TEAMWORK AND COMMUNICATION TRAINING

WHY WE CARE: IMPACT OF PATIENT ERROR 98,000 Americans die each year as a result of preventable medical errors* Costs associated with all medical errors is $29 billion annually* “NATIONAL PROBLEM OF EPIDEMIC PROPORTIONS”** * To Err Is Human: Building a Safer Health System ** Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact

To Err Is Human Institute of Medicine 1999 Medical errors hurt people Medical errors cost billions Medical errors erode trust Medical errors reduce satisfaction of patients and healthcare providers This IOM report found that most errors are related to faulty systems, processes and conditions that lead people to either make mistakes or fail to prevent them. Medical errors affect almost 100,000 people per year and cost between 17 and 29 billion dollars. The most common team related deficiencies are failure to effectively communicate and failure to effectively cross monitor.

WHY DO ERRORS HAPPEN? DISTRACTION FATIGUE POOR COMMUNICATION/MULTIPLE HIERARCHY The same factors found to cause errors in the aviation industry translate to medicine – fatigue from working long hours can result in loss of vigilance, frequent interruptions and distractions shift focus away from critical details, inadequate communication and poor handoffs can lead to loss of vital information, and established hierarchy may make less experienced personnel less likely to speak up when they notice a mistake. All team training approaches focus on communication strategies, resource allocation, flattening of hierarchies, and managing the work environment to remove causes of error. POOR COMMUNICATION/MULTIPLE HANDOFFS

WHY DO ERRORS HAPPEN? In 2004, a Sentinel Alert issued by JACHO revealed that most cases of perinatal death and injury are caused by problems with an organization’s culture and communication failures between providers.

Joint Commission Sentinel Alert 2004 Recommendation “Conduct team training in perinatal areas to teach staff to work together and communicate more effectively” “…conduct clinical drills …. and conduct debriefings to evaluate team performance and identify areas for improvement.” JACHO, like many other organizations, has made recommendations regarding the need for development specifically of obstetric patient safety programs.

VALIDATION OF TEAM TRAINING/SIMULATION Reduction in clinical errors (31%  4%) Improved clinical management decisions with simulation drills Hospital or unit based training/simulation is just as effective as Simulation Center Process Improvements “decision to incision” time reduced by twelve minutes (33 mins  21mins) Early studies of the impact of team training in several Emergency Departments (military/academic centers) revealed a very large decline in numbers of observed clinical errors. Several studies from the UK demonstrated improved clinical management skills (both in terms of the quality of decision making, as well as the timeliness of decision making) when residents and midwives underwent simulation training for a series of obstetric emergencies. They also found that in hospital or unit based training is as effective as that obtained through a specialized Simulation Center. I think this is a really important point – for departments like ours performing our drills and team training in house is more cost effective and efficient, and most importantly it allows us to practice communication and skills with those team members with whom we work on a daily basis. By performing these drills on our unit and in our hospital we are much more likely to identify systems errors and opportunities for improvement. (Example of PCAs running to the blood bank) Studies have also been able to measure statistically significant improvements in team work behavior, staff attitudes toward team work and staff assessments of institutional support.

Teamwork behaviors can be transferred to clinical environments Decreased frequency and severity of adverse events Fewer malpractice claims Improved staff scores on patient safety attitude questionnaires In 2007, BIDMC reported on their success with implementing Med Teams on their OB unit. They gradually integrated training of approximately 220 staff, assigned coaches to reinforce team behaviors, and used public praise to reinforce good teamwork behaviors. They compared their Adverse Outcomes Index for the three years prior to implementation of team training, to data from 2003 – 2006, the four years after implementation was complete. For the study time period, there were 19,000+ deliveries and a 23% decrease in adverse events. They also noted a significant decline in the severity of events – using a Weighted Adverse Outcomes Score there was a 33% decrease and using the Severity Index, a 13% decline in severity of adverse events.

CRICO OB Patient Safety Program Launched in 2003 Team Training Simulation Drills Online Courses on fetal monitoring and shoulder dystocia OB Practice Guidelines Test CRICO (which is the malpractice provider for the Harvard affiliated institutions) launched its Obstetric Patient Safety Program in 2003 after reviewing 10 years of closed obstetric malpractice cases, in which they found that over 40% of these claims the issues leading to the events related to poor team work and communication failures. They offered a 10% reduction in premium cost to its members who agreed to participate in a program of patient safety training. This training includes a fairly extensive (4 hr) initial team training, with yearly refreshers, participation in simulation drills covering a variety of low frequency but high acuity emergencies. It also requires online courses on management of fetal heart rate tracings and shoulder dystocia. Members also must complete a written test on OB practice guidelines on a yearly basis. In the 4 years after initiation of the team training programs, across the Harvard institutions, there was a decrease in both the numbers of OB claims (53 to 31) and the severity of events. With that, the costs dropped from 62.6 million dollars to 44.7 million.

TEAM CONCEPTS APPLIED TO HEALTHCARE In the Labor and Delivery setting, every delivery is, by necessity, a multidisciplinary event involving nursing, obstetrics (OB/CNM), anesthesiology, pediatrics, and unit support staff (scrub tech/unit coordinator). “Individual competence in clinical skills is not enough; team coordination, communication, and cooperative skills are essential to effective and safe performance.”

WHAT ARE TEAMS AND WHY HAVE THEM? A team is two or more people who achieve a mutual goal through interdependent and adaptive actions Effective teams are more likely to notice mistakes early and address them before they lead to harmful outcomes.

