Patient Safety Update
Team Training a Success in Interventional Radiology
Interventional Radiology is wrapping up a year-long teamwork training program that enhanced communication among vascular interventional staff and effected improvements in patient safety.
The Partners Radiology-led program, which kicked off late in 2006 at BWH and MGH, had two goals: to decrease errors by improving communication and teamwork and to improve staff perceptions of the safety climate. Radiology’s Richard Baum, MD, medical director, Rick Foley, MS, BSN, RN, nurse manager, and Carol Upson, chief radiologic technologist, formed the BWH steering committee.
Before the team trained together, Radiology nurse educator De’Ann McNamara, RN, and Eileen Bozadjian, RN, program manager for Quality, were trained as observers.
“They learned how to observe behaviors of their peers relating to communication and teamwork in the clinical environment,” Andrea Kelly, JD, RN, patient safety manager for Partners, said.
In January 2007, the entire vascular interventional team of physicians, nurses, technologists and support staff, met for a four-hour training session on communication and teamwork. After the training, McNamara and Bozadjian observed how well their colleagues communicated and worked together using the skills they had learned.
At BWH, the enhanced teamwork fostered an important improvement in patient safety. McNamara and Michael Stecker, MD, noticed that patients with lines sometimes were sent to the PACU without the lines being capped. “De’Ann and Mike joined together to form a post-procedure pause and created a checklist sticker to put on the charts of patients with lines as a reminder to staff,” Kelly said.
McNamara and Bozadjian also observed the Vascular Interventional Radiology team at MGH, and the two MGH observers did the same at BWH so the teams could share ideas and learn from each other.
Since then, MGH has adopted a BWH best practice: multidisciplinary morning rounds. Each morning, the entire BWH Interventional Radiology team gathers to go over the patient list and discuss any problems or issues. “It’s a great way to communicate and allow everyone to have a voice,” Kelly said.
Kelly is awaiting survey results to measure the impact of the team training program. “We surveyed staff prior to the training and then after it,” she said. “It will be interesting to see the results of the recent survey because the first survey indicated that staffs’ original perceptions of safety were very good.”
The Partners team training program was the idea of Scott Gazelle, MD, MPH, PhD, director of Partners Radiology. He worked with Allen Frankel, MD, then director of Patient Safety for Partners, to create a program to span IR suites in Partners hospitals. “Nothing like this had ever been done for radiology in any other health system,” Kelly said.
Gazelle added, “We are thrilled with the outcome of this program, which is the first whole-unit team training program in any department of radiology. The program represents an important collaborative effort across Partners HealthCare System, and one of many quality and safety efforts being led by Partners Radiology.”
The programs were rolled out to Faulkner Hospital and North Shore Medical Center this March.
At BWH, team training is also underway in the Thoracic Operating Rooms and is being rolled out in the post-partum units and the NICU in the Connors Center for Women and Newborns. Perinatal staff completed the training in 2005.