A Structured Communication and Team Training Program to Improve Perioperative Patient Safety

Meghan Michael, MD

Meghan Michael, MD

Meghan Michael, MD
Associate Professor of Anesthesiology and Pain Management, Division of Neuroanesthesia
The University of Texas Southwestern Medical Center

Dr. Michael’s project is entitled: “A Structured Communication and Team Training Program to Improve Perioperative Patient Safety”

Background: The perioperative environment poses distinct challenges to team communication as it requires multiple healthcare professionals and their teams to engage in a complex series of frequent, high acuity care transitions. Perioperative sentinel events, mortality, and malpractice costs can be reduced by using team-focused handoffs. The need for team training has been increasingly recognized, with recent evidence indicating that team training is associated with decreased surgical mortality.1 However, recent meta-analyses show a persistent lack of team training in health professional curricula, revealing a critical need for handoff interventions that are interprofessional and provide clinicians with the teamwork competency training needed to improve perioperative handoff safety.2 The APSF 2017 Consensus Recommendations highlight the importance of “leadership buy-in, inclusion of all members of the team, and suggest that experiential and team training… are essential for perioperative handoff improvement”.3 Furthermore, the HATRICC trial demonstrates the importance of observation of and interviews with key partners to understand work practices and behaviors (contextual inquiry) as well as the involvement of key partners in the development of any new processes (participatory design).4

Implementation of the I-PASS program – a multifaceted handoff intervention organized around the mnemonic I-PASS (Illness Severity; Patient Summary; Action Items; Situational Awareness and Contingency Planning; Synthesis by Receiver) – is associated with reductions in preventable medical errors and adverse events during shift changes within a given health profession. While I-PASS has been successfully implemented in diverse environments, with most recent data showing a 47% decrease in handoff-related adverse events,5 these findings have not included interprofessional perioperative handoffs. Meanwhile, studies that do include the perioperative environment describe notable obstacles with adherence.6,7 The common problem with adaptation to the perioperative environment is a lack of interprofessional teamwork competency training. To address this issue, the I-PASS program, which includes tools for a needs assessment, an implementation guide, educational materials, faculty recruitment and development materials, and assessment tools, must also include an interprofessional educational strategy that builds critical teamwork competencies.

Hypothesis and Specific Aims: We hypothesize that implementing our comprehensive, teamwork-focused perioperative adaptation of the I-PASS program will reduce preventable errors and harms as well as improve teamwork, handoff quality, and clinician perceptions of acceptability and effectiveness.

Aim 1. Conduct a needs assessment using contextual inquiry to develop a teamwork-focused handoff intervention in the perioperative environment. By engaging all key partners in our neurosurgical, neurointerventional, and skull-based ENT units, we will describe the barriers to and facilitators to implementing a structured handoff program across the perioperative continuum. We hypothesize that the use of contextual inquiry (recorded interviews and handoffs which are then coded and analyzed) will elucidate the unique needs of those who work in the perioperative environment. These data will inform the design and implementation of a multimodal intervention that will include an educational strategy for teamwork competencies specific for perioperative handoffs.

Aim 2. Design and implement a competency-based educational strategy focused on the teamwork skills needed to enhance an I-PASS program adapted for use in each phase of the perioperative continuum. Building on my previous work analyzing perioperative handoffs,8-12 and with the goal of developing a comprehensive, innovative framework for multimodal perioperative handoffs, we will design a tailored interprofessional curriculum that emphasizes teamwork competencies that are most relevant to perioperative handoffs based on the needs assessment. We will use a systems approach based on modern adult learning theory that is guided by educational best practices13 and incorporates skills acquisition training. We hypothesize that iteration and optimization of our Team FIRST educational strategy will enhance the adoption of a perioperative I-PASS program, as measured via clinician ratings of curriculum acceptability and effectiveness.

Aim 3: Determine whether adapting the I-PASS program to the perioperative setting using competency-based team training will lead to: a) a reduced rate of serious medical errors (primary outcome; measured using an established active surveillance methodology) and b) increased teamwork competencies (measured using adapted, validated instruments to assess handoff quality and teamwork competencies). We will also measure efficiency of care by determining handoff duration as well as operating room (OR) turnover time. We hypothesize that our innovative perioperative handoff intervention will reduce medical errors and increase teamwork competencies.

Impact: We believe that implementing a teamwork-based interprofessional handoff educational strategy among perioperative clinicians throughout the perioperative continuum will substantially improve patient safety and teamwork without compromising efficiency or clinician satisfaction. After obtaining preliminary data, we will iterate and optimize this intervention and subsequently implement and study our educational strategy on a larger scale, with the ultimate goal of nationwide dissemination and enhanced patient safety.

