NEONATOLOGY:A TEAM SPORT

Roger F. Soll, MDProfessor of PediatricsUniversity of Vermont

Workshop on Perinatal StrategiesScottsdale, ArizonaApril 9, 2010

JOE BUTTERFIELD:THE ULTIMATE TEAM PLAYER

a physician witha physician with ““a heroic passiona heroic passionfor children. That passion wentfor children. That passion wentbeyond medicine and into thebeyond medicine and into the

political arena, where Dr.political arena, where Dr.Butterfield spent many years as aButterfield spent many years as alobbyist advocating for children'slobbyist advocating for children'sissues and encouraging others toissues and encouraging others to

do the samedo the same””..

• The NICU as a Team• Teams within Teams• Teams of Teams

NEONATOLOGY:A TEAM SPORT

WHAT IS A TEAM?

Two or more individuals who• perform some work related task,• interact with one another dynamically,• have a shared past and a foreseeableshared future, and

• share a common fate

Salas 1993

WHAT IS A TEAM?

New York YankeesSWAT TeamAirline Crew

NICU Staff!

WHAT IS A TEAM?

Individual BrilliantPhysician/Nurse

vs.

Highly Functional Team

WHAT IS A TEAM?

Discordance in perception of team performancebetween physicians and nurses

Grant MJ J Nurs Care Qual 2006; 21: 223-9

WHAT IS A TEAM?

WHAT IS A TEAMWORK?

Behaviors that facilitate effectiveteam member interaction

Beaubien 2004

WHAT IS A TEAMWORK?

Development of Potentially Better Practices forthe Neonatal Intensive Care Unit as a Culture ofCollaboration: Communication, Accountability,

Respect, and Empowerment.

Judy Ohlinger, RN, MSN, Mark S. Brown, MD, MSPH , Sue Laudert, MD,Sue Swanson, RN, NNP| and Ona Fofah, MD on Behalf of the CARE

Group

PEDIATRICS Vol. 111 No. 4 April 2003, pp. e471-e481

WHAT CREATES ANEFFECTIVE TEAM?

• Clear, shared purpose, goals, and values

• Effective communication among and between teams and teammembers

• Lead by example: "walk the talk“

• Nurture a collaborative environment with trust and respect

• Live principled standards of conduct and standards of excellence

• Nurture competent and committed teams and team members

• Commit to conflict management

POTENTIALLY BETTERPRACTICES

Clear, shared purpose, goals,

and values

“It’s about the baby!”

POTENTIALLY BETTERPRACTICES

TEAM COMMUNICATION

Effective communication among andbetween teams and team members

TEAM COMMUNICATION

““That sure is aThat sure is abig storm aroundbig storm aroundNew York CityNew York City””

vs.vs.

““Captain, I amCaptain, I amconcerned aboutconcerned aboutflying into thatflying into that

stormstorm””

TEAM COMMUNICATION

Korean Airline DisasterKorean Airline Disaster

No one would tell the pilotNo one would tell the pilotthat he was flying directly intothat he was flying directly into

a mountaina mountain

Under time pressure, it can be difficult to obtain attentionfully and to communicate effectively.

Assertion is when individuals persist in speaking up to ensurethat there is shared understanding and a resolution of a

situation of concern (e.g., delivery room crisis)

ASSERTION

• Get the person's attention• Express your concern• State the problem• Recommend action• Achieve a decision

Use communication ground rules:- Make eye contact- Listen to understand- Repeat back what the person says- Call people by their first name

Steps to take for improved communicationin a delivery room emergency

WHAT IS A LEADER?WHAT IS A LEADER?

• Lead by example: "walk the talk“

• Nurture a collaborative environment with trust and respect

• Live principled standards of conduct and standards of excellence

• Nurture competent and committed teams and team members

POTENTIALLY BETTERPRACTICES: LEADERSHIP

WHAT TYPE OF TEAM AREYOU ON?

LEADERSHIP?

SELF ASSESSMENT

Using Organizational AssessmentUsing Organizational AssessmentSurveys for Improvement in NeonatalSurveys for Improvement in Neonatal

Intensive CareIntensive Care

Baker and coworkers. Pediatrics 2003; 111: e419Baker and coworkers. Pediatrics 2003; 111: e419--2525

SELF ASSESSMENT

Baker and coworkers. Pediatrics 2003; 111: e419Baker and coworkers. Pediatrics 2003; 111: e419--2525

Measured organizational cultureMeasured organizational culture-- CoordinationCoordination-- TeamworkTeamwork-- LeadershipLeadership-- Conflict managementConflict management-- Unit cultureUnit culture

TYPES OF ORGANIZATIONAL CULTURE

Baker and coworkers. Pediatrics 2003; 111: e419Baker and coworkers. Pediatrics 2003; 111: e419--2525

