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What Is the Return on Investment for Implementation of a Crew Resource Management Program at an Academic Medical Center?
Abstract
Crew Resource Management (CRM) training has been used successfully within hospital units to improve quality and safety. This article presents a description of a health system-wide implementation of CRM focusing on the return on investment (ROI). The costs included training, programmatic fixed costs, time away from work, and leadership time. Cost savings were calculated based on the reduction in avoidable adverse events and cost estimates from the literature. Between July 2010 and July 2013, roughly 3000 health system employees across 12 areas were trained, costing 12.6 million to as much as 9.1 to $24.4 million. CRM presents a financially viable way to systematically organize for quality improvement.
... 9À15 Furthermore, a recent study in the United States showed that implementation of a CRM program has a high return on investment. 16 Studies have shown a large variety in content and outcomes: some studies found a positive effect on patient outcomes, while others did not find an effect. 9,13,17À19 Could this be because there is a difference of views between CRM trainers? ...
... 24 Lastly, few studies have been performed on the costbenefit analysis of CRM implementation in the medical field. One study by Moffatt-Bruce et al. (2019) showed that the implementation of CRM in medicine has led to fewer avoidable patient harm, mostly from fewer medicine errors. This study estimated that this created a positive return on investment. ...
... Of course, controlling for confounding factors is very difficult in a large-scale study and further research on this subject is desirable. 16 ...
Objective
Medical Crew Resource Management (CRM) training courses are designed to increase patient safety by reducing the effects of human errors. These training courses are most popular in surgery and a wide range of medical CRM training courses for surgical teams is now available. However, the effects of these CRM training courses on patient outcomes are inconclusive. Although surgical teams feel the need to be trained in team collaboration skills, they are often puzzled about what criteria to apply when choosing a medical CRM training course. This study aimed to compare CRM training courses on didactic components and simulation-exercises to explore if these courses are interchangeable.
Methods
In this qualitative study, semi-structured interviews were conducted among 10 main CRM training providers of surgical teams in the Netherlands.
Results
Although a large variety was found in the content of CRM training courses, the most substantial differences were found in the simulation-exercises. Nine out of 10 trainers stated that standard simulation-exercises would be a step forward to ensure quality in CRM trainings. According to the trainers, the implementation of medical CRM can reduce human errors and as a result, preventable patient complications. They suggested a quality standard for CRM trainers in the medical field to ensure the quality of medical team training as a way to reach this.
Conclusions
Medical CRM training courses are diverse and noninterchangeable. Trainers expect that if CRM becomes part of surgical training and is embedded in operating theatre culture, it could be of great value for patients and professionals.
... The transfer of essential elements of the aviation safety culture such as CRM training to the medical sector has been demonstrated to increase patient safety in hospitals [22]. Despite the costs of CRM training, it presents a financially viable way to systematically organize for quality improvement due to cost savings based on the reduction in avoidable adverse events [23]. In this context, the purpose of this study was to determine whether patient safety and employee satisfaction in hospitals may benefit from the engagement of highly trained medical professionals working in both air rescue service and medical facilities. ...
Background: Air rescue crew members work equally in aviation and medicine, and thus occupy an important interface between the two work environments of aviation and medicine. The aim of this study was to obtain responses from participants to a validated online-based questionnaire regarding whether hospitals may benefit from the commitment of a medical hospital staff which is also professionally involved in the aviation system as emergency physicians and Helicopter Emergency Medical Services Technical Crew Members (HEMS TC). Furthermore, it focused on the question of whether the skills acquired through Crew Resource Management (CRM) training in the air rescue service might also be used in the ground-based rescue service and, if so, whether they may have a positive effect. Methods: Medical air rescue staff of 37 German air rescue stations was included. Between 27 November 2020 and 03 March 2021, 253 out of 621 employees (response rate: 40.7%) participated voluntarily in a validated anonymized online survey. A quantitative test procedure was performed using the modified questionnaire on teamwork and patient safety (German version). Results: The examination and interpretation of the internal consistency (Cronbach’s alpha) resulted in the following reliabilities: Factor I (Cooperation): α = 0.707 (good); Factor II (Human factors): α = 0.853 (very good); Factor III (Communication): α = 0.657 (acceptable); and Factor IV (Safety): α = 0.620 (acceptable). Factor analysis explained 53.1% of the variance. Conclusions: The medical clinicians participating in this online survey believed that the skills they learned in human factors training such as CRM are helpful in their daily routine work in hospitals or other medical facilities, as well as in their ground-based rescue service activities. These findings may result in the recommendation to make CRM available on a regular to the medical staff in all medical facilities and also to ground-based rescue service staff aiming to increase patient safety and employee satisfaction.
