Modeling Risk and Reducing Liability through Better Communication and Teamwork

1. Modeling Risk and Reducing Liability through Better Communication and Teamwork David P. Baker, PhD IMPAQ International, LLC

2. Overview • Preparing for Demonstration Grant (R21) • Research Team • David P. Baker, PhD (Principal Investigator) • Patrice Weiss, MD (Co-Investigator) • Laurie Spotswood, MSEd, CLS (Research Specialist) • Tony Slonim, MD, DPH (Co-Investigator)

3. Background • Relations between lawsuits, payouts, and negligence is muddy at best • The Harvard Malpractice Study • Reviewed 30,000 hospital records • Found the incidence of malpractice was much larger than the incidence of claims • Ineffective communication between patients/families and clinicians yield lawsuits • Patients/families are viewed as critical members of the care team • TeamSTEPPS® introduced by AHRQ for clinician teamwork • Little work on how to include/train patients/families

4. Study Aims • Aim 1: To identify clinical events that are highly dependent on provider teamwork, require patient/ families to be effective members of the team, and vary in terms of risk and liability. • Aim 2: To identify the root causes of these events, including where critical teamwork breakdowns occur. • Aim 3: To conduct a series of focus groups to ascertain how patient/family and provider communication should occur to mitigate risk and reduce liability and to identify TeamSTEPPS tools that could be used to enable patients/families to be more effective members of the care team. • Aim 4: To develop and pilot test a TeamSTEPPS intervention(s) that teaches patients/families how to be members of the care team and enhances communication between patients/families and providers.

5. Aim 1 • Goal • Identify and select events that require teamwork and vary in terms of risk and liability in Labor and Delivery (L&D) • Approach • Reviewed RAND (2008) report and identified candidate events that require teamwork • Identified 18 candidate events in L&D • Surveyed 10 clinical experts • Degree of Risk • Likelihood of Liability • Requirement for Teamwork

6. Aim 1 Results Liability Risk

7. Aim 2 • Goal • Identify the root causes of these events, including where critical teamwork breakdowns occur • Root causes included: (1) risk factors; (2) individual, team, & systems factors; (3) clinical team members; and (4) patient and family responsibilities • Divided L&D into six phases: (1) pre-hospital; (2) triage/ assessment; (3) monitoring/laboring; (4) delivery; (5) post-partum L&D; and (6) post-partum mother baby unit. • Approach • Two phases of key informant interviews with clinical staff • Phase I – Identify events (12 interviews) • Phase II – Validate events (11 interviews) • Identified common root causes across all four events (identified during Aim 1)

8. Aim 2 Results

9. Aim 2 Results

10. Aim 3 • Goal • Collect information from patients and family members in order to: • Verify patient and family responsibilities • Identify the root causes per event that patients would want disclosed and clinical staff would feel should be disclosed • Identify TeamSTEPPS tools and strategies patients would find useful • Approach • Four patient and family focus groups; one per L&D event • Verified the patient and family responsibilities clinicians identified • Facilitated discussion about what patients and families want clinicians to disclose • Conducted disclosure survey of patients and providers focused on the different events • Reviewed and discussed TeamSTEPPS tools • 47 patient and family members; 13 clinicians

11. Aim 3 ResultsPatient Mean Disclosure Ratings

12. Aim 3 ResultsClinician Mean Disclosure Ratings

13. Aim 3 ResultsCorrelations between Clinician and Patient Disclosure Ratings

14. Aim 4 • Goal • To develop and pilot test a TeamSTEPPS intervention(s) that teaches patients/families how to be members of the care team and enhances communication between patients/families and providers • Approach • Developed a 45-minute, patient and family oriented TeamSTEPPS module for L&D • 28 participants • Collected pre-post data on participant reactions and learning • Reactions: instrumentality and affective • Learning: attitudes (T-TAQ) and knowledge (Learning Benchmarks)

15. TeamSTEPPS Training Objectives • Describe how the patient and family fits into the clinical team • Describe the patient and family responsibilities as team members • Describe the clinical team member roles and responsibilities • Describe the core components of team leadership, assertion, and communication • Describe TeamSTEPPS tools that can be used by patients • Briefs, Huddles and Debriefs • Assertive Statement and Two-Challenge Rule • SBAR and Check Back

16. Aim 4 - Results • Reactions • Overall mean rating was 4.18, on a 5-point scale • “This training would be appropriate for patients in all care settings” • “This training should be offered by …. in the future” • Learning • Attitudes • Pre-training Mean (4.51) • Post-training Mean (4.55) • Learning • Pre-training Mean (10.86 items correct) • Post-training Mean (12.28 items correct)

17. Conclusions • Clinicians generally showed high agreement when assessing the degree of risk, liability, and teamwork associated with specific clinical events in L&D • Regardless how events varied in terms of risk and liability, the individual, team, and system failures were generally common across events • Patients/family members were found to agree about which failures were important to disclose, and type of adverse event did not affect these results • Clinicians on the other hand showed far more variability regarding what should be disclosed, and these results did appear to be affected by adverse event type • Patients/families like TeamSTEPPS, intended to use the tools taught, would recommend the training to others, and showed gains in knowledge

18. Next Steps • Negotiating with an implementation site • Examine transfer of the trained skills • Determine if there is a relation to clinical outcomes