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Integrated Approach to Reduce Perinatal Adverse Events: Standardized Processes, Interdisciplinary Teamwork Training, and Performance Feedback

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Abstract

Objective: To improve safety practices and reduce adverse events in perinatal units of acute care hospitals. Data sources: Primary data collected from perinatal units of 14 hospitals participating in the intervention between 2008 and 2012. Baseline secondary data collected from the same hospitals between 2006 and 2007. Study design: A prospective study involving 342,754 deliveries was conducted using a quality improvement collaborative that supported three primary interventions. Primary measures include adoption of three standardized care processes and four measures of outcomes. Data collection methods: Chart audits were conducted to measure the implementation of standardized care processes. Outcome measures were collected and validated by the National Perinatal Information Center. Principal findings: The hospital perinatal units increased use of all three care processes, raising consolidated overall use from 38 to 81 percent between 2008 and 2012. The harms measured by the Adverse Outcome Index decreased 14 percent, and a run chart analysis revealed two special causes associated with the interventions. Conclusions: This study demonstrates the ability of hospital perinatal staff to implement efforts to reduce perinatal harm using a quality improvement collaborative. Findings help inform the relationship between the use of standardized care processes, teamwork training, and improved perinatal outcomes, and suggest that a multiplicity of integrated strategies, rather than a single intervention, may be essential to achieve high reliability.

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... Nearly half of the studies originated from the United States (n = 24, 48%). 42,[44][45][46][47]50,51,[53][54][55]59,60,[62][63][64][65][66][67][69][70][71][72][73][74] The remainder were from the UK (n = 9), 6,35,36,52,58,[75][76][77][78] Australia (n = 4), 38,49,79,80 Tanzania (n = 2), 41,81 Canada (n = 2), 37,57 and Brazil (n = 2). 61,68 Single studies originated from Ethiopia, 40 Ireland, 39 Mexico, 82 New Zealand, 48 Scotland, 56 Spain, 43 ...
... 23 The most frequently reported F I G U R E 1 PRISMA flowchart of identification, screening, eligibility, and study selection process 29 clinical governance strategy was organization-led comprehensive patient safety programs (n = 9 studies). 42,51,57,59,60,[65][66][67]72 The next most frequent clinical governance strategy was checklists to standardize care (n = 5 studies), 55,56,62,74,82 for example, a surgical checklist to improve safety in obstetric surgery. 56 Other reported clinical governance strategies were maternity handover (n = 3 studies), 6,79,83 audit tools (n = 2 studies) such as medical record audits to detect adverse events, 43,47 implementing continuous cardiotocography (n = 2 studies), 35,81 and staffing arrangements in labor units (n = 2 studies). ...
... The majority of studies which implemented clinical governance strategies measured clinical outcomes for the woman and/or her newborn (n = 10 studies; See Table 2a). These clinical outcomes included maternal morbidity (n = 4 studies), 45,47,63,69 adverse events (n = 3 studies), 42,43,51 and intervention rates (ie, operative births, n = 1 study). 66 Two studies measured a combination of clinical outcomes. ...
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Background Safety is a priority for organizations that provide maternity care, however, preventable harm and errors in maternity care remain. Maternity care is considered a high risk and high litigation area of health care. To mitigate risk and litigation, organizations have implemented strategies to optimize women's safety. Our objectives were to identify the strategies implemented by organizations to optimize women's safety during labor and birth, and to consider how the concept of safety is operationalized to measure and evaluate outcomes of these strategies. Method This scoping review was conducted using the Joanna Briggs Institute Scoping Review Methodology. Published peer-reviewed literature indexed in CINAHL, Medline, and Embase, databases from 2010 to 2020, were reviewed for inclusion. Fifty studies were included. Data were extracted and thematically analyzed. Results Three categories of organizational strategies were identified to optimize women's safety during labor and birth: clinical governance, models of care, and staff education. Clinical governance programs (n = 30 studies), specifically implementing checklists and audits, models of care, such as midwifery led-care (n = 11 studies), and staff training programs (n = 9 studies), were predominately for the management of obstetric emergencies. Outcome measures included morbidity and mortality for woman and newborns. Three studies discussed women's perceptions of safety during labor and birth as an outcome measure. Conclusions Organizations utilize a range of strategies to optimize women's safety during labor and birth. The main outcome measure used to evaluate strategies was focused on clinical outcomes for the mother and newborn.
... Finally, the robustness and methodological quality of the studies and synthesis is assessing with respect to their limitations and biases. Of the nine selected studies, [26][27][28][29][30][31][32][33][34] seven were conducted in the USA, 26-30 32 34 one in the UK 33 and one in India. 31 All studies used some variation of a prospective cohort approach, with one study incorporating a retrospective analysis as well. ...
... Only three studies isolated in situ simulation as the primary intervention at onset, 26 27 34 while an additional study temporally separated a multitude of interventions, including in situ simulation, to assess for individual effects. 32 The majority of studies (n=5) incorporated in situ simulation as part of a broad educational intervention. 28-31 33 Seven studies were single arm, 26 27 29 31-34 and seven studies used a clearly defined preintervention baseline period for statistical comparisons. ...
... 28-31 33 Seven studies were single arm, 26 27 29 31-34 and seven studies used a clearly defined preintervention baseline period for statistical comparisons. [27][28][29][30][31][32][33] Two studies used other hospital inpatient units as the control group. 28 30 Four of the selected studies had intervention periods of 1 year or less, 27 29 30 34 with the remaining five studies implementing intervention periods lasting between 2 and 6 years. ...
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Background The use of in situ simulation has previously been shown to increase confidence, teamwork and practical skills of trained professionals. However, a direct benefit to patient outcomes has not been sufficiently explored. This review focuses on the effect of in situ simulation training in a hospital setting on morbidity or mortality. Methods A combined search was conducted in PUBMED, OVID, WEB OF SCIENCE, CINAHL, SCOPUS and EMBASE. 478 studies were screened with nine articles published between 2011 and 2017 meeting the inclusion criteria for analysis. Results This review selected eight prospective studies and one prospective-retrospective study. Three studies isolated in situ simulation as an experimental variable while the remaining studies implemented in situ programmes as a component of larger quality improvement initiatives. Seven studies demonstrated a significant improvement in morbidity and/or mortality outcomes following integrated in situ simulation training. Conclusion Existing literature, albeit limited, demonstrates that in situ training improves patient outcomes either in isolation or within a larger quality improvement programme. However, existing evidence contains difficulties such as isolating the impact of in situ training from various potential confounding factors and potential for publication bias.
... [1][2][3] Poor quality of care contributes to morbidity and mortality, and therefore attention has shifted to the quality of care. 4,5 The effect of improving quality of care during labour and delivery, will reflect in health indicators such as perinatal mortality and birth asphyxia rates. 6 The disease burden is high, particularly in LMIC. ...
... 3,4 It is clear that a multifactorial approach rather than any one single intervention is the key to improving quality of care provided, as so many factors are involved in making the peripartum period a safe one. 5 The incidence of stillbirths or neonatal deaths due to intrapartum asphyxia in a low-risk pregnancy is regarded as a sensitive measure of the quality of care given around the time of labour and childbirth. 6 In this maternity unit where the research was carried out, high-risk referrals were dealt with, as well as low-risk mothers who attended the clinics or the labour ward for antenatal care and delivery. ...
