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Health Quality Improvement using Instructional
Communication and Teamwork Videos: An
Outcome Study
Neil Cowie
This Session is sponsored by:
Health Quality Improvement using
Instructional Communication and
Teamwork Videos:
An Outcome Study Pilot
Neil Cowie Department of Anesthesiology, University of Saskatchewan
April 11, 2013
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
Health Quality Improvement Using Instructional Communication and Teamwork …
Health Quality Improvement Using Instructional Communication and Teamwork …
Problem
• “Near misses” in patient care
• Lapses in interprofessional communication
and teamwork
• Urgent induction of General Anesthesia for
STAT Cesarean Birth
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
• 70% of sentinel events in obstetric practice are
attributable to errors in communication and
teamwork The Joint Commission
Medical Simulation
Health Quality Improvement Using Instructional Communication and Teamwork …
Health Quality Improvement Using Instructional Communication and Teamwork …
http://www.medicine.usask.ca/acutec
areteamwork/intro/index.php
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
Study Design
Video Clips
Debriefing
Competencies
Q
Q
Q
Nov, 2010
April, 2011
Feb, 2012
Competencies
• Situational Awareness
• SBARR
• Closed Loop Communication
• Leadership
• Shared Mental Model
• Overcoming Hierarchy
• Mutual Support
• Conflict Resolution
• Avoiding Distraction
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
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
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
QUALITY
IMPROVEMENT
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
Future
Questions
MoreOB
Questionnaire
Non-Technical Skills
Health Quality Improvement Using Instructional Communication and Teamwork …
Questionnaire:
Technical Skills
– Application of monitors
– Assistance with securing airway for intubation
– How to assist if intubation fails
CPSI Safety Competencies
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
Items Reflecting Behavior of the Team
Items Reflecting Behavior of the Team

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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
  • 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
  • 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