538093
research-article2014
AJMXXX10.1177/1062860614538093American Journal of Medical QualityO’Leary et al
Article
Implementation of Unit-Based Interventions to Improve Teamwork and Patient Safety on a Medical Service
American Journal of Medical Quality 2015, Vol. 30(5) 409–416 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860614538093 ajmq.sagepub.com
Kevin J. O’Leary, MD, MS1, Amanda J. Creden, BS1, Maureen E. Slade, MS, RN, CS2, Matthew P. Landler, MD1, Nita Kulkarni, MD1, Jungwha Lee, PhD, MPH1, John A. Vozenilek, MD3, Pamela Pfeifer, RN2, Susan Eller, RN, MSN4, Diane B. Wayne, MD1, and Mark V. Williams, MD5
Abstract In a prior study involving 2 medical units, Structured Interdisciplinary Rounds (SIDRs) improved teamwork and reduced adverse events (AEs). SIDR was implemented on 5 additional units, and a pre- versus postintervention comparison was performed. SIDR combined a structured format for communication with daily interprofessional meetings. Teamwork was assessed using the Safety Attitudes Questionnaire (score range = 0-100), and AEs were identified using queries of information systems confirmed by 2 physician researchers. Paired analyses for 82 professionals completing surveys both pre and post implementation revealed improved teamwork (mean 76.8 ± 14.3 vs 80.5 ± 11.6; P = .02), which was driven mainly by nurses (76.4 ± 14.1 vs 80.8 ± 10.4; P = .009). The AE rate was similar across study periods (3.90 vs 4.07 per 100 patient days; adjusted IRR = 1.08; P = .60). SIDR improved teamwork yet did not reduce AEs. Higher baseline teamwork scores and lower AE rates than the prior study may reflect a positive cultural shift that began prior to the current study. Keywords patient safety, teamwork, interprofessional care, hospital medicine Communication and teamwork are tightly linked to patient safety.1-4 Hospital settings present important challenges to teamwork, especially on medical units. Teams are large, membership is dynamic, and individual team members care for multiple patients at the same time. On medical services, team members are seldom in the same place at the same time, resulting in suboptimal communication practices.5,6 This research group previously reported the impact of Structured Interdisciplinary Rounds (SIDRs) implemented on one hospitalist and one teaching service unit.7-9 SIDRs use a structured format for communication during regular interprofessional meetings facilitated by unit-based clinical leaders. The group found significant improvements in ratings of the teamwork climate and a reduction in the rate of adverse events (AEs) compared to control units. Although promising, this prior research is limited in that it evaluated implementation of the intervention on only 2 units, and analysis of AEs was restricted to only one of the study units. Herein, the research group reports the results of the INTERdisciplinary Approaches to Communication and Teamwork (INTERACT) study. The INTERACT study had the following goals: (a) broadly implement prepared
nurse–physician coleadership and SIDR, (b) determine the impact on ratings of teamwork climate, and (c) assess the benefit in reducing the adjusted rate of AEs.
Methods Setting and Study Design This pre- versus postintervention study compared results from patients and professionals on 5 general medical units at Northwestern Memorial Hospital (NMH), an 854-bed tertiary care teaching hospital in Chicago, Illinois. Four of the 5 units consisted of 30 beds and one 1
Northwestern University Feinberg School of Medicine, Chicago, IL Northwestern Memorial Hospital, Chicago, IL 3 University of Illinois College of Medicine at Peoria, IL 4 Stanford School of Medicine, Stanford, CA 5 University of Kentucky, Lexington, KY 2
Corresponding Author: Kevin J. O’Leary, MD, MS, Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, 211 E. Ontario St, 7th Floor, Chicago, IL 60611. Email: [email protected]
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had 23 beds. Two units were staffed by teaching service physician teams composed of 1 attending, 1 resident, 1 or 2 interns, and 0 to 3 medical students. Two units were staffed by hospitalist physicians who worked independently without the assistance of resident physicians. One unit was staffed by a combination of teaching service physician teams and hospitalists working independently without the assistance of resident physicians. As a result of a prior intervention, physicians worked on specific units in an effort to improve communication practices.10 The study was approved by the Northwestern University Institutional Review Board.
Intervention The INTERACT intervention had 2 components: prepared nurse–physician coleadership and SIDR. The research group selected unit medical directors, with nursing leadership input, to partner with established unit nurse managers to improve quality and safety for their units. These unit coleaders (ie, unit medical directors and nurse managers) received specific training for their role in collaboration with the Northwestern Memorial Academy, NMH’s training center for professional development, and the Northwestern University Simulation Technology and Immersive Learning Center. Coleadership training consisted of six 90-minute sessions over a 12-week period. Session topics included patient safety principles, coaching, change management, defining roles and responsibilities, characterizing leadership styles with the aid of Myers-Briggs Type Indicator assessments,11 and simulation-based training designed to enhance skills to facilitate interprofessional communication in SIDR. SIDR, as has been described previously, used a structured format for communication during regular interprofessional meetings.9 Unit coleaders led working groups, with representatives from each professional type, in determining the best time, format, duration, and location for SIDR. Based on working group decisions, SIDR took place each weekday in the late morning in unit conference rooms and was intended to last 30 to 40 minutes. The unit nurse manager and medical director co-facilitated discussion during SIDR each day. All physicians, nurses, and the pharmacist, social worker, and case manager for each unit attended SIDR. Physician attendance was staggered so that 1 physician entered the room at a time to discuss his or her patients; all other professionals attended SIDR for the entire duration. The structured communication tool was used in SIDR for all patients newly admitted to the unit (ie, within last 24 hours). (The tool is available in the online appendix at http://ajmq .sagepub.com/supplemental.) All other patients also were discussed, but without the assistance of a structured
communication tool. The timing of SIDR was coordinated across units as some professionals (ie, pharmacists, social workers) cared for patients on 2 units. For example, the 13 West unit held SIDR at 10:30 am and 13 East held SIDR at 11:15 am to allow their common pharmacist to attend both units’ SIDR. SIDR was implemented on March 1, 2010.
SIDR Characteristics and Attendance A researcher attended SIDR on randomly selected study units 3 times a week for one year. The researcher recorded the duration of SIDR, the number of newly admitted and total patients on the unit, the number of patients discussed each day, the number of patients for whom the structured communication tool was used during discussion, and attendance for each professional type.
Assessing Hospital Professionals’ Ratings of Teamwork and SIDR A survey was administered to physicians, nurses, social workers, case managers, and pharmacists working on study units during a 3-month period before implementation of the interventions and during a similar 3-month period one year after implementation. The first portion of the survey assessed teamwork climate using the Safety Attitudes Questionnaire (SAQ) developed by Sexton et al.12-14 The SAQ teamwork climate domain includes 14 questions using a 5-point Likert-type scale and generates a score ranging from 0 to 100. A second portion of the survey obtained demographic data, including age, sex, race/ethnicity, time at NMH, and profession. A final portion of the postimplementation survey assessed perceptions of SIDR including efficiency, collaboration among team members, and patient care using a 5-point Likerttype scale. Surveys were Internet based (www.surveymonkey.com) and delivered via e-mail. Nonresponders received up to 3 reminder e-mails.