... Our secondary analysis, capturing both workflow overhaul and simulation training (Figure 1b), allows an estimate of the effectiveness of the trial interventions under optimal institutional adherence to con- [15,32,33]. Therefore, future research needs to focus on barriers and enablers of simulation training for stroke teams in order to promote a more widespread use. ...
Background
The objective of the STREAM trial was to evaluate the effect of simulation training on process times in acute stroke care.
Methods
The multicenter prospective interventional STREAM trial was conducted between 10/2017 and 04/2019 at seven tertiary care neurocenters in Germany with a pre- and post-interventional observation phase. We recorded patient characteristics, acute stroke care process times, stroke team composition and simulation experience for consecutive direct-to-center patients receiving i.v. thrombolysis (IVT) and/or endovascular therapy (EVT). The intervention consisted of a composite intervention centered around stroke-specific in situ simulation training. Primary outcome measure was the ‘door-to-needle’ time (DTN) for IVT. Secondary outcome measures included process times of EVT and measures taken to streamline the preexisting treatment algorithm.
Results
The effect of the STREAM intervention on the process times of all acute stroke operations was neutral. However, secondary analyses showed a DTN reduction of 5 min from 38 min pre (interquartile range [IQR] 25 – 43 min) to 33 min (IQR 23 – 39 min), p = 0.03) post intervention achieved by simulation-experienced stroke teams. Concerning EVT, we found significantly shorter door-to-groin times in patients who were treated by teams with simulation experience as compared to simulation-naive teams in the post interventional phase (-21 min, simulation-naive: 95 min, IQR 69 – 111 vs. simulation-experienced: 74 min, IQR 51 – 92, p = 0.04).
Conclusions
An intervention combining workflow refinement and simulation-based stroke team training has the potential to improve process times in acute stroke care.
... Cost-effectiveness has been analysed for Crew Resource Management training. 262 However, with the current literature search, no comparable studies of patient safety education interventions for medical schools could be found. ...
: Patient safety is an activity to mitigate preventable patient harm that may occur during the delivery of medical care. The European Board of Anaesthesiology (EBA)/European Union of Medical Specialists had previously published safety recommendations on minimal monitoring and postanaesthesia care, but with the growing public and professional interest it was decided to produce a much more encompassing document. The EBA and the European Society of Anaesthesiology (ESA) published a consensus on what needs to be done/achieved for improvement of peri-operative patient safety. During the Euroanaesthesia meeting in Helsinki/Finland in 2010, this vision was presented to anaesthesiologists, patients, industry and others involved in health care as the 'Helsinki Declaration on Patient Safety in Anaesthesiology'. In May/June 2020, ESA and EBA are celebrating the 10th anniversary of the Helsinki Declaration on Patient Safety in Anaesthesiology; a good opportunity to look back and forward evaluating what was achieved in the recent 10 years, and what needs to be done in the upcoming years. The Patient Safety and Quality Committee (PSQC) of ESA invited experts in their fields to contribute, and these experts addressed their topic in different ways; there are classical, narrative reviews, more systematic reviews, political statements, personal opinions and also original data presentation. With this publication we hope to further stimulate implementation of the Helsinki Declaration on Patient Safety in Anaesthesiology, as well as initiating relevant research in the future.
... Not only have sepsis CDS systems been implemented in several health systems since 2016, but multiple studies have shown improvement in patient outcomes. 14,15 2017: In 2017, Moffatt-Bruce et al 16 published "What Is the Return on Investment for Implementation of a Crew Resource Management Program at an Academic Medical Center?" It has 974 downloads, making it the 38th most downloaded AJMQ article in the last 20 years. ...
