Case Study: How Team Training Helped Support Rural Obstetrics

By starting at its biggest facilities and actively sharing lessons with smaller locations, one hospital group improved the quality of care throughout the organization.

Obstetrics often is a somewhat-independent service within the scope of a hospital — until a serious adverse event occurs. Although rare, a severe obstetric event can have a devastating effect on an entire community, especially in rural areas where residents know each other.

Births are not evenly distributed across hospitals in the United States. The top 500 of the 3,200 hospitals in the United States that offer obstetric care account for almost half of all deliveries.1 About 40 percent of hospital births occur at hospitals that have less than 500 deliveries a year.2,3 Research has shown that obstetric complications significantly are more likely to occur at hospitals with low annual delivery volumes.2,4 Hospitals and care providers with lower delivery volumes have fewer opportunities to gain the experience needed to treat a wide range of obstetric complications.

An initial response to these data would be to close obstetric services in low-volume hospitals. However, doing so potentially increases the distance women in rural areas would need to travel to access obstetric services. The American College of Obstetricians and Gynecologists has estimated that almost 80 percent of women who live in the country’s most rural counties do not have a local hospital with obstetric services.5 Thus, closure alone is not the answer to improving the safety and quality of obstetric care in rural areas.

Recognizing the associated risks of care at lower-volume hospitals, the OB-GYN organization has called for better matching of patient risk level with hospitals, based on staffing, expertise and ancillary support.2 ACOG also recommends hospitals develop collaborative plans of care for transfer of women with complications and that higher-level hospitals provide lower-level hospitals with training related to quality-improvement initiatives, education, and severe maternal morbidity and mortality review.2

Effective teamwork is important for improving obstetric care in all settings, given the shift toward value-based reimbursement and the associated need for improved care coordination. However, it is especially important for rural hospitals, where good stewardship of available medical dollars is critical. Effective teamwork can help conserve these dollars. For example, the ability to better manage emergencies onsite can help reduce the number of transfers to tertiary obstetric centers, thus retaining associated revenue for the rural hospital. Improving the capacity of teams to handle obstetric complications can reduce adverse outcomes and the associated stress on obstetricians, potentially increasing physician retention, which can be more challenging in rural locations.

Obstetric team training has been shown to be effective in improving patient safety, reducing the number of adverse obstetric events and the number of malpractice claims.6,7 In fact, the first recommendation listed in the Joint Commission’s Sentinel Event Alert on preventing infant death and injury during delivery relates to team training: “Conduct team training in perinatal areas to teach staff to work together and communicate more effectively.”8

Several team training models exist, most of them based on crew resource management, which was initially created by military aviation for improving teamwork and communication. These models include the U.S. Department of Veterans Affairs’ Medical Team Training and the U.S. Agency for Healthcare Research and Quality’s Team Strategies and Tools to Enhance Performance and Patient Safety, or TeamSTEPPS. The models share an emphasis on improving communication, increasing situational awareness, and improving teamwork during complications and emergency situations by practicing responses in simulation exercises.

A Closer Look

Situation: Avera Health is a faith-based health system with 300 facilities throughout South Dakota, North Dakota, Minnesota, Iowa and Nebraska. It includes 17 hospitals with obstetric services, with about 5,400 deliveries each year. Of these, the flagship hospital provides about 2,200 annual deliveries, five hospitals provide 400 to 550 a year, three hospitals provide 125 to 150 a year, and eight rural hospitals provide fewer than 100 deliveries annually. Overall, about 60 percent of Avera’s hospitals provide less than 1,000 annual deliveries.

In 2009, staff at the flagship hospital, Avera McKennan Hospital and University Health Center, in Sioux Falls, South Dakota, completed an obstetric team training initiative. Leaders of the health system deemed the project successful, logging improved patient-care outcomes, such as a lower postpartum hemorrhage rate and a reduced time to start an emergency C-section, as well as improved physician and nurse job satisfaction. Health system leaders wanted to improve the consistency of care quality across their facilities, which included the more-rural hospitals.

They set a strategic goal of spreading the training quickly, to affect the care of as many patients as possible. In addition, leaders hoped the training would help improve the work-life balance and practice experience of physicians in rural locations. As a result, they looked to take team training to the next-lower volume level: the five hospitals providing 400 to 550 deliveries a year.