Identification of AEs The research group randomly selected 1380 patients admitted to the study units between March 1, 2009, and February 28, 2011, for identification of AEs. The group used an adapted version of a traditional 2-stage medical record review.15-18 In the first stage, potential AEs were identified using 51 automated queries of the Northwestern Medicine Enterprise Data Warehouse (EDW). The EDW is an integrated database of all clinical data from the hospital’s electronic health record (PowerChart Millennium; Cerner Corporation, Allentown, NJ), hospital and physician billing systems, incident reporting system, and admission/discharge/transfer system. The EDW queries
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O’Leary et al were based on traditional screening criteria and the Institute for Healthcare Improvement Global Trigger Tool (ie, the Care and Medication Module Triggers).17,18 A prior study by the research group found these automated screens identified a similar number of AEs as manual medical record screening.19 Use of the automated method allowed for blinded identification of potential AEs and a larger number of patient records to be screened than would have been possible with manual medical record abstraction. For each patient with 1 or more potential AEs identified, one of 3 clinical research nurses abstracted the medical record and created a narrative summary for each potential AE. In the second stage, 2 physician-researchers (MPL and NK) independently reviewed each narrative summary in a blinded fashion to confirm whether or not an AE occurred and to determine the preventability and severity of AEs. The research group defined an AE as an injury caused by medical management rather than the natural history of the illness20 and included injuries that prolonged the hospital stay or produced disability as well as injuries that resulted in transient disability or abnormal lab values.21 Physician reviewers rated the presence and preventability of AEs using a 6-point scale similar to that used in prior studies, with a score of ≥4 indicating a positive result.2,18 Because the same AE could be detected by more than 1 screening criteria, physician reviewers indicated duplicate screens representing the same AE. The physician reviewers also classified AEs according to 4 levels of severity (life-threatening, serious, clinically significant, or trivial).22 After independent ratings, physician reviewers discussed discrepancies to achieve consensus ratings and assigned AEs to one of 10 prespecified categories. Each research nurse had prior medical record review experience and underwent 2 days of training specifically for the study, including a description of the study, definitions of terms, and practice using cases from the research group’s prior research. Both physician reviewers had extensive prior experience with the methods used and received similar although less-intensive training. The research group assessed the reliability of medical record abstractions by conducting duplicate abstractions and consensus ratings for a randomly selected sample of 294 patients. The interrater reliability was good for determining presence, preventability, and severity of AEs (κ = .63, κ = .68, and κ = .73, respectively).
Data Analysis The research group calculated descriptive statistics to report characteristics of SIDR, including mean duration, mean number of newly admitted and total patients
on units per day, overall percentage of patients discussed in SIDR, percentage of patients for whom the structured communication tool was used, and attendance by profession. The group compared patient and professional characteristics pre and post implementation using χ2 and t tests. t Tests were used to compare teamwork climate scores for all professional participants before and after implementation of the interventions, and paired t tests were used to conduct paired analyses of teamwork climate scores for professionals completing surveys both before and after implementation of the interventions. The research group classified AEs as serious if rated as serious or life threatening. The group calculated rates of AEs per 100 patient days for the pre- and postintervention periods and created multivariable Poisson regression models to compare the rates of total, preventable, and serious AEs before and after implementation of the interventions. Covariates included age, sex, race, payer, source of admission, night admission, weekend admission, case mix, Medicare Severity Diagnosis-Related Group weight, and total number of Elixhauser comorbidities. All analyses were conducted using Stata version 11.2 (StataCorp LP, College Station, TX).
Results Characteristics of SIDR Across all units, including 170 total observations of SIDR (range = 33-36 per unit), the mean duration was 36.5 ± 8.4 minutes and 97.7% of patients were discussed during SIDR (see online Appendix Table 1, available at http://ajmq.sagepub.com/supplemental). Attendance was greater than 75% for all professional types (physicians, nurses, social workers, case managers, and pharmacists). Surprisingly, adherence to the structured communication tool for new patients was only 34.4%. Teaching units spent significantly more time in discussion per patient (1.5 ± 0.2 vs 1.3 ± 0.3 minutes; P < .001), used the structured communication tool more often (52.7% vs 20.3%; P < .001), and had greater attendance by physicians, pharmacists, and unit medical directors compared to hospitalist service units.
Characteristics of Professionals and Patients There were no significant differences in professionals’ age, sex, race, or years at NMH between study periods (Table 1). One patient from the preintervention period was excluded as representing duplicate data. There were no significant differences in patient characteristics between study periods (Table 2).
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Table 1. Characteristics of Professionals. Preintervention (Total n = 165)
Postintervention (Total n = 222)
P Value
n = 96 34.3 (9.5) 93 (97) 42 (44) 6.1 (5.5) n = 20 32.7 (2.1) 12 (60) 10 (50) 3.1 (2.6) n = 35 27.3 (1.8) 16 (46) 11 (31) 1.8 (1.5) n=7 28.3 (3.0) 7 (100) 2 (29) 3.1 (2.5) n=7 39.0 (11.1) 6 (86) 3 (43) 11.7 (11.0)
n = 117 34.7 (11.2) 115 (98) 47 (41) 6.9 (8.2) n = 31 32.9 (3.1) 16 (52) 17 (55) 3.1 (2.5) n = 57 27.8 (2.0) 35 (61) 22 (37) 2.0 (1.3) n=8 28.9 (3.1) 7 (88) 3 (38) 2.8 (1.5) n=9 39.9 (9.6) 8 (89) 3 (33) 10.3 (9.9)
.80 .92 .55 .39 .72 .56 .74 .98 .24 .14 .49 .56 .72 .33 .71 .72 .87 .85 .70 .80
Nurses Mean age (SD), years Women, n (%) Nonwhite race, n (%) Mean time at the institution (SD), years Hospitalist physicians Mean age (SD), years Women, n (%) Nonwhite race, n (%) Mean time at the institution (SD), years Resident physicians Mean age (SD), years Women, n (%) Nonwhite race, n (%) Mean time at the institution (SD), years Pharmacists Mean age (SD), years Women, n (%) Nonwhite race, n (%) Mean time at the institution (SD), years Social work/case management Mean age (SD), years Women, n (%) Nonwhite race, n (%) Mean time at the institution (SD), years
Ratings of Teamwork and Perceptions of SIDR Overall, 165 of 250 (66%) eligible health care professionals completed the preintervention surveys and 222 of 283 (78%) completed the postintervention surveys. Teamwork climate scores were higher in the postintervention period, but the result was not statistically significant (mean 76.2 ± 14.2 vs 78.3 ± 14.2; P = .15) (Table 3). Paired analyses for the 82 professionals completing surveys both before and after implementation of the interventions revealed significant improvement in teamwork climate (mean 76.8 ± 14.3 vs 80.5 ± 11.6; P = .02), which was driven mainly by improved ratings by nurses (76.4 ± 14.1 vs 80.8 ± 10.4; P = .009). The majority of physicians (59/85; 69%) and nurses (89/104; 86%) and all pharmacists, social workers, and case managers agreed or strongly agreed that attending SIDR improved the efficiency of their workday (see online Appendix Table 2, available at http://ajmq.sagepub.com/supplemental). Similarly, the majority of physicians (72/85; 85%) and nurses (99/112; 88%) and all pharmacists, social workers, and case managers agreed or strongly agreed that SIDR improved team collaboration and patient care. The vast majority of physicians (69/85;
81%) and nurses (103/116; 89%) and all pharmacists, social workers, and case managers agreed or strongly agreed that SIDR should continue indefinitely.
