It is a misty Tuesday morning, the streetlamps still on and the usually busy parking lots are near empty at Madigan Army Medical Center. A group of registered nurses, midwives, doctors and residents arrive to start their shifts and gather around a large television mounted on the wall. Joining them at the television are some of the staff who worked through the night and are getting ready to leave.
But they’re not watching the news or the latest reality or medical shows together. The television screen shows the list of current patients, and what rooms they’re in, and also lets the arriving medical team know about upcoming appointments for the day. Discussing the patients together with the arriving and departing teams highlights one of the most important safety programs used at the hospital — communication.
Communication — between providers and with patients — is the focus of many procedures that ensure quality patient care at Madigan, said Colonel Peter Napolitano, maternal-fetal medicine fellowship director and instructor for current and upcoming safety procedures.
One aspect of this commitment to safety is TeamSTEPPS — Strategies and Tools to Enhance Performance and Patient Safety. This national program is sponsored by the U.S. government’s Agency for Healthcare Research and Quality. There are five components of this approach to care. The first — team structure — ensures that everyone involved with the process is aware of their part with the team. Communication encourages members of the team to freely speak up with any questions or concerns they may have throughout the patient-care process. Leadership encourages everyone involved to know what they are trying to accomplish, when changes are needed and what is needed to finish the project. Situation monitoring encourages team members to look for both positive and negative aspects of what the mission is. And last, mutual support gives everyone equal weight in ensuring team members have knowledge and resources to do their part.
In 2001, a U.S. Department of Defense research program measured the outcomes of a new safety program on fast-paced, intense departments like intensive care, emergency and labor and delivery. Seven military hospitals, including Madigan, were included in the study using a new program based on an aviation safety program — Crew Resource Management. That’s where anyone responsible to get the aircraft off the ground who sees a safety issue must report it, regardless if they are a baggage handler, a pilot or a mechanic. Every provider in labor and delivery was trained in this initial program, which showed a significant improvement in time performing a cesarean section, once it had been determined to be needed and set up a more focused emphasis on obstetric patient safety.
After the study, the MedTeam program was cut due to licensing disagreements from the private company who put the safety approach together. TRICARE Management Activity and AHRQ teamed up to create a new national program, using the same foundations as the CRM to create an open environment in health care. Between 2005 and 2009, leaders like Napolitano, charge nurses, and other providers became champions for the program by teaching any new employees about it.
Providers are also trained using a role-play exercise involving three different problems that a particular department may find. It goes over the correct way to approach the program versus the incorrect approach, giving providers training in real-life situations.
Madigan is a team resource center, meaning they can train the trainers, whom they call “champions,” who, in turn, train their team members on TeamSTEPPS. Once the new system was implemented, the program piloted at Madigan was spread to civilian universities. There are now five civilian universities, with representatives who petitioned to learn the program from a civilian training site for a two-and-a-half day course. Since 2011, new employees at military hospitals must be trained in this program.
This foundational idea in TeamSTEPPS ensures providers leave military ranks and hospital titles at the hospital door. However, in a hospital with a mix of military and hospital hierarchy, it is not an easy task
“This is a culture change, which can take years and can be a very long process,” Napolitano said. “With this eagle on my chest, it’s unlikely a private first class is going to just walk up to me and tell me something I may need to know without going through his or her chain of command. This program encourages this kind of openness.”
One example of this program in motion came from a day with back-to-back indicated C-sections. The brief meeting set up how to best deal with the three surgeries, one after another, efficiently while taking in account the time it takes to clean up in between the hour-long procedures. Because the program encourages everyone working on a unit to attend the shift brief, not just the nurses and doctors, a housekeeper present at the meeting recognized she could help reduce the wait time. She worked with fellow housekeepers to clean the operating room between the cases to cut the surgery prep time down to 10 minutes from the usual 30 minutes.
“It gives everybody a chance to see what needs to be done so those who are not directly assigned to patient care can jump in and help without being asked and thus help accomplish the mission in the fastest way possible resulting in excellent efficient care,” Napolitano said. “This is all due to the team brief meeting, which lasts between five to 10 minutes.”
A huddle may be called, lasting only about a minute, when emergencies arise. These act as even shorter medical briefs by ensuring the whole team is aware of any problem and how they will approach it. A debrief may also be called after any event or surgery where the team may improve, so the team can review the case and make acknowledgments or recommend improvements.
The Situation, Background, Assessment and Request (SBAR) method is a tool that improves communication between medical providers where key essential elements of the patients care are brought up first, up front, so one can more quickly act on them. When approaching someone about a problem, team members start with what the situation is.
“This is important so we know what the problem is immediately without wading through background info,” Napolitano said.
Then the team will take the time to gather background information to get to the core of the problem and look at care options. This helps streamline provider’s abilities to quickly react to problems. It creates a more streamlined approach that focuses on the problem first, then zooms out to what lead up to the situation and how to solve it.
The other side
The team also includes patients and their families. The check-back program ensures that providers communicate between one another and patients. Requests, procedures and answers to questions are repeated by the person receiving the information. This ensures members of the team, such as a nurse in the operation room, are getting the correct instruments and medications. Patients can also ask for clarification if they are confused. Family members are encouraged to participate, whether it’s looking for behavioral changes in the patient or asking questions for their loved one, who may not be able to.
Checklists are used before care is given to ensure everyone on the team knows what to expect and nothing is missed. This is the Safe Cesarean Section program, which is similar to the World Health Organization surgery checklist, but involves three meetings and more interaction with patients.
It is currently only used at Madigan.
The pre-operation meeting ensures the team is all present, and covers if the patient needs additional care and their medical history. In the room, while waiting for the sanitizing scrub to dry on the woman’s stomach, a checklist is read aloud, every
team member states their name, the process is gone over and finally, the patient is asked to repeat some of this information. This ensures the patient knows and understands what the medical team is going to do to help her.
Once the procedure is completed, there is a team debrief to go over what went well as well as what improvements or changes could be made.
Patients are also encouraged to be involved in this process using TEAMUP — Team, Education, Asking, Medications, Understanding and Perspective. While meeting together with the care team, the patient should be educated on what is happening with their care, ask questions (using the same SBAR principle), manage medications, and understand what changes may arise, and ensure the patient’s perspective is shared with their providers. Patients then have the chance to ask questions and fully understand what will or may happen during the delivery process, or any other hospitalization.
“These steps ensure we know what the patient needs and they know what to expect,” he said. “When we gave an exit survey to patients who experienced the TEAMUP method, they were significantly more satisfied with their perceived involvement with their care and felt like their providers genuinely cared about their needs.”