Problem Addressed

Problem Addressed

Communication failures are a leading but preventable cause of adverse events in health care.

• Many communication failures lead to adverse events: A review of more than 14,000 root-cause analysis reports submitted to the VA National Center for Patient Safety (NCPS) found that communication failures were involved in more than 75 percent of adverse events. Communication failure has been identified as a pivotal factor in nearly two-thirds (65 percent) of sentinel events reported by the Joint Commission since 1995.¹
• Communication problems can be addressed by teamwork training: The landmark Institute of Medicine (IOM) report, To Err is Human, disseminated in 1999, recommended the application of CRM principles in health care systems as a means of addressing suboptimal communication.² The VA has demonstrated a significant association between more collaborative and coordinated care by health care teams and higher levels of patient satisfaction.¹

Description of the Innovative Activity

The VA NCPS MTT program, which is based on principles of CRM drawn from the aviation industry, seeks to improve patient care outcomes by enhancing communication between health care professionals. MTT features a 14-month commitment from participating VAMCs: development of an interdisciplinary implementation team that will engage with NCPS staff for 2 months of preparation and planning, a full-day interactive learning session hosted by the VA facility and facilitated by clinical peers (three NCPS faculty members including a physician, a nurse, and a communication specialist), administration of baseline and post-intervention Safety Attitudes Questionnaires, and followup semistructured interviews with reports of program activities and lessons learned over the course of 12 months. The MTT program, which has been implemented in 79 VAMCs, has five primary components, described below:

• Application: The VAMC scheduled to enroll in a specific time block will submit an application at least three months prior to hosting a learning session to take part in the MTT program. Applying to the program involves committing to the formation of an interdisciplinary medical team and selecting an MTT project from a menu of six options, each of which is designed to enhance communication among staff. A facility may select more than one option. The six options are:
  1. Preoperative briefings and postoperative debriefings in the operating room (OR)—required project for surgical groups
  2. Interdisciplinary patient-centered briefings (rounds) in an intensive care unit (ICU) or medical-surgical unit
  3. Interdisciplinary administrative briefings (for unit management like an ICU or management of unit-to-unit relationships like the OR and SPD - Supplies, Processing and Distribution)
  4. Standardized patient hand-offs (RN-to-RN, RN-to-MD, MD-to MD, OR-to-ICU or PACU)
  5. Code team members debriefing of code blue events
  6. VA Strategic Nap Program for fatigue management
• Preparation and planning: After the application is submitted and the learning session date has been confirmed, the VAMC has a minimum of 2 months to prepare and plan for the learning session. The NCPS faculty participates in conference calls with the facility’s implementation team 2 months, 6 weeks, and 2 weeks before the planned learning session. The conference calls focus on team organization, promotion of the program in the facility, and selection of the MTT project.
• Interactive learning session: The participating VAMC serves as the host for the all-day interactive learning session that uses various CRM techniques, briefings and debriefings, the language of effective communication, interdisciplinary rounds, standardized patient hand-offs such as Situation-Background-Assessment-Recommendation (SBAR), Graded Assertiveness, Call Out, Step Back, Repeat Back/Read Back, Dynamic Skepticism, the Two-Attempt Rule, Situational Awareness, Work Load Distribution, and Fatigue Management. These sessions include faculty role play and filmed clinical vignettes (produced by NCPS faculty) to augment teaching points and stimulate discussion. For surgical groups, the OR is closed to elective procedures and surgical clinics are closed on that day. NCPS faculty challenge traditional precepts and practices in health care and focus on their primary objective of engaging participants in vigorous and spirited dialogue.