Teamwork and

Communication for

Quality & Safety:

James P. Bagian, MD, PE

Director

Center for Healthcare Engineering and Patient Safety

University of Michigan

jbagian@med.umich.edu

It’s More Than Checklists

Overview

Problem

Background

Strategy

Interventions

VA – 2001-2006

Root Cause Analyses (RCA)

Database*

~70% to 80% of RCAs cited COMMUNICATION FAILURE as, at least one of the root causes/contributing factors for an adverse event or close call report.

*SPOT Database: VA National Center for Patient Safety, April, 2008 Completed RCAs, Number = 8661.

Assumptions

Current OR situation was unacceptable

Communication was factor

Improvement was possible

The risk from intervening was less than

the status quo

Didn’t require absolute evidence base,

evaluate on the fly

Communication Skills

In medical school and nursing

school, the focus is on

successful communication

with the patient.

Aviation Safety

&

Crew Resource Management

(CRM)

Tenerife – March 1977

Pan Am KLM

Fatalities - 583

Crew Resource Management

(CRM)*

Origin: 1979-80 NASA workshops examining the role of human error in airline crashes Research into aviation accidents in 1970s

Definition: “Using all available sources – information, equipment, and people – to achieve safe and efficient operations.”

Focus: safety, efficiency, and morale of humans working together

LOFT: “Line Oriented Flight Training” Work in flight simulators and measurement of airline crew

performance

Briefings and Debriefings * Musson D, Helmreich RL. Team training and resource management in health care: Current issues and future

directions. Harvard Health Policy Review. 2004; 5(1): 25-35.

CRM Training*

Required by FAA and worldwide – “the way of doing business”

Aircrew performance measured by materials, organization, individual, and group variables

Expanded aviation training from technical focus to human factors dimensions – stress, fatigue, communication, shared awareness, and teamwork

Outcomes: efficiency, safety, customer satisfaction

Airline crew surveys: CRM relevant, useful, and effective in changing attitudes and behavior to improve safety

CRM accepted by industry on face validity

* Musson D, Helmreich RL. Team training and resource management in health care: Current issues and future

directions. Harvard Health Policy Review. 2004; 5(1): 25-35.

Corrigan J, Kohn LT, Donaldson MS. To Err Is Human. Washington, DC: National Academy

Press; 2000.

“…establish team training

programs for personnel in critical

care areas using proven methods

such as the crew resource

management training techniques

employed in aviation.”

Institute of Medicine

Teamwork

What are the characteristics of a

TEAM?

Characteristics of a Powerful

Team

Common Purpose

Clear Roles

Accepted Leadership

Effective Processes

Solid Relationships

Excellent Communications

Exceptional Results

18

VHA NCPS Medical Team Training Program

2005 -2010

Mean = 74 Attendees Per Learning Session

Largest One Day Session = 208 (Baltimore, MD Jan 14, 2010)

Largest Facility Attendance = 356 (Dallas, TX December 9-11, 2008)

MTT Plan

Identify and guide implementation

team at site

Define responsibilities, goals, and

tools (e.g., checklist content)

Baseline data – e.g., SAQ

OR-wide training on communication,

briefings and debriefings

Follow-up, measure and assist/advise

Months Prior

Weeks/Days Prior

Implement

Months

Culture Measurement

Survey open to all MDs, RNs, Techs in OR

and PACU

SAQ (Safety Attitude Questionnaire)

Nationally accepted, validated, normed

Short (~35 questions)

Online

Anonymous

Shorter and more focused than AHRQ

Briefings

Dialogue among principals using

concise, relevant information to

promote clear and effective

communication

- Real time

- Face-to-face

- All team members present

- All team members participate

Why Do a Briefing?

Establish a platform for common

understanding

Gives people permission to be frank & honest

Gets everyone on the same page

Provides a structure for collaborative

planning

Creates a shared mental model

23

Situational Awareness

Definition: The continuous perception of

self and team in relation to the dynamic

environment and the ability to make

adjustments.

The one most important aid in maintaining

Situational Awareness is a common

understanding of the briefed plan.

