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
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
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
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
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