High affiliation, concern with teamworkHigh affiliation, concern with teamworkand participationand participation

Based on risk taking innovation andBased on risk taking innovation andchangechange

Reflecting the values and norms associatedReflecting the values and norms associatedwith bureaucracywith bureaucracy

Emphasizing efficiency and achievementEmphasizing efficiency and achievement

Group Culture:Group Culture:

DevelopmentalDevelopmentalCulture:Culture:

HierarchicalHierarchicalCulture:Culture:

Rational Culture:Rational Culture:

SELF ASSESSMENT

Self assessment tools useful butSelf assessment tools useful butnot directly correlated to outcomenot directly correlated to outcome

Promoted discussion ofPromoted discussion oforganizational and team issuesorganizational and team issues

Baker and coworkers. Pediatrics 2003; 111: e419Baker and coworkers. Pediatrics 2003; 111: e419--2525

THE PROJECT ORIENTED TEAM

FocusedFocusedTypicalTypical ““Business ModelBusiness Model””

Needs:Needs:Clear Vision/PurposeClear Vision/Purpose

Multidisciplinary representationMultidisciplinary representationClear ground rulesClear ground rules

Clear expectations for productionClear expectations for production

Can learn successful behaviorsCan learn successful behaviorsfor this type offor this type of ““teamworkteamwork””

RAPID RESPONSE TEAM

Rapid Response TeamsRapid Response Teams(AKA Medical Emergency Teams)(AKA Medical Emergency Teams)

Highly experienced clinicians dispatchedHighly experienced clinicians dispatchedto evaluate and triage patientsto evaluate and triage patients

with rapidly deteriorating clinical statuswith rapidly deteriorating clinical status

RAPID RESPONSE TEAM

Reduce morbidity and mortalityReduce morbidity and mortalityrelated to cardiopulmonary arrestrelated to cardiopulmonary arrest

--in adults (in adults (DaceyDacey 2007, Hillman 2005) and2007, Hillman 2005) and-- children (children (SharekSharek 2007)2007)

TEAMWORK IN NEONATALRESUSCITATION

Simulation Based TrainingSimulation Based Training

Teamwork and quality duringneonatal care in the delivery room.

Thomas EJ, Sexton JB, Lasky RE, Helmreich RL,Crandell DS, Tyson J.

J Perinatol. 2006 Mar;26(3):163-9.

Experts believe good teamwork among health care providersmay improve quality.

The investigators sought to measure the frequency of teambehaviors during delivery room care and to explore how these

behaviors relate to the quality of care.

Teamwork and qualityduring neonatal care in the delivery room

OBJECTIVE

The investigators video recorded neonatalresuscitation teams then used independent

observers to measure teamwork behaviors andcompliance with Neonatal ResuscitationProgram (NRP) guidelines (a measure of

quality of care).

Teamwork and qualityduring neonatal care in the delivery room

STUDY DESIGN

All teams (n=132) exhibited the behaviors regardinginformation sharing and inquiry

All but one team exhibited vigilance and workload management.

Other behaviors were present less often:

• assertion 19.9%• teaching 16.7%• leadership 19.7%• evaluation of plans 12.9%• intentions stated 9.1%.

Teamwork and qualityduring neonatal care in the delivery room

RESULTS

Factor analysis identified three fundamental components ofteamwork:

1. communication (comprised of information sharing and inquiry);2. management (workload management and vigilance); and3. leadership (assertion, intentions shared, evaluation of plans, and

leadership).

All three components were weakly but significantly correlated withindependent assessments of NRP compliance and an overall

rating of the quality of care.

Teamwork and quality

during neonatal care in the delivery room

RESULTS

Most team behaviors can be reliably observed during delivery roomcare by neonatal resuscitation teams, and some are infrequently

used.

Weak but significant and consistent correlations found among thesebehaviors with independent assessments of NRP compliance and an

overall rating of the quality of care.

These findings support additional efforts to study team training fordelivery room care and other areas of healthcare.

Teamwork and quality

during neonatal care in the delivery room

CONCLUSIONS

Teaching teamwork during the NeonatalResuscitation Program: a randomized trial.

Thomas EJ, Taggart B, Crandell S, Lasky RE, Williams AL, Love LJ, SextonJB, Tyson JE, Helmreich RL.

Perinatol. 2007 Jul;27(7):409-14. Epub 2007 Jun 7.

OBJECTIVE: To add a team training and human errorcurriculum to the Neonatal Resuscitation Program (NRP)

and measure its effect on teamwork.

The investigators hypothesized that teams that receivedthe new course would exhibit more teamwork behaviors

than those in the standard NRP course.

Teaching teamwork during theNeonatal Resuscitation Program: a randomized trial

STUDY DESIGN:Interns were randomized to receive NRP with team

training or standard NRP, then video recorded when theyperformed simulated resuscitations at the end of the day-

long course.

