Bring cutting-edge MedTeams’ concepts to your ED: Novel program eliminates errors, cuts liability risks
Would you like to cut your risk management cases in half and reduce medication errors that lead to unwanted outcomes? A unique project is underway that has produced convincing data to accomplish exactly that. The MedTeams project applies behavioral science techniques, used for aviation safety, in the ED.
"The idea is to increase efficiency, avoid errors, and improve patient satisfaction. This tool will revolutionize the way we practice emergency medicine." says Matthew Rice, MD, FACEP, medical corps chief at the department of emergency medicine at Madigan Army Medical Center in Tacoma, WA, and one of the program’s developers.
Ten EDs implemented cutting-edge techniques and then collected data on employee satisfaction, errors, turnaround times, and complaints. "This has tremendous potential impact for ED managers," says Dallas Peak, MD, FACEP, clinical assistant professor of emergency medicine at Methodist Hospital in Indianapolis and a physician investigator for MedTeams. "The parameters we focused on are foremost on every manager’s mind."
A curriculum was developed based on the concept of reducing errors through teamwork. "We specifically aimed the curriculum at errors that commonly occurred in our respective institutions, and developed ways to circumvent these through proper teamwork skills," says Peak. The impact of teamwork training on errors was dramatic, he adds.
The MedTeams concept is different from traditional efforts to improve efficiency and reduce costs, such as re-engineering, reorganization, and workforce reduction, stresses Jorie Klein, RN, president of the Society of Trauma Nurses. "Hospitals are paying consulting fees to right size’ the workforce and develop service excellence programs," she notes. "These processes often create a fragmented infrastructure for the providers." They don’t address how the medical team works together, argues Klein. "MedTeams’ focus is on the medical team’s response, structure, communication, situation awareness, and team review," she says. "The outcomes of MedTeams implementation are a decrease in medical errors, increased efficiency, improved resource utilization, and improved patient satisfaction."
Complete cultural change
Madigan Army Medical Center’s ED has undergone a complete cultural change after implementing MedTeams, says Rice. "Within the past two years of training, we have been able to solve problems that have frustrated us for years," he reports. "We’ve gone from having a high turnover of personnel, patients who aren’t as happy as they should be, and risk management cases being higher than we’d like, to a culture that’s much more focused on solving problems as a team."
Patient complaints have steadily decreased since the project’s inception, notes Rice. "Up until a year ago, we had between six and 10 complaint letters a month," he says. "For the past several months, we had three letters, and there has been a steady downward trend over the last two years."
Staff turnover has also decreased. "Our clerks, who are the lowest paid people, would turn over regularly, and we had trouble recruiting nurses and medics," says Rice. "Now, people usually leave because they are moving, not because they are dissatisfied with the job itself. These improvements are measurable and specific."
Risks reduced by half
The 10 EDs involved in the project conducted a review of all malpractice and risk management claims during the past eight years. The results were tabulated and analyzed. "This was a very interesting part of the study in itself, and represents one of the largest malpractice/risk management studies done to date," notes Peak.
The findings showed dramatic results for those EDs enrolled in MedTeams, Peak reports. "The preliminary results for the project show an 80% decrease in observed errors in the experimental group, and no change in the control group," he says.
Although the actual number of errors that were avoided is impossible to know, the results are clearly significant, says Rice. "However, we estimate that we reduced our risk management cases by 50%," he says.
The number of cases identified as potential lawsuits, or actual lawsuits filed, has decreased by half, Rice notes. "According to the National Patient Safety Foundation, as many as 10% of bad outcomes are related to physician/medical errors, and I think team training helps reduce those errors," he says.
Savings of $4 per ED patient
To determine reduction of risks, the MedTeams researchers spent hundreds of hours observing ED providers nationwide, says Robert Simon, EdD, chief scientist for the crew performance group at Dynamics Research Corporation in Andover, MA. "Then we quantified things in a more systematic way by looking at closed cases at a number of participating hospitals," he explains. "We looked to see if there was a teamwork technique that had been in place, would it have avoided or at least mitigated the error?"
