Stanley Davis

Didactic and simulation nontechnical skills team training to improve perinatal patient outcomes in a community hospital.

BACKGROUND Birth trauma is a low-frequency, high-severity event, making obstetrics a major challenge for patient safety. Yet, few strategies have been shown to eliminate preventable perinatal harm. Interdisciplinary team training was prospectively evaluated to assess the relative impact of two different learning modalities to improve nontechnical skills (NTS)--the cognitive and interpersonal skills, such as communication and teamwork, that supplement clinical and technical skills and are necessary to ensure safe patient care. METHODS Between 2005 and 2008, perinatal morbidity and mortality data were prospectively collected using the Weighted Adverse Outcomes Score (WAOS) and a culture of safety survey (Safety Attitudes Questionnaire) at three small-sized community hospitals. In a small cluster randomized clinical trial conducted in the third quarter of 2007, one of the hospitals served as a control group and two served as the treatment intervention sites--one hospital received the TeamSTEPPS didactic training program and one hospital received both the TeamSTEPPS program along with a series of in-situ simulation training exercises. RESULTS A statistically significant and persistent improvement of 37% in perinatal morbidity was observed between the pre- and postintervention for the hospital exposed to the simulation program. There were no statistically significant differences in the didactic-only or the control hospitals. Baseline perceptions of culture of safety were high at all three hospitals, and there were no significant changes. CONCLUSIONS A comprehensive interdisciplinary team training program using in-situ simulation can improve perinatal safety in the hospital setting. This is the first evidence providing a clear association between simulation training and improved patient outcomes. Didactics alone were not effective in improving perinatal outcomes.

In situ simulation: a method of experiential learning to promote safety and team behavior.

The healthcare system has an inconsistent record of ensuring patient safety. One of the main factors contributing to this poor record is inadequate interdisciplinary team behavior. This article describes in situ simulation and its 4 components-–briefing, simulation, debriefing, and follow-up—as an effective interdisciplinary team training strategy to improve perinatal safety. The purpose of this manuscript is to describe the experiential nature of in situ simulation for the participants. Involved in a pilot study of 35 simulations in 6 hospitals with over 700 participants called, “In Situ Simulation for Obstetric and Neonatal Emergencies,” conducted by Fairview Health Services in collaboration with the University of Minnesotas Academic Health Center.

Identifying key nursing and team behaviours to achieve high reliability.

AIM The aim of the present study was to measure markers of key nursing behaviours in interdisciplinary teams during critical events to assess the extent of high reliability. BACKGROUND Technical and team competence are necessary to achieve high reliability to ensure safe patient care. Technical competence is generally assured because of professional training, licensure and practice standards. During critical events, team competence is difficult to observe, measure and evaluate in interdisciplinary teams. METHOD During critical events, in situ simulation was the method used to observe interdisciplinary interaction of nursing behaviours regarding communication. Seventeen trials were conducted and videotaped for evaluation at four hospital sites. RESULTS Key nursing behavioural markers for interdisciplinary interaction were described: situational awareness, use of situation, background, assessment, recommendation-response (SBAR-R), closed-loop communication and shared mental model. CONCLUSION Skills necessary for nurses to contribute to highly reliable, interdisciplinary teams are not consistently observed during critical events and constitute breaches in defensive barriers for ensuring patient safety. IMPLICATIONS FOR NURSING MANAGEMENT Nurses have a key role in assuring effective team performance through the transfer of critical information. Nurses need to recognize and identify important clinical and environmental cues, and act in order to ensure that the team progresses along the optimal course for patient safety.

