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Cultivating Collaboration

6. Train Together So Every Team's the "A" Team

Training the team

Coordinated efforts: Dr. Erin Clark, Labor and Delivery Nurse Janet Fisher, Dr. Zuzana Stehlikova, Certified Nurse Midwife Susanna Cohen, Nurse Educator Kim Meyer, and mock “patient” Kristina McAfee train as a team to ensure an efficient, synchronized emergency response.

Breaking down traditional hierarchies to build better emergency communication

A Patient's Story

Laurie Nail and Baby

Laurie Nail’s Early Delivery
It was supposed to be a routine prenatal visit. But when Laurie Nail’s OB examined her, he knew something wasn’t right. He told her to go immediately to our hospital to see perinatologist Dr. Jan Byrne. Realizing she might be admitted, Laurie quickly stopped at home to grab her bag and meet her husband. But before she could even leave her house, her water broke and she started bleeding.

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“We had the ‘A’ Team today,” said the attending physician, after her OB emergency staff expertly resolved a frightening postpartum hemorrhage. And while the procedure had gone particularly well, it left us wondering: Shouldn’t any aggregate team be able to come together and perform with skilled precision? Why did some emergencies go so well, while others weren’t quite as seamless?

“Response to an emergency shouldn’t rely on the ‘A team’,” says Janet Fisher, labor and delivery nurse. “Everyone on our staff should be able to work at that level of care.” This philosophy was the driving factor behind our OB team training project, which brought together physicians, midwives, residents, anesthesiologists, nurses and medical assistants—along with blood bank coordinators, hospital operators and even graphic designers—to create a new emergency response system that was thorough, targeted and highly coordinated.

Train as a team

Instead of zeroing in on individual heroes, our team training focuses on how all responders function as a group. From the most senior attending physicians to the newest MAs, interdisciplinary teams train together in simulated environments, practicing group communication skills that can make the difference between life and death. Bringing everyone together is a coordination challenge of epic proportions, but according to Janet, it’s worth it.

“It’s about the community coming together, and all of us working as a team.” —Bernice Tenort, Nurse Manager, Labor and Delivery

“Collaboration isn’t just prep and response. It’s training. It’s each person understanding their specific role and how they fit into our rapid response system,” says Bernice Tenort, nurse manager of the Labor and Delivery Unit. This translates to a single person communicating orders, so that no one gets conflicting directives and the noise level in the room stays low. “It’s hard to be quiet in emergency, but it’s critical for everyone to hear what’s being said.”

Think out loud

In our simulated training sessions, we learned that the MA is the responder who’s most likely to get bombarded with orders. In a typical emergency, they may be asked to do multiple things at once. We train them to assertively ask what the priority is. Otherwise, they’re trying to do it all, and that can bring the whole process to a halt.

To facilitate a more organized system, our training focuses on closed-loop communication, the same process that NASA and the aviation industry use. The practice involves repeating back instructions when one team member makes a request of another—so that all instructions are clear and consistently communicated, and there’s less of a margin for error. “It all comes down to communication,” says Kim Meyer, nurse educator for Labor and Delivery. “It’s about breaking down the traditional hospital hierarchy so anyone can say something in an emergency that others may have missed.”

Collaborate beyond the clinical team

Coordinating an emergency response doesn’t just involve synchronizing the responders. We also reached far beyond our OB training team to get help from the larger academic community. For starters, we worked with hospital operators to improve our system for declaring an emergency.

In the past, OB emergencies could see the whole staff rushing to a room at once—or worse, not enough staff showing up. To solve this, we created an OB Rapid Response system that included defining criteria for calling an emergency, creating a standardized code for OB emergencies and sending out high-level pages to appropriate team members. “It’s all about getting the right people in the right room at the right time,” says Bernice. We also recognized that training doesn’t stop after we’ve completed our simulation exercises. To stay on track for the long term, we worked with the University’s Communications Department and tapped students in an advanced graphic design class to develop signs and posters that reiterate our OB rapid response procedures, from our paging procedures to our closed-loop communication practices. “We’re used to communicating with health services academics,” says Bernice. “But this was a real step across academic boundaries.”

Create a safe learning environment

At the end of the day, our training sessions aren’t just about practicing. They’re about improving. That’s why we create videos of each session and play them back, giving team members the opportunity to talk honestly and critically about the team’s performance—and how to make it better. “The videos are unforgiving,” says Kim. “They can be hard to watch. But we emphasize that everyone is vulnerable, and that our learning environment is a safe, confidential place.”

With time staff have learned to give powerful constructive criticism—the kind of feedback that moves teams forward. “It’s a huge culture change,” says Janet. “It’s very hard to break traditional barriers about who is ‘right’ in any hospital setting. But there have been incredible breakthrough moments where people have said things that are really reflective, and vital.”

While speaking up isn’t always easy, it’s the right thing to do for our hospital and, most importantly, our patients. And every day, with every simulation, we’re learning to do it better.

How realistic is the training? Tell us your experiences .