Emergency Delivery Simulations:  How to Develop Effective Teamwork Michele R. Lauria MD, MS Associate Professor OB/GYN Med...
Emergency Deliveries: Creating Excellence Out of Chaos
Objectives <ul><li>How process mapping improves clinical care </li></ul><ul><li>Establish the rate limiting steps in the p...
Patient Safety & Simulation Ideas from Jeffrey B. Cooper, PhD Harvard medical School Director, Center for Medical Simulation
Medical Errors <ul><li>Eighth leading cause of death USA </li></ul><ul><li>Annual cost $29 billion </li></ul><ul><li>Syste...
Quality <ul><li>What the medical errors experts say: </li></ul><ul><ul><li>No one should be hurt by care process </li></ul...
What is an Accident <ul><li>The Normal Accident </li></ul><ul><li>Unpredictable </li></ul><ul><li>Highly Complex </li></ul...
Simulation <ul><li>Improve knowledge base </li></ul><ul><ul><li>Management of rare events </li></ul></ul><ul><ul><ul><li>T...
Microsystem problems <ul><li>System weaknesses:  procedures insensitive to how things really happen </li></ul><ul><li>Late...
A Lesson from Anesthesia <ul><li>1950-70's 1+mortalities/10,000 GET </li></ul><ul><li>1970's first studies of medical erro...
Anesthesia Solution <ul><li>President of the ASA made patient safety the primary theme and goal </li></ul><ul><ul><li>Ensu...
Anesthesia Today <ul><li>Risk GET in healthy individuals 1/100,00 </li></ul><ul><li>Premiums decreased  </li></ul><ul><ul>...
Elements of an HRO <ul><li>Safety #1 priority </li></ul><ul><ul><li>Safety trumps production always </li></ul></ul><ul><li...
Microsystem Lessons <ul><li>Standardization has benefits </li></ul><ul><ul><li>OB is further than most fields in medicine ...
Creating Team Work
M&M Conferences/Debriefings <ul><li>Multidisciplinary </li></ul><ul><ul><li>All staffing levels </li></ul></ul><ul><li>Ope...
Near Miss Box <ul><li>Box to report events </li></ul><ul><ul><li>What almost happened </li></ul></ul><ul><ul><li>What prev...
Simulation:  Two Processes <ul><li>NNEPQIN identifies ED critical area </li></ul><ul><ul><li>Feb 9 process mapping </li></...
Eight  Drills Completed Using Simulator <ul><li>Steps: </li></ul><ul><li>Instructor Creates a Scenario </li></ul><ul><li>P...
Drills Continued <ul><li>4. Debrief Immediately After Drill </li></ul><ul><ul><li>Replay video tape to Team </li></ul></ul...
Creating Team Work <ul><li>Defined roles </li></ul><ul><ul><li>Everyone understands other person’s role </li></ul></ul><ul...
Challenges <ul><li>STAFFING FACTORS:   </li></ul><ul><li>Difficult to assemble the same team on a routine basis </li></ul>...
Countermeasures <ul><li>Invited staff who were dissatisfied with the present process </li></ul><ul><li>Held drills same ti...
Lessons Learned <ul><li>Pagers frequently didn’t work </li></ul><ul><ul><li>“ Painted” Stat Pagers </li></ul></ul><ul><ul>...
Principles for Drills <ul><li>Fun </li></ul><ul><li>Create Tension </li></ul><ul><ul><li>Asthmatic can’t be intubated, spi...
Drill One
Sometime Months Later
What is our Real Purpose <ul><li>Create demonstration video </li></ul><ul><li>Train new staff </li></ul><ul><li>Test the s...
The Normal Accident <ul><li>Highly Coupled Systems </li></ul><ul><ul><li>Not a linear production </li></ul></ul><ul><ul><l...
Swiss Cheese
NNEPQIN <ul><li>Ordinary people collaborating </li></ul><ul><li>Emergency Cesarean Section Tool Kit </li></ul><ul><ul><li>...
NNEPQIN <ul><li>Roving Simulator </li></ul><ul><li>Common Trainer </li></ul><ul><ul><li>Share solutions, lessons learned <...
Materials Available @ NNEOB.org
Pt potential need for stat  C/S Consent for possible  C/S Notify teams of possibility Prepare for possibility Patient deli...