Article
To study the changes in the rates of perinatal mortality, birth asphyxia, and caesarean sections in relation to interventions implemented over the past 18 years, in a tertiary centre in South India.
... [1][2][3] Poor quality of care contributes to morbidity and mortality, and therefore attention has shifted to the quality of care. 4,5 The effect of improving quality of care during labour and delivery, will reflect in health indicators such as perinatal mortality and birth asphyxia rates. 6 The disease burden is high, particularly in LMIC. ...
... 3,4 It is clear that a multifactorial approach rather than any one single intervention is the key to improving quality of care provided, as so many factors are involved in making the peripartum period a safe one. 5 The incidence of stillbirths or neonatal deaths due to intrapartum asphyxia in a low-risk pregnancy is regarded as a sensitive measure of the quality of care given around the time of labour and childbirth. 6 In this maternity unit where the research was carried out, high-risk referrals were dealt with, as well as low-risk mothers who attended the clinics or the labour ward for antenatal care and delivery. ...
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Objective: To study the changes in the rates of perinatal mortality, birth asphyxia and Caesarean sections in relation to interventions implemented over the past 18 years, in a tertiary centre in South India. Design: Retrospective study. Setting: Labour and maternity unit of a tertiary centre in South India. Population or sample: Women who gave birth between the years 2000 and 2018. Methods: Information from perinatal audits, chart reviews and data retrieved from the electronic database were used. Interventions implemented during this time period were audits and training, obstetric re-organisation and minor changes in staffing and infrastructure. Main outcome measures were perinatal mortality rate, birth asphyxia rate and Caesarean section rate. Results: Perinatal mortality rate decreased from 44 per 1000 births in 2000 to 16.4 per 1000 births in 2018 (P <0.001). The rates of babies born with birth asphyxia requiring admission to the neonatal unit decreased from 24 per 1000 births in 2001 to 0.7 per 1000 births in 2018 (P <0.00001). The overall Caesarean section rate was maintained close to 30%. Conclusion: In a large tertiary hospital in South India, with 14,000 deliveries per year, a policy of rigorous audits of stillbirths and birth asphyxia, electronic fetal monitoring and the introduction of standardized criteria for trial of scar, reduced the perinatal mortality and the rate of babies born with birth asphyxia over the past 18 years, without an increase in the Caesarean section rate. This article is protected by copyright. All rights reserved.
... The findings also revealed that there was a strong relationship between feedback quality and teamwork effectiveness in accounting firms, and this matches similar observations in other professional contexts such as healthcare (Oseni et al., 2017;Riley et al., 2016). This reiterates the fact that receiving quality feedback enhances the readiness of individuals in any organization to work collaboratively. ...
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Purpose: The objective of this research is to investigate the impact of an interactive performance measurement system which factors in the quality of feedback and teamwork effectiveness for assessing job performance and in so doing, promote good governance practices. Design/Methodology/Approach: To achieve this objective, we conducted a survey of public accounting firms in Indonesia. The analysis of the survey was undertaken using the SmartPLS. Findings: Based on the research, we found teamwork effectiveness to be a mediating factor between interactive performance measurement and job performance. Research Limitations/Implications: This research indicates that teamwork effectiveness is an important contributing factor to job performance as reported by companies adopting the interactive performance measurement system. Originality/Value: This research is the first to empirically examine the positive effects of feedback quality and teamwork effectiveness by considering the relationship between interactive control use and job performance in public accounting firms.
... [13] Riley et al. emphasized the formation of an interdisciplinary team of professionals, extensive teamwork training, a multiplicity of integrated strategies instead of a single intervention to achieve high reliability in obstetrics and gynecology. [14] Portela et al. stated in the results of their study that creating conditions for inter professional work groups, better communication and coordination, improving system member accountability, investing in technical competence of team members, and coordination of organizational structures and processes, all together can help improve the quality of women and pregnancy care. [15] According to the results of Bahreini, Riley, and Portela studies, and the present study, it is estimated that lack of management in planning of mangers and managerial errors at the academic and ministry levels, including inadequate supervision of physicians' training and lack of teamworking and lack of collaborative common management plans among the medical and obstetrical services have resulted in preventable errors and require targeted policies and effective interventions. ...
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INTRODUCTION: Investigating severe maternal morbidity and near-miss cases are applied internationally as a new indicator to examine the quality of maternal care and as an effective strategy to reduce maternal mortality. This study aimed to determine the root causes of severe maternal morbidity in order to improve maternal health. MATERIALS AND METHODS: The present research is a descriptive case series study. The data was obtained from the hospital and health records of mothers admitted to hospitals affiliated to Isfahan University of Medical Sciences due to severe morbidity in the first 6 months of 2018, which were selected randomly. The data collection was completed by interviews with the mentioned mothers and 14 related health-care staffs and that led to the development of the morbidity story. The compiled story of each case was evaluated by the root analysis team's opinion. Causes of morbidity were determined according to a root cause analysis checklist composing of factors such as health-care services (human and structural factors), family-social status, and disease status of maternal morbidity. RESULTS: The findings indicated that human factors related to the health system led to severe maternal morbidity more than any cause. Inadequate knowledge and skills of service providers, disregard for guidelines and protocols, lack of teamworking, and lack of considering competency were the most important human factors. Disease condition, family, and social status were the other related factors, respectively. CONCLUSION: Human factors are the most important cause of maternal morbidity based on the results of this study. Therefore, modifying the health structure can be one of the most important reducing factors for maternal mortality in order to improve the services for these individuals.
... 47 In addition, it is suggested to integrate this with other quality care strategies, such as interdisciplinary team training, standardisation of evidence-based care and feedback on team performance. 45 strengths and weaknesses of the study The strengths of this study are that it describes the profile of AE and GP in obstetric services of different levels of complexity and may be useful in identifying opportunities for improvements in the quality of delivery care, as well as to propose a method for monitoring and analysing the quality of obstetric care based on standardised indicators. Comparative results between facilities and countries highlight the importance of the context for prioritising quality problems, while stressing similarities in the type of problems to address. ...
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Objective To evaluate the quality of delivery care in maternity wards in Brazil and Mexico based on good practices (GP) and adverse events (AE), in order to identify priorities for improvement. Design A multicentre cross-sectional study with data collection from medical records between 2015 and 2016 to compare indicators of maternal and neonatal GP and EA based on the Safe Childbirth Checklist and standardised obstetric quality indicators. Two Brazilian and five Mexican maternity wards participated in the study. Descriptive statistics and χ ² tests were performed to assess performance and significant differences between the hospitals investigated. Sampling We analysed 720 births in Brazil and 2707 in Mexico, which were selected using a systematic random sampling of 30 medical records every fortnight for 12 2-week periods in Brazil and 18 2-week periods in Mexico. We included women and their newborns, excluding those with congenital malformations. Results The Mexican hospitals showed greater adherence to GP (58.2%) and a lower incidence of AE (12.9%) than the participating institutions in Brazil (26.8% compliance with GP and 16.0% AE). In spite of these differences, the relative importance of particular quality problems and type of AE are similar in both countries. Tertiary hospitals, caring for women at higher risk, have significantly (p<0.001) higher rates of AE (27.2% in Brazil and 29.6% in Mexico) than institutions attending women at lower risk, where the frequency of AE ranges from 4.7% to 11.2%. Differences were significant (p<0.001) for most indicators of GP and AE. Conclusion Data from outcome and process measures revealed similar types of failures in the quality of childbirth care in both countries and indicate the need of rationalising the use of antibiotics for the mother and episiotomy, encouraging greater adherence to partograph and to the use of magnesium sulfate for the treatment of severe preeclampsia/eclampsia.
