How UCSF is changing hospital teamwork for the sake of the patients
According to The Joint Commission (formerly JCAHO), communication breakdowns are the most common cause of medical errors, leading to delays in care, medication mistakes, and even wrong-side surgeries.
That’s why 225 healthcare providers recently gathered to improve communication between disciplines for the sake of patient safety.
Providers from the University of California San Francisco (UCSF), including hospitalist attendings, nurses, case managers, pharmacists, internal medicine house staff members, therapists, and unit clerks, participated in six different sessions as part of the Triad for Optimal Patient Safety (TOPS) program.
To improve team communication for patient safety, providers from one inpatient medical unit participated in the four-hour teamwork training session as part of a 15-month project spearheaded by UCSF that resulted in the paper “A Multidisciplinary Teamwork Training Program: The TOPS Experience,” published in the Journal of General Internal Medicine in October. The project was aimed at improving unit-based safety culture through a series of targeted teamwork and communication intervention.
The goal of this massive undertaking is to help heal a fractured system, says Niraj L. Sehgal, MD, MPH, assistant professor in the division of hospital medicine at UCSF. “It’s clear that as hospital care has gotten more complex—sicker patients, more disciplines involved, newer systems, including technology—we have to develop better systems for communication around patient care,” he says.
One place, one time
The TOPS project pulled staff members from multiple disciplines for the same training simultaneously, tackling logistics, which was the biggest challenge. Prior teamwork training programs focused on closed environments, in which providers trained only with other providers from the same physical medical setting.
Adding to the challenge, TOPS’ efforts were uniquely aimed at a medical unit setting, such as where unit-based nurses and service-based physicians treat patients who span several units at a given time. Most providers attending the sessions had never experienced what TOPS called a multidisciplinary training setting. The providers hadn’t received education at the same time as other staff members, a practice that may seem counterintuitive to healthcare professionals who rely heavily on handoffs and multiple services on multiple floors in the hospital.
The TOPS teamwork training program consisted of:
- Foundation building (20 minutes): Defining the role of teamwork and communication in patient safety
- A video (30 minutes): Watching First, Do No Harm, a video demonstrating the role systems and individuals play in medical errors, followed by a facilitated discussion
- Team training didactic (60 minutes): Defining error chains, team behaviors, and communication skills
- Two small group scenarios (45 minutes each): Practicing team behaviors and communication skills
- The closing (20 minutes): Discussing how to improve practices and multidisciplinary education
In the context of mixed lectures and interactive group work sessions, different disciplines were able to communicate in a shared learning environment, Sehgal says. “Most of us at different disciplines … are trained with a set of skills, but completely in silos,” he says. “We all go through our own educational systems, our own training, and then we are thrown, metaphorically, on the same unit and then asked to work together and figure out how to take care of the patient in the best way. Not many other industries do it that way.”
Leaping the communication gap
Doctors and nurses are trained to report clinical information in very different ways. Nurses tend to speak narratively, whereas doctors relay information in more direct terms.
“The way we are taught to communicate clinical information is different—not right or wrong—just different,” says Sehgal.
“When everyone is in the same room at the same time, you don’t have one discipline filling in another discipline’s voice,” says Michael Fox, RN, clinical nurse III at UCSF Medical Center School of Nursing at the time the study was conducted.
The training program instructors taught staff members about SBAR, a communication tool that many doctors hadn’t heard of. An acronym for Situation, Background, Assessment, and Recommendation, SBAR is a shared way to convey critical information between providers.
Another communication tool is what Sehgal and Fox call the critical conversation, a brief, direct conversation between the doctor and nurse through a telephone call or face-to-face to reduce the number of back-and-forth pages. These critical conversations should occur at admission, change in condition, and discharge times.
In addition, UCSF made efforts to standardize its text-page communication with a set language about urgency and priority of information, including to whom the page is sent, the patient name and description of the event, whether callback is needed, and the pager’s name, title, location, and callback number. A consistent language helps doctors prioritize the pages.
Tips to institute a teamwork training program
Hospitals are forced to choose between different patient safety investments, such as computerized provider order entry, electronic health records, and bar coding. For administrators, making the decision to implement teamwork training programs will not be an easy one.
Nevertheless, Sehgal and Fox say shifting safety education to a multidisciplinary audience and engaging them in the work they’re already dedicated to is important. They suggest the following tips:
- Create partnerships across multiple disciplines, identifying project leaders called champions
- Dedicate time slots for training; don’t force providers to participate in the training
- Include outside consultants and local hospital leaders
- Acknowledge that teamwork training is just the start, and plan for more multidisciplinary education