Peter D. Mills

Association between implementation of a medical team training program and surgical mortality.

CONTEXT There is insufficient information about the effectiveness of medical team training on surgical outcomes. The Veterans Health Administration (VHA) implemented a formalized medical team training program for operating room personnel on a national level. OBJECTIVE To determine whether an association existed between the VHA Medical Team Training program and surgical outcomes. DESIGN, SETTING, AND PARTICIPANTS A retrospective health services study with a contemporaneous control group was conducted. Outcome data were obtained from the VHA Surgical Quality Improvement Program (VASQIP) and from structured interviews in fiscal years 2006 to 2008. The analysis included 182,409 sampled procedures from 108 VHA facilities that provided care to veterans. The VHAs nationwide training program required briefings and debriefings in the operating room and included checklists as an integral part of this process. The training included 2 months of preparation, a 1-day conference, and 1 year of quarterly coaching interviews MAIN OUTCOME MEASURE The rate of change in the mortality rate 1 year after facilities enrolled in the training program compared with the year before and with nontraining sites. RESULTS The 74 facilities in the training program experienced an 18% reduction in annual mortality (rate ratio [RR], 0.82; 95% confidence interval [CI], 0.76-0.91; P = .01) compared with a 7% decrease among the 34 facilities that had not yet undergone training (RR, 0.93; 95% CI, 0.80-1.06; P = .59). The risk-adjusted mortality rates at baseline were 17 per 1000 procedures per year for the trained facilities and 15 per 1000 procedures per year for the nontrained facilities. At the end of the study, the rates were 14 per 1000 procedures per year for both groups. Propensity matching of the trained and nontrained groups demonstrated that the decline in the risk-adjusted surgical mortality rate was about 50% greater in the training group (RR,1.49; 95% CI, 1.10-2.07; P = .01) than in the nontraining group. A dose-response relationship for additional quarters of the training program was also demonstrated: for every quarter of the training program, a reduction of 0.5 deaths per 1000 procedures occurred (95% CI, 0.2-1.0; P = .001). CONCLUSION Participation in the VHA Medical Team Training program was associated with lower surgical mortality.

The SQUIRE (Standards for QUality Improvement Reporting Excellence) guidelines for quality improvement reporting: explanation and elaboration

As the science of quality improvement in health care advances, the importance of sharing its accomplishments through the published literature increases. Current reporting of improvement work in health care varies widely in both content and quality. It is against this backdrop that a group of stakeholders from a variety of disciplines has created the Standards for QUality Improvement Reporting Excellence, which we refer to as the SQUIRE publication guidelines or SQUIRE statement. The SQUIRE statement consists of a checklist of 19 items that authors need to consider when writing articles that describe formal studies of quality improvement. Most of the items in the checklist are common to all scientific reporting, but virtually all of them have been modified to reflect the unique nature of medical improvement work. This “Explanation and Elaboration” document (E & E) is a companion to the SQUIRE statement. For each item in the SQUIRE guidelines the E & E document provides one or two examples from the published improvement literature, followed by an analysis of the ways in which the example expresses the intent of the guideline item. As with the E & E documents created to accompany other biomedical publication guidelines, the purpose of the SQUIRE E & E document is to assist authors along the path from completion of a quality improvement project to its publication. The SQUIRE statement itself, this E & E document, and additional information about reporting improvement work can be found at http://www.squire-statement.org.

Differences in Nurse and Surgeon Perceptions of Teamwork: Implications for Use of a Briefing Checklist in the OR

The quality of teamwork among health care professionals is known to affect patient outcomes. In the OR, surgeons report more favorable perceptions of communication during procedures and of teamwork effectiveness than do nurses. We undertook a quality improvement project in the Veterans Health Administration to confirm reported teamwork differences between perioperative nurses and surgeons and to examine the implications of these differences for improving practice patterns in the OR. The Safety Attitudes Questionnaire, which measures safety culture, including the quality of communication and collaboration among health care providers who routinely work together, was administered in 34 hospitals. Perioperative nurses who participated in the survey rated teamwork higher with other nurses than with surgeons, but surgeons rated teamwork high with each other and with nurses. On five of six communication and collaboration items, surgeons had a significantly more favorable perception than did perioperative nurses. To increase the likelihood of success when implementing the use of checklist-based crew resource management tools, such as the World Health Organizations Surgical Safety Checklist, project leaders should anticipate differences in perception between members of the different professions that must be overcome if teamwork is to be improved.

