Reducing medical error in the Military Health System: How can team training help?

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Abstract

Medical error causes more than 98,000 deaths annually [Kohn, L. T., Corrigan, J. M., and Donaldson, M. S. (1999). To err is human: Building a safer health system. Washington, DC: National Academies Press.] making it a national epidemic during the late 1990s. In reaction, Congress passed the National Defense Authorization Act mandating the Department of Defense (DoD) to establish processes for patient safety in the military health care and veteran affairs. Among the many processes for patient safety identified by the DoD, team training stepped to the forefront in 2001 when the TRICARE Management Activity (TMA) commissioned the development of two programs based upon Crew Resource Management training from the aviation industry. A recent evaluation of these programs identified several limitations including the establishment of two distinct approaches to teamwork and an inability to leverage the larger body of team training available. TeamSTEPPS, or the Team Strategies and Tools to Enhance Performance and Patient Safety, was developed to address the cultural issues facing the military health system and to take advantage of the state-of-the-art evidence-base on team training. Despite success, several challenges remain representing opportunities for human resources professionals and organizational researchers to help improve this program and further research on the impact of team training on patient safety.

Introduction

Preventable medical error is the cause of 98,000 deaths annually (Kohn, Corrigan, & Donaldson, 1999). Seventy percent of all medical errors are attributed to breakdowns in the interactions among health care providers and health care teams (Studdert, Brennan, & Thomas, 2002). These breakdowns often are a result of poor coordination and communication among health care workers, outdated organizational policies that hinder as opposed to reinforce and value safe care, and long standing cultural norms that reinforce protecting oneself as opposed to protecting the wellbeing of patients. In order to address these breakdowns, there must be change not only in the communication practices among health care workers but also in the organizational culture in which health care services are delivered.

The Institute of Medicine report, To Err is Human, put forth a detailed set of recommendations to improve the practice of health care and reduce errors (Kohn et al., 1999). Recommendations addressed such issues as the need for electronic medical records, the need to emphasize patient safety and error mitigation in the professional training of health care workers, and the need to improve team performance in health care organizations through training and measurement, which is the focus of the current discussion. Combining these strategies (and others presented in the Institute of Medicine report) was viewed as reinforcing a culture of safety and moving health care toward becoming a high reliability institution.

Since To Err is Human, the continued emphasis on safety and the strategies to improve it have not lost any momentum. Numerous reports, professional meetings, and publications have continued to champion the need to improve safety and many have identified team training as a significant strategy in achieving that goal (Barach and Small, 2000, Barach and Weingart, 2004, Hamman, 2003, Leonard et al., 2004, Leonard and Tarrant, 2001). For example, the October 2004 issue of Quality and Safety in Health Care was dedicated to improving team performance through the use of simulation and training. Moreover, Baker and his colleagues recently published an article that outlined how team competencies, training, and the assessment of these skills might be incorporated into the professional education of physicians (Baker et al., 2005). Collectively this work (as well as other research) aligns with recent studies by the Association of American Medical Colleges and Accreditation Council for Graduate Medical Education that identify the importance of communication and coordination in the delivery of care (Adams, Goodwind, Searcy, Norris, & Oppler, 2001).

Similar to civilian health care, the DoD has taken an active role in improving team performance of health care workers assigned to different military treatment facilities (MTFs). One of the major foci of the DoD patient safety agenda has been the development, implementation, and integration of team training throughout the military health system (MHS). Team training (and its adaptations like crew resource management training) has had a long history of success in military operations. Beginning with the work of Briggs and Naylor (1965) up through the more recent efforts of Cannon-Bowers and colleagues under the Tactical Decision Making Under Stress program (Cannon-Bowers & Salas, 1998), much has been learned about team performance and how to train teams to be effective. One of the major goals of the DoD patient safety program is to transition these lessons learned regarding teamwork, and more specifically team training, to health care.

The purpose of this review then is to describe a large-scale DoD initiative to reduce medical error by introducing a team training program that was developed based on the extensive evidence regarding the efficacy of this approach. To do this, we initially present some background information on patient safety and how the DoD became a key organization leading the charge to promote safer health care. Specifically, we focus on team training and how this particular strategy became a central tenant in DoD efforts. Next, we present an overview of the military health system and the specific challenges confronted by the DoD in delivering team training.

Once we have completed a review of the background information, we then turn to a description of the team training initiative that is presently being deployed DoD-wide. Here, we first demonstrate how teamwork plays a major role in the delivery of care and which teamwork skills are likely to be most relevant and therefore require training. Once we establish these teamwork skills, we then describe the DoD's initial efforts to teach these teamwork skills to professional staff within the MHS. Here, we present the results of a comprehensive case study analysis of two existing training programs, which were the precursors to the present-day course. Upon completion of this review, we then describe the new program, TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety). In this section we provide a brief description of the course, overview its strengths and weaknesses, and provide a summary of how and where the course has been deployed in the MHS to date. We also provide a description of next steps, since this was the initial version of the course, and the DoD envisions continually updating and refining these materials.