The retrospective study indicated that, of 4.7 million patient visits in this retrospective study, there were 68 closed cases during that eight-year period. "Twenty-nine of them were judged to involve teamwork failures, and the average settlement was $560,000 per lawsuit," Simon notes. "What that means is of the total amount of indemnity costs, $3.45 of every visit could have been eliminated if people had been trained in teamwork skills."
That figure factors heavily in the average annual medical malpractice costs for an ED physician, says Simon. "Depending on where the physician practices, their average malpractice cost per patient is about $2-6. So $3.45 is a very significant number."
Teamwork training could result in significant cost reductions, emphasizes Simon. "Based on error reductions occurring now in the hospitals and other efficiency cost savings, we are conservatively estimating that hospitals will be able to save at least $4 per patient," he says. "Therefore, EDs that see 20,000 patients a year should realize about $80,000 in cost avoidance the first year, and the same amount of savings every year thereafter."
The average number of risk management and malpractice cases is estimated as high as one for every 20,000 visits, notes Rice. "So with our volume, we would expect 4-5 cases per year on average," he explains. "However, we’ve only had one case in two years and that was relatively minor. We probably have one of the lowest risk management rates anywhere, as a result of this training."
Eventually, insurance premiums will be reduced as a result. "Avoidance of errors and enhancing provider-patient communication are two things insurance companies want to look at," says Rice. "These things make a big difference relative to claims, so they will appropriately adjust premiums based on these risk management issues."
Here are some concepts from the MedTeams project to implement in your ED:
Increase communication between physicians and nurses. "For the first time, we have doctors and nurses talking directly with one another and sharing ideas and information," says Peak. "Our department has around 50 beds and saw 84,000 patients last year. We have a residency program and train other service’s residents as well as medical students. So there may be as many as 10 physicians seeing patients at any given time."
Communication was the weak link in the ED’s system, Peak acknowledges. "It was entirely possible for a physician to see a patient, write orders, obtain results, and release the patient, [while] having never spoken to a nurse," he says. "MedTeams has changed how we do business. The team structure promotes a much closer collaboration of physicians and nurses."
Effective communication is the "lifeline" of medical teams, Peak emphasizes. "Everyone is working together and it’s not the old game of the docs vs. the nurses’ that we used to play," he says. "Our department is also physically large and geographically divided. So MedTeams enables us to change from running one big, inefficient department to running three smaller, more efficient ones."
Physicians can focus on optimizing patient flow when there are fewer patients to manage on their team, says Peak. "The nurses also help out by staying in better contact with the physician leader for their team," he explains.
Keep all staff members informed. "We insist there be some way in the ED to achieve broad situational awareness," says Simon. "Some EDs do this with status boards, others have clever ways of moving charts around, or attach colored flags to charts. However you choose to do it, there needs to be a system so that other members of the team can get a quick update on what is going on. One or two people should not be holding all the keys."
Communicate with frequent team meetings. Routine team meetings ensure that plans don’t slip off track and that details are not missed, says Peak. "The nurses know what the physicians are waiting on and can keep patients informed. Likewise, the nurses can provide crucial information to the physicians that affects their decision making," he explains.
Frequent team meetings resolved the problem of prolonged stays in the ED on admitted patients, says Peak. "In some cases, a physician would forget to submit a bed request. Four or five hours would pass until someone would ask, why is that patient still here?’ and track down the problem," he explains. Now a system of built-in checks through team meetings and a better sense of "ownership" for the team’s patients reduces delays.
Too often, a situation with a patient is only known by one or two staff members, Simon notes. "It’s important to occasionally huddle up at the status board to share what is going on with a patient," he says. "Staff may feel they are too busy for that, but status meetings last only 30 seconds or a minute."
After having a status meeting, staff are able to conduct the next hour much more effectively, Simon explains. "The staff should know what a physician has in mind. For example, will the patient be admitted or discharged from the ED?" he says.