... In einer amerikanischen Studie konnte gezeigt werden, dass die Einführung und das regelmäßige Human-factor-Training bereits nach 3 Jahren zu einer 25 %igen Reduktion der vermeidbaren unerwünschten Ereignisse führte. Die resultierenden Einsparungen belaufen sich auf einen 2-stelligen Millionenbereich [6]. Aktuell finden Untersuchungen und Studien für die Analyse des IC-Kursprinzips deutschlandweit statt. ...
Patient safety has become a central and measurable key factor in the routine daily medical practice. The human factor plays a decisive role in safety culture and has moved into focus regarding the reduction of treatment errors and undesired critical incidents. Nonetheless, the systematic training in communication and interpersonal competences has so far only played a minor role. The German Society of Orthopaedics and Trauma (DGOU) in cooperation with the Lufthansa Aviation Training initiated a course system for interpersonal competence. Several studies confirmed the reduction of critical incidents and costs after implementation of a regular and targeted human factor training. The interpersonal competence should be an essential component of specialist training within the framework of a 3‑column model.
Antecedentes: Los profesionales deben ser capaces de atender lasnecesidades clínicas y psicosociales de los pacientes de manera simultánea.Objetivo: Evaluar una intervención educativa con entrenamiento combinadode habilidades técnicas y comunicativas en situaciones de cuidados críticosdentro de un curso de posgrado en ciencias de la salud para equipos de altodesempeño. Diseño: Método mixto, utilizando un DAFO y un panel de expertos.Participantes: estudiantes de posgrado, profesoras y panelista. Métodos:Fase 1, los participantes evaluaron la intervención utilizando un DAFOsurgiendo un listado de acciones de mejora que fue evaluado y priorizadoen la fase 2. Resultados: Las fortalezas destacadas por los estudiantesfueron la fidelidad de los escenarios, la adquisición simultánea de diferenteshabilidades y el debriefing de buen juicio. Aunque detectaron deficiencias enlas sesiones debriefing, consideraron escasas las sesiones de simulaciónconjunta. Las fortalezas destacadas por las profesoras fueron la fidelidad, eldebriefing, la capacitación y el compromiso. También consideraron deficienteel pre-briefing, los recursos, y la heterogeneidad en el modelo de debriefing.Conclusiones: Es importante centrarse en los puntos de acción para la mejorade la competitividad del programa de posgrado, así como en los aspectos pre-briefing y debriefing.
Early complications following periodontal and dental implant surgeries are typically attributed to technique or poor biological response, ignoring the possibility of the human element. Interestingly, significant experience is not correlated with increased success, whereas evidence supports the impact of clinical behavior on patient outcome. This is the result of errors, much like those scrutinized in other high‐risk technical fields, such as aviation. What can be surprising is that those who make these errors are very well acquainted with best practices. Given this, how is it possible for the conscientious practitioner to fail to apply protocols that are nonetheless very well known? Recently, the concepts of human and organizational factors have been translated to medicine, though dentistry has been slow to recognize their potential benefit. This review lists specific human factor behaviors, such as use of checklists and crew resource management, which might improve postsurgical outcome.
Havayolu işletmeleri tarihsel süreç içerisinde farklı krizler neticesinde finansal başarısızlığa maruz kalmışlardır. 1978 yılındaki petrol krizi neticesinde yakıt maliyetleri artarak finansal krizler yaşanmıştır. 2001 yılında yaşanan ikiz kule terör saldırısı ve 2008 yılında yaşanan küresel ekonomik kriz neticesinde havayolu işletmeleri büyük zararlar etmiştir. Havayolu işletmeleri özellikle kriz zamanlarında finansal başarısızlıklara karşı tedbir almak zorundadırlar. Bu bağlamda çalışmanın amacı havayolu işletmelerinde finansal başarısızlık riskinin makroekonomik belirleyicilerinin saptanmasıdır. Bu
çalışma, geleneksel havayolu işletmelerinde makroekonomik faktörlerin finansal başarısızlığa etkisi üzerine odaklanmıştır. Çalışma kapsamında finansal başarısızlık riskine etki eden faktörler, 2009 ile 2019 yılları arasında 11 geleneksel havayolu işletmesi örnekleminde inceleme yapılmıştır. Makroekonomik faktörler olarak; Faiz oranı, döviz kuru, enflasyon ve brent petrol fiyatı değişkenleri kullanılmıştır. Finansal başarısızlık göstergesi olarak Altman Z'' skoru kullanılmıştır. Yapılan rassal etkiler panel veri analizi sonucuna göre faiz oranı ve döviz kuru değişkenlerinin finansal başarısızlığı negatif etkilediği sonucuna varılmıştır.
