June 22, 2017
It seemed like a routine operation: removing a small tumor from a woman’s pelvis. The team of six professionals — two surgeons, two anesthetists, and two nurses — had huddled to review the patient’s records and performed the excision without complications. Now they were relaxing and debriefing as the patient recovered.
Then came the alarm. The patient could not breathe. The team dynamic had to be altered swiftly to deal with an emergency cricothyroidotomy. One of the anesthetists took charge, while the surgeon who had removed the tumor was assigned to do chest compressions.
The “patient” — a manikin equipped with a pulse and heartbeat, breathing and intestinal sounds, body fluids, and other realistic signs of life — pulled through. And the surgical team learned fresh lessons in the value of communication and teamwork by taking part in the “Operating Room Team Training with Simulation Program,” funded by a CRICO grant and implemented across 10 Harvard-affiliated institutions.
“It was great because we all had something to bring to the table,” said Lorena Olivero, the scrub nurse at the simulation, after the handling of the mock crisis, which took place at the STRATUS Center for Medical Simulation at Brigham and Women’s Hospital. “We saw how important everyone’s expertise is.”
In recent years, safety experts have underscored the virtues of teamwork training in preventing patient harm. (See “Five Questions” with Dr. Tejal Gandhi.)
Studies and reports from the Institute for Healthcare Improvement, the National Quality Forum, the Joint Commission, and the Accreditation Council for Graduate Medical Education, among others, say respect, open communication, and the willingness of all medical team members simply to speak up are fundamental not just to surgical practice but also to the everyday delivery of safe care in all settings.
Training medical staff to function like a smooth and supportive team can take any number of forms. Surgical simulation is certainly one, but creating a collegial environment among caregivers with disparate duties can be done in less formal ways. At the Cambridge Health Alliance, for example, three nurses put together a simple training video and slideshow aimed at bridging communications gaps among staff. (See below.)
According to the Agency for Healthcare Research and Quality (AHRQ), a federal agency with a focus on improving health care safety, successful teamwork training programs like its own TeamSTEPPS are being implemented in many clinical environments. Those include emergency departments, operating rooms, obstetrics units, and outpatient primary care clinics. They are also being used to train hospital leadership in responding to safety events.
ARHQ says evidence supporting the benefits of such programs is growing. A landmark study in the Veterans Affairs hospital system showed a significant reduction in surgical mortality was associated with team training. Other studiesshow that improving caregivers’ “knowledge of teamwork principles” improves the safety climate in many settings.
In its research into surgery-related malpractice claims, CRICO has found that “communication breakdowns are the second most common factor identified in contributing to error, after technical performance.” That’s a key reason why CRICO, which provides professional liability insurance and patient safety services to the Harvard medical community, is funding interprofessional surgical team training for organizations.
STRATUS, meanwhile, offers its simulation programming to providers of all sizes.
“There’s nothing that’s going to save more lives in the next 20 years than effective communication,” said Charles N. Pozner, M.D., executive director at STRATUS, who often joins his staff in observing OR teams handle his “patients” through a one-way mirror. “The answer to a problem is almost always in the room. It just doesn’t always get to the patient.”
In a typical simulation, the OR team is thrown curveballs aimed at emphasizing the need to speak up and coordinate tasks while managing unforeseen situations and complications.
Behind the scenes, Pozner’s staff manipulates monitors and alarms while calling out problems over speakers. (In one instance, a delay in warm blood delivery had to be made known promptly and forcefully to the team by a nurse, leading to vital safety adjustments.)
A key component of the simulations is the post-operative debriefing, when Pozner and his assistant director of simulation-based learning, Jamie Robertson, PhD, MPH, drive home points of emphasis. On the day of the “emergency cricothyroidotomy,” the caregivers delved into the question of how one of them needed to assert crisis leadership while remaining open to guidance from team members rather than, say, just barking orders.
“We’ve all dealt with those types,” said Olivero.
According to physicians and nurses who have done simulations, many social barriers prevent them from speaking up during the exercise despite their genuine concern for the “patient.” Those include hierarchical norms, territorial norms, fear of being wrong, fear of embarrassment for self or others, presumed institutional repercussions, natural avoidance of conflict, respect for authority, concern for reputation, and not knowing what to say.
“An anesthesiologist, for example, might feel uncomfortable challenging a surgeon or making suggestions about a surgical problem,” said Kathy Dwyer, senior program director for patient safety with CRICO. “Adverse surgical outcomes are often the result of such ineffective team communication.”
Some 450 surgeons and their teams across 10 organizations have been trained to date in simulated situations, Dwyer said, adding, “It is very exciting to see this grow.”
When a trio of nurses at Cambridge Health Alliance detected “barriers to communications” among registered nurses and certified nursing assistants there, they set out to improve the tone by producing a short video depicting the virtues of respect and civility in all interactions on their unit. In essence, the unit was not working to its full potential as a team.
They began the project by holding staff focus groups. Stephanie A. Racca, BSN, RN, a nurse manager at the Alliance, said she and her two colleagues soon learned that “both RNs and CNAs felt they could not rely on each other for help” because of a “perceived lack of respect for each other and little understanding of each other's role in patient safety.”
“But we also learned that both sides really wanted to address these issues,” she added. “That’s when we decided to make a movie.” Her film team included Sarai Lamothe, BSN, RN, and Candice Stahl, BSN, RN.
“We realized that perhaps the best way to address these common communication complaints,” said Lamothe, "was to depict scenes that illustrated the ‘incorrect or bad’ version of a specific scenario versus the ‘correct or good’ version of how communication ought to be carried out.” (See figure 1.)
Six scenarios were shown in the film — three put forth by the CNAs and three by the RNs. One scenario by the CNAs had to do with implicit messaging around respect (See figure 2.)
“We have a CNA on the right asking the nurse for assistance,” Racca explained, “and the RN responds, ‘Ask one of your colleagues.’ The CNA then responds, ‘Aren’t you my colleague?’” Another scene in the film shows how face to face conversations lead to a safer and more collegial atmosphere.
After the full movie was shown and discussed, Racca said, staff members were far more likely to feel that colleagues supported one another. They were also more likely to feel positive about the “culture of patient safety” in the unit. (See figure 3.)
As for applying CHA’s lessons to other facilities, Racca recommended that organizations include an objective outsider to facilitate mediation; involve a fair representation of staff in the effort; and continue to address the issue because “nothing is solved or finished after a few meetings — the efforts to improve communication must be on-going.”
“One surprising lesson was the notable appreciation and change in attitude that occurred among many of the staff from the onset simply because this issue was being addressed,” Racca said. “Staff members were notably happy that teamwork was on the agenda.”
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