Actions: To spread the training to its lower-volume hospitals, Avera leaders worked with the same training consultant, Susan Mann, MD, of the QualBridge Institute, who implemented it at the flagship hospital. The first step, Mann says, was to get buy-in for the initiative. Lori Popkes, Avera McKennan’s chief nursing officer, presented executive leaders with information to win approval for the needed resources and presented department chairs and nursing managers with information to gain engagement of frontline clinicians. The leaders’ key points of interest were improving patient safety, improving teamwork and communication, increasing the capability to handle obstetric emergencies on site, and developing a more consistent process for transfer to tertiary centers.

The planning process involved completion of pre-implementation surveys to gather information about the clinical settings of each site, such as the availability of in-house anesthesia staff and blood bank services.

The first phase of the project included site visits to the hospitals selected for training. A team of physician and nurse consultants spent a half-day at each site, gathering more information on the existing setup, assessing the geographic location and organizational culture, and asking clinical staff about their concerns. These visits helped to identify the specific areas of risk for each site. Using the responses, Mann developed specific training plans for the five hospitals.

The second phase included face-to-face training at the flagship hospital, attended by representatives from each site. At the 1½-day event, participants engaged in sessions on such topics as how to review agreements and plans for transfer, implementing team training at their home institution, and running debriefing sessions after simulation. They also learned five specific teamwork strategies: physician-nurse huddles, interdisciplinary team meetings every morning and evening, pre-procedure briefings, post-event debriefings and checklists for maternal transports. And they rotated through five simulation stations — emergency maternal transport, postpartum hemorrhage, shoulder dystocia, vacuum delivery and neonatal resuscitation — to increase their experience with obstetric emergencies. During simulations, participants practiced the new communication and teamwork techniques, focusing special attention on maternal transports.

During the third phase, learners returned to their home sites to train their colleagues. Kimberlee McKay, MD, the health system’s director of obstetric services, helped facilitate the local team training. Each hospital tailored implementation; for example, one chose to implement all five team strategies simultaneously, while another initially implemented only one.

In addition, sites received virtual support during this phase, through regular teleconferences with faculty from the training consultancy. Teleconferences were held weekly for four weeks, then every other week for two months. Faculty members also were available for email and telephone support.

The organization did face some barriers to implementation, Popkes says — resistance to change, concerns about the time required for training, lack of awareness of existing gaps (such as insufficient situational awareness), and lack of appreciation of the value of team training.

Popkes and McKay found that the most effective method for overcoming these obstacles was communication and the use of adult learning techniques to engage learners. Beginning a year before the planned initiation, they began planting the seed with data, simple stories and messaging. They found that the most effective messages included:

• “Team training is about elevating the level of quality and safety for every patient on the floor.”

• “You’re telling me that you want to get in an airplane where the crew, the pilot and the co-pilot didn’t go through their checklist?”

• “When we are busy is when teamwork is most important.”

• “It will save time to know what you need to know _before_an emergency.”

They found that with time and repeated messaging, clinicians from all five sites eventually engaged in the training and in using the new teamwork skills.

Results: Staff feedback was “tremendously positive,” Popkes says. Staff regarded the training as time well-spent. In fact, the sole complaint voiced was a desire for longer training sessions.

Given the low frequency of serious events in obstetrics, it is too early to observe any changes in patient-outcome data. However, the health system already has seen several improvements in care processes. For example, St. Mary’s Hospital, which has about 500 annual deliveries, has experienced better coordination and communication between clinical teams.

The critical access hospital in Pierre, South Dakota, is at least a three-hour drive from other facilities. There is one anesthesiologist to cover obstetrics and surgery, and women with obstetric emergencies must be transported downstairs to the surgical suite. If all the operating rooms are in use, the obstetric case must wait. Initially, staff believed the answer to the problem was building a dedicated OR in the labor-and-delivery unit. However, as McKay explained to the staff, an extra room would be useless without the availability of the surgical team.

