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 $29 billion annually*
“NATIONAL PROBLEM OF EPIDEMIC PROPORTIONS”**
* To Err Is Human: Building a Safer Health System** Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact
To Err Is Human Institute of Medicine 1999
Medical errors hurt people Medical errors cost billions Medical errors erode trust Medical errors reduce
satisfaction of patients and healthcare providers
FATIGUE DISTRACTION
HIERARCHY
POORCOMMUNICATION/MULTIPLEHANDOFFS
WHY DO ERRORS HAPPEN?
WHY DO ERRORS HAPPEN?
In 2004, a Sentinel Alert issued by JACHO revealed that most cases of perinatal death and injury are caused by problems with an organization’s culture and communication failures between providers.
Joint Commission Sentinel Alert 2004
Recommendation
“Conduct team training in perinatal
areas to teach staff to work together and communicate more effectively”
“…conduct clinical drills …. and conduct debriefings to evaluate team performance and identify areas for improvement.”
VALIDATION OF TEAM TRAINING/SIMULATION
Reduction in clinical errors (31% 4%) Improved clinical management decisions
with simulation drills Hospital or unit based training/simulation
is just as effective as Simulation Center Process Improvements
“decision to incision” time reduced by twelve minutes (33 mins 21mins)
• Teamwork behaviors can be transferred to clinical environments
• Decreased frequency and severity of adverse events
• Fewer malpractice claims
• Improved staff scores on patient safety attitude questionnaires
CRICO OB Patient Safety Program
Launched in 2003 Team Training Simulation Drills Online Courses on
fetal monitoring and shoulder dystocia
OB Practice Guidelines Test 4 yrs
prior 4 yrs after
0
10
20
30
40
50
60
70
Numbers of claimsCost ($ 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 effort
Teamwork 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
Per
form
ance
COMFORT ZONE
WORKOVERLOA
D
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”