Overview

The Harvard Center for Medical Simulation developed a realistic simulation experience to help labor and delivery care providers improve teamwork, communication, and crisis management skills. Harvard-affiliated obstetricians can receive a 10 percent discount on their malpractice premiums for three years by participating in the program and completing other continuing medical education activities.

Issue: A sense of professional pride, while laudable, can become dangerous if it makes clinicians reluctant to call for help or to seek advice during critical events, says Roxane Gardner, M.D., a faculty member at Brigham and Women's Hospital's Department of Obstetrics and Gynecology and assistant professor at Harvard Medical School. Many physicians assume that their teamwork skills are good, but surveys reveal that nurses often do not share their perception [1, 2]. During a crisis, a team might become fixated on one issue and fail to see other important aspects of the problem. Team leaders might give commands without establishing who is responsible for responding. Likewise, team members might be hesitant to share critical information because they don't want to appear unknowledgeable or they assume that others already are aware of it. In the aviation industry, pilots and other cockpit personnel use simulators to practice procedural and crisis management skills as part of Crew Resource Management training [3].

The anesthesiology discipline has successfully adapted this approach to train for crisis events [4]. The Harvard Risk Management Foundation, the malpractice insurer for Harvard teaching hospitals, has seen its anesthesiology malpractice claims drop to "near zero" since it began offering anesthesiologists a $500 discount to participate in team training, which is "one of several things making the practice of anesthesiology safer," says Bob Hanscom, director of loss prevention for the insurer. This experience suggests that other medical personnel could benefit from simulation-based training to improve both technical and non-technical skills, especially for managing rare critical situations [5]. The growing costs of defending medical malpractice lawsuits against obstetrical providers has prompted interest in the development of similar simulation-based critical event training for experienced labor and delivery care providers. An analysis of closed malpractice claims, for example, revealed that failure in teamwork was a contributing factor in 43 percent of obstetrical malpractice cases, according to Hanscom.

Objective and Intervention: To better prepare clinicians and staff to handle critical situations that occur in labor and delivery, the Harvard Center for Medical Simulation created a high-fidelity, simulation-based Labor and Delivery Crisis Resource Management (CRM) training course designed to increase teamwork and procedural skills among multidisciplinary teams of providers. This case study describes the development and early experiences of this innovative program.

Organization: The Harvard Center for Medical Simulation is a not-for-profit educational organization dedicated to improving the quality of health care by teaching teamwork and clinical decision-making using simulation. Located in Cambridge, Mass., the center offers physicians, nurses, and technicians the opportunity to practice communication and procedural skills in a realistic, simulated health care environment. The center was founded by the anesthesia departments of the Harvard Medical School–affiliated hospitals: Beth Israel Deaconess Medical Center, Brigham and Women's Hospital, Children's Hospital, and Massachusetts General Hospital.

Date of Implementation: The Center for Medical Simulation began pilot testing labor and delivery simulations in February 2002. The Harvard Risk Management Foundation announced in June 2003 that they would offer participants a premium discount. The first full-fledged, simulation-based labor and delivery CRM course was offered in September 2003.

Key Measures: The Center for Medical Simulation uses the following measures of impact and effectiveness for the labor and delivery CRM course:

• reported critical incidents;
• malpractice claims experience;
• perceived culture of safety, as measured by the Safety Climate Scale, and;
• participant evaluation.

The Center for Medical Simulation also is evaluating the possibility of using an observational team performance measure, such as the one developed for the MedTeams project [6].

Process of Change: Obstetrics faculty from Harvard-affiliated teaching institutions developed a six-hour, simulation-based training course emphasizing cooperation and communication among a multidisciplinary labor and delivery care team. The team typically includes three obstetricians, an obstetrical anesthesiologist, and three labor and delivery nurses. The simulation experience incorporates computerized, remotely controlled mannequins in a simulated operating room environment. The course begins with an orientation on the use and capabilities of the mannequins and the purpose of the day as a confidential learning experience.