... As such, lessons from this study designed to address IHT can be applied to the more general care processes for critically-ill patients subject to care transitions within the same institution. Previous evidence has demonstrated that processes of care for various non-neurological conditions can be standardized and improved by implementing local care pathways and guidelines to reduce ambiguity and variability in practice [23][24][25]; we embarked on such an initiative locally based on the focused gaps in clinical practice such as blood pressure management and anti-coagulant reversal. ...
Goal: Interhospital transfer (IHT) facilitates access to specialized neurocritical care but may also introduce unique risk. Our goal was to describe providers' perceptions of safety threats during IHT for patients with nontraumatic intracranial hemorrhage. Materials and methods: We employed qualitative, semi-structured interviews at an academic medical center receiving critically-ill neurologic transfers, and 5 referring hospitals. Interviewees included physicians, nurses, and allied health professionals with experience caring for patients transferred between hospitals for nontraumatic intracranial hemorrhage. Interviews continued until data saturation was reached. Coding occurred concurrently with interviews. Analysis was inductive, using the constant comparative method. Findings: The predominant impediments to safe, high-quality neurocritical care transitions between hospitals are insufficient communication, gaps in clinical practice, and lack of IHT structure. Insufficient communication highlights the unique communication challenges specific to IHT, which overlay and compound known intrahospital communication barriers. Gaps in clinical practice revolve primarily around the provision of neurocritical care for this patient population, often subject to resource availability, by receiving hospital emergency medicine providers. Lack of structure outlines providers' questions that emerge when institutions fail to identify process channels, expectations, and accountability during complex neurocritical care transitions. Conclusions: The predominant impediments to safe, high-quality neurocritical care transitions between hospitals are insufficient communication, gaps in clinical practice, and lack of IHT structure. These themes serve as fundamental targets for quality improvement initiatives. To our knowledge, this is the first description of challenges to quality and safety in high-risk neurocritical care transitions through clinicians' voices.
... Fortunately, strong evidence suggests that health care team training works (Riley et al., 2016;Salas, Burke, Bowers, & Wilson, 2001;, and science and practice offer specific strategies, delivery methods, and tools proven to enhance team processes and attitudes toward teamwork (e.g., TeamSTEPPS; Brock et al., 2013). A meta-analytic review of crew resource management (CRM) conducted by O'Dea, O'connor, and Keogh (2014) showed a strong positive impact on learning and behavior. ...
Article
The present review synthesizes existing evidence and theory on the science of health care teams and health care team training. Ten observations are presented that capture the current state of the science, with applications to both researchers and practitioners. The observations are drawn from a variety of salient sources, including meta-analytic evidence, reviews of health care team training, primary investigations, and the authors’ collective expertise in developing and implementing medical team training. These observations provide insight into the team (e.g., psychological safety) and organizational-level (e.g., culture for teamwork) factors that drive effective health care teamwork, as well as advancements and best practices for designing and implementing team training initiatives (e.g., multilevel measurement). We highlight areas where new knowledge has emerged, and offer directions for future research that will continue to improve our understanding of health care teams in the future.
... Several broad observations about these projects are salient. First is that two of the three demonstration projects achieved some positive impacts on patient safety outcomes ( Burstein et al. 2016;Riley et al. 2016a,b). Second, although these demonstration projects also intended to assess the impact of best practice adoption on malpractice claiming, only one of the projects was successful in testing this possibility because of varied resource, data, and empirical design limitations. ...
Article
Objective: To identify lessons learned from the experience of the Agency for Healthcare Research and Quality (AHRQ) Patient Safety and Medical Liability (PSML) Demonstration Program. Data sources/study setting: On September 9, 2009, President Obama directed the Secretary of Health and Human Services to authorize demonstration projects that put "patient safety first" with the intent of reducing preventable adverse outcomes and stemming liability costs. Seven demonstration projects received 3 years of funding from AHRQ in the summer of 2010, and the program formally came to a close in June 2015. Study design: The seven grantees implemented complex, broad-ranging innovations addressing both patient safety and medical liability in "real-world" contexts. Some projects featured novel approaches, while others implemented adaptations of existing models. Each project was funded by AHRQ to collect data on the impact of its interventions. In addition, AHRQ funded a cross-cutting qualitative evaluation focused on lessons learned in implementing PSML interventions. Data collection/extraction methods: Site visits and follow-up interviews supplemented with material abstracted from formal project reports to AHRQ. Principal findings: The PSML demonstration projects focused on three broad approaches: (1) improving communication around adverse events through disclosure and resolution programs; (2) preventing harm through implementation of clinical "best practices"; and (3) exploring alternative methods of settling claims. Although the demonstration contributed to accumulating evidence that these kinds of interventions can positively affect outcomes, there is also evidence to suggest that these interventions can be difficult to scale. Conclusions: In addition to producing at least preliminary positive outcomes, the demonstration also lends credence to the idea that targeted interventions that improve some aspect of patient safety or malpractice performance may also contribute more broadly to institutional culture and the alignment of all parties around reducing risk and preventing harm. However, more empirical work needs to be carried out to quantify the effect of such interventions.
Article
As knowledge specialization increases, organizations need to find ways to integrate knowledge from different domains. Modern healthcare is a case in point. With increasingly complex patient conditions, hospitals need to create treatment routines which integrate knowledge from several different medical domains. However, such integration is inhibited by the boundaries resulting from disciplinary knowledge specialization, an aspect largely unexplored in theory on routine formation. Drawing on theory on routines and epistemic communities, this study investigates the dynamics involved in forming routines across disciplinary boundaries. An exploratory case study of the creation of new routines spanning different medical disciplines in breast cancer care is performed. The results indicate an iterative process of boundary spanning, internal analysis, and subsequent synthesis to form routines consistent with the practices of different disciplines.
Article
Objective: To develop and test of a measure of patient-centered care (PCC) culture in hospital-based perinatal care. Data sources: US perinatal hospitals; 1 provided survey development data and 14 contributed data for survey testing. Study design: We used qualitative and quantitative methods to develop the Mother-Infant Centered Care (MICC) culture survey. Qualitative methods included observation, focus group, interviews, and expert consultations to adapt items from other settings and create new items capturing dimensions of PCC articulated by The Commonwealth Fund. We quantitatively assessed survey psychometric properties using reliability (Cronbach's α and Pearson correlation coefficients) and validity (exploratory and confirmatory factor analysis [CFA]) statistics, and refined the survey. After confirming aggregation suitability (ICCs), we calculated "MICC culture scores" at the individual-, unit-, and hospital-level and assessed associations between scores and survey-collected, staff-reported outcomes to evaluate concurrent validity. Data collection: Survey development included 12 site-visit observations, one semi-structured focus group (five participants), two semi-structured interviews, five cognitive interviews, and three expert consultations. Survey testing used online surveys administered to obstetric and neonatal unit staff (N=316). Principal findings: Using responses from 10 hospitals with ≥4 responses from both units (n=240), the 20-item MICC culture survey demonstrated reliability (Cronbach's α=0.95) while capturing all PCC dimensions (subscale Cronbach's α=0.72-0.87). CFA showed validity through goodness-of-fit (overall chi-square=214 [p-value=0.012], SRMR=0.056, RMSEA=0.041, CFI=0.97, and TLI=0.96). Aggregation statistics (ICCs<0.05) justify unit- and hospital-level aggregation. Demonstrating preliminary validity, individual-, unit-, and hospital-level MICC culture scores were associated with all outcomes (satisfaction with care provided, within-unit team effectiveness, and relational coordination [RC] between units) (p-values<0.05), except for neonatal unit scores and RC (p-value=0.11). Conclusions: The MICC culture survey is a psychometrically sound measure of PCC culture for hospital-based perinatal care. Survey scores are associated with staff-reported outcomes. Future studies with patient outcomes will aid identification of improvement opportunities in perinatal care.