Impact of Interventions on AEs Overall, 76 patients during the preintervention period (11.0%) and 76 patients during the postintervention period (11.0%) experienced 1 or more AEs (P = .99). Patients experienced a similar rate of total, preventable, and serious AEs during the pre- and postintervention periods (Table 4). Subgroup analyses by service type (teaching vs nonteaching hospitalist service) found no differences in the rate of AEs. Categories of AEs are shown in Table 5. Adverse drug events accounted for the largest portion of AEs, followed by falls. The rate of adverse drug events was 2.27 per 100 patient days during the preintervention period and 2.31 per 100 patient days during the postintervention period (adjusted incidence rate ratio 1.04; P = .82). The rate of AEs not categorized as drug related was 1.63 per 100 patient days during the preintervention period and 1.75 per 100 patient days during the postintervention period (adjusted incidence rate ratio 1.12; P = .61).
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O’Leary et al Table 2. Characteristics of Patients. Preintervention (n = 689)
Postintervention (n = 690)
P Value
57.1 (18.9) 343 (49.8) 319 (47.9) 379 (55.0) 191 (27.7)
55.7 (18.1) 320 (46.4) 295 (44.7) 377 (54.6) 191 (27.7)
.16 .21 .24 .89 .99
269 (39.0) 237 (34.4) 71 (10.3) 112 (16.3)
233 (33.8) 256 (37.1) 92 (13.3) 109 (15.8)
.11
619 (89.8) 65 (9.4) 5 (0.7)
620 (89.9) 67 (9.7) 3 (0.4)
.84
201 (29.2) 88 (12.8) 66 (9.6) 48 (7.0) 34 (4.9) 38 (5.5) 28 (4.1) 31 (4.5) 26 (3.8) 26 (3.8) 103 (15.0) 130 (18.9) 2.6 (1.8) 1.4 (1.8)
186 (27.0) 86 (12.5) 72 (10.4) 49 (7.1) 40 (5.8) 34 (4.9) 35 (5.1) 31 (4.5) 33 (4.8) 31 (4.5) 93 (13.5) 129 (18.7) 2.6 (1.9) 1.3 (1.5)
.94 .94 .77 .26
Mean age (SD) Women, n (%) Nonwhite race, n (%) Night admission, n (%) Weekend admission, n (%) Payer, n (%) Medicare Private Medicaid Self-pay/other Admission source, n (%) Emergency department External transfer Direct admission Case mix, n (%) Diseases of the circulatory system Diseases of the digestive system Diseases of the respiratory system Injury and poisoning Symptoms, signs, and ill-defined conditions Endocrine and nutritional disorders Diseases of the genitourinary system Diseases of the skin and subcutaneous tissue Mental illness Infectious and parasitic diseases Other Intensive care unit stay during admission, n (%) Mean number of Elixhauser comorbidities (SD) Mean MS-DRG weight (SD) Abbreviation: MS-DRG, Medicare Severity Diagnosis Related Group.
Discussion The research group successfully implemented complementary unit-based interventions, prepared nurse–physician coleadership and SIDR, across 5 general medical units, resulting in improved ratings of teamwork yet no change in the rate of AEs. Similar to the group’s prior studies evaluating the impact of SIDR, improved teamwork ratings were explained mainly by changes among nurses. This finding is consistent with prior research showing that nurses are often dissatisfied with the quality of teamwork with physicians, while physicians are relatively unaware of deficiencies.5,23,24 The findings of the current study differ from the research group’s prior studies evaluating SIDR in several important ways. Although paired analyses revealed significant improvement in teamwork climate, unpaired analyses showed no difference between the pre- and postimplementation periods. This finding relates to high
preintervention teamwork climate scores and likely is explained by changes that began prior to the current study. Compared to their prior research, the research group found improved teamwork climate on units before these interventions were made. Specifically, the teamwork climate score among 49 nurses on the control units in the preliminary studies evaluating SIDR was a mean 69.9 ± 17.9 in January 2009 compared to the baseline mean teamwork climate score of 76.4 ± 14.1 among nurses in the current study (December 2009 to February 2010). Notably, both hospitalists and residents were exposed to SIDR through rotations on the original study units, and this may have altered their attitudes and communication skills with staff on other units. Furthermore, in the months preceding the start of the current study, the research group noticed units beginning to learn from those involved in the preliminary research and modifying the format and frequency of the traditional “discharge rounds,” which had been in place for many years. Changes
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Table 3. Professionals’ Ratings of Teamwork. Unpaired Analyses All professionals Mean Teamwork Climate Score (SD) Nurses Mean Teamwork Climate Score (SD) Hospitalists Mean Teamwork Climate Score (SD) Residents Mean Teamwork Climate Score (SD) Pharmacists Mean Teamwork Climate Score (SD) Social work/case management Mean Teamwork Climate Score (SD) Paired Analyses
Preintervention
Postintervention
P value
n = 165 76.2 (14.2) n = 96 74.9 (14.5) n = 20 82.0 (12.9) n = 35 78.5 (13.8) n=7 71.8 (11.0) n=7 69.5 (13.9)
n = 222 78.3 (14.2) n = 117 77.2 (74.6) n = 31 78.6 (17.1) n = 57 82.2 (13.1) n=8 74.1 (8.8) n=9 71.0 (12.5)
.15 .25 .45 .20 .66 .84
Postintervention
P value
n = 82 80.5 (11.6) n = 57 80.8 (10.4) n=8 80.1 (18.4) n=7 88.7 (7.2) n=4 76.2 (7.2) n=6 71.7 (13.2)
.02 .009 .60 .32 .68 .47
Preintervention
All professionals Mean Teamwork Climate Score (SD) Nurses Mean Teamwork Climate Score (SD) Hospitalists Mean Teamwork Climate Score (SD) Residents Mean Teamwork Climate Score (SD) Pharmacists Mean Teamwork Climate Score (SD) Social work/case management Mean Teamwork Climate Score (SD)
n = 82 76.8 (14.3) n = 57 76.4 (14.1) n=8 84.2 (13.3) n=7 82.0 (16.5) n=4 73.7 (12.4) n=6 67.4 (13.9)
Table 4. Impact of Interventions on Adverse Events. Unadjusted Adjusted Incidence Unadjusted Adjusted Incidence Rate Rate Ratio Preintervention Postintervention Ratio (95% CI) P Value P Value (95% CI)a Adverse events (AEs) on all units, no. (AEs per 100 days) Any Preventable Serious Adverse events (AEs) on teaching units, no. (AEs per 100 days)b Any Preventable Serious Adverse events (AEs) on hospitalist units, no. (AEs per 100 days)b Any Preventable Serious
(n = 689)
(n = 690)
98 (3.90) 38 (1.51) 14 (0.56) (n = 272)
102 (4.07) 38 (1.52) 11 (0.44) (n = 277)
1.04 (0.79-1.38) 1.00 (0.64-1.57) 0.79 (0.36-1.73)
1.08 (0.82-1.43) 1.02 (0.65-1.60) 0.86 (0.39-1.92)
.77 .99 .55
.60 .94 .72
43 (3.54) 16 (1.32) 10 (0.82) (n = 245)
46 (3.87) 22 (1.85) 2 (0.17) (n = 245)
1.09 (0.72-1.65) 1.40 (0.74-2.67) 0.20 (0.04-0.93)
1.19 (0.78-1.82) 1.50 (0.78-2.91) 0.27 (0.06-1.28)
.68 .30 .04
.23 .23 .10
30 (3.70) 14 (1.73) 3 (0.37)
25 (3.00) 9 (1.08) 3 (0.36)
0.81 (0.48-1.38) 0.62 (0.27-1.45) 0.97 (0.20-4.82)
0.82 (0.48-1.41) 0.62 (0.26-1.45) 0.97 (0.19-4.90)
.44 .27 .97
.48 .27 .97
Abbreviation: CI, confidence interval. a Poisson regression-adjusted age, sex, race, payer, source of admission, night admission, weekend admission, Medicare Severity Diagnosis Related Group weight, and total number of Elixhauser comorbidities with days on study unit as exposure variable. b Total number of patients for teaching and hospitalist units does not equal overall total because one study unit included patients on both the teaching and hospitalist services.
