NEONATOLOGY: A TEAM SPORT Roger F. Soll, MD Professor of Pediatrics University of Vermont Workshop on Perinatal Strategies Scottsdale, Arizona April 9, 2010
JOE BUTTERFIELD: THE ULTIMATE TEAM PLAYER a physician with aa heroic passion for children. That passion went beyond medicine and into the political arena, where Dr. Butterfield spent many years as a lobbyist advocating for children's issues and encouraging others to do the same.
NEONATOLOGY: A TEAM SPORT The NICU as a Team Teams within Teams Teams of Teams
WHAT IS A TEAM?
WHAT IS A TEAM? Two or more individuals who perform some work related task, interact with one another dynamically, have a shared past and a foreseeable shared future, and share a common fate Salas 1993
WHAT IS A TEAM? New York Yankees SWAT Team Airline Crew NICU Staff!
WHAT IS A TEAM? Individual Brilliant Physician/Nurse vs. Highly Functional Team
WHAT IS A TEAM? Discordance in perception of team performance between physicians and nurses Grant MJ J Nurs Care Qual 2006; 21: 223-9
WHAT IS A TEAMWORK?
WHAT IS A TEAMWORK? Behaviors that facilitate effective team member interaction Beaubien 2004
WHAT CREATES AN EFFECTIVE TEAM? Development of Potentially Better Practices for the Neonatal Intensive Care Unit as a Culture of Collaboration: Communication, Accountability, Respect, and Empowerment. Judy Ohlinger, RN, MSN, Mark S. Brown, MD, MSPH, Sue Laudert, MD, Sue Swanson, RN, NNP and Ona Fofah, MD on Behalf of the CARE Group PEDIATRICS Vol. 111 No. 4 April 2003, pp. e471-e481
POTENTIALLY BETTER PRACTICES Clear, shared purpose, goals, and values Effective communication among and between teams and team members Lead by example: "walk the talk Nurture a collaborative environment with trust and respect Live principled standards of conduct and standards of excellence Nurture competent and committed teams and team members Commit to conflict management
POTENTIALLY BETTER PRACTICES Clear, shared purpose, goals, and values It s about the baby!
TEAM COMMUNICATION Effective communication among and between teams and team members
TEAM COMMUNICATION That sure is a big storm around New York City vs. Captain, I am concerned about flying into that storm
TEAM COMMUNICATION Korean Airline Disaster No one would tell the pilot that he was flying directly into a mountain
ASSERTION Under time pressure, it can be difficult to obtain attention fully and to communicate effectively. Assertion is when individuals persist in speaking up to ensure that there is shared understanding and a resolution of a situation of concern (e.g., delivery room crisis)
Steps to take for improved communication in a delivery room emergency Get the person's attention Express your concern State the problem Recommend action Achieve a decision Use - communication ground rules: Make eye contact Listen to understand Repeat back what the person says Call people by their first name
WHAT IS A LEADER?
POTENTIALLY BETTER PRACTICES: LEADERSHIP Lead by example: "walk the talk Nurture a collaborative environment with trust and respect Live principled standards of conduct and standards of excellence Nurture competent and committed teams and team members
WHAT TYPE OF TEAM ARE YOU ON?
LEADERSHIP?
SELF ASSESSMENT Using Organizational Assessment Surveys for Improvement in Neonatal Intensive Care Baker and coworkers. Pediatrics 2003; 111: e419-25
SELF ASSESSMENT Measured organizational culture - Coordination - Teamwork - Leadership - Conflict management - Unit culture Baker and coworkers. Pediatrics 2003; 111: e419-25
TYPES OF ORGANIZATIONAL CULTURE Group Culture: High affiliation, concern with teamwork and participation Developmental Culture: Based on risk taking innovation and change Hierarchical Culture: Reflecting the values and norms associated with bureaucracy Rational Culture: Emphasizing efficiency and achievement Baker and coworkers. Pediatrics 2003; 111: e419-25
SELF ASSESSMENT Self assessment tools useful but not directly correlated to outcome Promoted discussion of organizational and team issues Baker and coworkers. Pediatrics 2003; 111: e419-25
THE PROJECT ORIENTED TEAM Focused Typical Business Model Needs: Clear Vision/Purpose Multidisciplinary representation Clear ground rules Clear expectations for production Can learn successful behaviors for this type of teamwork
RAPID RESPONSE TEAM Rapid Response Teams (AKA Medical Emergency Teams) Highly experienced clinicians dispatched to evaluate and triage patients with rapidly deteriorating clinical status
RAPID RESPONSE TEAM Reduce morbidity and mortality related to cardiopulmonary arrest -in adults (Dacey 2007, Hillman 2005) and - children (Sharek 2007)
TEAMWORK IN NEONATAL RESUSCITATION Simulation Based Training
Teamwork and quality during neonatal care in the delivery room. Thomas EJ, Sexton JB, Lasky RE, Helmreich RL, Crandell DS, Tyson J. J Perinatol. 2006 Mar;26(3):163-9.
