是一项护理活动,很少有医生参加TeamSTEPPS培训。在过去的5年,这一情况发生了改变。现在,医生在培训参加者中的比例达10%。我们观察到,医生可能更加容易认可团队工作的重要性和接纳TeamSTEPPS工具和策略。当医生领导TeamSTEPPS时,组织可能获得更大的成功。发展TeamSTEPPS之初,部分参与的医生认为“相互监测绩效”的概念挑战了医生的权威。现在,医生更支持团队合作,重视到TeamSTEPPS的价值,常常是TeamSTEPPS执行和使用的倡导者。

视点8 广度和深度是最好的处方

当在全美发起TeamSTEPPS项目实施时,曾经讨论是否增加新的培训者的数量或为执行者提供直接支持。但最终选择重点关注用现有的资源培养尽可能多的个人。项目得到了医疗保险和医疗补助服务(Medicare and Medicaid Services)中心的支持,该中心要求下属的每个质量改进机构培训2名主教练。2008年到2010年期间,超过3500名新的培训者接受了AHRQ的培训。这些早期参与者在随后培训他人,应用工具和策略中获得了巨大的成功。一个早期应用TeamSTEPPS名叫Northwell Health的机构,培训了他们庞大卫生保健体系中的每一个人,效果显着。

视点9 第二个“P”很重要

起初,TeamSTEPPS只包含一个“P”(即“Patient Safety”,患者安全)。Dr. John Webster,一个早期参与计划的整形外科医生,坚持TeamSTEPPS应包括另外一个“P”(即“performance”,绩效)。他认为,这个项目不仅要关注患者安全,也应该致力于推动高水平的团队表现,并且吸引他的同事和医院管理者参与其中。Dr. John Webster的观点是正确的。过去10年,TeamSTEPPS通过增进团队绩效,最终提高了患者安全。

视点10 TeamSTEPPS令人惊讶

难以想象人们接受TeamSTEPPS的程度。今天,美国估计有35%的卫生保健人员接触了TeamSTEPPS。全球对TeamSTEPPS的接受程度很难估计。当接到来自欧洲的一个电话,看到阿拉伯国家一个关于TeamSTEPPS的指南,听说南美要建立一个培训中心时,不言而喻,惊讶不已。TeamSTEPPS已经有了自己的生命,它已经被证明是如此宝贵的患者安全资源。

综上所述,未来10年TeamSTEPPS将会进一步发展,特别是医疗费用报销与质量和安全的关系被明确之后。TeamSTEPPS将会如组织机构所期望的那样,改善临床绩效和医疗费用报销。持续的成功依赖于研究者和执行者的通力合作。希望继续推动关于团队合作、团队培训和患者安全的重要性的认识。

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    2018-03-18 yyj062
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    2017-06-03 三生有幸9135

    学习一下谢谢分享

    0

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    2017-06-03 楠博One

    学习谢谢分享

    0

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    2017-06-03 daiyaozu

    学习了,不错

    0

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    2017-06-03 飛歌

    学习了很有用

    0