Managing obstetric risk: Is your labor and delivery team ready?
Build a shared mindset to ensure safe deliveries through planning, communication, checklists and teamwork
- Hand offs vary in content, creating potential gaps in patient care.
- Approximately 50% of paid liability claims involve alleged misuse of oxytocin.
Poor communication: improving teamwork
Recent statistics from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) indicate that inadequate communication between providers or between providers and patients/families is the root cause of 60% to 70% of investigated sentinel events in medicine.14 Obstetrics faces the same challen-ges. JCAHO Sentinel Event #30 investigated 47 perinatal deaths and reported that poor communication was the most frequently cited root cause, involved in 72% of adverse events, with 55% of cases additionally involving an organization culture preventing effective teamwork and communication.15 Major problems in organizational culture included excessive hierarchy, intimidation, lack of a structured chain of communication, and failure to function as a team. In our experience, root cause analyses of sentinel events have identified at least 1 staff member who recognized imminent danger but did not feel empowered to speak up.
Outside expert reviews and safety culture surveys such as the Safety Attitude Questionnaire or the Agency for Healthcare Research and Quality (AHRQ) Safety Culture Survey may help identify weaknesses in the coordination and communication of the various members of the obstetrical teams (eg, nurses, obstetricians, anesthesiologists, neonatologists, administration, and ancillary services). However, traditional training paradigms and institutionalized hierarchies have made ineffective teamwork nearly universal. Physicians, midwives, nurses, and staff train in isolated silos, speaking different "languages" and exhibiting often conflicting perspectives, yet they are all expected to work in teams.16 This potential problem is exacerbated by voluntary limits on attending hours and mandatory restrictions on resident duty hours, the net effect being an increase in the number of patient care hand offs or transfers of care responsibility among providers.17 Hand offs tend to vary in content, creating potential gaps in patient care.18
A team training program based on crew resource management programs initiated and tested by the airline and defense industries has been shown to enhance communication in those settings.19 Similar interventions have helped to improve teamwork—although not necessarily outcomes—in medicine and obstetrics.20-23 More powerfully, a recent retrospective health services cohort study demonstrated lower surgical mortality in Veterans Health Administration centers that implemented structured team training programs.24 Examples of formalized team training exercises for medicine include AHRQ's Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS), the Veterans Administration's Medical Team Training, and MedTeams. Training staff in these settings can take months and new hires need to be trained episodically over time. Furthermore, JCAHO, in Sentinel Event #30, explicitly recommended team training for obstetrical units.15
In the Labor and Birth Unit at Yale-New Haven Hospital, our approach to building an obstetrical team is a formal process. Team training often involves 4- to 8-hour seminars coupled with videos, lectures, and role playing for a mix of individual attendees—physicians, nurses, ancillary staff—within the obstetrical team. Attendees are familiarized with the concept of the shared mental model for communication: an organized way for team members to conceptualize how a team works and to predict and understand how their team members must behave to improve overall team performance.25,26 Other concepts and techniques that units can begin without formal team training but with appropriate dissemination include:
The unique feature of our chain of command is that we group nurses and physicians together at each level, encouraging consultation between them before taking the issue to the next step. Units that have implemented these elements and formal team training seminars still require continuous support to avoid inevitable erosions in team behavior. Over time, staff members will still come to a manager to complain about an uncomfortable situation where they did not speak up.
Leadership should remain committed to supporting effective communication at the point of care and before solving the problem, address how the staff member could have addressed the problem directly by using structured communication tools. Post-event review sessions that bring together the individuals involved in a difficult case also can be opportunities to evaluate why some people might not have spoken up during or immediately after the event and to review and reinforce team training principles learned in the seminars.