Implementation of Unit Based Interventions to Improve Teamwork and Patient Safety on a Medical Service

Background:

Teamwork is essential to providing safe hospital care. In a prior study involving 2 medical units in our hospital, Structured Inter‐Disciplinary Rounds (SIDR) improved teamwork climate and reduced adverse events (AE).

Methods:

We sought to implement complementary unit‐based interventions, Prepared Nurse‐Physician Co‐Leadership and SIDR, on 5 additional medical units and assess the impact on teamwork climate and patient safety. The study was a pre‐ vs. post‐intervention comparison involving 387 hospital professionals and 1379 patients in a large urban teaching hospital. Prepared Nurse‐Physician Co‐Leadership involved the creation of unit medical director and nurse manager partnerships for each unit. These unit co‐leaders received leadership and patient safety training and led inter‐professional working groups to design SIDR, which combined a structured format for communication with inter‐professional meetings every weekday morning. Unit co‐leaders facilitated SIDR which was attended by all physicians, nurses, and the pharmacist, social worker, and case manager for each unit. We assessed teamwork climate using the Safety Attitudes Questionnaire (score range 0‐100) and identified AEs using automated queries of information systems with confirmation by 2 physician researchers.

Results:

Overall, 165 of 250 (66%) professionals completed the pre‐ and 222 of 283 (78%) completed the post‐intervention surveys. Teamwork climate was similar in the pre‐ and post‐intervention periods (median 80.4, IQR 69.6‐85.7 vs. 80.4, IQR 73.1‐87.5; p=0.12). Paired analysis for 67 professionals revealed significant improvement in teamwork climate (median 80.4, IQR 71.4‐83.9 vs. 82.1, IQR 76.8‐85.7; p=0.005), which was mainly driven by improved nurses’ ratings (80.4, IQR 73.2‐85.7 vs. 82.1, IQR 78.6‐86.5; p=0.006). Overall, 76 patients during the pre‐ (11.0%) and 76 patients during the post‐intervention period (11.0%) experienced one or more AE (p=0.99). The rate of AEs was 3.90 per 100 patient‐days during the pre‐ and 4.07 per 100 patient‐days during the post‐intervention period (adjusted incidence rate ratio 1.08; p=0.60). Post‐hoc analyses revealed higher baseline teamwork climate scores and lower AE rates compared to prior controls in the same study site. Specifically, the teamwork climate score among 49 nurses on the control units in our preliminary studies evaluating SIDR was a median 69.6 (IQR=53.8‐85.7) and the rate of AEs was 7.2 to 7.7 per 100 patient‐days.

Conclusions:

Prepared Nurse‐Physician Co‐Leadership and SIDR improved teamwork climate yet did not reduce the rate of AEs. Earlier implementation of the interventions on 2 units within the study site may have initiated a positive cultural shift which spread to other units prior to the current study.