Pre-Op Briefing

Entire Surgical Team

Attending surgeon

Anesthesiologist/CRNA

Circulator

Scrub nurse/tech

Resident, PA, perfusionist, others

Guided by checklist

OR suite prior to anesthetic induction

Does not replace pre-op planning

Complements the TIMEOUT

Supporting Long Term

Memory Checklists

Put knowledge in the world vs. in the head

Recognition is better than recall

Tool to Guide and Improve Communication

Checklist Philosophy

“Read and Verify” checklists

“Read and Do” checklists

Read and Verify

Read and Do

IV Insertion Checklist

Before Insertion

• Patient Identification……………………………..CONFIRMED

• Correct Side………………………………………CONFIRMED

• Catheter Size……………………………………..CONFIRMED

• Equipment…………………………………………AT BEDSIDE

• Patient……………………………………………..BRIEFED

After Insertion

• Tourniquet…………………………………………REMOVED

• Line………………………………………………...FLUSHED

• Pump……………………………………………….SET (with fluids)

• Sharps………………………………………………DISPOSED

• Site…………………………………………………..LABELED

• Documentation…………………………………….COMPLETE

Checklist-Driven Preoperative Briefing

Checklist-Driven Preoperative Briefing

Post-op Debriefing

Entire Surgical Team Attending surgeon Anesthesiologist/CRNA Circulator Scrub nurse/tech Resident, PA, perfusionist, others

Guided by checklist

What went well? What did not go well? What can we do to improve our processes? What did we learn?

Timing – when patient is stable before attending leaves (update prior to patient leaving OR)

Method to track debrief items and follow-up:

Leadership Group

The Checklist is the Tool that

Provides the Framework for

Communication

Communication Techniques

Communication techniques

Call out/transparent thinking

Directed communication

Closed-loop communication / Feedback

Read back / Repeat back

Teamwork, communication protocols

Dynamic Skepticism

Assertive statements / wording

3 W’s, SBAR, 4 steps

Dynamic Skepticism

Attitude of constantly questioning and

evaluating the patient care environment

Avoid trusting what appears to be obvious

Do not assume!

Seek facts

Verification is NOT a mistrust of others

Questioning and verifying is safe practice

Asking the Right Question

“Any questions?”

VS

“What is your biggest concern for today?”

Clarity

Communication should be

Specific

Direct

Concise

DO NOT “Hint and Hope”

Hint and Hope

Communication

“Boy that grass is really getting tall out there!”

Hint and Hope

Communication

“There’s Lightning Coming out of that one”

August 2, 1985

137 Fatalities

3 “W”s

1. What I see

2. What I’m concerned about

3. What I want

SBAR

Situation What is the problem?

Background Brief background information

Assessment What is your assessment of the patient?

Recommendations

What do you recommend?

Response Close the loop

R

Assertive Statements

Direct and clearly communicated statements that facilitate patient advocacy in decision-making.

• Not a license to be rude

• Use “I” statements, rather than “You” statements

• “I” statements describe your experience rather than another’s shortcomings

• Give people options

4 Step Assertive Communication Tool 1. Get Attention - State name/position - Strip away title

2. State concern - Preface with “I’m uncomfortable” 3. Offer Alternative - …….

4. Pose question - to get resolution

Assertive Communication Standardized Communication Tools

“Assertiveness with Respect”

When all else fails?

Chain of Command

Avoid Hint and Hope

1. Specific 2. Direct 3. Concise

3 W’s

1. What I see

2. What I’m concerned about

3. What I want

4 Step Assertive Tool

1. Get Attention

2. State Concern

“I’m uncomfortable with…”

3.Offer Solution

4.Pose Question

Use Chain of Command

SBARR

TAKE ACTION

OR

STEP BACK

Engage Team

Results

**

Carney, et al, Differences in Nurse and Surgeon Perceptions of Teamwork.

AORN J. 2010Jun;91(6):722-9

Are they working in the same OR?

Medical Team Training Safety Attitudes Questionnaire

* *

* P < 0.05 paired, Students t-test N = 3138 Questionnaires

In this clinical area, it is easy to speak up. I would feel safe being a patient here.