 
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Emergency Delivery Simulations: How to Develop Effective Teamwork

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  • Surveillance: describe how you discovered the problem…routine chart audit, voluntarily reported adverse event or near miss, proactive hazard screening, etc…)
  • Emergency Delivery Simulations: How to Develop Effective Teamwork

    1. 1. Emergency Delivery Simulations: How to Develop Effective Teamwork Michele R. Lauria MD, MS Associate Professor OB/GYN Medical Director NNEPQIN
    2. 2. Emergency Deliveries: Creating Excellence Out of Chaos
    3. 3. Objectives <ul><li>How process mapping improves clinical care </li></ul><ul><li>Establish the rate limiting steps in the processes in emergency cesarean deliveries </li></ul><ul><li>Identify underutilized local resources that could improve patient care </li></ul><ul><li>Describe how to initiate and learn from simulation experiences </li></ul><ul><li>Develop tools to review and learn from emergency cesarean deliveries and simulation experiences </li></ul>
    4. 4. Patient Safety & Simulation Ideas from Jeffrey B. Cooper, PhD Harvard medical School Director, Center for Medical Simulation
    5. 5. Medical Errors <ul><li>Eighth leading cause of death USA </li></ul><ul><li>Annual cost $29 billion </li></ul><ul><li>Systems problems </li></ul><ul><ul><li>Just like other industries </li></ul></ul><ul><ul><li>Columbia disaster </li></ul></ul><ul><ul><ul><li>Culture: show it is not safe </li></ul></ul></ul><ul><ul><li>Don’t’ recognize problems until the disaster </li></ul></ul>
    6. 6. Quality <ul><li>What the medical errors experts say: </li></ul><ul><ul><li>No one should be hurt by care process </li></ul></ul><ul><ul><li>Can’t have quality unless safety is first </li></ul></ul><ul><li>Model: High reliability organizational culture </li></ul><ul><ul><li>High risk fields </li></ul></ul><ul><ul><li>Minimal accidents </li></ul></ul><ul><ul><li>Ie: Airlines, explosives, aircraft carrier </li></ul></ul><ul><li>Can we expand errors to include failure to follow recognized guidelines? </li></ul><ul><ul><li>Errors folks say no…. </li></ul></ul><ul><ul><li>Errors are rare events, quality issues are common </li></ul></ul>
    7. 7. What is an Accident <ul><li>The Normal Accident </li></ul><ul><li>Unpredictable </li></ul><ul><li>Highly Complex </li></ul><ul><li>Highly Coupled/Interactive </li></ul><ul><li>More than one unexpected error </li></ul><ul><ul><li>Safety systems bypassed </li></ul></ul><ul><ul><li>Safety systems create error through chaos </li></ul></ul><ul><li>Poor Communication </li></ul><ul><li>Knowledge Deficit </li></ul>
    8. 8. Simulation <ul><li>Improve knowledge base </li></ul><ul><ul><li>Management of rare events </li></ul></ul><ul><ul><ul><li>Tracheostomy traning in anesthesia </li></ul></ul></ul><ul><ul><li>Early training of common problems </li></ul></ul><ul><ul><ul><li>Shoulder dystocia drills </li></ul></ul></ul><ul><ul><li>Realistic & expensive </li></ul></ul><ul><ul><ul><li>Boston site $900/MD/day </li></ul></ul></ul><ul><ul><li>Ie airlines, aerospace </li></ul></ul><ul><li>Team Training </li></ul><ul><ul><li>? How realistic… need elements </li></ul></ul><ul><ul><li>Fun is key </li></ul></ul><ul><ul><li>Sports teams </li></ul></ul><ul><li>Process mapping </li></ul><ul><li>Microsystems testing </li></ul>
    9. 9. Microsystem problems <ul><li>System weaknesses: procedures insensitive to how things really happen </li></ul><ul><li>Latent failures: problems lurking throughout the care process </li></ul><ul><li>Lack of teamwork: </li></ul><ul><ul><li>Poor communication </li></ul></ul><ul><ul><li>Focus on hierarchy instead of expertise </li></ul></ul><ul><li>Failure to appreciate the limits of human performance </li></ul><ul><li>Cultures that blame people instead of system </li></ul><ul><ul><li>Don't learn about their problems </li></ul></ul><ul><ul><li>For fear of exposure, don't discuss problems </li></ul></ul>
    10. 10. A Lesson from Anesthesia <ul><li>1950-70's 1+mortalities/10,000 GET </li></ul><ul><li>1970's first studies of medical error and human factors </li></ul><ul><li>1980's malpractice crisis escalates </li></ul><ul><ul><li>Media coverage of deaths and brain damage </li></ul></ul><ul><ul><ul><li>same thing is happening in OB </li></ul></ul></ul><ul><ul><li>Malpractice premiums increase </li></ul></ul>