Objective
Simulation-based training has a significant effect in enhancing professionals’ skills in the helicopter emergency medical service (HEMS) setting and is reported to be more effective than other learning strategies. The main objective of this study was to assess the efficacy of a specific high-fidelity simulation (HFS) training course for HEMS nurses before entering into operational service.
Methods
This report describes the first Italian experience of a specifically designed HFS training program for HEMS nurses held in Bologna, Italy, in a dedicated scenario with a mock-up helicopter and an advanced mannequin.
Results
A total of 14 nurses participated in the SAFE2019 (Simulazione ad Alta Fedeltà per l'Elisoccorso–High-Fidelity Simulation for HEMS) courses. The aspects considered most useful and effective were related to team working, communication issues, and nontechnical skills (NTS) development. Moreover, participants suggested implementing a series of scheduled HFS retraining sessions.
Conclusion
HFS in a dedicated HEMS scenario during the orientation period has contributed to enhanced technical competencies and NTS, increasing comfort and situational awareness for new entrant flight nurses. Simulation may represent a valuable resource to assess and maintain competencies through periodic retraining sessions for full HEMS teams or when new devices are adopted.
It remains imperative that providers of anesthesia are proficient in basic life support (BLS) as well as advanced cardiac life support (ACLS). The principles and resuscitation techniques learned through BLS and ACLS will enable the anesthesia provider to intervene during office-based emergencies and optimize patient outcomes. Successful resuscitation requires teamwork, regular certification/recertification in BLS and ACLS, and monthly mock codes. Crisis resource management (CRM) is critical to ensure strong teamwork, adequate communication, and a cohesive response to office-based emergencies.
Purpose of review
Reliable data indicates increasing numbers of patients are harmed when receiving healthcare. The landmark paper “To Err is Human” posited that adverse events occur in the context of the complexity of systems within medicine and are not due to intentional harm. Crisis resource management (CRM) originated in aviation in 1980. CRM is defined as the cognitive, social, and personal resource skills that complement technical skills and contribute to safe task performance. It is a risk-reducing strategy utilized in aviation that has led to significant reduction in human error–related airline fatalities. CRM was adopted from commercial aviation by medicine in 1990 in an attempt to improve patient safety and reduce morbidity and mortality attributed to medical errors.
Recent findings
In the last 40 years, commercial and military aviation has standardized CRM training which has led to a track record of success in improving safety for flight crews and passengers with flight-related mortality significantly decreasing. In stark contrast, nearly 30 years of CRM training in healthcare has been highly variable in content, quality, and outcomes. In this time, the number of patient deaths attributed to medical mistakes has increased from an estimated 50,000–100,000 in 1999 to over 250,000 per year from a 2016 estimate.
Summary
It is time to reassess how CRM is being deployed in healthcare. Full CRM integration will require significant cultural and embedded organizational changes. Proficient CRM skills are a necessary, but not sufficient, condition for adverse event rate reduction: CRM should not be just what we do—it has to be a part of who we are as medical professionals.
Patients are safer and receive higher quality care when providers work as a highly effective team. Investment in optimising healthcare teamwork has swelled in the last 10 years. Consequently, evidence regarding the effectiveness for these interventions has also grown rapidly. We provide an updated review concerning the current state of team-training science and practice in acute care settings.
A PubMed search for review articles examining team-training interventions in acute care settings published between 2000 and 2012 was conducted. Following identification of relevant reviews with searches terminating in 2008 and 2010, PubMed and PSNet were searched for additional primary studies published in 2011 and 2012. Primary outcomes included patient outcomes and quality indices. Secondary outcomes included teamwork behaviours, knowledge and attitudes.