Such simple pieces of information can impact several nursing activities, says Simon. "There is no more guesswork on the nurse’s part," he adds. "They may have thought the patient had just a tummy ache, but it turns out that the doctor thinks there is cardiac involvement, or vice versa. Those things need to be verbalized."
Ensure administrative support. "There are really two essential elements: a grassroots’ desire to improve the system, and administrative support and supervision for the project," says Peak.
Staff enthusiasm for the team concept is key, says Peak. "Our staff had a strong feeling that something needed to be done, and MedTeams was embraced as a solution for some of our problems," he explains. "However, some of these ideas represent challenges to the old way of doing things. So they require some extra effort to get started."
Supervision from administration helps to keep the process going in its early stages, notes Peak. "The project also needs some victories," he says. "People want to see visible signs that it’s working at some level."
Do an end-of-shift review. "When there are saves, you have to give staff credit in real time," says Gregory Jay, MD, PhD, FACEP, director of emergency medicine residency research at Rhode Island Hospital in Providence. "The best way to do this is with an end-of-the-shift review—to go over where the team succeeded or failed."
End of shift reviews should be done in 2-4 minutes, Jay advises. "Work loads are onerous and will continue to be with managed care, and people have to get home. So it needs to be brief," he says. "There is no other opportunity in very busy clinical settings to provide that kind of feedback. We can provide administrative feedback, but how many memos can they write? In the trenches, we know how many errors are occurring because we see them all the time."
Avoid finger pointing. Instead of pointing a finger at an individual, the emphasis is shifted to team successes and failures. "When something doesn’t go perfectly, we say the team failed, rather than identifying the person who caused this to happen," says Rice.
The goal is to move away from "blaming and shaming," says Simon. "Instead, take the approach of asking, this is what happened, now what can we learn from it?’" he suggests. "We assume people are trying to do their best, and other things get in the way, such as problems with communications and systems."
Discuss team saves at M&M conferences. "Historically, the purpose of these conferences is to identify team failures, not successes," Jay notes. "Now we talk about saves that are clearly attributed to teamwork. It is important to highlight near misses where the team recovered."
Invite nurses to attend M&M meetings. "Prior to this, nurses never came to the conference," says Jay. "Now we make it a point to have them there, especially for the cases they are involved with." Discussions are lively, and result in a much richer understanding of the case, he notes.
Nurses can help decipher the record, says Jay. "Prior to that we had only the physician’s opinion, but now we have another piece of historical insight about what happened. As a result, teamwork failures are more easily identified," he explains.
Stress collaboration between nurses and physicians. "For too many years, nurses and physicians have been practicing on parallel tracks, never mingling or crossing with one another, only communicating when they really have to," says Jay. "There is an opportunity for far more communication to occur, and safety issues are a key part of that."
Be prepared for a lengthy implementation. "This is a work in evolution, not something that happens overnight," says Jay.
Full scale implementation of MedTeams concepts can take a year or more, Jay reports. "Most of the effort does not go into training the teams. Most goes into implementing and keeping concepts alive after people are out of the classroom," he adds.
Clinicians who are task-oriented may view team concepts as additional work, notes Simon. "It may seem like team responsibilities are making their lives more difficult," he says. "Ultimately, physicians and nurses are better connected with people they work with and enjoy their jobs more, but that takes time because it’s not the way they were trained."
The rationale behind MedTeams is easy to grasp, but putting it into everyday practice takes work, says Peak. "We have only begun to see the full effect of MedTeams in this regard. Changing habits takes time and effort. We have to constantly remind one another of our goals for effective communication."
Focus on the patient’s needs instead of tasks. "ED nurses and physicians are task oriented. The focus is on the next most important thing to do, and so forth," says Simon. "MedTeams teaches people to switch their focus to patient needs."
Identify and break error chains. "We contend that medical misadventures or errors rarely happen over a period of five or 10 seconds. They happen over weeks, months, or years," says Simon. "Things have unfolded to make it possible for an error to happen. We call that an error chain."