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O’Leary et al Table 5. Impact of Interventions on Adverse Events by Category.a Categories of Adverse Events (AE), No. (AEs per 100 days) Adverse drug event Non–adverse drug eventb Fall Operative/procedural injury Manifestation of poor glycemic control Hospital-acquired infection Acute renal failure Pressure ulcer Venous thromboembolism Delirium Other
Preintervention Postintervention (n = 689) (n = 690) 57 (2.27) 41 (1.63) 10 (0.40) 6 (0.24)
58 (2.31) 44 (1.75) 8 (0.32) 8 (0.32)
5 (0.20)
8 (0.32)
6 (0.24)
5 (0.20)
7 (0.28) 1 (0.04) 1 (0.04)
2 (0.08) 8 (0.32) 1 (0.04)
1 (0.04) 4 (0.16)
0 (0.00) 4 (0.16)
a
Unadjusted and adjusted incidence rate ratios for adverse drug events in comparison to the preintervention period were 1.02, P = .92, and 1.04, P = .82, respectively. b Unadjusted and adjusted incidence rate ratios for adverse events that were not drug related were 1.07, P = .74, and 1.12, P = .61, respectively.
included inviting staff nurses to rounds and devoting attention to the daily plan of care (rather than focusing solely on discharge plans). Despite efforts to contain the spread of interventions prior to the current study, the research group was unable to completely prevent it. The study findings suggest that positive culture change in one part of an organization may spread to other parts prior to explicit actions to foster spread. Implementation of SIDR was successful in that the vast majority of team members were present and the overwhelming majority of patients were discussed during SIDR. Adherence to use of the structured communication tool for new patients was suboptimal. One explanation may be a perception that use of the structured communication tool would lengthen the duration of SIDR. Another explanation may be that professionals felt use of the communication tool was unnecessary, possibly after using it initially and then developing a sense of security about knowing the list of items. No improvement was found in the rate of AEs during the postintervention period. Similar to the findings of high preintervention teamwork climate scores, the research group found lower baseline AE rates in the current study compared to their prior research. The prior study evaluating the impact of SIDR on AEs for a single teaching unit found a rate of 7.2 to 7.7 AEs per 100 patient days for control patients. The much lower rate of 3.9 AEs
per 100 patient days during the preintervention period may be explained by the favorable changes in teamwork culture and corresponding behaviors that the research group believes began prior to the start of the current study. Of note, the current study used automated, computer-based rules to identify potential AEs. Prior research in the same setting found this method to identify a similar to slightly higher number of AEs compared to traditional manual medical record review. Therefore, the research group feels it is unlikely that the failure to detect a difference in the current study is related to the automated detection method. This study has several limitations. First, the study reflects the experience of a medical service in a single academic medical center. Larger studies are needed to assess the impact of similar interventions on teamwork climate and patient safety. Though other hospitals are likely to struggle similarly with interdisciplinary teamwork, baseline surveys may help identify hospitals that are ideal candidates for interventions. Second, teamwork climate was assessed using a validated survey rather than direct observation of teamwork behaviors in the clinical setting. As mentioned earlier, one of the barriers to teamwork is the dispersion of team members, making direct observation and assessment of teamwork-related behaviors very difficult. Third, narrative summaries of potential AEs were based on information available from the medical record, which may have lacked some detail to allow assessment of the presence, preventability, and severity of AEs.
Conclusion Prepared nurse–physician coleadership and SIDR resulted in improved ratings of teamwork yet no change in the rate of AEs. Earlier implementation of the same interventions on other units within the study site likely initiated a positive cultural and behavioral shift. Future studies should assess the benefit of similar interventions on other types of units (eg, antepartum, neurology, surgical). Additionally, future research efforts should conduct baseline assessments of teamwork climate to identify ideal study sites and explore factors associated with the successful spread of interventions within organizations. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article:
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This study was funded by the Agency for Healthcare Research and Quality, Grant No. R18 HS019630.
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benchmarking data, and emerging research. BMC Health Serv Res. 2006;6:44. 13. Kho ME, Carbone JM, Lucas J, Cook DJ. Safety climate survey: reliability of results from a multicenter ICU survey. Qual Saf Health Care. 2005;14:273-278. 14. Sexton JB, Makary MA, Tersigni AR, et al. Teamwork in the operating room: frontline perspectives among hospitals and operating room personnel. Anesthesiology. 2006;105:877-884. 15. US Department of Health and Human Services, Office of Inspector General. Adverse events in hospitals: national incidence among Medicare beneficiaries. http://oig.hhs. gov/oei/reports/oei-06-09-00090.pdf. Published November 2010. Accessed May 9, 2014. 16. Classen DC, Resar R, Griffin F, et al. “Global trigger tool” shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff (Millwood). 2011;30:581-589. 17. Hiatt HH, Barnes BA, Brennan TA, et al. A study of medical injury and medical malpractice. N Engl J Med. 1989;321:480-484. 18. Thomas EJ, Studdert DM, Burstin HR, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care. 2000;38:261-271. 19. O’Leary KJ, Devisetty VK, Patel AR, et al. Comparison of traditional trigger tool to data warehouse based screening for identifying hospital adverse events. BMJ Qual Saf. 2013;22:130-138. 20. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients— results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324:370-376. 21. Stelfox HT, Bates DW, Redelmeier DA. Safety of patients isolated for infection control. JAMA. 2003;290:1899-1905. 22. Weissman JS, Schneider EC, Weingart SN, et al. Comparing patient-reported hospital adverse events with medical record review: do patients know something that hospitals do not? Ann Intern Med. 2008;149:100-108. 23. Makary MA, Sexton JB, Freischlag JA, et al. Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder. J Am Coll Surg. 2006;202: 746-752. 24. Thomas EJ, Sexton JB, Helmreich RL. Discrepant attitudes about teamwork among critical care nurses and physicians. Crit Care Med. 2003;31:956-959.