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This study used a cross-sectional survey design in an aim to compare the technology readiness (TR) of hospital-based nurse educators (HBNEs) that use highfidelity simulation (HFS) and those that do not use HFS in order to determine if a difference in TR might account for the lack of widespread adoption of HFS in the hospital setting. An online survey was administered to HBNEs from two national organizations: ANPD and SSH. Descriptive statistics and quantitative data analyses were conducted and reported as well as qualitative findings. Descriptive statistics revealed the average age of HBNE to be 45-46 years of age, possessing a master’s degree, and less than five years of experience as a nurse educator. Quantitative data analysis used for hypothesis testing did not reveal any statistical significance in TR between HBNE groups, however, additional qualitative inqury did reveal interesting insights with regard to desire to implement HFS, barriers to HFS adoption and use, and support for HFS adoption. This study adds to the limited body of knowledge regarding HFS adoption and use in the hospital-setting. Recommendations for future study include inquiry into barriers to HFS adoption and use in the hospital setting; TR of hospital administrators and perceptions of value are also recommended. Adviser: Justin Olmanson
Chapter
The current estimate of preventable harm is 440,000 lives harmed per year (James J Patient Saf 9:122–8, 2013). One can’t help but wonder why despite the multiple strategies devised for preventing adverse events, healthcare has not succeeded at achieving a sustainable patient safety platform that reduces adverse events. In fact by one estimate, healthcare is the third leading cause of death in the United States (US) (Makary et al. BMJ 353:i2139, 2016). It is in this landscape that a new immersive learning tool—namely simulation—is making an impact on improving the quality and safety of healthcare delivery. Simulation is an educational technique that replaces or amplifies real experiences with guided experiences in order to create a situation or environment to allow persons to experience a representation of a real event for the purpose of practice, learning, evaluation, testing, or to gain understanding of systems or human actions (Healthcare Simulation Dictionary. 1st ed. 2016. p. 33. www.ssih.org/dictionary). Simulation has been used by system engineers and human factor experts in industries outside of healthcare to better understand and improve service delivery by individuals, teams, and systems (Deutsch et al. Hum Factors 58:1082–95, 2016). This immersive learning strategy has particular relevance in high-stake industries, such as healthcare, which is challenged by a constant influx of trainees, high rates of staff turnover, and the need for continuing medical education to maintain skills (IOM. Redesigning continuing education in the health professions. Washington, D.C.: The National Academies Press; 2010). Simulation offers healthcare a strategy to improve the quality and safety of patient care.
Background: The Safety Program for Perinatal Care (SPPC) seeks to improve safety on labor and delivery (L&D) units through three mutually reinforcing components: (1) fostering a culture of teamwork and communication, (2) applying safety science principles to care processes; and (3) in situ simulation. The objective of this study was to describe the SPPC implementation experience and evaluate the short-term impact on unit patient safety culture, processes, and adverse events. Methods: We supported SPPC implementation by L&D units with a program toolkit, trainings, and technical assistance. We evaluated the program using a pre-post, mixed-methods design. Implementing units reported uptake of program components, submitted hospital discharge data on maternal and neonatal adverse events, and participated in semi-structured interviews. We measured changes in safety and quality using the Modified Adverse Outcome Index (MAOI) and other perinatal care indicators. Results: Forty-three L&D units submitted data representing 97,740 deliveries over 10 months of follow-up. Twenty-six units implemented all three program components. L&D staff reported improvements in teamwork, communication, and unit safety culture that facilitated applying safety science principles to clinical care. The MAOI decreased from 5.03% to 4.65% (absolute change -0.38% [95% CI, -0.88% to 0.12%]). Statistically significant decreases in indicators for obstetric trauma without instruments and primary cesarean delivery were observed. A statistically significant increase in neonatal birth trauma was observed, but the overall rate of unexpected newborn complications was unchanged. Conclusions: The SPPC had a favorable impact on unit patient safety culture and processes, but short-term impact on maternal and neonatal adverse events was mixed.
Chapter
Simulation-based medical education and simulation-based validation of training are growing tools to allow for skill development in an environment where mistakes can result in harm to patients and physicians or staff. While the method has been slow to be adopted by subspecialties, medical schools and residencies are developing robust programs as a response to a changing paradigm in healthcare where hours are restricted but efficiency and quality are expected. To accommodate the growing demands of learners and create a high-yield teaching environment, simulation-based medical education is being developed for many cardiac procedures. Unfortunately, simulators are often used solely as a method to familiarize a learner with the device. However, when used properly and within a planned curriculum, a comprehensive simulation-based medical education program can be an effective tool, enhancing the learner’s engagement, and can be developed with the goal of improving measured healthcare outcomes. Lastly, simulation-based medical education and training may be used to validate particular skill sets and define proficiency, and may even have a future role in accreditation.
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In obstetrics, a nationally accepted set of quality indicators for patient safety was not available in the United States until the development of a set of 10 adverse outcome measures-the Adverse Outcome Index (AOI). The National Perinatal Information Center (NPIC) developed hospital discharge data-based algorithms combined with a small set of supplemental patient data for calculation of the AOI. A study was conducted to determine the specificity, sensitivity, positive predictive value (PPV), and negative predictive value (NPV) of the AOI by using the National Perinatal Information Center (NPIC) algorithm. A retrospective chart review of 4,252 obstetrical and neonatal charts from 2003 through 2007 was performed. NPIC definitions were compared with the "gold standard"-chart review. A total of 229 deliveries among the 4,000 randomly selected charts had at least one adverse outcome, reflecting an AOI of 5.7%. For detection of the 10 adverse outcomes within the AOI, the overall sensitivity of the AOI was 81.7%, specificity was 98.2%, PPV was 86.3%, and NPV was 97.4%. The Kappa value for agreement between the coded charts and the chart review was 0.82 (standard deviation = 0.01, 95% confidence interval [CI] = 0.80-0.85), which is considered very good. The AOI is highly reliant on accurate coding and provider documentation and requires validation with manual chart review. Concurrent chart review improves the accuracy of the AOI. Caution is advised when using the AOI as an exclusive measure of assessing obstetric quality because it may be heavily influenced by a single outcome measure; perineal laceration rates represented twice the frequency of all other outcomes combined. The AOI should be modified to better measure preventable adverse events and include a means of accounting for preexisting conditions.