A model for developing high‐reliability teams

AIM To develop a model for high reliability in health care quality and patient safety. BACKGROUND A high-reliability health organization (HRO) has measurable near perfect performance in quality and safety. High reliability is necessary in health care where the consequences of error are high and the frequency is low. KEY ISSUES Despite a decade of intense focus on quality and safety since a series of reports from the Institute of Medicine (IOM), health care is not a completely safe industry and quality is not what it should be to ensure high reliability for patients. CONCLUSIONS A model for high reliability is presented that includes the individual skills necessary to assure high-reliability teams on a patient care unit. High-reliability teams (HRT) form an essential core of a HRO. These teams and their organizations value a culture of safety every day with every patient encounter. IMPLICATIONS FOR NURSING MANAGEMENT Nurse managers can lead in creating a HRO by first developing HRTs on their patient care unit.

A Perinatal Care Quality and Safety Initiative: Are There Financial Rewards for Improved Quality?

BACKGROUND Although costs of providing care may decrease with hospital initiatives to improve obstetric and neonatal outcomes, the accompanying reduced adverse outcomes may negatively affect hospital revenues. METHODS In 2008 a Minnesota-based hospital system (Fairview Health Services) launched the Zero Birth Injury (ZBI) initiative, which used evidence-based care bundles to guide management of obstetric services. A pre-post analysis of financial impacts of ZBI was conducted by using hospital administrative records to measure costs and revenues associated with changes in maternal and neonatal birth injuries before (2008) and after (2009-2011) the initiative. RESULTS For the Fairview Health Services hospitals, after adjusting for relevant covariates, implementation of ZBI was associated with a mean 11% decrease in the rate of maternal and neonatal adverse outcomes between 2008 and 2011 (adjusted odds ratio [AOR] = 0.89, p = .076). As a result of the adverse events avoided, the hospital system saved

Decreasing Malpractice Claims by Reducing Preventable Perinatal Harm.

284,985 in costs but earned

The Nature, Characteristics and Patterns of Perinatal Critical Events Teams

324,333 less revenue, which produced a net financial decrease of

Failure Modes and Effects Analysis Based on In Situ Simulations: A Methodology to Improve Understanding of Risks and Failures

39,348 (or a

Integrated Approach to Reduce Perinatal Adverse Events: Standardized Processes, Interdisciplinary Teamwork Training, and Performance Feedback

305 net financial loss per adverse event avoided) in 2011, compared with 2008. CONCLUSIONS Adoption of a perinatal quality and safety initiative that reduced birth injuries had little net financial impact on the hospital. ZBI produced better clinical results at a lower cost, which represents potential savings for payers, but the hospital system offering improved quality reaped no clear financial rewards. These results highlight the important role for shared-savings collaborations (among patients, providers, government and third-party payers, and employers) to incentivize QI. Widespread adoption of perinatal safety initiatives combined with innovative payment models may contribute to better health at reduced cost.

A Perinatal Care Quality and Safety Initiative: Hospital Costs and Potential Savings

OBJECTIVE To evaluate the association of improved patient safety practices with medical malpractice claims and costs in the perinatal units of acute care hospitals. DATA SOURCES Malpractice and harm data from participating hospitals; litigation records and medical malpractice claims data from American Excess Insurance Exchange, RRG, whose data are managed by Premier Insurance Management Services, Inc. (owned by Premier Inc., a health care improvement company). STUDY DESIGN A quasi-experimental prospective design to compare baseline and postintervention data. Statistical significance tests for differences were performed using chi-square, Wilcoxon signed-rank test, and t-test. DATA COLLECTION Claims data were collected and evaluated by experienced senior claims managers through on-site claim audits to evaluate claim frequency, severity, and financial information. Data were provided to the analyzing institution through confidentiality contracts. PRINCIPAL FINDINGS There is a significant reduction in the number of perinatal malpractice claims paid, losses paid, and indemnity payments (43.9 percent, 77.6 percent, and 84.6 percent, respectively) following interventions to improve perinatal patient safety and reduce perinatal harm. This compares with no significant reductions in the nonperinatal claims in the same hospitals during the same time period. CONCLUSIONS The number of perinatal malpractice claims and dollar amount of claims payments decreased significantly in the participating hospitals, while there was no significant decrease in nonperinatal malpractice claims activity in the same hospitals.