Health Quality Improvement using Instructional Communication and Teamwork Videos: An Outcome Study Neil Cowie

This Session is sponsored by:

Health Quality Improvement using Instructional Communication and

Teamwork Videos:

An Outcome Study Pilot Neil Cowie Department of Anesthesiology, University of Saskatchewan

April 11, 2013

Team Members

Angela Bowen, College of Nursing, University of Saskatchewan

Kalyani Premkumar, Department of Community Health and Epidemiology

College of Medicine, University of Saskatchewan

Susan Kuling, Previous Nurse Manager, Labour and Birth Unit, Saskatoon Health Region

Mark Burbridge, Department of Anesthesia, College of Medicine, University of Saskatchewan

Jocelyne Martel, Obstetrican, Saskatoon Health Region

Problem

• “Near misses” in patient care• Lapses in interprofessional communication

and teamwork• Urgent induction of General Anesthesia for

STAT Cesarean Birth

Legal SettlementsCerebral palsy lawsuit settles for $3.8 million

Brain damage in newborn settlement is $3.5 million

Birth injuries leave twin with cerebral palsy: $2.8 Million Settlement

$5.65 million settlement for Rhode Island baby's brain damage related to birth trauma

Delay in c-section resulting in brain damage settlement is $3 million

Settlement for newborn's brain damage is $4 million

• 70% of sentinel events in obstetric practice are attributable to errors in communication and teamwork The Joint Commission

Medical Simulation

http://www.medicine.usask.ca/acutecareteamwork/intro/index.php

Goals of Study• Make a movie of a simulated OB event• Use web-based “Trigger Videos” to teach skills in

communication and teamwork to Obstetrical Nurses

• Measure outcome• Continuing professional development for self-

directed learning on the web

Study Design

Video ClipsDebriefing

Competencies

Q

QQ

Nov, 2010

April, 2011

Feb, 2012

Competencies

• Situational Awareness• SBARR• Closed Loop Communication• Leadership• Shared Mental Model• Overcoming Hierarchy• Mutual Support• Conflict Resolution• Avoiding Distraction

Findings

• Improved technical knowledge• More critical of the team (anesthesia) after

the educational intervention• Ten months later, had applied many of the

team competencies into personal practice– Speak up– Assertiveness– Conflict resolution

Presentations

• Board of RUH Foundation• Simulation in Healthcare• São Paulo• POGO for Nurses• Women's Health, Obstetric, and Neonatal Nurses

Conference• Canadian Anesthetists Society• MedEdPortal• Senior leadership SHR• IHI Summit, Washington DC

What did we find out?

• Unable to publish study• Unbelievable turnover of nursing staff• Fixed and decreasing numbers of nursing

education days• Self directed training video has not been

offered to nursing staff

QUALITY IMPROVEMENT

Project Failure

• Project will fail if dependent on the actions of another team

• Project will fail if multiple groups must change Behavior and culture change is slow

• If management doesn’t support, things will not change

Future

Questions

MoreOB

QuestionnaireNon-Technical Skills

Questionnaire: Technical Skills

– Application of monitors– Assistance with securing airway for intubation– How to assist if intubation fails

CPSI Safety Competencies

7 Deadly Sins of Quality Improvement

• Narrow focus• Assuming change in behavior of staff• Process decisions made by administrators• Too many active projects at one time• Lack of focus• Decisions made on satisfaction scores rather

than outcomes• Erroneously assume leadership supports

changes

Items Reflecting Behavior of the Team

Items Reflecting Behavior of the Team