Finally, we present a series of lessons learned from launching this large-scale human resource intervention. Most of the lessons learned were derived from our experience developing and deploying TeamSTEPPS, but some are based on our earlier experiences with launching a similar team training program for aircrews within the US Navy and experiences we have gained in working closely with the airlines in their efforts to integrate teamwork principles into technical skills training for commercial airline pilots. When appropriate, we also raise specific questions that should be addressed by future research.

Section snippets

Background

Although the patient safety movement can be traced back prior to the publication of To Err is Human, this report did what no other publication had done before, it generated a demand for action that was heeded by the Federal government, the media, the health care profession, and the research community (Baker, Gustafson, Beaubien, Salas, & Barach, 2003). In the service of this mandate, the Federal government established agencies and task forces whose directive is to improve patient safety

Teamwork and training in health care

Throughout the health care community small groups of individuals work together in intensive care units, operating rooms, labor and delivery wards, and family-medicine practices. To make safe and efficient patient care a priority, physicians, nurses, pharmacists, technicians, and other health professionals must coordinate their activities. However, even though a myriad of conditions addressed by health care professionals require interdisciplinary teams, members of these teams are rarely trained

TeamSTEPPS

TeamSTEPPS focuses on the core principles of teamwork identified by researchers like Mumford, Zaccaro, Harding, Jacobs, and Fleishman (2000) and Kraiger, Ford, and Salas (1993) by teaching specific tools and strategies that can be used to improve teamwork performance in the military medical environment. The evidence-base for this course was expanded to include the larger body of team research and extra attention was given to developing opportunities for practice using tools and strategies

Next steps

Despite the fact the TeamSTEPPS program has been designed to address patient safety goals set by the TMA for all DoD MTFs, it is clear that challenges remain for the TeamSTEPPS program to be effective. Among these challenges exists a series of research problems for the future that can be used by organizational researchers and human resources professionals to conduct research on the effectiveness of team training in the MHS.

Summary

In this paper, we have provided an overview of a large-scale DoD human resources initiative to improve patient safety and reduce medical error in more than 460 facilities with more than 200,000 health care providers. A review of the national epidemic resulting from medical errors and the federal government's response to this epidemic are provided. Specifically, we summarize the role of the DoD and the TRICARE Management Activity in developing team training interventions to address this epidemic

Acknowledgements

We would like to acknowledge the efforts of those who helped bring this large-scale DoD project to fruition. We would like to thank James Battles of the Agency for Healthcare Research and Quality and Heidi King of the TRICARE Management Activity for their leadership. We would also like to acknowledge such technical contributors as Dr. Paul Barach, Dr. Steven Pratt, Dr. Susan Mann, Dr. Ronald Marcus, Penny Greenberg, Lauren Toomey, Renee Claire-Norris, Capt. John Webster, M.D. (ret.), and

References (60)

  • P. Barach et al.

    Trauma team performance

  • E.L. Blickensderfer et al.

    Theoretical bases for team self-corrections: Fostering shared mental models

  • G.E. Briggs et al.

    Team versus individual training, training task fidelity, and task organization effects on transfer performance by three-man teams

    Journal of Applied Psychology

    (1965)
  • J.A. Cannon-Bowers et al.

    Making decisions under stress: Implications for individual and team training

    (1998)
  • J.A. Cannon-Bowers et al.

    Defining competencies and establishing team training requirements

  • DeChurch, L. A. & Marks, M. A. (2003). Teams leading teams: Examining the role of leadership in multi-team systems. An...
  • E.E. Entin et al.

    Adaptive team coordination

    Human Factors

    (1999)
  • W.R. Hamman

    The complexity of team training: What we have learned from aviation and its applications to medicine

    Quality and Safety in Health Care

    (2004)
  • R.L. Helmreich

    Managing human error in aviation

    Scientific American

    (1997)
  • R.L. Helmreich et al.

    Why crew resource management? Empirical and theoretical bases of human factors training in aviation

  • R.L. Helmreich et al.

    Team performance in the operating room

  • R.L. Helmreich et al.

    Culture, error, and Crew Resource Management

  • S.D. Hosek et al.

    Reorganizing the military health system: Should there be a joint command?

    (2001)
  • D.L. Kirkpatrick

    Evaluation of training

  • G. Klein et al.

    Adaptive Teams

  • Klein, C. A., Salas, E., Burke, C. S., Goodwin, G. F., Halpin, S., Diaz Granados, D., Badum, A. (in press). Does team...
  • R. Klimoski et al.

    Team mental model: Construct or metaphor?

    Journal of Management

    (1994)
  • L.T. Kohn et al.

    To err is human: Building a safer health system

    (1999)
  • Kohsin, B. Y. (2002). Talking paper on the status of AF [Air Force] Medical Team Management. Unpublished...
  • S.W. Kozlowski et al.

    Developing adaptive teams: A theory of compilation and performance across levels and time

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    1

    Please address all correspondence regarding the TeamSTEPPS program to David P. Baker at [email protected]. Tel.: +1 202 403 5036.

    2

    Tel.: +1 202 403 5643.

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    Tel.: +1 202 403 5188.

    4

    Tel.: +1 703 681 0064x3611.

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    Tel.: +1 703 681 0064x3686.

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    Tel.: +1 407 882 1325.

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