    11. 11. Anesthesia Solution <ul><li>President of the ASA made patient safety the primary theme and goal </li></ul><ul><ul><li>Ensure no one is hurt </li></ul></ul><ul><ul><li>Free safety newsletter to everyone </li></ul></ul><ul><ul><li>Funded many safety projects and research </li></ul></ul><ul><ul><li>Partnered with industry </li></ul></ul><ul><ul><ul><li>Pulse oximetry </li></ul></ul></ul><ul><ul><ul><li>End tidal C02 </li></ul></ul></ul><ul><li>Standards for minimal monitoring </li></ul><ul><ul><li>Simple and easy to accept </li></ul></ul><ul><ul><li>Start small, build incrementally. </li></ul></ul><ul><li>Studied closed claims </li></ul><ul><li>Simulation and crisis management </li></ul>
    12. 12. Anesthesia Today <ul><li>Risk GET in healthy individuals 1/100,00 </li></ul><ul><li>Premiums decreased </li></ul><ul><ul><li>1987 $35,000 </li></ul></ul><ul><ul><li>2001 $9,000 </li></ul></ul><ul><li>Involve patients and families </li></ul><ul><li>Disclose error </li></ul>
    13. 13. Elements of an HRO <ul><li>Safety #1 priority </li></ul><ul><ul><li>Safety trumps production always </li></ul></ul><ul><li>Pre-occupation with failure </li></ul><ul><li>Commitment to resilience </li></ul><ul><li>Practice is routine </li></ul><ul><li>Deference to expertise, not hierarchy </li></ul><ul><li>Sensitivity to day to day operations </li></ul><ul><li>Reliance on team work </li></ul>
    14. 14. Microsystem Lessons <ul><li>Standardization has benefits </li></ul><ul><ul><li>OB is further than most fields in medicine </li></ul></ul><ul><li>Excessive procedure-alization can be counterproductive </li></ul><ul><ul><li>Flexibility to meet individual patient needs </li></ul></ul><ul><li>Teams and microsystems are critical </li></ul><ul><ul><li>Real teams train </li></ul></ul><ul><ul><li>Performance degrades when training stops </li></ul></ul><ul><ul><li>No one can tell me frequency of training </li></ul></ul><ul><ul><ul><li>Q 18 mos for skills </li></ul></ul></ul>
    15. 15. Creating Team Work
    16. 16. M&M Conferences/Debriefings <ul><li>Multidisciplinary </li></ul><ul><ul><li>All staffing levels </li></ul></ul><ul><li>Open discussion of error </li></ul><ul><ul><li>Or less than ideal perofrmance </li></ul></ul><ul><ul><li>“ Near Misses” </li></ul></ul><ul><li>Supportive environment </li></ul><ul><li>No individual blame </li></ul><ul><li>Method of closing the loop </li></ul>
    17. 17. Near Miss Box <ul><li>Box to report events </li></ul><ul><ul><li>What almost happened </li></ul></ul><ul><ul><li>What prevented it from happening </li></ul></ul><ul><ul><li>System fix </li></ul></ul><ul><li>Reward ideas and ingenuity </li></ul><ul><ul><li>Unit Newsletter </li></ul></ul>
    18. 18. Simulation: Two Processes <ul><li>NNEPQIN identifies ED critical area </li></ul><ul><ul><li>Feb 9 process mapping </li></ul></ul><ul><ul><li>March Simulation drills, document refinement </li></ul></ul><ul><li>DHMC with VOX </li></ul><ul><ul><li>Collaborative team training </li></ul></ul><ul><ul><ul><li>8 participating hospitals </li></ul></ul></ul><ul><ul><li>Create the perfect video </li></ul></ul><ul><ul><li>Started 10/03 </li></ul></ul>
    19. 19. Eight Drills Completed Using Simulator <ul><li>Steps: </li></ul><ul><li>Instructor Creates a Scenario </li></ul><ul><li>Pre- Meeting to Discuss Areas for improvement from last drill </li></ul><ul><li>Run the Drill, Video Taping all Action </li></ul><ul><li>Required Process Mapping </li></ul>
    20. 20. Drills Continued <ul><li>4. Debrief Immediately After Drill </li></ul><ul><ul><li>Replay video tape to Team </li></ul></ul><ul><ul><li>Discuss what we learned i.e. </li></ul></ul><ul><ul><ul><li>Went Well </li></ul></ul></ul><ul><ul><ul><li>Went Poorly </li></ul></ul></ul><ul><ul><ul><li>What to practice </li></ul></ul></ul><ul><ul><ul><li>Barriers </li></ul></ul></ul><ul><ul><li>Set Goals for next Drill </li></ul></ul><ul><li>Everyone Participates </li></ul>
    21. 21. Creating Team Work <ul><li>Defined roles </li></ul><ul><ul><li>Everyone understands other person’s role </li></ul></ul><ul><li>Speak Back </li></ul><ul><li>Questioning </li></ul><ul><li>Thinking the problem out loud </li></ul><ul><li>Flat communication structure </li></ul>