Teamwork and quality during neonatal care in the delivery room OBJECTIVE Experts believe good teamwork among health care providers may improve quality. The investigators sought to measure the frequency of team behaviors during delivery room care and to explore how these behaviors relate to the quality of care.
Teamwork and quality during neonatal care in the delivery room STUDY DESIGN The investigators video recorded neonatal resuscitation teams then used independent observers to measure teamwork behaviors and compliance with Neonatal Resuscitation Program (NRP) guidelines (a measure of quality of care).
Teamwork and quality during neonatal care in the delivery room RESULTS All teams (n=132) exhibited the behaviors regarding information sharing and inquiry All but one team exhibited vigilance and workload management. Other behaviors were present less often: assertion 19.9% teaching 16.7% leadership 19.7% evaluation of plans 12.9% intentions stated 9.1%.
Teamwork and quality during neonatal care in the delivery room RESULTS Factor analysis identified three fundamental components of teamwork: 1. communication (comprised of information sharing and inquiry); 2. management (workload management and vigilance); and 3. leadership (assertion, intentions shared, evaluation of plans, and leadership). All three components were weakly but significantly correlated with independent assessments of NRP compliance and an overall rating of the quality of care.
Teamwork and quality during neonatal care in the delivery room CONCLUSIONS Most team behaviors can be reliably observed during delivery room care by neonatal resuscitation teams, and some are infrequently used. Weak but significant and consistent correlations found among these behaviors with independent assessments of NRP compliance and an overall rating of the quality of care. These findings support additional efforts to study team training for delivery room care and other areas of healthcare.
Teaching teamwork during the Neonatal Resuscitation Program: a randomized trial. Thomas EJ, Taggart B, Crandell S, Lasky RE, Williams AL, Love LJ, Sexton JB, Tyson JE, Helmreich RL. Perinatol. 2007 Jul;27(7):409-14. Epub 2007 Jun 7.
Teaching teamwork during the Neonatal Resuscitation Program: a randomized trial OBJECTIVE: To add a team training and human error curriculum to the Neonatal Resuscitation Program (NRP) and measure its effect on teamwork. The investigators hypothesized that teams that received the new course would exhibit more teamwork behaviors than those in the standard NRP course.
Teaching teamwork during the Neonatal Resuscitation Program: a randomized trial STUDY DESIGN: Interns were randomized to receive NRP with team training or standard NRP, then video recorded when they performed simulated resuscitations at the end of the daylong course. Outcomes were assessed by observers blinded to study arm allocation and included the frequency or duration of six team behaviors: inquiry, information sharing, assertion, evaluation of plans, workload management and vigilance.
Teaching teamwork during the Neonatal Resuscitation Program: a randomized trial RESULT: The interns in the NRP with team training group exhibited more frequent team behaviors than interns in the control group: [number of episodes per minute (95% CI)] information sharing: 1.06 (0.24, 1.17) vs. 0.13 (0.00, 0.43); inquiry: 0.35 (0.11, 0.42) vs. 0.09 (0.00, 0.10); assertion: 1.80 (1.21, 2.25) vs. 0.64 (0.26, 0.91); team behavior: 3.34 (2.26, 4.11) vs. 1.03 (0.48, 1.30) (P-values <0.01 for all comparisons).
Teaching teamwork during the Neonatal Resuscitation Program: a randomized trial RESULT: Vigilance and workload management were practiced throughout the entire simulated code by nearly all the teams in the NRP with team training group (100% for vigilance and 88% for workload management) vs. only 53 and 20% of the teams in the standard NRP. No difference was detected in the frequency of evaluation of plans.
Teaching teamwork during the Neonatal Resuscitation Program: a randomized trial CONCLUSION: Compared with the standard NRP, NRP with a teamwork and human error curriculum led interns to exhibit more team behaviors during simulated
TEAMS OF TEAMS COLLABORATIVE QUALITY IMPROVEMENT Vermont Oxford Network NICQ Regional Collaboratives State based: California, Ohio, North Carolina, Tennessee or Country based: Ireland Mission based Collaboratives Children s Hospitals
NIC/Q COLLABORATIVES Series of multi-organization neonatal improvement Collaboratives for Vermont Oxford Network members beginning in 1995 The NIC/Q Collaboratives have 3 primary goals: To achieve measurable improvements in the quality, safety and efficiency of NICU care. To develop new resources, tools and knowledge for quality improvement in the NICU. To disseminate this improvement knowledge to the neonatology community.