Predictors of successful implementation of preoperative briefings and postoperative debriefings after medical team training

BACKGROUND The purpose of this study was to examine which factors at a medical team training learning session predict future success in the implementation of preoperative briefings and postoperative debriefings at health care facilities. METHODS A Likert score rating for physician involvement, leadership support, and composition of the implementation team was recorded for 64 VHA facilities at the time of a learning session by 3 medical team training educators. At a mean follow-up period of 8.2 months (standard error, .4 mo), a briefing score was established from quarterly semistructured interviews with the facilitys implementation team. RESULTS In a multivariable regression, leadership involvement at the time of the learning session was the best predictor of future briefing/debriefing success (R = .34, P = .03). CONCLUSIONS Full implementation of the patient safety tool preoperative briefings and postoperative debriefings is dependent on facility leadership support.

Briefing guide study: preoperative briefing and postoperative debriefing checklists in the Veterans Health Administration medical team training program

BACKGROUND The purpose of this study was to examine the outcomes of checklist-driven preoperative briefings and postoperative debriefings during the Veterans Health Administration (VHA) medical team training program. METHODS A briefing score (1, never started; 2, started then discontinued; 3, maintained on original targeted cases; 4, expanded to other services; 5, briefing all cases, all services) was established at 10.1 ± .3 months after introduction of the checklist. Outcomes included antibiotic and deep venous thrombosis prophylaxis compliance rates before and after use of the checklist. RESULTS Antibiotic (97.0% ± .1% vs 92.1% ± 1.5%; P = .01) and deep venous thrombosis (95.7% ± .8% vs 85.1% ± 4.6%; P = .05) prophylaxis compliance rates were higher after initiation of a surgical checklist. CONCLUSIONS Checklist-driven preoperative briefings and postoperative debriefings are associated with improvements in patient safety for surgical patients.

Incorrect Surgical Procedures Within and Outside of the Operating Room: A Follow-up Report

OBJECTIVE To describe incorrect surgical procedures reported from mid-2006 to 2009 from Veterans Health Administration medical centers and build on previously reported events from 2001 to mid-2006. DESIGN Retrospective database review. SETTING Veterans Health Administration medical centers. INTERVENTIONS The Veterans Health Administration implemented Medical Team Training and continues to support their directive for ensuring correct surgery to improve surgical patient safety. MAIN OUTCOME MEASURES The categories were incorrect procedure types (wrong patient, side, site, procedure, or implant), major or minor surgery, in or out of the operating room (OR), adverse event or close call, specialty, and harm. RESULTS Our review produced 237 reports (101 adverse events, 136 close calls) and found decreased harm compared with the previous report. The rate of reported adverse events decreased from 3.21 to 2.4 per month (P = .02). Reported close calls increased from 1.97 to 3.24 per month (P ≤ .001). Adverse events were evenly split between OR (50) and non-OR (51). When in-OR events were examined as a rate, Neurosurgery had 1.56 and Ophthalmology had 1.06 reported adverse events per 10 000 cases. The most common root cause for adverse events was a lack of standardization of clinical processes (18%). CONCLUSIONS The rate of reported adverse events and harm decreased, while reported close calls increased. Despite improvements, we aim to achieve further gains. Current plans and actions include sharing lessons learned from root cause analyses, policy changes based on root cause analysis review, and additional focused Medical Team Training as needed.