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research-article2014
AJMXXX10.1177/1062860614538093American Journal of Medical QualityO’Leary et al
Article
Implementation of Unit-Based Interventions to Improve Teamwork and Patient Safety on a Medical Service
American Journal of Medical Quality 2015, Vol. 30(5) 409–416 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860614538093 ajmq.sagepub.com
Kevin J. O’Leary, MD, MS1, Amanda J. Creden, BS1, Maureen E. Slade, MS, RN, CS2, Matthew P. Landler, MD1, Nita Kulkarni, MD1, Jungwha Lee, PhD, MPH1, John A. Vozenilek, MD3, Pamela Pfeifer, RN2, Susan Eller, RN, MSN4, Diane B. Wayne, MD1, and Mark V. Williams, MD5
Abstract In a prior study involving 2 medical units, Structured Interdisciplinary Rounds (SIDRs) improved teamwork and reduced adverse events (AEs). SIDR was implemented on 5 additional units, and a pre- versus postintervention comparison was performed. SIDR combined a structured format for communication with daily interprofessional meetings. Teamwork was assessed using the Safety Attitudes Questionnaire (score range = 0-100), and AEs were identified using queries of information systems confirmed by 2 physician researchers. Paired analyses for 82 professionals completing surveys both pre and post implementation revealed improved teamwork (mean 76.8 ± 14.3 vs 80.5 ± 11.6; P = .02), which was driven mainly by nurses (76.4 ± 14.1 vs 80.8 ± 10.4; P = .009). The AE rate was similar across study periods (3.90 vs 4.07 per 100 patient days; adjusted IRR = 1.08; P = .60). SIDR improved teamwork yet did not reduce AEs. Higher baseline teamwork scores and lower AE rates than the prior study may reflect a positive cultural shift that began prior to the current study. Keywords patient safety, teamwork, interprofessional care, hospital medicine Communication and teamwork are tightly linked to patient safety.1-4 Hospital settings present important challenges to teamwork, especially on medical units. Teams are large, membership is dynamic, and individual team members care for multiple patients at the same time. On medical services, team members are seldom in the same place at the same time, resulting in suboptimal communication practices.5,6 This research group previously reported the impact of Structured Interdisciplinary Rounds (SIDRs) implemented on one hospitalist and one teaching service unit.7-9 SIDRs use a structured format for communication during regular interprofessional meetings facilitated by unit-based clinical leaders. The group found significant improvements in ratings of the teamwork climate and a reduction in the rate of adverse events (AEs) compared to control units. Although promising, this prior research is limited in that it evaluated implementation of the intervention on only 2 units, and analysis of AEs was restricted to only one of the study units. Herein, the research group reports the results of the INTERdisciplinary Approaches to Communication and Teamwork (INTERACT) study. The INTERACT study had the following goals: (a) broadly implement prepared
nurse–physician coleadership and SIDR, (b) determine the impact on ratings of teamwork climate, and (c) assess the benefit in reducing the adjusted rate of AEs.
Methods Setting and Study Design This pre- versus postintervention study compared results from patients and professionals on 5 general medical units at Northwestern Memorial Hospital (NMH), an 854-bed tertiary care teaching hospital in Chicago, Illinois. Four of the 5 units consisted of 30 beds and one 1
Northwestern University Feinberg School of Medicine, Chicago, IL Northwestern Memorial Hospital, Chicago, IL 3 University of Illinois College of Medicine at Peoria, IL 4 Stanford School of Medicine, Stanford, CA 5 University of Kentucky, Lexington, KY 2
Corresponding Author: Kevin J. O’Leary, MD, MS, Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, 211 E. Ontario St, 7th Floor, Chicago, IL 60611. Email: [email protected]
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had 23 beds. Two units were staffed by teaching service physician teams composed of 1 attending, 1 resident, 1 or 2 interns, and 0 to 3 medical students. Two units were staffed by hospitalist physicians who worked independently without the assistance of resident physicians. One unit was staffed by a combination of teaching service physician teams and hospitalists working independently without the assistance of resident physicians. As a result of a prior intervention, physicians worked on specific units in an effort to improve communication practices.10 The study was approved by the Northwestern University Institutional Review Board.
Intervention The INTERACT intervention had 2 components: prepared nurse–physician coleadership and SIDR. The research group selected unit medical directors, with nursing leadership input, to partner with established unit nurse managers to improve quality and safety for their units. These unit coleaders (ie, unit medical directors and nurse managers) received specific training for their role in collaboration with the Northwestern Memorial Academy, NMH’s training center for professional development, and the Northwestern University Simulation Technology and Immersive Learning Center. Coleadership training consisted of six 90-minute sessions over a 12-week period. Session topics included patient safety principles, coaching, change management, defining roles and responsibilities, characterizing leadership styles with the aid of Myers-Briggs Type Indicator assessments,11 and simulation-based training designed to enhance skills to facilitate interprofessional communication in SIDR. SIDR, as has been described previously, used a structured format for communication during regular interprofessional meetings.9 Unit coleaders led working groups, with representatives from each professional type, in determining the best time, format, duration, and location for SIDR. Based on working group decisions, SIDR took place each weekday in the late morning in unit conference rooms and was intended to last 30 to 40 minutes. The unit nurse manager and medical director co-facilitated discussion during SIDR each day. All physicians, nurses, and the pharmacist, social worker, and case manager for each unit attended SIDR. Physician attendance was staggered so that 1 physician entered the room at a time to discuss his or her patients; all other professionals attended SIDR for the entire duration. The structured communication tool was used in SIDR for all patients newly admitted to the unit (ie, within last 24 hours). (The tool is available in the online appendix at http://ajmq .sagepub.com/supplemental.) All other patients also were discussed, but without the assistance of a structured
communication tool. The timing of SIDR was coordinated across units as some professionals (ie, pharmacists, social workers) cared for patients on 2 units. For example, the 13 West unit held SIDR at 10:30 am and 13 East held SIDR at 11:15 am to allow their common pharmacist to attend both units’ SIDR. SIDR was implemented on March 1, 2010.
