William Riley

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.

The United States' potential blood donor pool: estimating the prevalence of donor‐exclusion factors on the pool of potential donors

BACKGROUND: Efforts to ensure donor and recipient safety have reduced the population of eligible voluntary blood donors. The current method for determining eligible blood donors in a population using only age as the criterion for excluding donors poorly reflects the large constellation of factors known to cause donor deferrals. An epidemiologic model has been developed to determine the prevalence of donor exclusions and thus improve the estimate of total eligible blood donors in the nation.

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.

Defining quality improvement in public health.

Many industries commonly use quality improvement (QI) techniques to improve service delivery and process performance. Yet, there has been scarce application of these proven methods to public health settings and the public health field has not developed a set of shared principles or a common definition for quality improvement. This article discusses a definition of quality improvement in public health and describes a continuum of quality improvement applications for public health departments. Quality improvement is a distinct management process and set of tools and techniques that are coordinated to ensure that departments consistently meet the health needs of their communities.

Public Health Department Accreditation Implementation: Transforming Public Health Department Performance

In response to a call for improved quality and consistency in public health departments, the Public Health Accreditation Board (PHAB) is leading a voluntary public health accreditation initiative in the United States. The public health department accreditation system will implement a comprehensive set of standards that set uniform performance expectations for health departments to provide the services necessary to keep communities healthy. Continuous quality improvement is a major component of PHAB accreditation, demonstrating a commitment to empower and encourage public health departments to continuously improve their performance. The accreditation process was tested in 30 health departments around the country in 2009 and 2010, and was launched on a national level in September 2011 at the National Press Club in Washington, DC.

Detecting breaches in defensive barriers using in situ simulation for obstetric emergencies

Background In Reasons safety model, high-reliability healthcare organisations are characterised by multiple layers of defensive barriers in depth associated with increased levels of safety in the care delivery system. However, there is very little empirical evidence describing and defining defensive barriers in healthcare settings or systematic analysis documenting the nature of breaches in these barriers. This study uses in situ simulation to identify defensive barriers and classify the nature of active and latent breaches in these barriers. Methods An in situ simulation methodology was used to study team performance during obstetrics emergencies. The authors conducted 46 trials of in situ simulated obstetrics emergencies in two phases at six different hospitals involving 823 physicians, nurses and support staff from January 2006 to February 2008. These six hospitals included a university teaching hospital, two suburban community hospitals and three rural hospitals. The authors created a high-fidelity simulation by developing scenarios based on actual sentinel events. Results A total of 965 breaches were identified by participants in 46 simulation trials. Of the 965 breaches, 461 (47.8%) were classified as latent conditions, and 494 (51.2%) were classified as active failures. Conclusions In Reasons model, all sentinel events involve a breached protective layer. Understanding how protective layers breakdown is the first step to ensure patient safety and establish a high reliability. These findings suggest where to invest resources to help achieve a high reliability. In situ simulation helps recognise and remedy both active failures and latent conditions before they combine to cause bad outcomes.

Realizing transformational change through quality improvement in public health

OBJECTIVE This article discusses the specific components necessary to achieve transformational change within public health departments as a means for creating sustained performance improvement and better outcomes in the health of the community. DESIGN This article provides a review of transformation change concepts and application to public health departments. RESULTS Transformational change for public health departments must be intentionally designed to achieve high performance. While all improvement requires change, not all change results in improvement. CONCLUSION The successful transformational change effort always occurs from the top-down, while the process improvement occurs from the bottom-up. Transformational change is possible in public health departments when small incremental improvements are linked with large-scale management changes to continually improve public health performance resulting in better population outcomes.

Knowledge, attitudes and practices surveys of blood donation in developing countries

Background and Objectives  Knowledge, attitude and practice (KAP) surveys have been used in many countries to understand factors that influence blood donation and as the basis for communication and donor mobilization strategies.

High reliability and implications for nursing leaders

AIM To review high reliability theory and discuss its implications for the nursing leader. BACKGROUND A high reliability organization (HRO) is considered that which has measurable near perfect performance for quality and safety. EVALUATION The author has reviewed the literature, discussed research findings that contribute to improving reliability in health care organizations, and makes five recommendations for how nursing leaders can create high reliability organizations. KEY ISSUES Health care is not a safe industry and unintended patient harm occurs at epidemic levels. Health care can learn from high reliability theory and practice developed in other high-risk industries. CONCLUSIONS Viewed by HRO standards, unintended patient injury in health care is excessively high and quality is distressingly low. HRO theory and practice can be successfully applied in health care using advanced interdisciplinary teamwork training and deliberate process design techniques. IMPLICATIONS FOR NURSING MANAGEMENT Nursing has a primary leadership function for ensuring patient safety and achieving high quality in health care organizations. Learning HRO theory and methods for achieving high reliability is a foremost opportunity for nursing leaders.