Both simulation and classroom-based team-training interventions can improve teamwork processes (eg, communication, coordination and cooperation), and implementation has been associated with improvements in patient safety outcomes. Thirteen studies published between 2011 and 2012 reported statistically significant changes in teamwork behaviours, processes or emergent states and 10 reported significant improvement in clinical care processes or patient outcomes, including mortality and morbidity. Effects were reported across a range of clinical contexts. Larger effect sizes were reported for bundled team-training interventions that included tools and organisational changes to support sustainment and transfer of teamwork competencies into daily practice.
Overall, moderate-to-high-quality evidence suggests team-training can positively impact healthcare team processes and patient outcomes. Additionally, toolkits are available to support intervention development and implementation. Evidence suggests bundled team-training interventions and implementation strategies that embed effective teamwork as a foundation for other improvement efforts may offer greatest impact on patient outcomes.
To evaluate the effectiveness of a hospital-wide initiative to improve patient safety by implementing high-reliability practices as part of a quality improvement (QI) program aimed at reducing all preventable harm.
A hospital wide quasi-experimental time series QI initiative using high-reliability concepts, microsystem-based multidisciplinary teams, and QI science tools to reduce hospital acquired harm was implemented. Extensive error prevention training was provided for all employees. Change concepts were enacted using the Institute for Healthcare Improvement's Model for Improvement. Compliance with change packages was measured.
Between 2010 and 2012, the serious safety event rate decreased from 1.15 events to 0.19 event per 10 000 adjusted hospital-days, an 83.3% reduction (P < .001). Preventable harm events decreased by 53%, from a quarterly peak of 150 in the first quarter of 2010 to 71 in the fourth quarter of 2012 (P < .01). Observed hospital mortality decreased from 1.0% to 0.75% (P < .001), although severity-adjusted expected mortality actually increased slightly, and estimated harm-related hospital costs decreased by 22.0%. Hospital-wide safety climate scores increased significantly.
Substantial reductions in serious safety event rate, preventable harm, hospital mortality, and cost were seen after implementation of our multifaceted approach. Measurable improvements in the safety culture were noted as well.
The purpose of this study was to develop, implement, and evaluate a comprehensive provider/team communication strategy, resulting in a toolkit generalizable to other settings of care. The specific aims included implementation of a structured communication tool; a standardized escalation process; daily multidisciplinary patient-centered rounds using a daily goals sheet; and team huddles. The study setting was the 477-bed medical center of the Denver Health and Hospital Authority, an integrated, urban safety-net system. Utilizing a pre-test/post-test design, baseline and post-intervention data were collected on pilot units (medical intensive care unit, acute care unit, and inpatient behavioral health units). Analysis of 495 communication events after toolkit implementation revealed decreased time to treatment, increased nurse satisfaction with communication, and higher rates of resolution of patient issues post-intervention. The resultant toolkit provides health care organizations with the means to implement teamwork and communication strategies in their own settings.
There is insufficient information about the effectiveness of medical team training on surgical outcomes. The Veterans Health Administration (VHA) implemented a formalized medical team training program for operating room personnel on a national level.
To determine whether an association existed between the VHA Medical Team Training program and surgical outcomes.
A retrospective health services study with a contemporaneous control group was conducted. Outcome data were obtained from the VHA Surgical Quality Improvement Program (VASQIP) and from structured interviews in fiscal years 2006 to 2008. The analysis included 182,409 sampled procedures from 108 VHA facilities that provided care to veterans. The VHA's nationwide training program required briefings and debriefings in the operating room and included checklists as an integral part of this process. The training included 2 months of preparation, a 1-day conference, and 1 year of quarterly coaching interviews
The rate of change in the mortality rate 1 year after facilities enrolled in the training program compared with the year before and with nontraining sites.