REFERENCES

  1. Neily, J., Mills, P. D., Young-Xu, Y., Carney, B. T., West, P., Berger, D. H., Mazzia, L. M., Paull, D. E., & Bagian, J. P. (2010). Association between implementation of a medical team training program and surgical mortality. JAMA, 304(15), 1693-1700. https://doi.org/10.1001/jama.2010.1506
  2. Fox, L., Onders, R., Hermansen-Kobulnicky, C. J., Nguyen, T. N., Myran, L., Linn, B., & Hornecker, J. (2018). Teaching interprofessional teamwork skills to health professional students: A scoping review. J Interprof Care, 32(2), 127-135. https://doi.org/10.1080/13561820.2017.1399868
  3. The Anesthesia Patient Safety Foundation. Perioperative Patient Safety Priorities. Accessed Feb 14, 2023. https://www.apsf.org/patient-safety-priorities/
  4. Lane-Fall MB, Christakos A, Russell GC, Hose BZ, Dauer ED, Greilich PE, et al: Handoffs and transitions in critical care-understanding scalability: study protocol for a multicenter stepped wedge type 2 hybrid effectiveness-implementation trial. Implement Sci. 2021;16(1):63.
  5. Starmer, A. J., Spector, N. D., O’Toole, J. K., Bismilla, Z., Calaman, S., Campos, M. L., Coffey, M., Destino, L. A., Everhart, J. L., Goldstein, J., Graham, D. A., Hepps, J. H., Howell, E. E., Kuzma, N., Maynard, G., Melvin, P., Patel, S. J., Popa, A., Rosenbluth, G., . . . Group, I. P. S. M. I. S. (2022). Implementation of the I-PASS handoff program in diverse clinical environments: A multicenter prospective effectiveness implementation study. J Hosp Med. https://doi.org/10.1002/jhm.12979
  6. Shahian DM, McEachern K, Rossi L, Chisari RG, Mort E: Large-scale implementation of the I-PASS handover system at an academic medical centre. BMJ Qual Saf 2017;26(9):760-770.
  7. Stenquist DS, Yeung CM, Szapary HJ, Rossi L, Chen AF, Harris MB: Sustained Improvement in Quality of Patient Handoffs After Orthopaedic Surgery I-PASS Intervention. J Am Acad Orthop Surg Glob Res Rev 2022;6(9).
  8. Michael MM, Ambardekar AP, Pukenas E, Karamchandani K, Nguyen H, Potestio CP, et al: Enablers and Barriers to Multicenter Perioperative Handoff Collaboration: Lessons Learned From a Successful Model Outside the Operating Room. Anesth Analg 2021;133(5):1358-1363.
  9. Sparling JS, France D, Abraham J, Duffy CC, Michael MM, Riesenberg LA, Lazzara EH, Mershon BH, Lane-Fall MB, Keebler JR, Weinger MB, Greilich PE: Handoff effectiveness research in perioperative environments (HERO) design studio: A conference report. Jt Comm J Qual Patient Saf 2023; in press
  10. Sheng J, Manjunath S, Michael M, Gajera P, Wang E, Sendelbach D: Integrating handover curricula in medical school. Clin Teach 2020;17(6):661-668
  11. Michael M, Griggs AC, Shields IH, Sadighi M, Hernandez J, Chan C. Improving handover competency in preclinical medical and health professions students: establishing the reliability and construct validity of an assessment instrument. BMC Med Educ 2021;21(1):518
  12. Greilich PE, Kilcullen M, Paquette S, Lazzara EH, Scielzo S, Hernandez J, Preble R, Michael M, Sadighi M, Tannenbaum S, Phelps E, Hoggatt Krumwiede K, Sendelbach D, Rege R, Salas E; Team FIRST Framework: Identifying Core Teamwork Competencies Critical to Interprofessional Healthcare Curricula. Clin Transl Sci Accepted Feb 14, 2023
  13. Riesenberg LA, Davis R, Heng A, Vong do Rosario C, O’Hagan EC, Lane-Fall M: Anesthesiology Patient handoff education interventions: A systematic Review. Jt Comm J Qual Patient Saf. 2022 Dec 15:S1553-7250(22)00296-3. doi: 10.1016/j.jcjq.2022.12.002. Epub ahead of print. PMID: 36631352.

Funding: $300,000 (July 1, 2023- June 30, 2025). This award is Joint APSF-FAER Mentored Research Training Grant (MRTG)