Improving patient safety with team coordination: challenges and strategies of implementation

The health care environment presents significant risk of errors leading to patient injury and harm. One method to promote patient safety involves improving team coordination. The MedTeams training program, a nationally funded research project, provided the framework for team training in several labor and delivery units in the United States. Many challenges were confronted when team training was implemented. Based on these experiences, specific strategies to ensure the success of team training are discussed.     

A Fetal Intensive Care Nursing Program

A fetal intensive care nursing program, developed by a university department of obstetrics and gynecology in an attempt to provide optimal care for each fetus, is described. The concept is to make each labor and delivery area a fetal intensive care unit. The 160-hour training program of lectures and clinical experience consists of a review of basic anatomy and physiology, gametogenesis, maternal and fetal physiology, and the dynamics of uteroplacental circulation, focusing heavily on the intrapartum period, including fetal monitoring, oxytocin administration, and recognition of fetal problems during the course of labor. Nurses successfully completing the program are more valuable members of the obstetric team, understanding the theory and technique basic to necessary intervention as indicated by nursing and physician assessment of the fetus.     

Extracorporeal Membrane Oxygenation and Indications for Cardiopulmonary Bypass in the Neonate

Extracorporeal membrane oxygenation (ECMO) is a rescue technique used for term and near-term neonates who have respiratory failure that is unresponsive to conventional therapy. The complexity of the equipment necessitates intensive training of a specialized team before setting up an ECMO unit. An understanding of the physiology underlying ECMO and the criteria used for patient selection assists the nurse in identifying neonates who might benefit from the technique.     

Multidisciplinary teamwork and communication training

Every delivery is a multidisciplinary event, involving nursing, obstetricians, anesthesiologists, and pediatricians. Patients are often in labor across multiple provider shifts, necessitating numerous handoffs between teams. Each handoff provides an opportunity for errors. Although a traditional approach to improving patient outcomes has been to address individual knowledge and skills, it is now recognized that a significant number of complications result from team, rather than individual, failures. In 2004, a Sentinel Alert issued by the Joint Commission revealed that most cases of perinatal death and injury are caused by problems with an organization's culture and communication failures. It was recommended that hospitals implement teamwork training programs in an effort to improve outcomes. Instituting a multidisciplinary teamwork training program that uses simulation offers a risk-free environment to practice skills, including communication, role clarification, and mutual support. This experience should improve patient safety and outcomes, as well as enhance employee morale.     

Creation of a healing enhancement program at an academic medical center

There has been a growing emphasis on evaluating and improving the experience of the hospitalized patient. In 2004, the Cardiovascular Surgery team at Mayo Clinic Rochester, though achieving a high level of technical expertise and clinical outcomes, recognized that patients were not rating their overall hospital experience as highly as was expected. After a systematic evaluation of the hospital experience, tension, stress, pain, and anxiety were identified as key challenges for patients.

A multidisciplinary team was created to evaluate pain management practices and explore methods for reducing pain, anxiety, and tension. An extensive review of the literature and site visits to other institutions provided the foundation for the program. The term “Healing Enhancement” was coined to identify the goals of this emerging paradigm that focused on all aspects of the patient's experience—mind, body, and spirit. Integrated therapies such as music, massage, guided imagery, and relaxation training were explored to measure their role in patient care.     

Entrenamiento de equipos interdisciplinares en urgencias obstétricas mediante simulación clínica

Objectives

To describe the healthcare team training in obstetric emergencies using clinical simulation with an interdisciplinary approach, developed at the Hospital virtual Valdecilla.

Material and methods

The program was aimed at health professionals involved in emergency obstetric care (obstetricians and gynecologists, anesthesiologists, intensivists and midwives). A working team was established to define the objectives, design the scenarios, and coordinate the completion of each course. Two simulation rooms were available with patient simulators, control rooms and audiovisual recording systems, an analysis room, a multipurpose classroom, and diverse medical and surgical equipment. To analyze the results of the program, the participants completed an evaluation survey.

