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    Managing obstetric risk: Is your labor and delivery team ready?

    Build a shared mindset to ensure safe deliveries through planning, communication, checklists and teamwork


    Key iconKey Points

    • 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:

    • SBAR (Situation, Background, Assessment, Recommendation): Standardized approaches to hand-off communications are a JCAHO National Patient Safety Goal requirement. SBAR is a structured communication/debriefing technique designed to ensure complete, coherent information transfer at hand offs or other points of contact.27 Important information is broken down into 4 categories: "Situation" explains what is happening to warrant the communication, "Background" explains the events leading up to the present situation, "Assessment" summarizes the problem, and "Recommendation" provides a suggested plan. SBAR typically is used for verbal hand offs, but we have developed written SBAR forms for all our common points of transfer, such as from our labor unit to the postpartum floors. Physicians may identify similarities to the "subjective, objective, assessment, and plan (SOAP)" note in our written charts, but using SBAR for verbal communication and in a nursing context may be new to most units.
    • Concerned, Uncomfortable, Scared (CUS) communication key words: We use these words to communicate to each other the level of discomfort or disagreement with an event or situation.28 On our unit, when a nurse may tell a physician that she is "concerned" about a fetal heart rate tracing, for instance, this code word prompts the physician to stop and listen. Using "uncomfortable" or "scared" increases the level of assertion, and the listener is prompted to immediately respond more closely and progressively pay more attention. In this case, your patients may thank you for using the CUS words.
    • The 2-challenge rule: This is a quick conflict resolution technique in which a team member may question an action twice and if a sufficient answer is not provided, he or she may halt that action.29 When an action is halted, the chain of command can be activated for conflict resolution.
    • Chain of command: While we call this tool a chain of command, we prefer to view this communication ladder as a chain of consultation.30 Providers and nurses use this during conflict resolution, going to progressively higher levels of authority if there are disagreements in the approach to care or to engage help in solving a complicated aspect of care.

    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.


    Edmund F Funai, MD
    Dr Funai is Chief Operating Officer, USF Health, and Vice President for Strategic Development, University of South Florida, Tampa, Florida.


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