SIDR Characteristics and Attendance A researcher attended SIDR on randomly selected study units 3 times a week for one year. The researcher recorded the duration of SIDR, the number of newly admitted and total patients on the unit, the number of patients discussed each day, the number of patients for whom the structured communication tool was used during discussion, and attendance for each professional type.
Assessing Hospital Professionals’ Ratings of Teamwork and SIDR A survey was administered to physicians, nurses, social workers, case managers, and pharmacists working on study units during a 3-month period before implementation of the interventions and during a similar 3-month period one year after implementation. The first portion of the survey assessed teamwork climate using the Safety Attitudes Questionnaire (SAQ) developed by Sexton et al.12-14 The SAQ teamwork climate domain includes 14 questions using a 5-point Likert-type scale and generates a score ranging from 0 to 100. A second portion of the survey obtained demographic data, including age, sex, race/ethnicity, time at NMH, and profession. A final portion of the postimplementation survey assessed perceptions of SIDR including efficiency, collaboration among team members, and patient care using a 5-point Likerttype scale. Surveys were Internet based (www.surveymonkey.com) and delivered via e-mail. Nonresponders received up to 3 reminder e-mails.
Identification of AEs The research group randomly selected 1380 patients admitted to the study units between March 1, 2009, and February 28, 2011, for identification of AEs. The group used an adapted version of a traditional 2-stage medical record review.15-18 In the first stage, potential AEs were identified using 51 automated queries of the Northwestern Medicine Enterprise Data Warehouse (EDW). The EDW is an integrated database of all clinical data from the hospital’s electronic health record (PowerChart Millennium; Cerner Corporation, Allentown, NJ), hospital and physician billing systems, incident reporting system, and admission/discharge/transfer system. The EDW queries
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O’Leary et al were based on traditional screening criteria and the Institute for Healthcare Improvement Global Trigger Tool (ie, the Care and Medication Module Triggers).17,18 A prior study by the research group found these automated screens identified a similar number of AEs as manual medical record screening.19 Use of the automated method allowed for blinded identification of potential AEs and a larger number of patient records to be screened than would have been possible with manual medical record abstraction. For each patient with 1 or more potential AEs identified, one of 3 clinical research nurses abstracted the medical record and created a narrative summary for each potential AE. In the second stage, 2 physician-researchers (MPL and NK) independently reviewed each narrative summary in a blinded fashion to confirm whether or not an AE occurred and to determine the preventability and severity of AEs. The research group defined an AE as an injury caused by medical management rather than the natural history of the illness20 and included injuries that prolonged the hospital stay or produced disability as well as injuries that resulted in transient disability or abnormal lab values.21 Physician reviewers rated the presence and preventability of AEs using a 6-point scale similar to that used in prior studies, with a score of ≥4 indicating a positive result.2,18 Because the same AE could be detected by more than 1 screening criteria, physician reviewers indicated duplicate screens representing the same AE. The physician reviewers also classified AEs according to 4 levels of severity (life-threatening, serious, clinically significant, or trivial).22 After independent ratings, physician reviewers discussed discrepancies to achieve consensus ratings and assigned AEs to one of 10 prespecified categories. Each research nurse had prior medical record review experience and underwent 2 days of training specifically for the study, including a description of the study, definitions of terms, and practice using cases from the research group’s prior research. Both physician reviewers had extensive prior experience with the methods used and received similar although less-intensive training. The research group assessed the reliability of medical record abstractions by conducting duplicate abstractions and consensus ratings for a randomly selected sample of 294 patients. The interrater reliability was good for determining presence, preventability, and severity of AEs (κ = .63, κ = .68, and κ = .73, respectively).
Data Analysis The research group calculated descriptive statistics to report characteristics of SIDR, including mean duration, mean number of newly admitted and total patients
on units per day, overall percentage of patients discussed in SIDR, percentage of patients for whom the structured communication tool was used, and attendance by profession. The group compared patient and professional characteristics pre and post implementation using χ2 and t tests. t Tests were used to compare teamwork climate scores for all professional participants before and after implementation of the interventions, and paired t tests were used to conduct paired analyses of teamwork climate scores for professionals completing surveys both before and after implementation of the interventions. The research group classified AEs as serious if rated as serious or life threatening. The group calculated rates of AEs per 100 patient days for the pre- and postintervention periods and created multivariable Poisson regression models to compare the rates of total, preventable, and serious AEs before and after implementation of the interventions. Covariates included age, sex, race, payer, source of admission, night admission, weekend admission, case mix, Medicare Severity Diagnosis-Related Group weight, and total number of Elixhauser comorbidities. All analyses were conducted using Stata version 11.2 (StataCorp LP, College Station, TX).
Results Characteristics of SIDR Across all units, including 170 total observations of SIDR (range = 33-36 per unit), the mean duration was 36.5 ± 8.4 minutes and 97.7% of patients were discussed during SIDR (see online Appendix Table 1, available at http://ajmq.sagepub.com/supplemental). Attendance was greater than 75% for all professional types (physicians, nurses, social workers, case managers, and pharmacists). Surprisingly, adherence to the structured communication tool for new patients was only 34.4%. Teaching units spent significantly more time in discussion per patient (1.5 ± 0.2 vs 1.3 ± 0.3 minutes; P < .001), used the structured communication tool more often (52.7% vs 20.3%; P < .001), and had greater attendance by physicians, pharmacists, and unit medical directors compared to hospitalist service units.
Characteristics of Professionals and Patients There were no significant differences in professionals’ age, sex, race, or years at NMH between study periods (Table 1). One patient from the preintervention period was excluded as representing duplicate data. There were no significant differences in patient characteristics between study periods (Table 2).