The 74 facilities in the training program experienced an 18% reduction in annual mortality (rate ratio [RR], 0.82; 95% confidence interval [CI], 0.76-0.91; P = .01) compared with a 7% decrease among the 34 facilities that had not yet undergone training (RR, 0.93; 95% CI, 0.80-1.06; P = .59). The risk-adjusted mortality rates at baseline were 17 per 1000 procedures per year for the trained facilities and 15 per 1000 procedures per year for the nontrained facilities. At the end of the study, the rates were 14 per 1000 procedures per year for both groups. Propensity matching of the trained and nontrained groups demonstrated that the decline in the risk-adjusted surgical mortality rate was about 50% greater in the training group (RR,1.49; 95% CI, 1.10-2.07; P = .01) than in the nontraining group. A dose-response relationship for additional quarters of the training program was also demonstrated: for every quarter of the training program, a reduction of 0.5 deaths per 1000 procedures occurred (95% CI, 0.2-1.0; P = .001).
Participation in the VHA Medical Team Training program was associated with lower surgical mortality.
Surgery has become an integral part of global health care, with an estimated 234 million operations performed yearly. Surgical complications are common and often preventable. We hypothesized that a program to implement a 19-item surgical safety checklist designed to improve team communication and consistency of care would reduce complications and deaths associated with surgery.
Between October 2007 and September 2008, eight hospitals in eight cities (Toronto, Canada; New Delhi, India; Amman, Jordan; Auckland, New Zealand; Manila, Philippines; Ifakara, Tanzania; London, England; and Seattle, WA) representing a variety of economic circumstances and diverse populations of patients participated in the World Health Organization's Safe Surgery Saves Lives program. We prospectively collected data on clinical processes and outcomes from 3733 consecutively enrolled patients 16 years of age or older who were undergoing noncardiac surgery. We subsequently collected data on 3955 consecutively enrolled patients after the introduction of the Surgical Safety Checklist. The primary end point was the rate of complications, including death, during hospitalization within the first 30 days after the operation.
The rate of death was 1.5% before the checklist was introduced and declined to 0.8% afterward (P=0.003). Inpatient complications occurred in 11.0% of patients at baseline and in 7.0% after introduction of the checklist (P<0.001).
Implementation of the checklist was associated with concomitant reductions in the rates of death and complications among patients at least 16 years of age who were undergoing noncardiac surgery in a diverse group of hospitals.
Five years ago, the Institute of Medicine (IOM) called for a national effort to make health care safe. Although progress since then has been slow, the IOM report truly "changed the conversation" to a focus on changing systems, stimulated a broad array of stakeholders to engage in patient safety, and motivated hospitals to adopt new safe practices. The pace of change is likely to accelerate, particularly in implementation of electronic health records, diffusion of safe practices, team training, and full disclosure to patients following injury. If directed toward hospitals that actually achieve high levels of safety, pay for performance could provide additional incentives. But improvement of the magnitude envisioned by the IOM requires a national commitment to strict, ambitious, quantitative, and well-tracked national goals. The Agency for Healthcare Research and Quality should bring together all stakeholders, including payers, to agree on a set of explicit and ambitious goals for patient safety to be reached by 2010.
Author Affiliations: National Center for Patient Safety, Department of Veterans Affairs (Mss Neily and West and Drs Mills, Young-Xu, Carney, Mazzia, Paull, and Bagian) and Department of Psychiatry, Dartmouth Medical School (Drs Mills and Young-Xu), Hanover, New ...
A Veteran's Health Administration quality improvement project yields positive results.
There's no way to prevent every patient fall, but leading hospitals are applying multifaceted protocols to prevent the ones they can, incorporating six changes recommended by the Institute for Healthcare Improvement.
In an attempt to enhance patient safety, health care facilities are increasingly turning to crew resource management (CRM) and other teamwork training interventions. However, there is still quite a bit about such training interventions that remain unclear. Accordingly, our primary intent herein is to provide some clarity by providing a review of the literature, in hopes of highlighting the current state of the literature as well as identifying the areas that should be addressed by researchers in this field going forward.
We searched various electronic databases and utilized numerous relevant search terms to maximize the likelihood of identifying all empirical research related to the use of CRM training within health care. Additionally, we conducted a manual search of the most relevant journals and also conducted a legacy search to identify even more articles. Furthermore, given that as a research team we have experience with CRM initiatives, we also integrate the lessons learned through this experience.