Results

A total of 30 members of clinical teams underwent training in the clinical entities most frequently involved in cases of maternal mortality (postpartum hemorrhage, amniotic fluid embolism and eclampsia), selected from the results of a survey of maternal death mailed to 69 Spanish hospitals. Each course consisted of three clinical cases performed in the operating room, postpartum and birthing room, followed by a debriefing session. Participants rated the courses as highly useful, highlighted the opportunity provided by clinical simulation to practice without risk and to train teamwork skills, and would recommend their peers to undergo the same training.

Conclusions

Training of healthcare teams in obstetric emergencies using simulation with an interdisciplinary approach provides safe and effective practice of diagnostic and treatment algorithms, as well as of communication and teamwork skills, before these situations are met in daily practice.     

Implementing Obstetrics Quality Improvement,Driven by Medico-legal Risk,is Associated With Improved Workplace Culture

ObjectiveThis study implemented a quality improvement program based on knowledge of medico-legal risk in obstetrics and sought to evaluate the impact of this program on workplace culture.MethodsThe study conducted needs assessments with front-line providers working in the obstetrical unit of the Queensway Carleton Hospital, an urban community hospital in Ottawa, Ontario, and included the safety, communication, operational reliability, and engagement (SCORE) survey. The study investigators delivered training in quality improvement science and co-developed three projects that were based on their alignment with local needs and aggregate medico-legal risk data: an organized team response to the need for an immediate cesarean section, a protocol for managing patients who present at term with pre-labour rupture of membranes, and regular morning team briefings. Outcome measures were determined for each project from a quality improvement indicator framework, and coaching was provided to project leads. Participants completed the SCORE survey and a program effectiveness tool after the intervention.ResultsThe majority of participants (75.2% of 153 pre-intervention and 63.1% of 157 post-intervention participants) completed the SCORE surveys. Post-intervention improvements were found in teamwork, learning environment, and safety climate, whereas levels of provider burnout remained high. Program effectiveness was highly rated, and most projects showed qualitative improvements.ConclusionThis study showed positive workplace culture change associated with the quality improvement intervention. Lessons learned from the implementation of this program can inform future quality improvement initiatives.     

Instituting an office-based surgery program in the gynecologist's office

Office-based surgery (OBS) provides many advantages for the patient, physician, operating room team, and health care system. Newer technologies provide an array of procedures appropriate to the office setting, and with careful preparation, many can be performed without compromising patient safety or comfort. Several states have specific regulatory requirements for OBS, although half of them provide neither guidelines nor regulation. The Federation of State Medical Boards provides current regulatory information across the United States; the American College of Obstetrics and Gynecology has recently issued guidelines that provide recommendations for instituting an OBS practice, and the American Medical Association and the American Society of Anesthesiologists provide guidelines that promote patient safety and comfort in the office setting. Many issues must be considered before instituting an OBS program. Practices that perform invasive procedures requiring more than minimal sedation are encouraged to seek formal accreditation because it assures patients of quality of care. Residency programs and professional societies are encouraged to provide training in OBS surgery and to develop programs to mentor the next generation of physicians.     

SimMom模拟人在产科医师培训中的作用

产科是一门实践性强、应急性高、对团队合作要求高的临床医学。在患者安全性要求更高的今天,产科医生需要通过模拟训练来提高临床操作技能和团队合作能力以应对各种急危重症。现对SimMom模拟人在产科医师培训中的研究进展进行讨论。     

Simulation and beyond – Principles of effective obstetric training

Simulation training provides a safe, non-judgmental environment where members of the multi-professional team can practice both their technical and non-technical skills. Poor teamwork and communication are recurring contributing factors to adverse maternal and neonatal outcomes. Simulation can improve outcomes and is now a compulsory part of the national training matrix. Components of successful training include involving the multi-professional team, high fidelity models, keeping training on-site, and focussing on human factors training; a key factor in adverse patient outcomes. The future of simulation training is an exciting field, with the advent of augmented reality devices and the use of artificial intelligence.     

