Susan Mann

Effects of teamwork training on adverse outcomes and process of care in labor and delivery: a randomized controlled trial.

OBJECTIVE: To evaluate the effect of teamwork training on the occurrence of adverse outcomes and process of care in labor and delivery. METHODS: A cluster-randomized controlled trial was conducted at seven intervention and eight control hospitals. The intervention was a standardized teamwork training curriculum based on crew resource management that emphasized communication and team structure. The primary outcome was the proportion of deliveries at 20 weeks or more of gestation in which one or more adverse maternal or neonatal outcomes or both occurred (Adverse Outcome Index). Additional outcomes included 11 clinical process measures. RESULTS: A total of 1,307 personnel were trained and 28,536 deliveries analyzed. At baseline, there were no differences in demographic or delivery characteristics between the groups. The mean Adverse Outcome Index prevalence was similar in the control and intervention groups, both at baseline and after implementation of teamwork training (9.4% versus 9.0% and 7.2% versus 8.3%, respectively). The intracluster correlation coefficient was 0.015, with a resultant wide confidence interval for the difference in mean Adverse Outcome Index between groups (–5.6% to 3.2%). One process measure, the time from the decision to perform an immediate cesarean delivery to the incision, differed significantly after team training (33.3 minutes versus 21.2 minutes, P=.03). CONCLUSION: Training, as was conducted and implemented, did not transfer to a detectable impact in this study. The Adverse Outcome Index could be an important tool for comparing obstetric outcomes within and between institutions to help guide quality improvement. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00381056 LEVEL OF EVIDENCE: I

Assessing Quality in Obstetrical Care: Development of Standardized Measures

BACKGROUND No nationally accepted set of quality indicators exists in obstetrics. A set of 10 outcome measures and three quality improvement tools was developed as part of a study evaluating the effects of teamwork on obstetric care in 15 institutions and > 28,000 patients. Each outcome was assigned a severity weighting score. MEASURES Three new obstetrical quality improvement outcome tools were developed. The Adverse Outcome Index (AOI) is the percent of deliveries with one or more adverse events. The average AOI during the pre-implementation data collection period of the teamwork study was 9.2% (range, 5.9%-16.6%). The Weighted Adverse Outcome Score (WAOS) describes the adverse event score per delivery. It is the sum of the points assigned to cases with adverse outcomes divided by the number of deliveries. The average WAOS for the preimplementation period was 3 points (range, 1.0-6.0). The Severity Index (SI) describes the severity of the outcomes. It is the sum of the adverse outcome scores divided by the number of deliveries with an identified adverse outcome. The average SI for the pre-implementation period was 31 points (range, 16-49). DISCUSSION The outcome measures and the AOI, WAOS, and SI can be used to benchmark ongoing care within and among organizations. These tools may be useful nationally for determining quality obstetric care.

Team function in obstetrics to reduce errors and improve outcomes.

Crew resource management (CRM), adapted from aviation for the practice of medicine, offers the potential of reducing medical errors, increasing employee retention, and improving patient satisfaction. CRM, however, requires a culture that promotes teamwork and acceptance of new concepts. Leadership is needed to transform the culture, as well as to train, coach, and sustain the behavior CRM demands. Culture change can be fostered through teamwork activities that, when made part of a daily routine, provides the basis for modeling teamwork skills and sets the stage for sustained culture change. New tools are available to measure processes as well as patient and staff satisfaction.

High performance teamwork training and systems redesign in outpatient oncology

Background Oncology care is delivered largely in ambulatory settings by interdisciplinary teams. Treatments are often complex, extended in time, dispersed geographically and vulnerable to teamwork failures. To address this risk, we developed and piloted a team training initiative in the breast cancer programme at a comprehensive cancer centre. Methods Based on clinic observations, interviews with key staff and analyses of incident reports, we developed interventions to address four high-risk areas: (1) miscommunication of chemotherapy order changes on the day of treatment; (2) missing orders on treatment days without concurrent physician appointments; (3) poor follow-up with team members about active patient issues; and (4) conflict between providers and staff. The project team developed protocols and agreements to address team members’ roles, responsibilities and behaviours. Results Using a train-the-trainer model, 92% of breast cancer staff completed training. The incidence of missing orders for unlinked visits decreased from 30% to 2% (p<0.001). Patient satisfaction scores regarding coordination of care improved from 93 to 97 (p=0.026). Providers, infusion nurses and support staff reported improvement in efficiency (75%, 86%, 90%), quality (82%, 93%, 93%) and safety (92%, 92%, 90%) of care, and more respectful behaviour (92%, 79%, 83%) and improved relationships among team members (91%, 85%, 92%). Although most clinicians reported a decrease in non-communicated changes, there was insufficient statistical power to detect a difference. Conclusions Team training improved communication, task coordination and perceptions of efficiency, quality, safety and interactions among team members as well as patient perception of care coordination.