Since team training, the labor-and-delivery staff has used the morning huddle to plan for scheduled cases and to share information about the status of patients in labor. Anticipating upcoming needs has allowed the staff to better coordinate care with the surgical team. Better communication between the obstetric and surgical staff has resulted in the rapid availability of the surgical team for emergency surgery 100 percent of the time. The coordinated response to obstetric emergencies, sometimes requiring a delay in the start time of a surgical case, has translated into improved care, such as the avoidance of hysterectomies in cases of postpartum hemorrhage. Emergency caesarean sections also have gone more smoothly since the training.

Mann thinks the training might also help with physician retention in rural locations. “Often young physicians, especially those just finished with training, may feel a lack of confidence in dealing with emergencies,” she says. “Working with staff who are well-trained to deal with emergencies as a team may reduce the stress these physicians experience as one of the few obstetricians in the area.”

With team training successfully spread to a total of six hospitals within the system, Avera leaders can proceed with taking training to the next batch of hospitals: the 11 that see fewer than 150 deliveries a year. Because of the organization’s commitment to high-quality care at all locations, leaders see this next step as an important investment in safety and quality.

Lessons Learned

Team training is a multidisciplinary endeavor, but its implementation requires leadership from physicians and nurses at the executive level. For a successful training program, those leaders must communicate the need for improved teamwork and the benefits of team training to midlevel leaders. The midlevel leaders need to communicate these benefits to the front lines of care to ensure active engagement of clinicians in the training program.

Avera’s initiative illustrated the power and benefits of teamwork between larger, more urban hospitals with smaller, more rural facilities. It fostered collaboration on two levels: First, a training expert from Boston worked with the health system’s rural experts to customize the training to fit local circumstances. Second, the larger sites within the health system helped train staff at the smaller, rural hospitals. As Popkes describes the collaboration, “It’s an incredible win-win for everyone.”

Rural hospitals serve a critical function in their communities. However, smaller hospitals often have low annual delivery volumes, which have been tied to a higher obstetric complication rate. Team training is an effective way to improve the safety and quality of obstetric care, especially in rural hospitals. Health care systems should consider including hospitals at more rural locations or with lower delivery volumes in team training initiatives to help improve communication, reduce burnout and replacement of physicians, and expedite safe transfer of care of critically ill patients.

At Avera, leaders have prioritized implementing team training across all facilities in the system — from the flagship to the small rural hospitals — to ensure the consistency of safety and quality throughout the enterprise. Physician leaders play an essential role in communicating the importance of teamwork to organizational leaders and in engaging frontline clinicians in training opportunities.

Diane W. Shannon, MD, MPH, is a freelance writer specializing in health care improvement topics, based in Boston, Massachusetts.

REFERENCES

1. Simpson KR. An overview of distribution of births in United States hospitals in 2008 with implications for small volume perinatal units in rural hospitals. _J Obstet Gynecol Neonatal Nurs._2011;40(4):432-9.

2. American College of Obstetricians and Gynecologists. Obstetric Care Consensus No. 2: Levels of maternal care. _Obstet Gynecol._2015;125(2):502-15.

3. American Hospital Association. AHA guide to the health care field. 2015 ed. Chicago (IL): AHA; 2014.

4. Kyser KL, Lu X, Santillan DA, Santillan MK, Hunter SK, Cahill AG, et al. The association between hospital obstetrical volume and maternal postpartum complications. _Am J Obstet Gynecol._2012;207:42.e1–42.17.

5. American College of Obstetricians and Gynecologists. Health disparities for rural women. Committee Opinion No. 429. Washington, DC: American College of Obstetricians and Gynecologists. 2009.

6. Pratt SD, Mann S, Salisbury M, Greenberg P, Marcus R, Stabile B, et al. John M. Eisenberg Patient Safety and Quality Awards. Impact of CRM-based training on obstetric outcomes and clinicians' patient safety attitudes. _Jt Comm J Qual Patient Saf._2007;33(12):720-5.

7. Pettker CM, Thung SF, Norwitz ER, Buhimschi CS, Raab CA, Copel JA, et al. Kuczynski E. Impact of a comprehensive patient safety strategy on obstetric adverse events. _Am J Obstet Gynecol._2009;200(5):492.e1-8.

8. Joint Commission. Sentinel event alert issue 30--July 21, 2004. Preventing infant death and injury during delivery. _Adv Neonatal Care._2004;4(4):180-1.