Based on our review of the literature, CRM and teamwork training programs generally appear beneficial to individual employees, the groups and teams within such settings, and overall health care organizations.
In addition to reviewing the literature that addressed CRM and teamwork training, we also highlight some of the more critical aspects of CRM training programs in order for such initiatives to be as successful as possible. Additionally, we detail various factors that appear essential to sustaining any benefits of CRM over the long haul.
The need for health services research is likely to rise rapidly as the population ages, health care costs soar, and therapeutic and diagnostic choices proliferate. Building an effective and efficient health care delivery system is a national priority. Yet the national health care quality report concludes that we lack the ability to monitor progress toward even basic quality and patient safety goals effectively.
The gap between the need to improve and our ability to do so exists in part because we fail to view the delivery of health care as science, we lack national improvement priorities, and we lack a national infrastructure to achieve our stated goals.
We discuss key challenges implicit in correcting these failures and recommend actions to expedite progress.
Background:
Ineffective communication among medical teams is a leading cause of preventable patient harm throughout the health care system. A growing body of literature indicates that medical teamwork improves the quality, safety, and cost-effectiveness of health care delivery, and expectations for teamwork in health care have increased. Yet few health care professions' curricula include teamwork training, and few medical practices integrate teamwork principles. Because of this knowledge gap, growing numbers of health care systems are requiring staff to participate in formal teamwork training programs. Seven evidence-based, practical, systematic success factors for preparing, implementing, and sustaining a team training and performance improvement initiative were identified. Each success factor is accompanied by tips for deployment and a real-world example of application.
Success factors:
(1) Align team training objectives and safety aims with organizational goals, (2) provide organizational support for the team training initiative, (3) get frontline care leaders on board, (4) prepare the environment and trainees for team training, (5) determine required resources and time commitment and ensure their availability, (6) facilitate application of trained teamwork skills on the job; and (7) measure the effectiveness of the team training program.
Discussion:
Although decades of research in other high-risk organizations have clearly demonstrated that properly designed team training programs can improve team performance, success is highly dependent on organizational factors such as leadership support, learning climate, and commitment to data-driven change. Before engaging in a teamwork training initiative, health care organizations should have a clear understanding of these factors and the strategies for their establishment.
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.
Communication failure, a leading source of adverse events in health care, was involved in approximately 75% of more than 7,000 root cause analysis reports to the Department of Veterans Affairs (VA) National Center for Patient Safety (NCPS).
The VA NCPS Medical Team Training (MTT) program, which is based on aviation principles of crew resource management (CRM), is intended to improve outcomes of patient care by enhancing communication between health care professionals. Unique features of MTT include a full-day interactive learning session (facilitated entirely by clinical peers in a health care context), administration of pre-and postintervention safety attitudes questionnaires, and follow-up semistructured interviews with reports of program activities and lessons learned.
Examples of projects in these facilities include intensive care unit (ICU) teams' patient-centered multidisciplinary rounds, surgical teams' preoperative briefings and debriefings, an entire operating room (OR) unit's adoption of "Rules of Conduct" for expected staff behavior, and an ICU team's use of the model for daily administrative briefings.
An MTT program based on applied CRM principles was successfully developed and implemented in 43 VA medical centers from September 2003 to May 2007.
Acknowledging the need to improve team communication and coordination among health care providers, health care administrators and improvement officers have been quick to endorse and invest in aviation crew resource management (CRM). Despite the increased interest in CRM there exists limited data on the effectiveness of CRM to change team behavior and performance in clinical settings.
Direct observational analyses were performed on 30 surgical teams (15 neurosurgery cases and 15 cardiac cases) to evaluate surgical team compliance with integrated safety and CRM practices after extensive CRM training.
Observed surgical teams were compliant with only 60% of the CRM and perioperative safety practices emphasized in the training program.
The results highlight many of the challenges the health care industry faces in its efforts to adapt CRM from aviation to medicine. Additional research is needed to develop and test new team training methods and performance feedback mechanisms for clinical teams.
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A comprehensive obstetrics patient safety program improves safety climate and culture
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