Effective interventions and implementation strategies to reduce adverse drug events in the Veterans Affairs (VA) system

Background: Adverse drug events (ADEs) account for considerable patient morbidity and mortality as well as legal, operational and patient care costs. In Veterans Affairs (VA) hospitals in the USA, all serious adverse events and “potential” adverse events are reviewed using root cause analysis (RCA). This study characterised RCA reports associated with ADEs to determine what actions VA RCA teams took to reduce the number or severity of ADEs, and to evaluate which actions were effective in doing so. Methods: Every medication-related RCA submitted to the VA National Center for Patient Safety in the fiscal year 2004 (143 reports), and one medication-related aggregated RCA from each facility (111 reports covering 4834 ADEs) were reviewed and coded. Facilities were interviewed about specifics of their reports and the results of their interventions. Results: The commonest classes of medication for which ADEs were reported were narcotics, chemotherapy, and diabetic and cardiovascular medications. The most common types of ADE were “wrong dose”, “wrong medication”, “failed to give medication”, and “wrong patient”. 993 actions were taken to address these ADEs, the majority (75.7%) of which were reported to be fully implemented. Improvements in equipment and improving clinical care at the bedside were associated with reports of improved outcomes (p = 0.018, and p = 0.017 respectively), and training and education were negatively correlated with reports of improved outcome (p = 0.005). Improving the process of medication order entry through the use of alerts or forcing functions was positively correlated with reports of improved outcomes (p = 0.022). Leadership support and involving staff were associated with higher implementation rates (p = 0.001 and p = 0.010, respectively). Conclusions: Changes at the bedside and improvement in equipment and computers are effective at reducing ADEs. Well-organised tracking and support from leadership and staff were characteristics of facilities successful at improving outcomes. Training without action was associated with worse outcomes.

Developing and Sustaining Quality Improvement Partnerships in the VA: The Colorectal Cancer Care Collaborative

ObjectiveThe Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI) seeks to develop partnerships between VA health services researchers and clinical managers, with the goal of designing and evaluating interventions to improve the quality of VA health care.MethodsIn the present report we describe one such initiative aimed at enhancing the continuum of colorectal cancer (CRC) care, including diagnosis, treatment and surveillance–the Colorectal Cancer Care Collaborative (C4).ResultsWe describe the process and thinking that led to two parallel quality improvement “collaboratives” that addressed (1) CRC screening and diagnostic follow-up and (2) the guideline concordance and timeliness of CRC treatment. Additionally, we discuss ongoing effort to spread lessons learned during the first stages of the project, which initially occurred at only a subset of VA facilities, throughout the VA health care system. The description of this initiative is organized around key questions that must be answered when developing, sustaining and spreading multi-component quality improvement interventions.ConclusionWe conclude with a discussion of lessons learned that we believe would apply to similar initiatives elsewhere, even if they address different clinical issues in health care settings with different organizational structures.

Using aggregate root cause analysis to improve patient safety.

The authors describe use of aggregate root cause analysis, which provides a systematic process for analyzing high-priority, frequent events.

Medical team training and coaching in the veterans health administration; assessment and impact on the first 32 facilities in the programme

Background Communication is problematic in healthcare. The Veterans Health Administration is implementing Medical Team Training. The authors describe results of the first 32 of 130 sites to undergo the programme. This report is unique; it provides aggregate results of a crew resource-management programme for numerous facilities. Methods Facilities were taught medical team training and implemented briefings, debriefings and other projects. The authors coached teams through consultative phone interviews over a year. Implementation teams self-reported implementation and rated programme impact: 1=‘no impact’ and 5=‘significant impact.’ We used logistic regression to examine implementation of briefing/debriefing. Results Ninety-seven per cent of facilities implemented briefings and debriefings, and all implemented an additional project. As of the final interview, 73% of OR and 67% of ICU implementation teams self-reported and rated staff impact 4–5. Eighty-six per cent of OR and 82% of ICU implementation teams self-reported and rated patient impact 4–5. Improved teamwork was reported by 84% of OR and 75% of ICU implementation teams. Efficiency improvements were reported by 94% of OR implementation teams. Almost all facilities (97%) reported a success story or avoiding an undesirable event. Sites with lower volume were more likely to conduct briefings/debriefings in all cases for all surgical services (p=0.03). Conclusions Sites are implementing the programme with a positive impact on patients and staff, and improving teamwork, efficiency and safety. A unique feature of the programme is that implementation was facilitated through follow-up support. This may have contributed to the early success of the programme.