TEAMWORK AND COMMUNICATION TRAINING

WHY WE CARE: IMPACT OF PATIENT ERROR

98,000 Americans die each year as a result of preventable medical errors*

Costs associated with all medical errors is $29 billion annually*

“NATIONAL PROBLEM OF EPIDEMIC PROPORTIONS”**

* To Err Is Human: Building a Safer Health System** Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact

To Err Is Human Institute of Medicine 1999

Medical errors hurt people Medical errors cost billions Medical errors erode trust Medical errors reduce

satisfaction of patients and healthcare providers

FATIGUE DISTRACTION

HIERARCHY

POORCOMMUNICATION/MULTIPLEHANDOFFS

WHY DO ERRORS HAPPEN?

WHY DO ERRORS HAPPEN?

In 2004, a Sentinel Alert issued by JACHO revealed that most cases of perinatal death and injury are caused by problems with an organization’s culture and communication failures between providers.

Joint Commission Sentinel Alert 2004

Recommendation “Conduct team training in perinatal areas to teach staff to work together and communicate more effectively”

“…conduct clinical drills …. and conduct debriefings to evaluate team performance and identify areas for improvement.”

VALIDATION OF TEAM TRAINING/SIMULATION Reduction in clinical errors (31% 4%) Improved clinical management decisions

with simulation drills Hospital or unit based training/simulation

is just as effective as Simulation Center Process Improvements

“decision to incision” time reduced by twelve minutes (33 mins 21mins)

• Teamwork behaviors can be transferred to clinical environments

• Decreased frequency and severity of adverse events

• Fewer malpractice claims

• Improved staff scores on patient safety attitude questionnaires

CRICO OB Patient Safety Program

Launched in 2003 Team Training Simulation Drills Online Courses on

fetal monitoring and shoulder dystocia

OB Practice Guidelines Test 4 yrs

prior 4 yrs after

010203040506070

Numbers of claimsCost ($ million)

TEAM CONCEPTS APPLIED TO HEALTHCARE In the Labor and Delivery setting, every delivery is, by necessity, a multidisciplinary event involving nursing, obstetrics (OB/CNM), anesthesiology, pediatrics, and unit support staff (scrub tech/unit coordinator). “Individual competence in clinical skills is not enough; team coordination, communication, and cooperative skills are essential to effective and safe performance.”

WHAT ARE TEAMS AND WHY HAVE THEM? A team is two or more people who achieve a

mutual goal through interdependent and adaptive actions

Effective teams are more likely to notice mistakes early and address them before they lead to harmful outcomes.

TYPES OF TEAMS Core Team – direct patient

care Coordinating Team –

Charge Nurse and Coordinating Physician

Support Team – those providing temporary resources (PP staff, Nursing Supervisor)

Administrative Team – OB Admin on call; Nursing Leadership

Contingency Team – help in emergencies (OB Stat, OB Hemorrhage)

Contingency

Team

ESSENTIAL ELEMENTS OF TEAMS

Common purpose and shared goals

Interdependent actions

Accountability

Collective effortTeamwork is a safety net that catches errors

before they can do harm

COMMON PURPOSE AND SHARED GOALS “Situational Awareness” – each

individual must communicate and share information and observations with other members of the team

“Shared Mental Models” – the shared understanding or knowledge about a situation among team members

Achieved through team meetings – active participation is the EXPECTATION

TEAM MEETINGS

Held at 8AM & 8PM

Called anytime, by anyone for concerns aboutclinical developments, management plans or conflict resolution

Used for resource management and planning

TEAM MEETINGS

Assure Shared Mental Model

Mutual Respect

Share Information

Ask Questions

Assess Plan

• Twice daily, every day• Interdisciplinary• Nonhierarchical• Resource Management• Educational

INTERDEPENDENT ACTIONS

All members of the team must look out for one another to ensure the best care is provided and that patient safety is achieved

Accomplished through mutual support and good communication Cross monitoring SBAR Check backs Call outs

COMMUNICATION TOOLS

Cross Monitoring – active awareness of the actions of other team members for the purpose of sharing workload and error prevention

This can only occur in a climate where it is expected that assistance will be actively offered, accepted and sought as a method of avoiding mistakes.

COMMUNICATION TOOLS

SBAR – a standardized method for presentation of patient information Describe the Situation Provide the Background Make an Assessment Communicate your Recommendations

For communication to be effective it needs to be complete, clear, brief, and timely

COMMUNICATION TOOLS

Closed Loop Communication Check Backs: repeating back information

that was given for example verbally repeating medication dose

and route when a verbal order is given Confirming an action has been completed (“Pedi

is on their way.”) Call Outs: verbalizing information that is

important to the team, especially during emergencies “It’s been 2 minutes” during a shoulder dystocia

ACCOUNTABILITY AND COLLECTIVE EFFORT Advocacy and Assertion – all team

members are encouraged and expected to voice concerns and assure their questions are adequately addressed Suggest alternatives Review consequences of each option Obtain consensus Always be respectful

ACCOUNTABILITY AND COLLECTIVE EFFORT

Low Moderate Very High

Low

High

Mod

Workload

High

Perf

orm

ance

COMFORT ZONE

WORKOVERLOAD

BOREDOM

Patient Risk Zone

Patient Risk Zone

To help manage resources and mitigate risk teams need to:

• Voluntarily adjust workload and set priorities

• Allocate resources on the basis of acuity, volume and team member skills

• Equitably distribute the workload

• Appropriately utilize resources within the team, the department, and outside the department

COLLECTIVE EFFORT

Debriefing allows for evaluation of the effectiveness of the team following an “event”.

Facilitated reflection has been shown to be a critical element for improving future performance of individuals and teams.

Allows identification of systems issues and opportunities for improvement

Components of Debriefing Timely Leader/Facilitator

Sets the tone Fosters dialogue Follows a consistent format

Includes those involved in the event Identifies opportunities for improvement Acknowledges good actions/behaviors Follow up plan Feedback to participants

TEAM DEBRIEFING FORM Key Considerations:

Was communication clear and effective? Were roles and responsibilities understood Was situational awareness maintained? Was the workload appropriate? Was help requested? Were errors mad or avoided?

Issues

Proposed Actions/Recommendations Date:

What went well?

What did not go well?

Opportunities for improvement?

Additional comments?

Sample Team Debriefing Form

BENEFITS OF TEAM TRAINING

Reduce clinical errors Improve maternal and neonatal

outcomes Improve process measures Increase patient satisfaction Improve staff satisfaction Reduce malpractice claims

“The nice thing about teamwork is you always have others on your side”