The goal is to find ways to break the error chain, notes Simon. "Team coordination is an economically efficient way to break the error chain," he says. "Sometimes systems just don’t work. For example, a lot of drugs have similar sounds, and dosages get lost in the fray of language in a busy ED. We can break that chain by having people check all verbal medical orders. That simple check in the system prevents an error going further."
Bad outcomes are rarely the result of a single error, Rice stresses. "For example, a patient is supposed to go to surgery and have his or her left leg amputated. First, the physician inadvertently writes amputation of right leg.’ Then, somebody comes in and prepares the right leg for surgery. Next, the anesthesiologist looks at the note and never talks to the patient. Finally, the patient’s right leg is prepped and removed," he explains.
The error begins at one point, then people fail to stop it, says Rice. "Perhaps they are afraid to challenge a person, or think that it’s not their job," he notes. "The way to break that chain is to give people responsibility for the patient themselves. Don’t assume that the staff physician knows better than the medic who spots something wrong."
Acknowledge the frequency of human error. "There is not a single pilot in aviation who wakes up and says, I am going to fly a perfectly good airplane in the ground.’ Likewise, there is not a single nurse or physician who wakes up and says, I’m going to screw up today,’" says Simon. "ED staff are well intentioned, highly trained, caring human beings in a complex environment, and they make mistakes. People are error prone, but there are ways to self-correct that."
Defensive reactions to being challenged or corrected are detrimental to patient care, says Simon. "In the past, people would feel as if they are not being trusted, but that’s not the case," he explains. "If you’re going to have a high reliability of self correcting, you must first acknowledge that people make mistakes all the time."
Physicians should welcome challenges, says Simon. "At first, doctors may feel that nurses are trying to tell them what to do, but it will actually make them more safe," he stresses. "An additional piece of information may save them from a lawsuit, so the physician’s own self-interest is served."
Don’t start project at the wrong time. "We don’t want hospitals to undertake a MedTeams program in the middle of a huge downsizing, renovation, or restructuring, because people can’t feel threatened if you’re going to effect this kind of change," says Simon. "There needs to be some stability and security for this to work."
Link teamwork to evaluations. "Ensure that these concepts are part of people’s practice by linking their performance as a team member to their evaluations," Simon recommends. "Use very well defined areas, such as is there cross monitoring?’ That way, people aren’t judged against an unknown standard."
Plan for occasional refresher courses. "Because we’re talking about a sea [of] change,’ we found that one or two refresher courses conducted several weeks or months later reinforced this. That way, new people coming in are introduced to these," says Rice.
Encourage staff not to say that’s not my job.’ "Team members must help other team members. We are all responsible for patient care," stresses Rice. "In the past, nurses might say, that’s the physician’s job’ or vice versa. Now it’s everyone’s responsibility to take care of an issue when it arises."
Identify specific teams. As part of the MedTeams program, every person working in the ED, from clerks to staff physicians, are assigned to specific teams, Rice explains. "You may have 30 people taking care of 300 patients a day. We have set up a visual identification system, so personnel know at any time who they are working with."
The system is color-coded. "A staff physician may wear a yellow arm band, and physician wears purple scrubs, and nurses either blue or green scrubs," Rice notes. "Those individuals on the team have multiple meetings during a work shift. For instance, the team may get together right after 7 a.m. to talk about problems which came up in the previous shift."
Even the patient is made a member of the team. "If a patient is assigned to a green bed, they have a sticker placed on their shoulder, and someone explains that they are on the green team," says Rice. "The patient is told, you and the other patients are the most important part of our jobs. If you need help, ask for anyone on the green team.’ This gets patients involved in their own care."
Every single staff member needs to be an advocate for the patient. "They need to be assertive without being inappropriate, and understand the responsibility that goes along with that," says Rice. "This is not a prescription for mutiny against chain of command. It’s allowing staff to have some authority in bringing changes to the surface. But there still needs to be a decision made by the person in authority."
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