    22. 22. Challenges <ul><li>STAFFING FACTORS: </li></ul><ul><li>Difficult to assemble the same team on a routine basis </li></ul><ul><li>Team members roles and responsibilities were confusing </li></ul><ul><li>ENVIRONMENT/TECHNICAL: </li></ul><ul><li>Unable to have bio-med tech support after 3 pm </li></ul><ul><li>Problems with the STAT c-section paging system </li></ul><ul><li>BEHAVIOR FACTORS: </li></ul><ul><li>Letting go of what has been done in the past </li></ul><ul><li>PATIENT FACTORS: </li></ul><ul><li>Identifying the maternal/fetal factors that result in urgent or STAT c-sections </li></ul>
    23. 23. Countermeasures <ul><li>Invited staff who were dissatisfied with the present process </li></ul><ul><li>Held drills same time and day of the week </li></ul><ul><li>Viewed videotaped drill, which brought realization to team members that team performance was not optimal </li></ul><ul><li>Collaborated with key person experienced in teaching Team Performance </li></ul><ul><li>Set time line for project </li></ul>
    24. 24. Lessons Learned <ul><li>Pagers frequently didn’t work </li></ul><ul><ul><li>“ Painted” Stat Pagers </li></ul></ul><ul><ul><li>Removed “forwarding” capabilities </li></ul></ul><ul><ul><li>Established Daily Testing Stat Paging System </li></ul></ul><ul><li>Reduced number of folks doing transport </li></ul><ul><li>Disconnecting IV’s </li></ul><ul><li>Reassigned MD tasks </li></ul><ul><ul><li>Critical communicators at scrub sink </li></ul></ul><ul><ul><li>Ask permission to leave room </li></ul></ul><ul><li>OR Grease Board: Meds, Allergies, Fetuses, Mec, GA, Indication </li></ul>
    25. 25. Principles for Drills <ul><li>Fun </li></ul><ul><li>Create Tension </li></ul><ul><ul><li>Asthmatic can’t be intubated, spinal not working, heart rate going down </li></ul></ul><ul><li>Low Tech </li></ul><ul><li>Dummy Chart </li></ul><ul><li>Trainer </li></ul><ul><li>Observers </li></ul>
    26. 26. Drill One
    27. 27. Sometime Months Later
    28. 28. What is our Real Purpose <ul><li>Create demonstration video </li></ul><ul><li>Train new staff </li></ul><ul><li>Test the system </li></ul><ul><li>Practice for rare events </li></ul><ul><li>Create a set of principles </li></ul><ul><ul><li>Become ingrained </li></ul></ul><ul><ul><li>Permit flexible responses </li></ul></ul>
    29. 29. The Normal Accident <ul><li>Highly Coupled Systems </li></ul><ul><ul><li>Not a linear production </li></ul></ul><ul><ul><li>Transform a product </li></ul></ul><ul><ul><ul><li>Pregnant woman no longer is </li></ul></ul></ul><ul><li>Complex Systems </li></ul><ul><li>Interactions unpredictable </li></ul><ul><li>Setting and Personnel Interact Unpredictably </li></ul><ul><li>Never just one error or person </li></ul>
    30. 30. Swiss Cheese
    31. 31. NNEPQIN <ul><li>Ordinary people collaborating </li></ul><ul><li>Emergency Cesarean Section Tool Kit </li></ul><ul><ul><li>Simulation Planning Guide </li></ul></ul><ul><ul><li>Global Process Map </li></ul></ul><ul><ul><li>Detailed Process Map </li></ul></ul><ul><ul><ul><li>Solutions for common problems </li></ul></ul></ul><ul><ul><li>Simulation task evaluation form </li></ul></ul><ul><ul><li>Drill debriefing form </li></ul></ul><ul><ul><li>Emergency delivery debriefing form </li></ul></ul><ul><ul><ul><li>Patient/Family </li></ul></ul></ul><ul><ul><ul><li>Staff </li></ul></ul></ul>
    32. 32. NNEPQIN <ul><li>Roving Simulator </li></ul><ul><li>Common Trainer </li></ul><ul><ul><li>Share solutions, lessons learned </li></ul></ul><ul><li>Saturdays </li></ul><ul><ul><li>After 2 weeks of having simulator locally </li></ul></ul><ul><li>Provide regional data analysis </li></ul><ul><ul><li>QA protected </li></ul></ul><ul><ul><li>? IRB approval </li></ul></ul>
    33. 33. Materials Available @ NNEOB.org
    34. 34. Pt potential need for stat C/S Consent for possible C/S Notify teams of possibility Prepare for possibility Patient delivers Take everyone off alert Resuscitate baby Communicate with family Finish C/S Count Change gloves Antibiotic prophylaxis X-ray if no pre-op count done If GET, is there a risk for pneumonia? Debrief Unit Debrief Patient & Family Global Process Map Patient needs stat C/S Decision made to do stat C/S Notify Unit Notify teams Move patient to OR Reevaluate in OR Prepare for C/S Anesthesia Scrub foley Prep Suction Delivery Baby

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