Health Quality Improvement using InstructionalCommunication and Teamwork Videos: AnOutcome StudyNeil CowieThis Session is ...
Health Quality Improvement usingInstructional Communication andTeamwork Videos:An Outcome Study PilotNeil Cowie Department...
Team MembersAngela Bowen, College of Nursing, University of SaskatchewanKalyani Premkumar, Department of Community Health ...
Problem• “Near misses” in patient care• Lapses in interprofessional communicationand teamwork• Urgent induction of General...
Legal SettlementsCerebral palsy lawsuit settles for $3.8 millionBrain damage in newborn settlement is $3.5 millionBirth in...
• 70% of sentinel events in obstetric practice areattributable to errors in communication andteamwork The Joint Commission
Medical Simulation
http://www.medicine.usask.ca/acutecareteamwork/intro/index.php
Goals of Study• Make a movie of a simulated OB event• Use web-based “Trigger Videos” to teach skills incommunication and t...
Study DesignVideo ClipsDebriefingCompetenciesQQQNov, 2010April, 2011Feb, 2012
Competencies• Situational Awareness• SBARR• Closed Loop Communication• Leadership• Shared Mental Model• Overcoming Hierarc...
Findings• Improved technical knowledge• More critical of the team (anesthesia) afterthe educational intervention• Ten mont...
Presentations• Board of RUH Foundation• Simulation in Healthcare• São Paulo• POGO for Nurses• Womens Health, Obstetric, an...
What did we find out?• Unable to publish study• Unbelievable turnover of nursing staff• Fixed and decreasing numbers of nu...
QUALITYIMPROVEMENT
Project Failure• Project will fail if dependent on the actions ofanother team• Project will fail if multiple groups must c...
Future
Questions
MoreOB
QuestionnaireNon-Technical Skills
Questionnaire:Technical Skills– Application of monitors– Assistance with securing airway for intubation– How to assist if ...
CPSI Safety Competencies
7 Deadly Sins of QualityImprovement• Narrow focus• Assuming change in behavior of staff• Process decisions made by adminis...
Items Reflecting Behavior of the Team
Items Reflecting Behavior of the Team
Health Quality Improvement Using Instructional Communication and Teamwork …
Health Quality Improvement Using Instructional Communication and Teamwork …
Health Quality Improvement Using Instructional Communication and Teamwork …
Health Quality Improvement Using Instructional Communication and Teamwork …
Health Quality Improvement Using Instructional Communication and Teamwork …
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Health Quality Improvement Using Instructional Communication and Teamwork …

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Improvement Story session at the 2013 Saskatchewan Health Care Quality Summit. For more information about the summit, visit www.qualitysummit.ca. Follow @QualitySummit on Twitter.

We created a multi-media, web-based learning resource that improved obstetrical nurses’ knowledge, team communication, performance and increased awareness of negative behaviors of the team surrounding emergency Caesarean birth under GA in a pilot study conducted in the Labour and Birth Unit at the Royal University Hospital. We hope it can serve as one strategy for improving teamwork thereby reducing adverse events in acute critical clinical situations.
Better Teams

Neil W. Cowie

Published in: Health & Medicine, Education
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Health Quality Improvement Using Instructional Communication and Teamwork …

  1. 1. Health Quality Improvement using InstructionalCommunication and Teamwork Videos: AnOutcome StudyNeil CowieThis Session is sponsored by:
  2. 2. Health Quality Improvement usingInstructional Communication andTeamwork Videos:An Outcome Study PilotNeil Cowie Department of Anesthesiology, University of SaskatchewanApril 11, 2013
  3. 3. Team MembersAngela Bowen, College of Nursing, University of SaskatchewanKalyani Premkumar, Department of Community Health and EpidemiologyCollege of Medicine, University of SaskatchewanSusan Kuling, Previous Nurse Manager, Labour and Birth Unit, Saskatoon Health RegionMark Burbridge, Department of Anesthesia, College of Medicine, University of SaskatchewanJocelyne Martel, Obstetrican, Saskatoon Health Region
  4. 4. Problem• “Near misses” in patient care• Lapses in interprofessional communicationand teamwork• Urgent induction of General Anesthesia forSTAT Cesarean Birth
  5. 5. Legal SettlementsCerebral palsy lawsuit settles for $3.8 millionBrain damage in newborn settlement is $3.5 millionBirth injuries leave twin with cerebral palsy: $2.8 MillionSettlement$5.65 million settlement for Rhode Island babys braindamage related to birth traumaDelay in c-section resulting in brain damage settlementis $3 millionSettlement for newborns brain damage is $4 million
  6. 6. • 70% of sentinel events in obstetric practice areattributable to errors in communication andteamwork The Joint Commission
  7. 7. Medical Simulation
  8. 8. http://www.medicine.usask.ca/acutecareteamwork/intro/index.php
  9. 9. Goals of Study• Make a movie of a simulated OB event• Use web-based “Trigger Videos” to teach skills incommunication and teamwork to ObstetricalNurses• Measure outcome• Continuing professional development for self-directed learning on the web
  10. 10. Study DesignVideo ClipsDebriefingCompetenciesQQQNov, 2010April, 2011Feb, 2012
  11. 11. Competencies• Situational Awareness• SBARR• Closed Loop Communication• Leadership• Shared Mental Model• Overcoming Hierarchy• Mutual Support• Conflict Resolution• Avoiding Distraction
  12. 12. Findings• Improved technical knowledge• More critical of the team (anesthesia) afterthe educational intervention• Ten months later, had applied many of theteam competencies into personal practice– Speak up– Assertiveness– Conflict resolution
  13. 13. Presentations• Board of RUH Foundation• Simulation in Healthcare• São Paulo• POGO for Nurses• Womens Health, Obstetric, and Neonatal NursesConference• Canadian Anesthetists Society• MedEdPortal• Senior leadership SHR• IHI Summit, Washington DC
  14. 14. What did we find out?• Unable to publish study• Unbelievable turnover of nursing staff• Fixed and decreasing numbers of nursingeducation days• Self directed training video has not beenoffered to nursing staff
  15. 15. QUALITYIMPROVEMENT
  16. 16. Project Failure• Project will fail if dependent on the actions ofanother team• Project will fail if multiple groups must changeBehavior and culture change is slow• If management doesn’t support, things willnot change
  17. 17. Future
  18. 18. Questions
  19. 19. MoreOB
  20. 20. QuestionnaireNon-Technical Skills
  21. 21. Questionnaire:Technical Skills– Application of monitors– Assistance with securing airway for intubation– How to assist if intubation fails
  22. 22. CPSI Safety Competencies
  23. 23. 7 Deadly Sins of QualityImprovement• Narrow focus• Assuming change in behavior of staff• Process decisions made by administrators• Too many active projects at one time• Lack of focus• Decisions made on satisfaction scores ratherthan outcomes• Erroneously assume leadership supportschanges
  24. 24. Items Reflecting Behavior of the Team
  25. 25. Items Reflecting Behavior of the Team

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