Team Approach to Care in Labor and Delivery

Changing to a teamwork culture in labor and delivery requires a real commitment. The skills involved can be taught to all healthcare providers. The benefits of a teamwork culture may include improved patient outcomes, less medical errors, and improved patient and staff satisfaction. Malpractice claim reduction may possibly occur through these improved outcomes and better communication with our patients.

Role of clinician involvement in patient safety in obstetrics and gynecology.

Patient safety is a significant concern for healthcare providers. Involving physicians in clinical quality activities in obstetrics and gynecology can be difficult for many reasons including time demands, lack of knowledge of process improvement activities, or change fatigue due to failure of adequate implementation of previous activities. This overview for improving the culture of safety identifies roles physicians can play from participating in quality assessment and improvement activities, improving teamwork between disciplines, communicating effectively, creating departmental guidelines, and deciding on outcome measures for benchmarking. An improved culture of safety is better for our patients and may reduce malpractice exposure.

The Maternal Health Compact

Many pregnant women in the rural United States have access only to low-resourced, low-volume hospitals. Linking such hospitals with tertiary care hospitals through telehealth services, quality-improvement aid, and transport may reduce morbidity and mortality.

Disseminating team training across an academic cancer center and community-based satellites.

188 Background: Dana-Farber Cancer Institute is the first cancer center to implement Team Training (TT). This program illustrates critical lessons about disseminating a quality improvement initiative across an academic center and its regional community-based satellites. METHODS We adapted TT principles to the needs of our satellite centers. This required recognizing different work flows and communication patterns, identifying hazards in routine communications, integrating satellite-main campus communication, and facilitating situational awareness when practicing at multiple sites. Key components included: support from executive leadership and Board of Trustees; previous success at the main campus; use of data and actual near-miss scenarios; development of workflows for critical communications; and workflows for shared care of patients at different sites. RESULTS Staff surveys demonstrated safer, more efficient, and more respectful practice environments. Higher scores were seen across most categories in comparison to main campus. We observed an increase in the number of chemotherapy orders without issues (81.7% to 91.9%) and a decrease in the number of missing (7.0% to 3.4%) or noncommunicated order changes (3.1% to 1.0%) when the patient arrived for treatment pre TT vs. post TT. Patient perception of teamwork, measured by Press-Ganey, showed a statistically significant increase at both the main and satellite campuses. CONCLUSIONS TT improved communication, task coordination, perceptions of efficiency, quality, safety, and patient perception of care coordination, at both the academic main campus and our community-based satellite practices. [Table: see text].

Effects of teamwork training on adverse outcomes and process of care in labor and delivery : A randomized controlled trial

ABSTRACT Reports from the Institute of Medicine propose that team training—and implementing team behaviors—can cut down on medical errors and enhance patient safety. The present investigators tested this idea in the area of obstetrics, a discipline that calls for intensive and error-free vigilance as well as effective communication between numerous disciplines. A cluster-randomized controlled trial was undertaken at 15 US hospitals: at seven a standardized teamwork training curriculum was introduced that focused on free communication and team structure. The remaining eight hospitals made up a control group. The curriculum (MedTeams Labor and Delivery Team Coordination Course) was based on care resource management, which attempts to utilize the ability of each team member to analyze and react to situations in ways that lessen the potential for error. A total of 1307 individuals were trained, and 28,536 deliveries were analyzed. Negative outcomes were quantified using an index outcome measure, the Adverse Outcome Index. The intervention and control groups were similar demographically and obstetrically at the outset. Adverse outcome indices also were comparable, and remained so after teamwork training was implemented. The only process measure that differed significantly after team training was in the interval from deciding to perform an immediate cesarean delivery to making the incision, which decreased from 33 to 21 minutes. There was considerable variability across hospitals in the commonest maternal outcome, a third- or fourth-degree perineal laceration following vaginal delivery, and also in the most prevalent neonatal outcome, unplanned admission to the neonatal intensive care unit. Postimplementation outcome measures did not differ significantly even after controlling for baseline differences. This study failed to show that teamwork training in obstetrical practices had any important clinical impact. Nevertheless, the Adverse Outcome Index might prove helpful when comparing obstetrical outcomes within and between institutions.