1. Modeling Risk and Reducing Liability through Better Communication and Teamwork David P. Baker, PhD IMPAQ International, LLC

2. Overview Preparing for Demonstration Grant (R21) Research Team – David P. Baker, PhD (Principal Investigator) – Patrice Weiss, MD (Co-Investigator) – Laurie Spotswood, MSEd, CLS (Research Specialist) – Tony Slonim, MD, DPH (Co-Investigator)

3. Background Relations between lawsuits, payouts, and negligence is muddy at best The Harvard Malpractice Study – Reviewed 30,000 hospital records – Found the incidence of malpractice was much larger than the incidence of claims Ineffective communication between patients/families and clinicians yield lawsuits Patients/families are viewed as critical members of the care team – TeamSTEPPS® introduced by AHRQ for clinician teamwork – Little work on how to include/train patients/families

4. Study Aims Aim 1: To identify clinical events that are highly dependent on provider teamwork, require patient/ families to be effective members of the team, and vary in terms of risk and liability. Aim 2: To identify the root causes of these events, including where critical teamwork breakdowns occur. Aim 3: To conduct a series of focus groups to ascertain how patient/family and provider communication should occur to mitigate risk and reduce liability and to identify TeamSTEPPS tools that could be used to enable patients/families to be more effective members of the care team. Aim 4: To develop and pilot test a TeamSTEPPS intervention(s) that teaches patients/families how to be members of the care team and enhances communication between patients/families and providers.

5. Aim 1 Goal – Identify and select events that require teamwork and vary in terms of risk and liability in Labor and Delivery (L&D) Approach – Reviewed RAND (2008) report and identified candidate events that require teamwork – Identified 18 candidate events in L&D – Surveyed 10 clinical experts Degree of Risk Likelihood of Liability Requirement for Teamwork

6. Aim 1 Results HighLow High Shoulder Dystocia Birth Trauma – Injury to Neonate – Vaginal Birth Post-Partum Hemorrhage Low Maternal Death Intra-partum Fetal Death Uterine Rupture Unplanned Admission to ICU (Mother or Baby) Unplanned Return to LD or OR Liability Risk

7. Aim 2 Goal – Identify the root causes of these events, including where critical teamwork breakdowns occur Root causes included: (1) risk factors; (2) individual, team, & systems factors; (3) clinical team members; and (4) patient and family responsibilities Divided L&D into six phases: (1) pre-hospital; (2) triage/ assessment; (3) monitoring/laboring; (4) delivery; (5) post-partum L&D; and (6) post-partum mother baby unit. Approach – Two phases of key informant interviews with clinical staff Phase I – Identify events (12 interviews) Phase II – Validate events (11 interviews) – Identified common root causes across all four events (identified during Aim 1)

8. Aim 2 Results Common Failures Triage/Assessment Clinician does not sufficiently educate patient/family about risks. Clinicians do not collect adequate information on patient's history. Patient/family does not provide adequate/honest information on patient's history. Clinician does not properly record patient's history. Clinicians do not understand patient or patient's family due to a language barrier. Clinician does not conduct an interview with patient privately to identify any important factors patient does not wish to be shared with other family members/father.

9. Aim 2 Results Common Patient and Family Responsibilities Triage/Assessment Provide accurate patient history by describing any past problems. Patient/family should ask questions about the plan of care. Patient/family should voice any concerns about the plan of care. Patient/family can cooperate with clinician requests. Ensures patient is compliant with her prescribed plan of care. Patient/family can be aware of and follow hospital rules.

10. Aim 3 Goal – Collect information from patients and family members in order to: Verify patient and family responsibilities Identify the root causes per event that patients would want disclosed and clinical staff would feel should be disclosed Identify TeamSTEPPS tools and strategies patients would find useful Approach – Four patient and family focus groups; one per L&D event Verified the patient and family responsibilities clinicians identified Facilitated discussion about what patients and families want clinicians to disclose Conducted disclosure survey of patients and providers focused on the different events Reviewed and discussed TeamSTEPPS tools – 47 patient and family members; 13 clinicians

11. Aim 3 Results Patient Mean Disclosure Ratings PhaseFailure Unplanned Return Shoulder Dystocia Post- partum Hem. Intra- partum Fetal Death Triage/Assessment Clinicians do not assess if mother is compliant with expectations for prenatal care 3.23.413.223.3 Triage/Assessment Mother's information is documented in different places (i.e., paper and electronic) 3.94.184.333.7 Triage/Assessment Physician and nursing documentation procedures differ 3.23.533.782.7 Triage/Assessment Clinician does not verbally communicate plan of care to nursing (not just electronically) 3.12.242.112.4 Triage/Assessment Prenatal records are not available or missing 2.61.351.562.2

12. Aim 3 Results Clinician Mean Disclosure Ratings PhaseDescription Unplanned Return Shoulder Dystocia Post- partum Hem. Intra- partum Fetal Death Triage/ Assessment Clinicians do not assess if mother is compliant with expectations for prenatal care 2.74 55 Triage/ Assessment Mother's information is documented in different places (i.e., paper and electronic) 2.71.673.672.33 Triage/ Assessment Physician and nursing documentation procedures differ 3 4.33 1.673 Triage/ Assessment Clinician does not verbally communicate plan of care to nursing (not just electronically) 3.7 3.672.33 Triage/ Assessment Prenatal records are not available or missing 31.332.33

13. Aim 3 Results Correlations between Clinician and Patient Disclosure Ratings Phase Unplanned Return to L&D Shoulder Dystocia Post-partum Hem. Intra-partum Fetal Death Pre-Hospital0.21-0.080.890.62 Triage/Assessment-0.370.280.300.37 Monitoring/Laboring0.80-0.080.550.30 Delivery0.710.860.280.96 Post-partum L&D0.650.390.740.12 Across All Phases0.700.190.570.48

14. Aim 4 Goal – To develop and pilot test a TeamSTEPPS intervention(s) that teaches patients/families how to be members of the care team and enhances communication between patients/families and providers Approach – Developed a 45-minute, patient and family oriented TeamSTEPPS module for L&D – 28 participants – Collected pre-post data on participant reactions and learning Reactions: instrumentality and affective Learning: attitudes (T-TAQ) and knowledge (Learning Benchmarks)

15. TeamSTEPPS Training Objectives Describe how the patient and family fits into the clinical team Describe the patient and family responsibilities as team members Describe the clinical team member roles and responsibilities Describe the core components of team leadership, assertion, and communication Describe TeamSTEPPS tools that can be used by patients –Briefs, Huddles and Debriefs –Assertive Statement and Two-Challenge Rule –SBAR and Check Back

16. Aim 4 - Results Reactions – Overall mean rating was 4.18, on a 5-point scale “This training would be appropriate for patients in all care settings” “This training should be offered by …. in the future” Learning – Attitudes Pre-training Mean (4.51) Post-training Mean (4.55) – Learning Pre-training Mean (10.86 items correct) Post-training Mean (12.28 items correct)

17. Conclusions Clinicians generally showed high agreement when assessing the degree of risk, liability, and teamwork associated with specific clinical events in L&D Regardless how events varied in terms of risk and liability, the individual, team, and system failures were generally common across events Patients/family members were found to agree about which failures were important to disclose, and type of adverse event did not affect these results Clinicians on the other hand showed far more variability regarding what should be disclosed, and these results did appear to be affected by adverse event type Patients/families like TeamSTEPPS, intended to use the tools taught, would recommend the training to others, and showed gains in knowledge

18. Next Steps Negotiating with an implementation site Examine transfer of the trained skills Determine if there is a relation to clinical outcomes