Participants begin to interact with the mannequins by conducting a brief physical examination. Center for Medical Simulation faculty members manipulate the mannequins from a control room, moving body parts and engaging in conversations to simulate patient responses. Participants often begin the simulation by feeling anxious or doubtful about the experience, but as they interact with the mannequins "you can see a change in body language signaling buy-in and involvement in the situation," says Gardner, who helped design and serves as faculty for the course. "It's rare that someone can't get into the moment," she says. The team next engages in a simulated labor and delivery scenario that involves some type of life-threatening complication, challenging them to intervene and make a decision about when to deliver. Participants then discuss their experiences with trained facilitators in an environment where they are free to express their feelings and discuss how they responded to each other and managed the event. The facilitator uses a videotape of the simulation to highlight where the team performed well and where performance could be improved, applying critical management principles such as role clarity, incident leadership, situational awareness, assertion, and closing the loop in communication.

After the debriefing, the team engages in a situation that includes some type of error, followed by another simulated crisis scenario to practice communication and decision-making skills. In all, three simulations and debriefings occur during the six-hour course. In the final debriefing, participants discuss how their interactions improved throughout the day. Simulation scenarios are taken from malpractice claim cases provided by the Harvard Risk Management Foundation. Names and other identifying details are altered to maintain confidentiality, but the fact that simulations are based on actual situations brings a sense of urgency and realism to the exercise. To heighten the sense of reality, some scenarios use faculty to play the role of a fatigued obstetrical colleague who needs help, advice, or moral support to deal with a challenging situation. Simulated fetal heart rate monitoring adds realism to scenarios in which the interpretation of a fetal heart rate tracing can be particularly vexing. The labor and delivery simulation course is part of an educational intervention promoted by the Harvard Risk Management Foundation as part of its Obstetrical Risk Reduction Program. Harvard-affiliated obstetricians can receive a 10 percent premium reduction for three years by participating in and evaluating the labor and delivery CRM course, responding to a safety climate survey, and completing certain online CME courses. Obstetricians also must review the Harvard Risk Management Foundation's obstetrical care guidelines and pass a test on their content to qualify for the discount.

Results: In-depth interviews were conducted with participants in the pilot course about six months after their simulation-based training. Participants reported that the training made a difference in their awareness of teamwork techniques, such as situational briefings to anticipate a patient's future needs. They also reported that the training had increased their understanding of the importance of getting resources ready before a crisis occurs. Some said that they had encountered actual scenarios that were similar to the simulations, and that they had been better prepared to handle them as a result of this experience. The Center for Medical Simulation is now surveying all CRM course participants one year after their training to learn whether the course has made a lasting difference in their skills and ability to handle critical events. Because the CRM course is relatively new, it is too early to tell if malpractice claims or critical incidents in labor and delivery have been reduced. Baseline safety climate surveys have been conducted and follow-up surveys are under way to measure any changes in organizational and team safety culture.

Next Steps: The Center for Medical Simulation has discovered that it is often difficult for course participants to practice newly learned teamwork skills in hospital environments without a critical mass of staff who have been through the same training. Moreover, a few hours of training per year are not enough to make sustainable changes in organizational and team culture, says Gardner. In response, the Harvard Risk Management Foundation recently awarded a grant to Allan Frankel, M.D., Partners Healthcare System's director of patient safety, and Gardner, a faculty member of the Center for Medical Simulation, to embed the principles of simulation-based team training in the real-world labor and delivery settings of Partner's affiliated hospitals. Following a "train-the-trainer" approach, Frankel and Gardner have enlisted a core group of labor and delivery leaders from each participating hospital to complete a comprehensive course in teamwork and communication. These teamwork champions will train all labor and delivery staff at their institutions using shorter, periodic one- to three-hour simulation-based teamwork courses modeled on the longer CRM course. The grant also supports implementation of obstetrical crisis drills at each institution. The drills present opportunities to practice and evaluate teamwork and procedural skills for rare occurrences on an ongoing basis.