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Table 1. Characteristics of Professionals. Preintervention (Total n = 165)
Postintervention (Total n = 222)
P Value
n = 96 34.3 (9.5) 93 (97) 42 (44) 6.1 (5.5) n = 20 32.7 (2.1) 12 (60) 10 (50) 3.1 (2.6) n = 35 27.3 (1.8) 16 (46) 11 (31) 1.8 (1.5) n=7 28.3 (3.0) 7 (100) 2 (29) 3.1 (2.5) n=7 39.0 (11.1) 6 (86) 3 (43) 11.7 (11.0)
n = 117 34.7 (11.2) 115 (98) 47 (41) 6.9 (8.2) n = 31 32.9 (3.1) 16 (52) 17 (55) 3.1 (2.5) n = 57 27.8 (2.0) 35 (61) 22 (37) 2.0 (1.3) n=8 28.9 (3.1) 7 (88) 3 (38) 2.8 (1.5) n=9 39.9 (9.6) 8 (89) 3 (33) 10.3 (9.9)
.80 .92 .55 .39 .72 .56 .74 .98 .24 .14 .49 .56 .72 .33 .71 .72 .87 .85 .70 .80
Nurses Mean age (SD), years Women, n (%) Nonwhite race, n (%) Mean time at the institution (SD), years Hospitalist physicians Mean age (SD), years Women, n (%) Nonwhite race, n (%) Mean time at the institution (SD), years Resident physicians Mean age (SD), years Women, n (%) Nonwhite race, n (%) Mean time at the institution (SD), years Pharmacists Mean age (SD), years Women, n (%) Nonwhite race, n (%) Mean time at the institution (SD), years Social work/case management Mean age (SD), years Women, n (%) Nonwhite race, n (%) Mean time at the institution (SD), years
Ratings of Teamwork and Perceptions of SIDR Overall, 165 of 250 (66%) eligible health care professionals completed the preintervention surveys and 222 of 283 (78%) completed the postintervention surveys. Teamwork climate scores were higher in the postintervention period, but the result was not statistically significant (mean 76.2 ± 14.2 vs 78.3 ± 14.2; P = .15) (Table 3). Paired analyses for the 82 professionals completing surveys both before and after implementation of the interventions revealed significant improvement in teamwork climate (mean 76.8 ± 14.3 vs 80.5 ± 11.6; P = .02), which was driven mainly by improved ratings by nurses (76.4 ± 14.1 vs 80.8 ± 10.4; P = .009). The majority of physicians (59/85; 69%) and nurses (89/104; 86%) and all pharmacists, social workers, and case managers agreed or strongly agreed that attending SIDR improved the efficiency of their workday (see online Appendix Table 2, available at http://ajmq.sagepub.com/supplemental). Similarly, the majority of physicians (72/85; 85%) and nurses (99/112; 88%) and all pharmacists, social workers, and case managers agreed or strongly agreed that SIDR improved team collaboration and patient care. The vast majority of physicians (69/85;
81%) and nurses (103/116; 89%) and all pharmacists, social workers, and case managers agreed or strongly agreed that SIDR should continue indefinitely.
Impact of Interventions on AEs Overall, 76 patients during the preintervention period (11.0%) and 76 patients during the postintervention period (11.0%) experienced 1 or more AEs (P = .99). Patients experienced a similar rate of total, preventable, and serious AEs during the pre- and postintervention periods (Table 4). Subgroup analyses by service type (teaching vs nonteaching hospitalist service) found no differences in the rate of AEs. Categories of AEs are shown in Table 5. Adverse drug events accounted for the largest portion of AEs, followed by falls. The rate of adverse drug events was 2.27 per 100 patient days during the preintervention period and 2.31 per 100 patient days during the postintervention period (adjusted incidence rate ratio 1.04; P = .82). The rate of AEs not categorized as drug related was 1.63 per 100 patient days during the preintervention period and 1.75 per 100 patient days during the postintervention period (adjusted incidence rate ratio 1.12; P = .61).
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O’Leary et al Table 2. Characteristics of Patients. Preintervention (n = 689)
Postintervention (n = 690)
P Value
57.1 (18.9) 343 (49.8) 319 (47.9) 379 (55.0) 191 (27.7)
55.7 (18.1) 320 (46.4) 295 (44.7) 377 (54.6) 191 (27.7)
.16 .21 .24 .89 .99
269 (39.0) 237 (34.4) 71 (10.3) 112 (16.3)
233 (33.8) 256 (37.1) 92 (13.3) 109 (15.8)
.11
619 (89.8) 65 (9.4) 5 (0.7)
620 (89.9) 67 (9.7) 3 (0.4)
.84
201 (29.2) 88 (12.8) 66 (9.6) 48 (7.0) 34 (4.9) 38 (5.5) 28 (4.1) 31 (4.5) 26 (3.8) 26 (3.8) 103 (15.0) 130 (18.9) 2.6 (1.8) 1.4 (1.8)
186 (27.0) 86 (12.5) 72 (10.4) 49 (7.1) 40 (5.8) 34 (4.9) 35 (5.1) 31 (4.5) 33 (4.8) 31 (4.5) 93 (13.5) 129 (18.7) 2.6 (1.9) 1.3 (1.5)
.94 .94 .77 .26
Mean age (SD) Women, n (%) Nonwhite race, n (%) Night admission, n (%) Weekend admission, n (%) Payer, n (%) Medicare Private Medicaid Self-pay/other Admission source, n (%) Emergency department External transfer Direct admission Case mix, n (%) Diseases of the circulatory system Diseases of the digestive system Diseases of the respiratory system Injury and poisoning Symptoms, signs, and ill-defined conditions Endocrine and nutritional disorders Diseases of the genitourinary system Diseases of the skin and subcutaneous tissue Mental illness Infectious and parasitic diseases Other Intensive care unit stay during admission, n (%) Mean number of Elixhauser comorbidities (SD) Mean MS-DRG weight (SD) Abbreviation: MS-DRG, Medicare Severity Diagnosis Related Group.
Discussion The research group successfully implemented complementary unit-based interventions, prepared nurse–physician coleadership and SIDR, across 5 general medical units, resulting in improved ratings of teamwork yet no change in the rate of AEs. Similar to the group’s prior studies evaluating the impact of SIDR, improved teamwork ratings were explained mainly by changes among nurses. This finding is consistent with prior research showing that nurses are often dissatisfied with the quality of teamwork with physicians, while physicians are relatively unaware of deficiencies.5,23,24 The findings of the current study differ from the research group’s prior studies evaluating SIDR in several important ways. Although paired analyses revealed significant improvement in teamwork climate, unpaired analyses showed no difference between the pre- and postimplementation periods. This finding relates to high
preintervention teamwork climate scores and likely is explained by changes that began prior to the current study. Compared to their prior research, the research group found improved teamwork climate on units before these interventions were made. Specifically, the teamwork climate score among 49 nurses on the control units in the preliminary studies evaluating SIDR was a mean 69.9 ± 17.9 in January 2009 compared to the baseline mean teamwork climate score of 76.4 ± 14.1 among nurses in the current study (December 2009 to February 2010). Notably, both hospitalists and residents were exposed to SIDR through rotations on the original study units, and this may have altered their attitudes and communication skills with staff on other units. Furthermore, in the months preceding the start of the current study, the research group noticed units beginning to learn from those involved in the preliminary research and modifying the format and frequency of the traditional “discharge rounds,” which had been in place for many years. Changes
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Table 3. Professionals’ Ratings of Teamwork. Unpaired Analyses All professionals Mean Teamwork Climate Score (SD) Nurses Mean Teamwork Climate Score (SD) Hospitalists Mean Teamwork Climate Score (SD) Residents Mean Teamwork Climate Score (SD) Pharmacists Mean Teamwork Climate Score (SD) Social work/case management Mean Teamwork Climate Score (SD) Paired Analyses
