Medical Team Training: Improving Communication in Healthcare
September / October 2007
Medical Team Training
Improving Communication in Healthcare
Though studies continue to show that communication failure is a major cause of adverse medical events, we decided to test this relationship by reviewing the experience of the Veterans Health Administration, a large integrated health system.
The VA National Center for Patient Safety (NCPS) has a large narrative patient safety database comprised of close call and adverse event reports, which has accrued approximately 325,000 Patient Safety Reports and more than 12,000 Root Cause Analysis reports since 2000. When searching our database, consistently 70-to-80% of the cases have identified communication failure as at least one root cause contributing factor in these events.
In an attempt to address communication failures in healthcare, we began to develop an intervention to improve communication and collaboration, focused on critical care areas. Our program, Medical Team Training (MTT), is a long-term effort to improve patient care and is based on a systems approach to problem solving.
Regardless of the caregiver involved, a poorly functioning communication process can repeatedly generate unfortunate sequences of events that place patients at risk for harm.
The aviation industry recognized that communication was a critical problem 25 years ago and developed Crew Resource Management (CRM) to address communication failure. CRM is defined as using all available sources — information, equipment, and people — to achieve safe and efficient operations. The focus of CRM is the safety, efficiency, and morale of humans working together.
Since healthcare has many features in common with aviation — high profile, complex technology, well educated professionals, and significant risk — we hypothesized that CRM principles have applications in healthcare. And they do!
Not Just “Flavor of the Month”
We are committed to the long-term improvement of healthcare delivery in the VA health system. We have observed that leadership support of patient safety in health systems often consists of lip-service, and is not matched with interventions and resources to improve the safety of patient care.
There is a plethora of aviation-based CRM programs provided by consultant groups. These seminar-based training sessions may be of limited effectiveness if they provide limited translations to healthcare, minimal preparation of health system professionals before the sessions, and minimal follow-up to facilitate the implementation of CRM interventions in their health systems after the sessions. Evaluation of these programs has been primarily limited to survey data suggesting that participants in these sessions valued what they had learned.
Program Structure
Preparation and planning begins at least two months prior to a scheduled MTT Learning Session. Key personnel in each facility organize an interdisciplinary Implementation Team. The focus of this team is to prepare for the Learning Session by creating a facility-specific implementation table made up of a CRM activity(s) chosen from a limited menu of options, and to sustain their project(s) for a minimum of one year.
Project options include:
- Briefings and debriefings by the surgical team in the conduct of surgical procedures in the OR.
- Conducting interdisciplinary patient-centered rounds in the ICU.
- Implementing a standardized process for transferring patient care responsibility (hand-offs) between healthcare professionals — e.g., nurse change of shift; nurse report to physician for change in patient condition; patient transfer from OR to ICU.
- Debriefing cardio-pulmonary resuscitation events and/or adverse patient events.
- Instituting interdisciplinary administrative briefings on a regular basis for proactive problem solving in clinical units or in work processes across units — e.g., OR, surgical services, and central medical supply — focused on improving the provision of surgical instruments and supplies for each surgical procedure.
- Instituting a fatigue management strategy in a clinical unit — e.g., a strategic napping plan for nursing and medical staff in the SICU.
Our MTT Learning Sessions are facilitated by three clinical faculty members selected from a pool of three surgeons, five masters-prepared nurses, and our program coordinator, who has a master’s degree in communication. Our nurse faculty members have backgrounds with considerable experience in surgical nursing, recovery room, the ICU, and cardiac care. Our surgeon faculty members have backgrounds in obstetrics and gynecology, thoracic and general surgery, and cardiothoracic surgery.
Each Learning Session is focused on overcoming a number of obstacles to effective communication, such as:
- Lack of information sharing.
- Working in professional “silos.”
- Failure of coordination across clinical units.
- Lack of staff assertiveness.
- Power differentials and organizational hierarchy.
- Loss of situational awareness.
- Failure to “speak up” when necessary for patient well-being.
- Lack of respect for others.
- Speaking in coded abbreviations, acronyms, and incomplete sentences.
Our Learning Sessions are very interactive: They are integrated with teaching films, produced by NCPS faculty, and clinical vignettes that demonstrate specific CRM activities applied to healthcare. The films include scenarios, such as team interactions during a change in patient condition, a code resuscitation, a code team debriefing, interdisciplinary administrative briefing in the ICU, briefing and debriefing a cardiac surgical procedure, patient hand-offs using a standardized process, and interdisciplinary rounds in the ICU.