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Background Bloodstream infections from central venous catheters (CVC-BSIs) increase morbidity and costs in intensive care units (ICUs). Substantial reductions in CVC-BSI rates have been reported using a combination of technical and non-technical interventions. Methods We conducted a 2-year, four-cluster, stepped non-randomised study of technical and non-technical (behavioural) interventions to prevent CVC-BSIs in adult and paediatric ICUs in England. Random-effects Poisson regression modelling was used to compare infection rates. A sample of ICUs participated in data verification. Results Of 223 ICUs in England, 215 (196 adult, 19 paediatric) submitted data on 2479 of 2787 possible months and 147 (66%) provided complete data. The exposure rate was 438 887 (404 252 adult and 34 635 paediatric) CVC-patient days. Over 20 months, 1092 CVC-BSIs were reported. Of these, 884 (81%) were ICU acquired. For adult ICUs, the mean CVC-BSI rate decreased over 20 months from 3.7 in the first cluster to 1.48 CVC-BSIs/1000 CVC-patient days (p<0.0001) for all clusters combined, and for paediatric ICUs from 5.65 to 2.89 (p=0.625). The trend for infection rate reduction did not accelerate following interventions training. CVC utilisation rates remained stable. Pre-ICU infections declined in parallel with ICU-acquired infections. Criterion-referenced case note review showed high agreement between adjudicators (κ 0.706) but wide variation in blood culture sampling rates and CVC utilisation. Generic infection control practices varied widely. Conclusions The marked reduction in CVC-BSI rates in English ICUs found in this study is likely part of a wider secular trend for a system-wide improvement in healthcare-associated infections. Opportunities exist for greater harmonisation of infection control practices. Future studies should investigate causal mechanisms and contextual factors influencing the impact of interventions directed at improving patient care.
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Objective: To determine whether obstetric team training in a medical simulation centre improves the team performance and utilisation of appropriate medical technical skills of healthcare professionals. Design: Cluster randomised controlled trial. Setting: The Netherlands. Sample: The obstetric departments of 24 Dutch hospitals. Methods: The obstetric departments were randomly assigned to a 1-day session of multiprofessional team training in a medical simulation centre or to no such training. Team training was given with high-fidelity mannequins by an obstetrician and a communication expert. More than 6 months following training, two unannounced simulated scenarios were carried out in the delivery rooms of all 24 obstetric departments. The scenarios, comprising a case of shoulder dystocia and a case of amniotic fluid embolism, were videotaped. The team performance and utilisation of appropriate medical skills were evaluated by two independent experts. Main outcome measures: Team performance evaluated with the validated Clinical Teamwork Scale (CTS) and the employment of two specific obstetric procedures for the two clinical scenarios in the simulation (delivery of the baby with shoulder dystocia in the maternal all-fours position and conducting a perimortem caesarean section within 5 minutes for the scenario of amniotic fluid embolism). Results: Seventy-four obstetric teams from 12 hospitals in the intervention group underwent teamwork training between November 2009 and July 2010. The teamwork performance in the training group was significantly better in comparison to the nontraining group (median CTS score: 7.5 versus 6.0, respectively; P = 0.014). The use of the predefined obstetric procedures for the two clinical scenarios was also significantly more frequent in the training group compared with the nontraining group (83 versus 46%, respectively; P = 0.009). Conclusions: Team performance and medical technical skills may be significantly improved after multiprofessional obstetric team training in a medical simulation centre.
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Ascension Health identified perinatal safety as one of eight priorities for action in a systemwide effort to achieve zero preventable injuries and deaths by July 2008. Three alpha sites developed and implemented transformational practices aimed at eliminating preventable birth trauma. Standardized order sets linked to all major areas of obstetrical care were either updated or developed and then tested and incorporated into the work flow of the labor and delivery units. Best practices were shared via team meetings and conference calls. Each site created systems to ensure that evidence-based practices were reliably followed for high-risk conditions associated with perinatal harm, that robust strategies for communication were adopted, and that collaborative practice was promoted among caregivers. By June 2006, all facilities achieved birth trauma rates that were at or near zero in conjunction with the implementation of these practices. Three alpha sites of differing size, patient demographics, and available resources, using a combined uniform and facility-specific approach, achieved a significant reduction in the incidence of birth trauma. Yet each site adopted unique site-specific processes designed to enhance practice on the basis of unit or institutional culture, market challenge, and/or the prospect for success.
Chapter
Measuring and managing for team performance: Emerging principles from complex environments" Teamwork has always been an important component of successful military operations. However, as the nature of military operations evolves in the post-cold war era, the ability of teams to work effectively in a dynamic and complex environment may play an even more critical role. As the nature of military organizations evolves and becomes more complex, it will be important to understand why some teams function better than others and how to instill the requisite skills in numerous geographically dispersed teams. The authors of this paper extracted twenty principles of teamwork from studies of decision making teams working in three complex tactical naval settings. Nine of the principles regard the nature of teamwork; seven regard team leadership; four regard the roles of individual team members. The findings presented here provide suggestions for managing teams effectively, measuring team performance, and for training teams in complex settings. They have application to peacekeeping operations, which are highly complex.
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Many 21st century operations are characterised by teams of workers dealing with significant risks and complex technology, in competitive, commercially-driven environments. Informed managers in such sectors have realised the necessity of understanding the human dimension to their operations if they hope to improve production and safety performance. While organisational safety culture is a key determinant of workplace safety, it is also essential to focus on the non-technical skills of the system operators based at the 'sharp end' of the organisation. These skills are the cognitive and social skills required for efficient and safe operations, often termed Crew Resource Management (CRM) skills. In industries such as civil aviation, it has long been appreciated that the majority of accidents could have been prevented if better non-technical skills had been demonstrated by personnel operating and maintaining the system. As a result, the aviation industry has pioneered the development of CRM training. Many other organisations are now introducing non-technical skills training, most notably within the healthcare sector. Safety at the Sharp End is a general guide to the theory and practice of non-technical skills for safety. It covers the identification, training and evaluation of non-technical skills and has been written for use by individuals who are studying or training these skills on CRM and other safety or human factors courses. The material is also suitable for undergraduate and post-experience students studying human factors or industrial safety programmes. © Rhona Flin, Paul O'Connor and Margaret Crichton 2008. All rights reserved.
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Intrapartum electronic fetal monitoring (EFM) is used for most women who give birth in the United States. As such, clinicians are faced daily with the management of fetal heart rate (FHR) tracings. The purpose of this document is to provide obstetric care providers with a framework for evaluation and management of intrapartum EFM patterns based on the new three-tiered categorization.
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To establish the feasibility of implementing a previously-published clinical standardized performance indicator, the Adverse Outcome Index (AOI), using routinely-collected data in a population-based perinatal database and to examine variation in the indicator over time and between hospitals. Maternal and newborn medical record data contained in the British Columbia Perinatal Data Registry, 2004-2013, were used to calculate an AOI (a composite of 10 maternal and newborn adverse events) and its severity-weighted scores, the Weighted Adverse Outcome Score and the Severity Index. Temporal trends in the indices were examined by plotting annual risks and weighted risks with 95 % confidence intervals. Hospital-level risks were calculated with 95 % confidence intervals, adjusting for patient case-mix. Among 410,054 singleton deliveries in British Columbia, the risk of AOI was 5.8 per 100, while the Weighted Adverse Outcome Score and Severity Index were 1.6 and 27.4, respectively. The risk of AOI did not change significantly over the study period, while the Severity Index decreased from 29.3 (95 % CI 26.7-31.9) in 2004 to 23.9 (22.0-25.8) in 2013. Fifteen of 52 hospitals had risks of AOI significantly above the provincial median. The hospitals' risks of AOI were not correlated with their Severity Indices (r = 0.02). The AOI can successfully be estimated using data from a population-based database, and used to monitor trends in safety of labour and delivery over time and between hospitals. The low correlation between frequency and severity of adverse events confirms the importance of considering event severity in perinatal population health surveillance.