Preintervention
Postintervention
P value
n = 165 76.2 (14.2) n = 96 74.9 (14.5) n = 20 82.0 (12.9) n = 35 78.5 (13.8) n=7 71.8 (11.0) n=7 69.5 (13.9)
n = 222 78.3 (14.2) n = 117 77.2 (74.6) n = 31 78.6 (17.1) n = 57 82.2 (13.1) n=8 74.1 (8.8) n=9 71.0 (12.5)
.15 .25 .45 .20 .66 .84
Postintervention
P value
n = 82 80.5 (11.6) n = 57 80.8 (10.4) n=8 80.1 (18.4) n=7 88.7 (7.2) n=4 76.2 (7.2) n=6 71.7 (13.2)
.02 .009 .60 .32 .68 .47
Preintervention
All professionals Mean Teamwork Climate Score (SD) Nurses Mean Teamwork Climate Score (SD) Hospitalists Mean Teamwork Climate Score (SD) Residents Mean Teamwork Climate Score (SD) Pharmacists Mean Teamwork Climate Score (SD) Social work/case management Mean Teamwork Climate Score (SD)
n = 82 76.8 (14.3) n = 57 76.4 (14.1) n=8 84.2 (13.3) n=7 82.0 (16.5) n=4 73.7 (12.4) n=6 67.4 (13.9)
Table 4. Impact of Interventions on Adverse Events. Unadjusted Adjusted Incidence Unadjusted Adjusted Incidence Rate Rate Ratio Preintervention Postintervention Ratio (95% CI) P Value P Value (95% CI)a Adverse events (AEs) on all units, no. (AEs per 100 days) Any Preventable Serious Adverse events (AEs) on teaching units, no. (AEs per 100 days)b Any Preventable Serious Adverse events (AEs) on hospitalist units, no. (AEs per 100 days)b Any Preventable Serious
(n = 689)
(n = 690)
98 (3.90) 38 (1.51) 14 (0.56) (n = 272)
102 (4.07) 38 (1.52) 11 (0.44) (n = 277)
1.04 (0.79-1.38) 1.00 (0.64-1.57) 0.79 (0.36-1.73)
1.08 (0.82-1.43) 1.02 (0.65-1.60) 0.86 (0.39-1.92)
.77 .99 .55
.60 .94 .72
43 (3.54) 16 (1.32) 10 (0.82) (n = 245)
46 (3.87) 22 (1.85) 2 (0.17) (n = 245)
1.09 (0.72-1.65) 1.40 (0.74-2.67) 0.20 (0.04-0.93)
1.19 (0.78-1.82) 1.50 (0.78-2.91) 0.27 (0.06-1.28)
.68 .30 .04
.23 .23 .10
30 (3.70) 14 (1.73) 3 (0.37)
25 (3.00) 9 (1.08) 3 (0.36)
0.81 (0.48-1.38) 0.62 (0.27-1.45) 0.97 (0.20-4.82)
0.82 (0.48-1.41) 0.62 (0.26-1.45) 0.97 (0.19-4.90)
.44 .27 .97
.48 .27 .97
Abbreviation: CI, confidence interval. a Poisson regression-adjusted age, sex, race, payer, source of admission, night admission, weekend admission, Medicare Severity Diagnosis Related Group weight, and total number of Elixhauser comorbidities with days on study unit as exposure variable. b Total number of patients for teaching and hospitalist units does not equal overall total because one study unit included patients on both the teaching and hospitalist services.
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O’Leary et al Table 5. Impact of Interventions on Adverse Events by Category.a Categories of Adverse Events (AE), No. (AEs per 100 days) Adverse drug event Non–adverse drug eventb Fall Operative/procedural injury Manifestation of poor glycemic control Hospital-acquired infection Acute renal failure Pressure ulcer Venous thromboembolism Delirium Other
Preintervention Postintervention (n = 689) (n = 690) 57 (2.27) 41 (1.63) 10 (0.40) 6 (0.24)
58 (2.31) 44 (1.75) 8 (0.32) 8 (0.32)
5 (0.20)
8 (0.32)
6 (0.24)
5 (0.20)
7 (0.28) 1 (0.04) 1 (0.04)
2 (0.08) 8 (0.32) 1 (0.04)
1 (0.04) 4 (0.16)
0 (0.00) 4 (0.16)
a
Unadjusted and adjusted incidence rate ratios for adverse drug events in comparison to the preintervention period were 1.02, P = .92, and 1.04, P = .82, respectively. b Unadjusted and adjusted incidence rate ratios for adverse events that were not drug related were 1.07, P = .74, and 1.12, P = .61, respectively.
included inviting staff nurses to rounds and devoting attention to the daily plan of care (rather than focusing solely on discharge plans). Despite efforts to contain the spread of interventions prior to the current study, the research group was unable to completely prevent it. The study findings suggest that positive culture change in one part of an organization may spread to other parts prior to explicit actions to foster spread. Implementation of SIDR was successful in that the vast majority of team members were present and the overwhelming majority of patients were discussed during SIDR. Adherence to use of the structured communication tool for new patients was suboptimal. One explanation may be a perception that use of the structured communication tool would lengthen the duration of SIDR. Another explanation may be that professionals felt use of the communication tool was unnecessary, possibly after using it initially and then developing a sense of security about knowing the list of items. No improvement was found in the rate of AEs during the postintervention period. Similar to the findings of high preintervention teamwork climate scores, the research group found lower baseline AE rates in the current study compared to their prior research. The prior study evaluating the impact of SIDR on AEs for a single teaching unit found a rate of 7.2 to 7.7 AEs per 100 patient days for control patients. The much lower rate of 3.9 AEs
per 100 patient days during the preintervention period may be explained by the favorable changes in teamwork culture and corresponding behaviors that the research group believes began prior to the start of the current study. Of note, the current study used automated, computer-based rules to identify potential AEs. Prior research in the same setting found this method to identify a similar to slightly higher number of AEs compared to traditional manual medical record review. Therefore, the research group feels it is unlikely that the failure to detect a difference in the current study is related to the automated detection method. This study has several limitations. First, the study reflects the experience of a medical service in a single academic medical center. Larger studies are needed to assess the impact of similar interventions on teamwork climate and patient safety. Though other hospitals are likely to struggle similarly with interdisciplinary teamwork, baseline surveys may help identify hospitals that are ideal candidates for interventions. Second, teamwork climate was assessed using a validated survey rather than direct observation of teamwork behaviors in the clinical setting. As mentioned earlier, one of the barriers to teamwork is the dispersion of team members, making direct observation and assessment of teamwork-related behaviors very difficult. Third, narrative summaries of potential AEs were based on information available from the medical record, which may have lacked some detail to allow assessment of the presence, preventability, and severity of AEs.
Conclusion Prepared nurse–physician coleadership and SIDR resulted in improved ratings of teamwork yet no change in the rate of AEs. Earlier implementation of the same interventions on other units within the study site likely initiated a positive cultural and behavioral shift. Future studies should assess the benefit of similar interventions on other types of units (eg, antepartum, neurology, surgical). Additionally, future research efforts should conduct baseline assessments of teamwork climate to identify ideal study sites and explore factors associated with the successful spread of interventions within organizations. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article:
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American Journal of Medical Quality 30(5)
This study was funded by the Agency for Healthcare Research and Quality, Grant No. R18 HS019630.
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