Lessons Learned: For those considering bringing simulation-based training to their own institution, Gardner stresses the importance of involving key leaders early in the development of these types of training programs. Center for Medical Simulation faculty found it was critical to actively involve not only the obstetrical leadership, but also nursing and anesthesia staff leaders. Getting buy-in from departmental leaders facilitated the acceptance of CRM training and culture change among frontline staff. To have an impact, patient safety has to be seen as a priority and be highly valued throughout the organization, she says. "The active involvement of our medical malpractice insurer was critical to the success of this program," says Gardner.

Harvard Risk Management Foundation formed a collaborative venture with the Center for Medical Simulation and provided funds that enabled the development of the labor and delivery CRM course. The premium discount was key to promoting obstetrician participation. Physician satisfaction surveys revealed that the malpractice insurer's requirement for obstetricians to pass a test demonstrating their knowledge of obstetrical guidelines has led them to more thoroughly familiarize themselves with the guideline requirements, which might improve outcomes of care. During pilot testing, the Center for Medical Simulation held simulations in both their stand-alone facility and in actual hospital labor and delivery units. Although the units provided a rich, real-life feeling, it was logistically difficult to schedule and occupy them for an entire day. Participants involved in simulation-based team training at their work site often were distracted by requests to help with usual workday tasks. As a result, the Center for Medical Simulation now exclusively conducts full-day CRM training courses at their facility. On the other hand, holding simulations at an actual worksite provided an opportunity for the team to test and discover whether a delivery room or operating room set-up was optimal. For example, when acting out a simulated code crisis in one newly renovated facility, clinicians realized that some equipment was not well situated for emergency response. For this reason, Gardner recommends that local facilities conduct periodic onsite drills to test their assumptions and improve the local environment.

Implications: The Center for Medical Simulation experience suggests that simulation-based training in crisis events can help improve teamwork, decision-making, and communication skills among multidisciplinary labor and delivery personnel. Simulated team interactions help participants "overcome their sense of pride in being autonomous" so they are more willing to seek advice or help in crisis situations, says Gardner. A simulation-based training course can be a transformational experience for participants, who often say that inadequate team interactions are more problematic than they had realized. For many participants, the course represents the first time anyone has engaged them in an in-depth discussion of teamwork and how to improve it, Gardner says. For

Further Information: Visit the Center for Medical Simulation Web site or contact Roxane Gardner, M.D., at rgardner1@partners.org.

References
[1] J. B. Sexton et al. (2000) Error, Stress, and Teamwork in Medicine and Aviation: Cross Sectional Surveys. British Medical Journal 320, 745–749. [2] E. J. Thomas et al. (2003) Discrepant Attitudes about Teamwork Among Critical Care Nurses and Physicians. Critical Care Medicine 31, 956–959. [3] R. L. Helmreich (2000) On Error Management: Lessons from Aviation. British Medical Journal 320, 781–785. [4] D. M. Gaba et al. (2001) Simulation-Based Training in Anesthesia Crisis Resource Management (ACRM): A Decade of Experience. Simulation & Gaming 32, 175–193. [5] D. M. Gaba (2000) Anaesthesiology as a Model for Patient Safety in Health Care. British Medical Journal 320, 785–788. [6] J. C. Morey et al. (2002) Error Reduction and Performance Improvement in the Emergency Department through Formal Teamwork Training: Evaluation Results of the MedTeams Project. Health Services Research 37, 1553–1581. March 2005

This study was based on publicly available information and self-reported data provided by the case study institution(s). The aim of Fund-sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. The studies are intended to enable other institutions to draw lessons from the studied organizations' experiences in ways that may aid their own efforts to become high performers. The Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund's case studies series is not an endorsement by the Fund for receipt of health care from the institution.