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Background: This study examines a national perinatal quality improvement collaborative designed to create high reliability through the use of evidence-based perinatal care bundles. The objective of this study is to determine whether hospitals serving low-income patient populations experienced lower compliance with perinatal care bundles than hospitals serving higher-income patient populations Objective: We investigated the relationship between the rate of perinatal bundle compliance within a hospital and the economic characteristics of the patients and surrounding community. We hypothesized a negative relationship between poverty and care bundle compliance. Methods: Using prospective data from 131,847 births over 34 months within 16 hospitals located in cities across the United States, we examined the relationship between compliance with evidence-based obstetrical care bundles and three measures of the poverty status of the patient population served and the hospital service area: 1) proportion of the obstetrical patients with Medicaid as the primary payer, 2) median income in the hospital service area, and 3) poverty rate in the hospital’s service area. Results: The findings indicate no difference in bundle compliance rates in relation to the economic characteristics of the participating hospitals and their patients. Conclusions: While previous research has indicated that patients of lower socioeconomic status are less likely to receive high quality care, the findings in this study indicate that hospital compliance with evidence-based perinatal care bundles did not differ by economic characteristics of the hospital service area. These results indicate uniformity of care across hospitals irrespective of patient economic characteristics.
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There is no question that interdisciplinary teams are becoming ubiquitous in healthcare. It is also true that experts do not necessarily combine to make an expert team. However when teams work well they can serve as adaptive systems that allow organisations to mitigate errors within complex domains, thereby increasing safety. The medical community has begun to recognise the importance of teams and as such has begun to implement team training interventions. Over the past 20 years the military and aviation communities have made a large investment in understanding teams and their requisite training requirements. There are many lessons that can be learned from these communities to accelerate the impact of team training within the medical community. Therefore, the purpose of the current paper is to begin to translate some of the lessons learned from the military and aviation communities into practical guidance that can be used by the medical community.
Article
The Institute for Healthcare Improvement applies a systems-focused, science-based approach to improving perinatal care. This approach is based on the pioneering work in quality improvement and statistical process control performed by Walter Shewhart and W. Edwards Deming, and it uses the Model for Improvement, a simple and effective tool for accelerating improvement. In 2008, the Institute for Healthcare Improvement articulated a Triple Aim for improvement-better care, better health for populations, and lower per capita costs. The Triple Aim has become a guiding framework throughout health care and also guides much of the work of the Institute for Healthcare Improvement. The Institute for Healthcare Improvement's collaborative effort to improve perinatal care-the Perinatal Improvement Community-is an ideal example of work that pursues all three dimensions of the Triple Aim. The improvement method used in the community creates the foundation for the kind of cultural transformation that Perinatal Improvement Community leaders and participants have learned is necessary to make significant and lasting change. Using a systems-focused and science-based approach to improvement equips obstetricians and gynecologists with the knowledge, skills, and tools they need to improve the systems of care they work in so they can deliver the best evidence-based care to all of their patients, all of the time.
Article
Idealized Design of Perinatal Care is an innovation project based on the principles of reliability science and the Institute for Healthcare Improvement's (IHI's) model for applying these principles to improve care.¹ The project builds upon similar processes developed for other clinical arenas in three previous IHI Idealized Design projects. The Idealized Design model focuses on comprehensive redesign to enable a care system to perform substantially better in the future than the best it can do at present. The goal of Idealized Design of Perinatal Care is to achieve a new level of safer, more effective care and to minimize some of the risks identified in medical malpractice cases.
Article
Healthcare safety and quality are critically important issues in obstetrics, and society, healthcare providers, patients and insurers share a common goal of working toward safer practice, and are continuously seeking strategies to facilitate improvements. To this end, 4 New York City voluntary hospitals with large maternity services initiated a unique collaborative quality improvement program. It was facilitated by their common risk management advisors, FOJP Service Corporation, and their professional liability insurer, Hospitals Insurance Company. Under the guidance of 4 obstetrics and gynecology departmental chairmen, consensus best practices for obstetrics were developed which included: implementation of evidence based protocols with audit and feedback; standardized educational interventions; mandatory electronic fetal monitoring training; and enhanced in-house physician coverage. Each institution developed unique safety related expertise (development of electronic documentation, team training, and simulation education), and experiences were shared across the collaborative. The collaborative group developed robust systems for audit of outcomes and documentation quality, as well as enforcement mechanisms. Ongoing feedback to providers served as a key component of the intervention. The liability carrier provided financial support for these patient safety innovations. As a result of the interventions, the overall AOI for our institutions decreased 42% from baseline (January-June 2008) to the most recently reviewed time period (July-December 2011) (10.7% vs 6.2%, p < 0.001). The Weighted Adverse Outcome Score (WAOS) also decreased during the same time period (3.9 vs 2.3, p = 0.001.) Given the improved outcomes noted, our unique program and the process by which it was developed are described in the hopes that others will recognize collaborative partnering with or without insurers as an opportunity to improve obstetric patient safety.
Although costs of providing care may decrease with hospital initiatives to improve obstetric and neonatal outcomes, the accompanying reduced adverse outcomes may negatively affect hospital revenues. In 2008 a Minnesota-based hospital system (Fairview Health Services) launched the Zero Birth Injury (ZBI) initiative, which used evidence-based care bundles to guide management of obstetric services. A pre-post analysis of financial impacts of ZBI was conducted by using hospital administrative records to measure costs and revenues associated with changes in maternal and neonatal birth injuries before (2008) and after (2009-2011) the initiative. For the Fairview Health Services hospitals, after adjusting for relevant covariates, implementation of ZBI was associated with a mean 11% decrease in the rate of maternal and neonatal adverse outcomes between 2008 and 2011 (adjusted odds ratio [AOR] = 0.89, p = .076). As a result of the adverse events avoided, the hospital system saved $284,985 in costs but earned $324,333 less revenue, which produced a net financial decrease of $39,348 (or a $305 net financial loss per adverse event avoided) in 2011, compared with 2008. Adoption of a perinatal quality and safety initiative that reduced birth injuries had little net financial impact on the hospital. ZBI produced better clinical results at a lower cost, which represents potential savings for payers, but the hospital system offering improved quality reaped no clear financial rewards. These results highlight the important role for shared-savings collaborations (among patients, providers, government and third-party payers, and employers) to incentivize QI. Widespread adoption of perinatal safety initiatives combined with innovative payment models may contribute to better health at reduced cost.
Article
This paper is concerned with defining organizational processes necessary to operate safely technologically complex organizations that can do great physical harm to themselves and their surrounding environments. The paper first argues that existing organizational research is little help in understanding organizational processes in such organizations It then identities nuclear powered aircraft earners as examples of potentially hazardous organizations with histories of excellent operations The paper then examines a set of components of "risk" identified by Perrow (1984) and antecedents to catastrophe elucidated by Shrivastava (1986) and discusses how carriers deal with these factors to lessen their potentially negative effects. The paper concludes with suggestions for future research.
