What Was Done?
Identification of Problem
Weak teamwork in the perioperative environment is associated with adverse events, patient harm, team member stress, and weakened interpersonal connection. Serious events in which malpractice is alleged result in financial payouts for compensation to the harmed patients. Practicing together to manage challenging situations and especially debriefing about individual and team performance leads to understanding of each other’s roles and improved performance. Interprofessional training via simulation has been shown to be effective in improving communication and coordination between individuals in different role groups and likely can reduce harm.
Specific Aims to Solve It
The primary aims of this system-wide, perioperative, interprofessional, simulation-based teamwork training program are to reduce adverse events and to lower patient harm and financial costs for compensation by enhancing teams’ relational coordination skills, which include articulating shared goals, developing shared knowledge of each other’s tasks and mutual respect.
How Simulation Was Part of the Solution
The captive insurance provider of the hospitals associated with Harvard Medical School (CRICO) has since 2001 offered lower malpractice insurance premiums for perioperative physicians who participate in simulation-based training, beginning with uni- professional Crisis Resource Management training for anesthesiologists and evolving to interprofessional training of teams, starting with operating obstetricians in 2004 and extending to all surgeons in high-risk specialties in 2015. The program has specific requirements for the aims of the simulation program, which are implemented in somewhat different ways by the several programs that provide simulation sessions that qualify. In addition to the full interprofessional-team simulation of 4-6 hours required every 3 years, a one-hour “booster” is required in the intervening two years, one uni-disciplinary and the other interdisciplinary. Each hospital creates its own booster session, requiring approval of CRICO. Some of those boosters have forms of simulation, e.g., tabletop simulation, but others are various exercises intended to reinforce the aims of the full-simulation training sessions. During the acute years of COVID- 19, a virtual program was created with the same aims and training concepts.
The full simulation sessions focus on enhancing awareness that the “culture” or “climate” of teams and dyads has an impact on clinical outcomes. The curriculum includes teaching how to move from a norm of implicit team coordination to demonstrating the value of articulating goals and dilemmas that the team faces, and how to “reset” a team that is off track. Underlying the team training program is promoting the value of assuming the best of each other and being curious about other people’s perspectives. Shifting reactions of righteous indignation to curiosity can be transformative for reducing complications and enhancing clinician well-being.
What Was the Outcome?
There are several outcomes intended from this program-- most notably improved patient care leading to reductions in preventable adverse events and the decreasing number of and amounts of payouts for malpractice claims. The program also aims to enhance feelings of belonging and respect among team members, which will not only impact clinical outcomes but also address the increasingly important issue of burnout reduction and retention of skilled practitioners.
This program began in 2001 and has evolved to its current instantiation that involves all anesthesiologists, OB/gyn surgeons and other surgeons in high-risk specialties working in one or more of 30 hospitals affiliated with HMS and offering operative services. The current version requires participation every 3 years in, at minimum, a half-day team training session in high-realism simulation plus a one-hour “booster”, in the intervening years, consisting of activities that reinforce the realistic simulation experience. Approximately 75% of all physicians insured by CRICO participate and their hospital departments receive substantially lower premiums for each participant. The average premium reduction is approximately 15%. Anesthesiologists receive a 63% reduction. The actuarial-based reductions are themselves a measure of success. A study of the association between simulation-based training and malpractice related insurance claims and payouts among obstetricians participating in the program found an approximately 50% reduction in the rate of claims per 100 covered-physician years with no change in the average payout per claim thus yielding a substantial financial savings. Also, participation in 2 or 3 training sessions was associated with a 3- or 6-fold decrease in rate of claims, respectively.
CRICO is planning adjustments to the program to reduce the interval between inter-professional training to two years.
How Was Hospital Leadership Engaged and/or Notified?
The leadership of each hospital, including leadership of the Departments of Surgery, Anesthesia and Nursing, was involved specifically in approving the program because it involved commitment of time of participating clinicians as well as use of resources. The insurance company, which is highly patient safety focused, was intimately involved in developing the specifics of the requirements and offering the financial incentives, which included involvement of their actuaries to adjust malpractice premium differences based on projected performance differences due to participation in the program.