Outcomes were assessed by observers blinded to studyarm allocation and included the frequency or duration of

six team behaviors: inquiry, information sharing,assertion, evaluation of plans, workload management and

vigilance.

Teaching teamwork during theNeonatal Resuscitation Program: a randomized trial

RESULT: The interns in the NRP with team training groupexhibited more frequent team behaviors than interns in thecontrol group: [number of episodes per minute (95% CI)]

• information sharing:1.06 (0.24, 1.17) vs. 0.13 (0.00, 0.43);

• inquiry: 0.35 (0.11, 0.42) vs. 0.09 (0.00, 0.10);• assertion: 1.80 (1.21, 2.25) vs. 0.64 (0.26, 0.91);• team behavior: 3.34 (2.26, 4.11) vs. 1.03 (0.48, 1.30)

(P-values <0.01 for all comparisons).

Teaching teamwork during theNeonatal Resuscitation Program: a randomized trial

RESULT:

Vigilance and workload management were practicedthroughout the entire simulated code by nearly all the teamsin the NRP with team training group (100% for vigilance and88% for workload management) vs. only 53 and 20% of the

teams in the standard NRP.

No difference was detected in the frequency of evaluation ofplans.

Teaching teamwork during theNeonatal Resuscitation Program: a randomized trial

CONCLUSION: Compared with the standard NRP, NRPwith a teamwork and human error curriculum led interns

to exhibit more team behaviors during simulated

Teaching teamwork during theNeonatal Resuscitation Program: a randomized trial

TEAMS OF TEAMS

COLLABORATIVE QUALITY IMPROVEMENTCOLLABORATIVE QUALITY IMPROVEMENT

•• Vermont Oxford Network NICQVermont Oxford Network NICQ•• RegionalRegional CollaborativesCollaboratives

•• State based: California, Ohio, NorthState based: California, Ohio, NorthCarolina, Tennessee orCarolina, Tennessee or•• Country based: IrelandCountry based: Ireland

•• Mission basedMission based CollaborativesCollaboratives•• ChildrenChildren’’s Hospitalss Hospitals

NIC/Q COLLABORATIVES

Series of multi-organization neonatal improvement Collaborativesfor Vermont Oxford Network members beginning in 1995

The NIC/Q Collaboratives have 3 primary goals:

• To achieve measurable improvements in the quality,safety and efficiency of NICU care.

• To develop new resources, tools and knowledge forquality improvement in the NICU.

• To disseminate this improvement knowledge to theneonatology community.

VERMONT OXFORD NETWORKVERMONT OXFORD NETWORKNIC/Q PROJECTNIC/Q PROJECT

Performance Feedback

Quality Training

Collaborative Learning

Site Visits and Benchmarking

Meetings, Listservs, Conference Calls

SUPPORTED BY A GRANT FROM THE DAVID AND LUCILE PACKARD FOUNDATION

Habit forChange

Habit forChange

Vermont Oxford Network NIC/Q

BETTER PRACTICES

Habit forSystemsThinking

Habit forEvidence-BasedPractice

Habit forCollaborativeLearning

• Clinical• Organizational• Operational

HABIT FOR CHANGEHABIT FOR CHANGE

•• Organizational ReadinessOrganizational Readiness

•• Knowledge, Skills and ToolsKnowledge, Skills and Tools

•• Model for ImprovementModel for Improvement

MODEL FOR IMPROVEMENTMODEL FOR IMPROVEMENT

AIMAIM

MEASUREMEASURE

CHANGESCHANGES

WHAT ARE WE TRYING TO ACCOMPLISH?WHAT ARE WE TRYING TO ACCOMPLISH?

HOW WILL WE KNOW THATHOW WILL WE KNOW THATA CHANGE IS AN IMPROVEMENT?A CHANGE IS AN IMPROVEMENT?

WHAT CHANGES CAN WE MAKE THATWHAT CHANGES CAN WE MAKE THATWILL LEAD TO AN IMPROVEMENT?WILL LEAD TO AN IMPROVEMENT?

PP

DDSS

AA

LANGLEY, NOLAN, ET AL. THE IMPROVEMENT GUIDE: A PRACTICAL APPROALANGLEY, NOLAN, ET AL. THE IMPROVEMENT GUIDE: A PRACTICAL APPROACH TO ENHANCING ORGANIZATIONALCH TO ENHANCING ORGANIZATIONALPERFORMANCE. JOSSEYPERFORMANCE. JOSSEY--BASS. SAN FRANCISCO, CALIFORNIA. 1996.BASS. SAN FRANCISCO, CALIFORNIA. 1996.