Background: Ascension Health identified perinatal safety as one of eight priorities for action in a systemwide effort to achieve zero preventable injuries and deaths by July 2008.Implementation: Three alpha sites developed and implemented transformational practices aimed at eliminating preventable birth trauma. Standardized order sets linked to all major areas of obstetrical care were either updated or developed and then tested and incorporated into the work flow of the labor and delivery units. Best practices were shared via team meetings and conference calls. Each site created systems to ensure that evidence-based practices were reliably followed for high-risk conditions associated with perinatal harm, that robust strategies for communication were adopted, and that collaborative practice was promoted among caregivers.Results: By June 2006, all facilities achieved birth trauma rates that were at or near zero in conjunction with the implementation of these practices.Discussion: Three alpha sites of differing size, patient demographics, and available resources, using a combined uniform and facility-specific approach, achieved a significant reduction in the incidence of birth trauma. Yet each site adopted unique site-specific processes designed to enhance practice on the basis of unit or institutional culture, market challenge, and/or the prospect for success.
In situ drills are a key adjunct to evidence-based protocols and established educational programs. Well-planned and conducted drills can further reinforce important educational concepts concerning high-risk events such as maternal hemorrhage, allow the team to develop skills to improve performance, and uncover systems errors. Evaluation of the findings from the drills and topics discussed during debriefing can lead to optimized training and refinement of the patient care setting to support an optimal environment for patient care and safety.
Article
Surgical trainees must maximise the educa- tional and developmental opportunities of time spent in the operating theatre. Post-operative debriefing on perfor- mance based on observed skills is one way of achieving this and is regularly done in other high-risk professions. The non-technical skills for surgeons (NOTSS) behaviour rating system allows surgeons to observe trainees' behav- iour in the workplace and provide feedback for skill improvement in a structured manner. This paper describes the process of debriefing using NOTSS and presents the results of a usability trial. Two case studies also illustrate how the system was used. The majority of surgical trainers who participated reported that the NOTSS system provided a common language to discuss non-technical skills and was a valuable adjunct to currently available assessment tools. Some trainers found interpersonal skills more difficult to rate than cognitive skills but 73% (n = 8) felt that routine use of the system would enhance patient safety.
Article
A comprehensive perinatal safety initiative (PSI) was incrementally introduced from August 2007 to July 2009 at a large tertiary medical center to reduce adverse obstetrical outcomes. The PSI introduced: (1) evidence-based protocols, (2) formalized team training with emphasis on communication, (3) standardization of electronic fetal monitoring with required documentation of competence, (4) a high-risk obstetrical emergency simulation program, and (5) dissemination of an integrated educational program among all healthcare providers. Eleven adverse outcome measures were followed prospectively via modification of the Adverse Outcome Index (MAOI). Additionally, individual components were evaluated. The logistic regression model found that within the first year, the MAOI decreased significantly to 0.8% from 2% (p<.0004) and was maintained throughout the 2-year period. Significant decreases over time for rates of return to the operating room (p<.018) and birth trauma (p<.0022) were also found. Finally, significant improvements were found in staff perceptions of safety (p<.0001), in patient perceptions of whether staff worked together (p<.028), in the management (p<.002), and documentation (p<.0001) of abnormal fetal heart rate tracings, and the documentation of obstetric hemorrhage (p<.019). This study demonstrates that a comprehensive PSI can significantly reduce adverse obstetric outcomes, thereby improving patient safety and enhancing staff and patient experiences.
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. 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. 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. 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.
Article
We evaluated the implementation of a labor and delivery unit team training program that included didactic sessions and simulation training with an active clinical unit. Over an 18-month follow-up time period, our team training program showed improvements in patient outcomes as well as in perceptions of patient safety including the dimensions of teamwork and communication.
Background: Evidence from other high-risk industries has demonstrated that teamwork skills can be taught and effective teamwork may improve safety. Increasingly, health care providers, hospital administrators, and quality and safety professionals are considering simulation as a strategy to improve quality and patient safety. Mobile obstetric simulation and team training program: A mobile obstetric emergency simulation and team training program was created to bring simulation technology and teamwork training used routinely in other high reliability fields directly to health care institutions. A mobile unit constituted a practical approach, given the expense of simulation equipment, the time required for staff to develop educational materials and simulation scenarios, and the need to have a standardized program to promote consistent evaluation across sites. Between 2007 and 2009, in situ simulation of obstetric emergencies and teamwork training was tested with more than 150 health care professionals in labor and delivery units across four rural and two community hospitals in Oregon. HOW DO ORGANIZATIONS DETERMINE WHICH TYPE OF SIMULATION IS BEST FOR THEM? Because simulation technologies are relatively costly to start and maintain, it can be challenging for hospitals and health care professionals to determine which format (send staff to a simulation center, develop in-house simulation program, develop a consortium of hospitals that run a simulation program, or use a mobile simulation program) is best for them. Conclusions: In situ simulation is an effective way to develop new skills, to maintain infrequently used clinical skills even among experienced clinical teams, and to uncover and address latent safety threats in the clinical setting.
Article
In Reason's 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. 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. 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. In Reason's 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.
Article
To develop a model for high reliability in health care quality and patient safety. A high-reliability health organization (HRO) has measurable near perfect performance in quality and safety. High reliability is necessary in health care where the consequences of error are high and the frequency is low. Despite a decade of intense focus on quality and safety since a series of reports from the Institute of Medicine (IOM), health care is not a completely safe industry and quality is not what it should be to ensure high reliability for patients. A model for high reliability is presented that includes the individual skills necessary to assure high-reliability teams on a patient care unit. High-reliability teams (HRT) form an essential core of a HRO. These teams and their organizations value a culture of safety every day with every patient encounter. Nurse managers can lead in creating a HRO by first developing HRTs on their patient care unit.
Article
We implemented a comprehensive strategy to track and reduce adverse events. We incrementally introduced multiple patient safety interventions from September 2004 through November 2006 at a university-based obstetrics service. This initiative included outside expert review, protocol standardization, the creation of a patient safety nurse position and patient safety committee, and training in team skills and fetal heart monitoring interpretation. We prospectively tracked 10 obstetrics-specific outcome. The Adverse Outcome Index, an expression of the number of deliveries with at least 1 of the 10 adverse outcomes per total deliveries, was analyzed for trend. Our interventions significantly reduced the Adverse Outcome Index (linear regression, r(2) = 0.50; P = .01) (overall mean, 2.50%). Concurrent with these improvements, we saw clinically significant improvements in safety climate as measured by validated safety attitude surveys. A systematic strategy to decrease obstetric adverse events can have a significant impact on patient safety.
In April 2008, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the American College of Obstetricians and Gynecologists, and the Society for Maternal-Fetal Medicine partnered to sponsor a 2-day workshop to revisit nomenclature, interpretation, and research recommendations for intrapartum electronic fetal heart rate monitoring. Participants included obstetric experts and representatives from relevant stakeholder groups and organizations. This article provides a summary of the discussions at the workshop. This includes a discussion of terminology and nomenclature for the description of fetal heart tracings and uterine contractions for use in clinical practice and research. A three-tier system for fetal heart rate tracing interpretation is also described. Lastly, prioritized topics for future research are provided.