Communication skills training in obstetrics and gynaecology: whom should we train? A randomized controlled trial

Objective To determine whether patient–physician communication in obstetrics and gynaecology can be improved by a training program and to investigate if physicians with poorer performance before the training show greater improvement in communication skills scores over the course of the study. Design Intervention study with randomisation in training (n = 16) and control group (n = 16) and patient satisfaction and communication skills of physicians as outcome variables. Physicians’ communication skills were assessed by independent raters using a standardised evaluation instrument (adapted version of the MAAS-R) to analyse video recorded interviews before and after the training. Patient satisfaction was assessed with a patient satisfaction questionnaire. Results Using general linear model (GLM) for repeated measures no group × time interaction nor time effects were found for physicians’ communication skills. No group × time interaction was found for patients’ satisfaction scores; however the significant time effect was mostly attributable to positive changes in patients’ rating of the training group. Physicians with poorer performance at the beginning showed greater improvements over the course of the study, especially in the training group. Conclusions In this randomized controlled trial marginal intervention effects for the improvement of communication skills and only partial changes in patient satisfaction scores from pre to post training were shown. However, physicians with poorer performance at the beginning showed greater improvements, suggesting that competence levels were already relatively high at the beginning of the study. Also, formation of communication training groups should be based on specific skill deficits rather than being implemented unspecifically for an entire team of physicians.     

Introduction of a Maternal-Fetal Medicine Tele-Ultrasound Program in Rural Alberta

ObjectivesWe established a program of Maternal-Fetal Medicine (MFM) telemedicine that is safe and acceptable. Since December 2019, a multi-disciplinary team has been planning this quality improvement project.MethodsWe performed a pilot study to investigate the feasibility of using telemedicine and tele-ultrasound to enable prompt MFM consultations for patients in remote locations. We began with the training of sonographers followed by implementation in a small pilot. Interim analysis of the acceptability and feasibility of the program was done through patient surveys, images audit, and review of neonatal outcomes.ResultsOur background epidemiologic data showed that in Alberta, between 2017 and 2022, 460 patients travelled >6 hours, and 5038 travelled >2 hours from home to reach their site of birth. Patients were appropriately triaged to delivery/consultation at the tertiary level center based on diagnosis/suspicion of anomalies, such as abnormally invasive placenta, intrauterine growth restriction, hydrops, and partial agenesis of the corpus callosum, all of which were confirmed postdelivery. There was no neonatal mortality, and the single stillbirth was related to an unpreventable peri-viable co-twin demise. The patient survey demonstrated that for >85% of respondents the program reduced costs and stress. Ultrasound image audit found improvement and consistency in image quality after 3 months of training combined with supervision.ConclusionMFM telemedicine is feasible and can be safe with adequate supervision. Additional support and resources are needed to scale and spread this quality improvement initiative.     

The childbearing center: an alternative birth setting.

A number of reports have noted the trend toward home deliveries. With the aim of providing an alternative to unattended home delivery, an out-of-hospital unit for women at low medical risk was opened in New York City in October 1975. Physical care is provided by a team of nurse-midwives, obstetricians, pediatricians, and ancillary health personnel. Childbirth education is an integral part of the program. Women are carefully screened both initially and during the course of pregnancy, and transfers are made to hospital services when required. In the first 31 months of the program, 244 births were managed in the unit. No life-threatening emergencies have occurred. Experience to date indicates that a unit of this kind can safely offer care to a low-risk obstetric population.     

Structured multidisciplinary intershift handover (SMITH): a tool for promoting safer intrapartum care

On the labour ward, the key to achieving patient safety is the intershift handover, which affords an opportunity for the team to undertake a baseline assessment of the current situation, anticipate problems, plan contingencies and subsequently maintain situational awareness. If optimised, the handover has immense potential not only for enhancing patient safety but also for reducing stress to staff. The handover should be regarded not as an end but as the beginning of the process of maintaining individual and team situational awareness throughout the shift. Each maternity unit should have a Structured Multidisciplinary Intershift Handover (SMITH) protocol, which encompasses pre-handover, handover and post-handover guidance. This paper describes the underlying principles, benefits and content of a SMITH protocol.     