VERMONT OXFORD NETWORK NIC/Q PROJECT Performance Feedback Quality Training Collaborative Learning Site Visits and Benchmarking Meetings, Listservs, Conference Calls SUPPORTED BY A GRANT FROM THE DAVID AND LUCILE PACKARD FOUNDATION
Vermont Oxford Network NIC/Q Habit for Change Habit for EvidenceBased Practice BETTER PRACTICES Clinical Organizational Operational Habit for Collaborative Learning Habit for Systems Thinking
HABIT FOR CHANGE Organizational Readiness Knowledge, Skills and Tools Model for Improvement
MODEL FOR IMPROVEMENT AIM WHAT ARE WE TRYING TO ACCOMPLISH? MEASURE HOW WILL WE KNOW THAT A CHANGE IS AN IMPROVEMENT? CHANGES A P S D WHAT CHANGES CAN WE MAKE THAT WILL LEAD TO AN IMPROVEMENT? LANGLEY, NOLAN, ET AL. THE IMPROVEMENT GUIDE: A PRACTICAL APPROACH APPROACH TO ENHANCING ORGANIZATIONAL PERFORMANCE. JOSSEYJOSSEY-BASS. SAN FRANCISCO, CALIFORNIA. 1996.
HABIT FOR SYSTEMS THINKING Complex Adaptive Systems Analyze Processes Measure Process Performance
HABIT FOR EVIDENCE BASED PRACTICE Ask the Right Question Search for the Best Evidence Critically Appraise the Evidence Apply the Evidence Evaluate Performance SACKETT DL, ET AL. EVIDENCE-BASED MEDICINE: HOW TO PRACTICE AND TEACH EBM. CHURCHILL-LIVINGSTONE. NEW YORK. 1997.
HABIT FOR COLLABORATIVE LEARNING Multidisciplinary Teams Collaboration within Teams External Benchmarking
POTENTIALLY BETTER PRACTICES Evidence often not definitive or does not address your specific circumstance Need for ongoing modification Need for local customization and local testing Understand the trade offs (risk/benefit ratio)
Infection: Potentially Better Practices Handwashing Nutrition Skin care Improved diagnosis Respiratory care Vascular access Unit culture
REDUCING NOSOCOMIAL INFECTION Ignaz Philipp Semmelweis Hungarian physician Puerperal fever Handwashing Mortality falls from 18.3 to 1.3 % 1818-1865
Reducing Nosocomial Infection QI Initiative Semmelweis Outcome Courtesy of R. Pfister
TRANSLATING EVIDENCE TO PRACTICE: PREVENTING NOSOCOMIAL INFECTION Efficacy: Handwashing helps prevent spread of hospital acquired infection Effectiveness and Efficiency: What agents are best to use? best bactericidal properties most cost effective How do we improve compliance? Where do we place sinks/hand washing stations?
C O A G-NEGA TIV E STA PH (% ) NICQ PROJECT: INFECTION OUTCOME 25 20 15 10 5 0 1994 1995 NIC/Q GROUP (N=6) 1996 1997 CONTROL (N=66) HORBAR ET AL. Collaborative Quality Improvement for Neonatal Intensive Care. Pediatrics. January 2001.
NIC/Q PROJECT INFECTION COSTS $80,000 COST $60,000 $40,000 $20,000 $0 1994 1995 NIC/Q GROUP (N=6) 1996 1997 CONTROL (N=9) ROGOWSKI ET AL. Economic Implications of NICU Collaborative Quality Improvement. Pediatrics, January 2001.
NIC/Q PROJECT Average Team Costs for Two Years Staff Time $48,000 Travel Expenses $20,000 Total $68,000 Rogowski et al. Economic Implications of NICU Collaborative Quality Improvement. Pediatrics. January 2001.
REDUCING NOSOCOMIAL INECTION: NIC/Q 2000 POTENTIALLY BETTER PRACTICES Improved hand hygiene compliance CVL setups re-evaluated and standardized Staff competency for CVL care improved Improved diagnosis of coag - Staph Kilbride HW, et al. Pediatrics 2003;111:e519-533
REDUCING NOSOCOMIAL INFECTION NIC/Q 2000: COMPARISON 1997 vs. 2001 5 of 6 NICUs improved. Overall change: 25% to 16% Infection Rate 50% 40% 30% 20% 10% 0% Unit A Unit B Uni C Unit D Unit E Unit F Kilbride HW, et al. Pediatrics 2003;111:e519-533
NICU AS A TEAM Remember There is no I in NCU Oh well there is, but keep it in perspective You are part of a team!
TEAMWORK AT IT S BEST!