Implementation and Initial Data
We are implementing our program in all VA Medical Centers that provide surgical services. However, all clinical units are welcome, and participation is subject to the discretion of the facility director. We estimate our national roll-out of this program will require 260 Learning Sessions in 130 VA Medical Centers during a 2-year period, wrapping up in late 2009.
To date, we have conducted 70 MTT Learning Sessions involving 54 facilities, with more than 3,000 participants. Staff members including physicians, nurses, and allied health personnel have enrolled from 46 operating rooms and 34 intensive care units. Other units participating have included the emergency department, cardiac catheterization laboratory, medical-surgical units, long-term care, and primary care clinics.
We have been collecting data for our rigorous program evaluation, which will test two hypotheses: In association with the implementation of the MTT program, patient outcomes and staff job satisfaction will improve. We will not have the statistical power to test our hypotheses until all VA Medical Centers have implemented this program for a minimum of 1 year.
Following the implementation of surgical team briefings and debriefings, the Houston VA Medical Center reported a statistically significant improvement in communication scores from a survey for surgeons, nurses, and anesthesiologists. In addition, the Houston facility reported the following:
- An increase in surgical patients receiving prophylactic antibiotics within 60 minutes of the surgical incision from 84% to 95%.
- An increase in patients receiving effective prophylaxis for Deep Vein Thrombosis prior to anesthetic induction from 92% to 100%.
- Pre-operative briefings identified 3.3% of patients whose surgical procedures were cancelled due to unacceptable risks identified during these briefings.
Narrative reports from participating staff in other VA Medical Centers have included the following:
- An OR team at one facility previously averaged 3,000 delay minutes per month for “total” delay reasons. After one month of implementing MTT briefings and debriefings, they are down to 900 delay minutes.
- One pre-op briefing prevented a wrong site/side surgical procedure.
- One pre-op briefing informed a surgical resident that he was in the wrong room.
- One facility had been tracking length of surgical procedures since MTT implementation, noting a 2-3 minute decrease per case.
- In one facility, pre-op briefings prevented at least two potentially harmful surgical procedures due to what was learned in the pre-op briefing.
- One facility tracked 213 cases through the MTT pre-op briefing, discovering patient safety issues, and prevented patient harm in seven of those cases (3%)
Putting It All Together
MTT is another example of our effort at VA to focus on how well care systems function and to move beyond the notion that individual performance can solve all patient care problems. Caregivers who participate in efforts of this kind are taking a giant step forward, one that clearly benefits our patients.
We cannot continue to rely solely on our technical skills, no matter how sophisticated they may be and how much effort we have made in developing them. We must become more effective members of a clinical team. A poorly functioning communication system too often leads to a care system that continues to generate the same problems, regardless of the caregiver’s personal skill and commitment to patient care.
All of the authors work at the VA National Center for Patient Safety (www.patientsafety.gov) in Ann Arbor, Michigan.
Lisa Falzetta is a nurse educator with the Medical Team Training (MTT) program. Her background is in cardiac nursing, andÝshe has a master’s degree in nursing administration and patient care services.ÝMost recently, Falzetta taught leadership and management at the University of Michigan School of Nursing and was project coordinator for GEM-Nursing, an online mentoring program for young people interested in the nursing profession.
Amy Carmack is a program specialist, faculty member, and manager of operations and logistics for the MTT program. She specializes in multiple forms of communication strategies, with more than 10 years of professional public speaking experience. Carmack has a master’s degree in communication studies.
Lori Robinson is an MTT nurse educator. Her background is in surgery and patient safety.ÝShe holds a BSN from Excelsior College, certification by the American Board of Perianesthesia Nursing, and is working on a MSN in healthcare systems management.ÝWhile working at the VA medical center in Anchorage, Robinson founded the Alaska Patient Safety Collaborative, a group of healthcare professionals focusing on a collaborative state-wide approach to patient safety.
Joe Murphy is the public affairs officer for the VA National Center for Patient Safety. He has nearly 20 years experience in public affairs for government, private sector organizations, and the military. Murphy is a graduate of the University of California, Berkeley, and has a master’s degree in human resources management from Golden Gate University, San Francisco, California. He is accredited by the Public Relations Society of America and may be contacted at Joe.Murphy@va.gov.
Ed Dunn is administrator of the MTT program as well as being an MTT faculty member and director of policy and clinical affairs for the VA NCPS. Dunn practiced cardiothoracic surgery for 20 years prior to joining NCPS in 2003. He has master’s degrees in public health, business administration, and public administration.