沙盘模拟在产科专科培训的应用初探

目的探讨沙盘模拟培训在产科专科培训应用中的可行性和有效性。 方法培训班以沙盘模拟形式对学员进行产科急危重症与助产技术培训，采用"沙盘推演—学员操作—导师点评—导师演示"的培训模式，内容包括子痫、产后出血、肩难产、阴道助产和新生儿窒息复苏。选取200名学员为研究对象，并随机分成5个团队，培训前后对学员进行理论知识和操作技能考核，根据考核标准由导师组进行打分，并对每个团队的抢救流程进行考核评分。同时培训前后发放调查问卷对培训课程进行反馈。 结果经培训后，学员的理论考核成绩(91.1±14.5)分较培训前(75.6±24.0)分明显提高，差异有统计学意义(P<0.05)。各操作模块考核前后成绩分别为：子痫(73.7±5.6)分与(90.6±3.9)分，产后出血(71.2±8.7)分与(88.9±4.8)分，阴道助产(70.1±7.9)分与(90.0±4.8)分，肩难产(74.6±5.7)分与(91.5±2.3)分，新生儿窒息(73.2±4.7)分与(91.2±2.5)分，培训后成绩明显提高，差异有统计学意义(P<0.05)。团队考核的Topsis分析结果显示，团队3在多项指标上都是最优秀的，综合排名第一名，尤其是方案设计。团队5在临床技能表现突出，在团队配合和患者沟通方面做得也比较好。团队2和团队4各项指标都表现不足。 结论团队3大部分成员来自三甲医院，经常参加产科模拟培训班，因此总体素质较高，而团队2和团队4来自基层医院的成员居多，接受培训的次数较少，因此成绩偏弱，尤其在流程、沟通和团队配合等方面，还需要加强培训。沙盘模拟培训作为一种新型的体验式培训模式，具有创新性、互动性、趣味性，并具有实战性，在产科急危重症专科培训中具有较大的发展前景。     

Interdisciplinary team training identifies discrepancies in institutional policies and practices

The objective of this study was to evaluate the impact of an interdisciplinary team-training program in obstetric emergencies on identifying unsupportive institutional policies and systems-based practices. We implemented a qualitative study design with a purposive sample of interdisciplinary physicians, nurses, and ancillary allied health professionals from 4 specialties (n = 79) to conduct a 6-month, weekly simulation-based intervention for managing obstetric emergencies. Debriefing focused on identifying discrepancies between clinical practice and institutional policies. Our data yielded 5 categories of discrepancies between institutional or departmental policy and actual clinical practice. Specific institutional policies and system-based practices were recommended to health system administration for reevaluation. Simulation-based interdisciplinary team training can inform system-wide quality improvement objectives that could lead to increased patient safety.     

Faking it? Simulation in the training of obstetricians and gynaecologists

PURPOSE OF REVIEW: This paper discusses the use of simulation as a training tool in obstetrics and gynaecology. RECENT FINDINGS: Modern medical training and patient pressure for treatment by more experienced clinicians have contributed to a reduction in the training opportunities available to junior doctors. Advances in information technology have led to the successful introduction of simulator-based training in many safety-critical industries such as aviation and nuclear power. In this editorial we describe simulation devices that are available to obstetrics and gynaecology and explain how simulation can benefit the patient, trainee and educator. We also explore how simulation could be integrated into obstetrics and gynaecology training programmes. SUMMARY: At present simulation is very much underused as a training tool in medicine, and features little in the postgraduate training curriculum. In obstetrics and gynaecology simulation could be used as an educational tool to assist in (1) transfer of knowledge, (2) practising diagnostic and simple practical skills, (3) surgical skills training, (4) emergency drill training and (5) human factors and team training. Whereas simulation should not be perceived as a replacement for training with real patients, educators should embrace the opportunities that simulation provides and integrate it into current training programmes to maximize training opportunities and patient safety.     

Are RN's the Best Family Planning Specialist Recruits?

A training program was initiated to give Registered Nurses and people with less medical experience the didactic and clinical instruction necessary to provide family planning, cancer screening and prenatal services to healthy patients. Both groups performed equally well, and relatively as soon, in the physical examination techniques at the end of the 20-week program. These new Family Planning Specialists will not replace any existing health care personnel, but will be additions to the health manpower team. The goal is to combat the shortage of health personnel. Rather than subtract from the practicing numbers of needed Registered Nurses by training them as Family Planning Specialists, it may be more reasonable to use persons with less medical experience who can be trained to perform as well as RN's.     

Implementing and sustaining in situ drills to improve multidisciplinary health care training

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.