Article
(1) Human rather than technical failures now represent the greatest threat to complex and potentially hazardous systems. This includes healthcare systems. (2) Managing the human risks will never be 100% effective. Human fallibility can be moderated, but it cannot be eliminated. (3) Different error types have different underlying mechanisms, occur in different parts of the organisation, and require different methods of risk management. The basic distinctions are between: Slips, lapses, trips, and fumbles (execution failures) and mistakes (planning or problem solving failures). Mistakes are divided into rule based mistakes and knowledge based mistakes. Errors (information-handling problems) and violations (motivational problems) Active versus latent failures. Active failures are committed by those in direct contact with the patient, latent failures arise in organisational and managerial spheres and their adverse effects may take a long time to become evident. (4) Safety significant errors occur at all levels of the system, not just at the sharp end. Decisions made in the upper echelons of the organisation create the conditions in the workplace that subsequently promote individual errors and violations. Latent failures are present long before an accident and are hence prime candidates for principled risk management. (5) Measures that involve sanctions and exhortations (that is, moralistic measures directed to those at the sharp end) have only very limited effectiveness, especially so in the case of highly trained professionals. (6) Human factors problems are a product of a chain of causes in which the individual psychological factors (that is, momentary inattention, forgetting, etc) are the last and least manageable links.(ABSTRACT TRUNCATED AT 250 WORDS)
Article
Surgical simulators are being promoted as a means of assessing a surgeon's technical skills. Little evidence exists that simulator performance correlates with actual technical ability. This study was undertaken to determine the criterion and construct validity of currently available surgical simulations in the evaluation of technical skill. Simulator assessment was carried out on 36 basic surgical trainees, 37 surgically naïve first-year medical students and 16 experienced general surgical consultants. Some 26 trainees and 36 students underwent repeat assessment after 6 months. A previously validated, 19-point technical skill assessment form, based on direct observation of trainee performance in the operating theatre, was also completed by each trainee's supervising consultant. An insignificant or weak correlation was found between simulator performance and both duration of basic surgical experience and consultant assessment of technical skill. Six months of basic surgical training led to an improvement in performance, not seen in an untrained control group, in only one of the six simulations tested. Discrimination between surgically naïve and experienced subjects was only demonstrated, in part, for four of the six tasks. The assessment of technical skill needs to be improved. Work is needed to establish the reliability and validity of currently available simulation models before they are formally introduced for high-stakes assessment.
Article
To minimize patient harm and injury, it's important that perinatal nurses, and those who care for women in the perinatal setting, be familiar with themes commonly associated with patient harm and accidents. These five cases will help determine whether an accident framework would be useful for a better understanding of causation, and using such a framework, strategies designed to decrease the probability of recurrence will be discussed, thereby increasing patient safety as well as minimizing adverse consequences to providers.
Article
Intensive efforts are under way to improve health care quality and safety throughout the United States and abroad. Many of these efforts use the quality improvement collaborative method, an approach emphasizing collaborative learning and exchange of insights and support among a set of health care organizations. Unfortunately, the widespread acceptance and reliance on this approach are based not on solid evidence but on shared beliefs and anecdotal affirmations that may overstate the actual effectiveness of the method. More effective use of the collaborative method will require a commitment by users, researchers, and other stakeholders to rigorous, objective evaluation and the creation of a valid, useful knowledge and evidence base. Development of this evidence base will require improved conceptions of the nature of quality problems, quality improvement processes, and the types of research needed to elucidate these processes. Researchers, journal editors, and funding agencies must also cooperate to ensure that published evaluations are relevant, comprehensive, and cumulative.
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There is no question that interdisciplinary teams are becoming ubiquitous in healthcare. It is also true that experts do not necessarily combine to make an expert team. However when teams work well they can serve as adaptive systems that allow organisations to mitigate errors within complex domains, thereby increasing safety. The medical community has begun to recognise the importance of teams and as such has begun to implement team training interventions. Over the past 20 years the military and aviation communities have made a large investment in understanding teams and their requisite training requirements. There are many lessons that can be learned from these communities to accelerate the impact of team training within the medical community. Therefore, the purpose of the current paper is to begin to translate some of the lessons learned from the military and aviation communities into practical guidance that can be used by the medical community.
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Organizations are increasingly becoming dynamic and unstable. This evolution has given rise to greater reliance on teams and increased complexity in terms of team composition, skills required, and degree of risk involved. High-reliability organizations (HROs) are those that exist in such hazardous environments where the consequences of errors are high, but the occurrence of error is extremely low. In this article, we argue that teamwork is an essential component of achieving high reliability particularly in health care organizations. We describe the fundamental characteristics of teams, review strategies in team training, demonstrate the criticality of teamwork in HROs and finally, identify specific challenges the health care community must address to improve teamwork and enhance reliability.
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To evaluate the effect of teamwork training on the occurrence of adverse outcomes and process of care in labor and delivery. A cluster-randomized controlled trial was conducted at seven intervention and eight control hospitals. The intervention was a standardized teamwork training curriculum based on crew resource management that emphasized communication and team structure. The primary outcome was the proportion of deliveries at 20 weeks or more of gestation in which one or more adverse maternal or neonatal outcomes or both occurred (Adverse Outcome Index). Additional outcomes included 11 clinical process measures. A total of 1,307 personnel were trained and 28,536 deliveries analyzed. At baseline, there were no differences in demographic or delivery characteristics between the groups. The mean Adverse Outcome Index prevalence was similar in the control and intervention groups, both at baseline and after implementation of teamwork training (9.4% versus 9.0% and 7.2% versus 8.3%, respectively). The intracluster correlation coefficient was 0.015, with a resultant wide confidence interval for the difference in mean Adverse Outcome Index between groups (-5.6% to 3.2%). One process measure, the time from the decision to perform an immediate cesarean delivery to the incision, differed significantly after team training (33.3 minutes versus 21.2 minutes, P=.03). Training, as was conducted and implemented, did not transfer to a detectable impact in this study. The Adverse Outcome Index could be an important tool for comparing obstetric outcomes within and between institutions to help guide quality improvement. (www.ClinicalTrials.gov), NCT00381056 I.
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Unlabelled: Obstetric admissions are the leading cause of hospitalization for women in the United States, accounting for over 4 million hospital discharges each year. Measuring the quality of inpatient obstetrical care provided to these women is becoming increasingly important to patients, providers, and insurers. While numerous quality measures have been proposed, there is no agreement as to which measures should be used. An ideal quality measure for inpatient obstetrics would encompass 5 major characteristics: 1) association with meaningful maternal and neonatal outcomes, 2) relation to outcomes that are influenced by physician/health system behaviors, 3) affordability for application on a large scale basis, 4) acceptability to practicing obstetricians as a meaningful marker of quality, and 5) reliability/reproducibility. Traditional quality measurement tools such as maternal mortality, neonatal mortality and cesarean delivery rate are flawed measures. New measurements such as risk-adjusted primary cesarean rates, the nulliparous term singleton vertex cesarean birth (NTSV) rate, and the Adverse Outcomes Index (AOI) are currently being studied but these measures require further validation before widespread adoption. Target audience: Obstetricians & Gynecologists, Family Physicians Learning objectives: After completion of this article, the reader should be able to summarize that quality measures of inpatient obstetrical care are numerous, explain that no one agrees on which measures should be used, and state that newer measures, once validated, should be considered.