TYPES OF TEAMS Core Team – direct patient care Coordinating Team – Charge Nurse and Coordinating Physician Support Team – those providing temporary resources (PP staff, Nursing Supervisor) Administrative Team – OB Admin on call; Nursing Leadership Contingency Team – help in emergencies (OB Stat, OB Hemorrhage) Administrative Staff Team Support Staff Coordinating Team Core Team Contingency Team

ESSENTIAL ELEMENTS OF TEAMS Common purpose and shared goals Interdependent actions Accountability Collective effort Teamwork is a safety net that catches errors before they can do harm Teams have to have certain essential elements.

COMMON PURPOSE AND SHARED GOALS “Situational Awareness” – each individual must communicate and share information and observations with other members of the team “Shared Mental Models” – the shared understanding or knowledge about a situation among team members Achieved through team meetings – active participation is the EXPECTATION

TEAM MEETINGS Held at 8AM & 8PM Called anytime, by anyone for concerns about clinical developments, management plans or conflict resolution Used for resource management and planning Team meetings are routine, scheduled at pre-determined times of day or situational as needs of the unit change. They are multidisciplinary, including Nursing, OB Providers (MD/CNM), Anesthesia, Pediatrics – and non hierarchical. We discuss patient situations and care plans, anticipated problems, resource management and workload distribution.

Assure Shared Mental Model TEAM MEETINGS Assure Shared Mental Model Mutual Respect Share Information Ask Questions Assess Plan Twice daily, every day Interdisciplinary Nonhierarchical Resource Management Educational Team meetings are the primary tool we use for communication and should be held at regular intervals during the day – how frequently depends on the busyness of the unit and level of acuity of the patients on the unit. Team meetings should be called by any one, at any time, if there is a general sense of not being aware of the situation on the unit, questions regarding patient care plans, strip interpretations, resource management/staffing concerns, etc.

INTERDEPENDENT ACTIONS All members of the team must look out for one another to ensure the best care is provided and that patient safety is achieved Accomplished through mutual support and good communication Cross monitoring SBAR Check backs Call outs

COMMUNICATION TOOLS Cross Monitoring – active awareness of the actions of other team members for the purpose of sharing workload and error prevention This can only occur in a climate where it is expected that assistance will be actively offered, accepted and sought as a method of avoiding mistakes.

COMMUNICATION TOOLS SBAR – a standardized method for presentation of patient information Describe the Situation Provide the Background Make an Assessment Communicate your Recommendations For communication to be effective it needs to be complete, clear, brief, and timely

COMMUNICATION TOOLS Closed Loop Communication Check Backs: repeating back information that was given for example verbally repeating medication dose and route when a verbal order is given Confirming an action has been completed (“Pedi is on their way.”) Call Outs: verbalizing information that is important to the team, especially during emergencies “It’s been 2 minutes” during a shoulder dystocia

ACCOUNTABILITY AND COLLECTIVE EFFORT Advocacy and Assertion – all team members are encouraged and expected to voice concerns and assure their questions are adequately addressed Suggest alternatives Review consequences of each option Obtain consensus Always be respectful

ACCOUNTABILITY AND COLLECTIVE EFFORT Low Moderate Very High High Mod Workload Performance COMFORT ZONE WORK OVERLOAD BOREDOM Patient Risk Zone To help manage resources and mitigate risk teams need to: Voluntarily adjust workload and set priorities Allocate resources on the basis of acuity, volume and team member skills Equitably distribute the workload Appropriately utilize resources within the team, the department, and outside the department

COLLECTIVE EFFORT Debriefing allows for evaluation of the effectiveness of the team following an “event”. Facilitated reflection has been shown to be a critical element for improving future performance of individuals and teams. Allows identification of systems issues and opportunities for improvement The area of MedTeams that we have been less effective and less structured with has been carrying out debriefings after and event. Studies on effective strategies for teaching adults suggest that active participation increases learning effectiveness and use of experiential learning is key to modifying behaviors. Part of learning through experience is reflection. Debriefing is just guided or facilitated reflection – has been shown to be a critical element for improving future performance of individuals and teams.

Components of Debriefing Timely Leader/Facilitator Sets the tone Fosters dialogue Follows a consistent format Includes those involved in the event Identifies opportunities for improvement Acknowledges good actions/behaviors Follow up plan Feedback to participants

Sample Team Debriefing Form

BENEFITS OF TEAM TRAINING Reduce clinical errors Improve maternal and neonatal outcomes Improve process measures Increase patient satisfaction Improve staff satisfaction Reduce malpractice claims Over the past 8 – 10 years there is a developing body of evidence that has been published in both Quality and Safety Journals and our specialty peer review publications, highlighting the positive impact team training and safety initiatives are having – not only on the care we provide our patients, but also on the attitudes of healthcare workers and the satisfaction of our patients. Generally specific process measures and eliminating specific types of clinical errors are the first of these goals to be achieved and are the easiest to track and report on. Behavioral changes that result in culture change of a unit or department are more gradual and a little less objective, and so are more difficult to demonstrate. Although, as the next slides will show can be done but most have discovered that to find a statistically significant positive change in these satisfaction measures, it takes several years. Luckily, really devastating maternal and neonatal outcomes are rare (no matter how we are managing our units), and so it takes much longer study time periods to prove the impact of team work.

“The nice thing about teamwork is you always have others on your side”