HABIT FORHABIT FORSYSTEMS THINKINGSYSTEMS THINKING

•• Complex Adaptive SystemsComplex Adaptive Systems

•• Analyze ProcessesAnalyze Processes

•• Measure Process PerformanceMeasure Process Performance

HABIT FOR EVIDENCEHABIT FOR EVIDENCEBASED PRACTICEBASED PRACTICE

•• Ask the Right QuestionAsk the Right Question

•• Search for the Best EvidenceSearch for the Best Evidence

•• Critically Appraise the EvidenceCritically Appraise the Evidence

•• Apply the EvidenceApply the Evidence

•• Evaluate PerformanceEvaluate Performance

SACKETT DL, ET AL. EVIDENCESACKETT DL, ET AL. EVIDENCE--BASED MEDICINE: HOW TO PRACTICEBASED MEDICINE: HOW TO PRACTICEAND TEACH EBM. CHURCHILLAND TEACH EBM. CHURCHILL--LIVINGSTONE. NEW YORK. 1997.LIVINGSTONE. NEW YORK. 1997.

HABIT FORHABIT FOR

COLLABORATIVE LEARNINGCOLLABORATIVE LEARNING

•• Multidisciplinary TeamsMultidisciplinary Teams

•• Collaboration within TeamsCollaboration within Teams

•• External BenchmarkingExternal Benchmarking

• Evidence often not definitive or does not address yourspecific circumstance

• Need for ongoing modification

• Need for local customization and local testing

• Understand the “trade offs” (risk/benefit ratio)

POTENTIALLY BETTER PRACTICES

Infection: Potentially Better PracticesInfection: Potentially Better Practices

•• HandwashingHandwashing

•• NutritionNutrition

•• Skin careSkin care

•• Improved diagnosisImproved diagnosis

•• Respiratory careRespiratory care

•• Vascular accessVascular access

•• Unit cultureUnit culture

REDUCING NOSOCOMIAL INFECTIONREDUCING NOSOCOMIAL INFECTION

Ignaz Philipp Semmelweis

• Hungarian physician

• Puerperal fever

• Handwashing

• Mortality falls from 18.3 to 1.3 %1818-1865

ReducingNosocomial Infection

QI Initiative

Outcome

SemmelweisSemmelweis

Courtesy of R. Pfister

TRANSLATING EVIDENCE TO PRACTICE:TRANSLATING EVIDENCE TO PRACTICE:PREVENTING NOSOCOMIAL INFECTIONPREVENTING NOSOCOMIAL INFECTION

Efficacy:

Handwashing helps prevent spread of hospital acquired infection

Effectiveness and Efficiency:

• What agents are best to use?• best bactericidal properties• most cost effective

• How do we improve compliance?• Where do we place sinks/hand washing stations?

NICQ PROJECT: INFECTION OUTCOME

0

5

10

15

20

25

1994 1995 1996 1997CO

AG

-NE

GA

TIV

ES

TA

PH

(%)

NIC/Q GROUP (N=6) CONTROL (N=66)

HORBAR ET AL. Collaborative Quality Improvement for Neonatal Intensive Care. Pediatrics. January 2001.

NIC/Q PROJECTINFECTION COSTS

$0

$20,000

$40,000

$60,000

$80,000

1994 1995 1996 1997

CO

ST

NIC/Q GROUP (N=6) CONTROL (N=9)

ROGOWSKI ET AL. Economic Implications of NICU Collaborative Quality Improvement. Pediatrics, January 2001.

NIC/Q PROJECTAverage Team Costs for Two Years

Staff TimeStaff Time $48,000$48,000

Travel ExpensesTravel Expenses $20,000$20,000

TotalTotal $68,000$68,000

Rogowski et al. Economic Implications of NICU Collaborative Quality Improvement.

Pediatrics. January 2001.

REDUCING NOSOCOMIAL INECTION:REDUCING NOSOCOMIAL INECTION:NIC/Q 2000NIC/Q 2000

• Improved hand hygiene compliance

• CVL setups re-evaluated and standardized

• Staff competency for CVL care improved

• Improved diagnosis of coag - Staph

Kilbride HW, et al. Pediatrics 2003;111:e519-533

POTENTIALLY BETTER PRACTICES

REDUCING NOSOCOMIAL INFECTIONREDUCING NOSOCOMIAL INFECTIONNIC/Q 2000: COMPARISON 1997 vs. 2001NIC/Q 2000: COMPARISON 1997 vs. 2001

Kilbride HW, et al. Pediatrics 2003;111:e519-533

0%

10%

20%

30%

40%

50%

Unit A Unit B Uni C Unit D Unit E Unit F

Infe

ctio

nRate

5 of 6 NICUs improved. Overall change: 25% to 16%

NICU AS A TEAMNICU AS A TEAM

Remember…

There is no “I” in NCU

Oh well…there is, but keep it in perspective…

You are part of a team!

TEAMWORK AT IT’S BEST!