0

2

4

6

8

10

% T

urn

ov

er

Pe

r Y

ea

r

Pre Post

Operating Room

Nursing Turnover

P = 0.02

45 Operating Rooms and 35 Intensive Care Units

Pre = 12 Months Prior to Learning Session

Post = 12 Months Following Learning Session

Leadership Participation Matters

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

1.8

TeamClimate SafetyClimateJobSa sfac on StressRecogni on

Percep onofmanagemnent

WorkingCondi ons

Diiferencebetw

eenM

axandM

inresponse(byroleave.)

SAQDimension

TeamConsensus:DisparitybetweenPhysiciansandNurses

(Smallnumbersarebe er)

2011disparity

2012disparity

Positive Consensus, Before and After MTT

0%

10%

20%

30%

40%

50%

60%

Team Climate Safety Climate Job Satisfaction Stress Recognition Perception of

management

Working Conditions

SAQ Dimension

% c

on

sen

su

s

PreMTT

PostMTT

Improved Results after One Year

MTT – Facility Level Impact

67% High Impact on OR Staff

73% High Impact on OR Patients

69% of OR Teams Improved Teamwork

66% of OR Teams Report Improved Efficiency

Eqpt Util (61%), Starts (35%), Duration (19%)

Safety Attitudes Questionnaire (SAQ) Significant Improvement (p<0.001):

Working Conditions, Perception of Mgmt, Job Satisfaction, Safety Climate, & Teamwork

Neily et al. Assoc. Between MTT and Surg Mortality. JAMA. 2010;304(15):1693-1700.

MTT Impact - VA

N=108; 74 MTT, 34 Control

MTT 50% greater decrease in mortality &

morbidity than Control, 18% & 17% respectively

Dose-response –

0.5 deaths/1000 procedures less per quarter

p=0.001

0.6 deaths/1000 procedures per increase in

briefing/debriefing p=0.001

70% reduction in reported OR related harm

Debriefings

Provide near real-time feedback

Must be prepared to handle reports

Prioritization

Action

Feedback must prompt to prevent cynicism

The engine for continuous improvement

Obstacles to Performing the

Debrief - Summary

Transparency and Feedback are the key

60%

44%

75%

27%

100%

36%

73%

100%

60%

0%

20%

55% 47%

71%

17%

0%10%20%30%40%50%60%70%80%90%

100%

Ora

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gy(1

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Neuro

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Pla

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6)

Oph

thalm

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Orth

op

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ics(1

4)

End

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e(1

1)

Tra

nspla

nt(1

)

Hepa

tobilia

ry(5

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Co

lore

cta

l(0)

Gyne

colo

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Uro

logy(1

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Min

imally

Invasiv

e(1

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Onco

log

y(7

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Tra

um

a B

urn

(12)

Pod 1 Pod 2 Pod 3

Debrief Participation For the week of Dec. 23

Se

rvic

e (#

Ca

se

s)

Increase from last week

No change from last week

Decrease from last week

Observational Data

MTT Summary

Systems Approach – Surgical issues must be

dealt with in the extended peri-operative period,

not solely in the OR Entire System of care must be Examined and

Engineered with desired results in mind – avoid

unintended consequences

Team Training – start in initial training & sustain

More than SBAR – Leadership Must Be Involved

Checklist-guided briefings and debriefings Can’t rely on individuals being careful (vigilant)

Compliance – Trust But Verify Consequences for Deliberate Non-Compliance

Beyond the Operating Room

Slide Title

Text here

Creating a

Shared

Mental

Model

If patients know what to

expect… they are

more likely to identify

and question an

unexpected or

unplanned event

• Providers Orders extracted from the electronic medical record

• Limited to current date

• Printed for each patient

Straightforward

Implementation

Nurses Review the Daily Plan with patients to:

Identify potential errors

Explain the day’s activity

Encourage questions

Provide patient education

17.6% of

the nurses

found at

least one

error as the

result of

The Daily

Plan

Improves the patient satisfaction

Strengthens communication

Provides patient education

Facilitates continuity of care

Conclusions Need to Provide Recurrent Teamwork Training

– Not ‘One and Done’ for OR and Floor

Data show that people more likely to be “on

the on same page” post implementation

MTT process (Debriefing) highlights issues

that need attention Must continue to improve system in place to deal

with debrief comments – Avoid BLACK HOLE

EFFECT

Ongoing Process – Requires Leadership

Move From:

Resistance

Pro forma Compliance