Health Quality Improvement Using Instructional Communication and Teamwork …
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Improvement Story session at the 2013 Saskatchewan Health Care Quality Summit. For more information about the summit, visit www.qualitysummit.ca. Follow @QualitySummit on Twitter. We created a multi-media, web-based learning resource that improved obstetrical nurses’ knowledge, team communication, performance and increased awareness of negative behaviors of the team surrounding emergency Caesarean birth under GA in a pilot study conducted in the Labour and Birth Unit at the Royal University Hospital. We hope it can serve as one strategy for improving teamwork thereby reducing adverse events in acute critical clinical situations. Better Teams Neil W. Cowie
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Health Quality Improvement Using Instructional Communication and Teamwork …
- 1. Health Quality Improvement using Instructional Communication and Teamwork Videos: An Outcome Study Neil Cowie This Session is sponsored by:
- 2. Health Quality Improvement using Instructional Communication and Teamwork Videos: An Outcome Study Pilot Neil Cowie Department of Anesthesiology, University of Saskatchewan April 11, 2013
- 3. Team Members Angela Bowen, College of Nursing, University of Saskatchewan Kalyani Premkumar, Department of Community Health and Epidemiology College of Medicine, University of Saskatchewan Susan Kuling, Previous Nurse Manager, Labour and Birth Unit, Saskatoon Health Region Mark Burbridge, Department of Anesthesia, College of Medicine, University of Saskatchewan Jocelyne Martel, Obstetrican, Saskatoon Health Region
- 6. Problem • “Near misses” in patient care • Lapses in interprofessional communication and teamwork • Urgent induction of General Anesthesia for STAT Cesarean Birth
- 7. Legal Settlements Cerebral palsy lawsuit settles for $3.8 million Brain damage in newborn settlement is $3.5 million Birth injuries leave twin with cerebral palsy: $2.8 Million Settlement $5.65 million settlement for Rhode Island baby's brain damage related to birth trauma Delay in c-section resulting in brain damage settlement is $3 million Settlement for newborn's brain damage is $4 million
- 8. • 70% of sentinel events in obstetric practice are attributable to errors in communication and teamwork The Joint Commission
- 13. Goals of Study • Make a movie of a simulated OB event • Use web-based “Trigger Videos” to teach skills in communication and teamwork to Obstetrical Nurses • Measure outcome • Continuing professional development for self- directed learning on the web
- 14. Study Design Video Clips Debriefing Competencies Q Q Q Nov, 2010 April, 2011 Feb, 2012
- 15. Competencies • Situational Awareness • SBARR • Closed Loop Communication • Leadership • Shared Mental Model • Overcoming Hierarchy • Mutual Support • Conflict Resolution • Avoiding Distraction
- 16. Findings • Improved technical knowledge • More critical of the team (anesthesia) after the educational intervention • Ten months later, had applied many of the team competencies into personal practice – Speak up – Assertiveness – Conflict resolution
- 17. Presentations • Board of RUH Foundation • Simulation in Healthcare • São Paulo • POGO for Nurses • Women's Health, Obstetric, and Neonatal Nurses Conference • Canadian Anesthetists Society • MedEdPortal • Senior leadership SHR • IHI Summit, Washington DC
- 18. What did we find out? • Unable to publish study • Unbelievable turnover of nursing staff • Fixed and decreasing numbers of nursing education days • Self directed training video has not been offered to nursing staff
- 20. Project Failure • Project will fail if dependent on the actions of another team • Project will fail if multiple groups must change Behavior and culture change is slow • If management doesn’t support, things will not change
- 21. Future
- 22. Questions
- 23. MoreOB
- 26. Questionnaire: Technical Skills – Application of monitors – Assistance with securing airway for intubation – How to assist if intubation fails
- 28. 7 Deadly Sins of Quality Improvement • Narrow focus • Assuming change in behavior of staff • Process decisions made by administrators • Too many active projects at one time • Lack of focus • Decisions made on satisfaction scores rather than outcomes • Erroneously assume leadership supports changes
- 29. Items Reflecting Behavior of the Team
- 30. Items Reflecting Behavior of the Team