1. TEAMWORK AND COMMUNICATION TRAINING

2. 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

3. 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.

4. 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

5. 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.

6. 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.

7. 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.

8. 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.

9. 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.

10. 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.”

11. 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.

12. 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

13. 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.

14. 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

15. 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.

16. 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.

17. 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

18. 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.

19. 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

20. 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

21. 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

22. 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

23. 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.

24. 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

25. Sample Team Debriefing Form

26. 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.

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