Multidisciplinary Teamwork and Communication Training Shad Deering, MD,* Lindsay C. Johnston, MD,† and Kathryn Colacchio, MD† Every delivery is a multidisciplinary event, involving nursing, obstetricians, anesthesiologists, and pediatricians. Patients are often in labor across multiple provider shifts, necessitating numerous handoffs between teams. Each handoff provides an opportunity for errors. Although a traditional approach to improving patient outcomes has been to address individual knowledge and skills, it is now recognized that a significant number of complications result from team, rather than individual, failures. In 2004, a Sentinel Alert issued by the Joint Commission revealed that most cases of perinatal death and injury are caused by problems with an organization’s culture and communication failures. It was recommended that hospitals implement teamwork training programs in an effort to improve outcomes. Instituting a multidisciplinary teamwork training program that uses simulation offers a risk-free environment to practice skills, including communication, role clarification, and mutual support. This experience should improve patient safety and outcomes, as well as enhance employee morale. Semin Perinatol 35:89-96 Published by Elsevier Inc. KEYWORDS teamwork, patient safety, labor and delivery, communication, simulation

I

n the hospital perinatal environment, every delivery is, by necessity, a multidisciplinary event. It involves nursing, a delivering provider (obstetrician, family medicine, or midwife), often an anesthesia provider, and a pediatrician to take care of the baby after delivery should resuscitation be required. It is also not unusual for patients to be in labor for many hours and be on the delivery ward across many different shifts, necessitating multiple handoffs between the providers and teams. Each handoff provides an opportunity for errors to occur. When you add the emotions and expectations held by the patient and family of a perfect delivery experience and child, even small mistakes or misunderstandings in the plan of care are magnified. Although a traditional approach to improving patient outcomes from the provider’s standpoint has been to pursue more education or by trying to address individual skills, it is

*Division of Maternal Fetal Medicine, Andersen Simulation Center, Madigan Army Medical Center, Tacoma, WA. †Division of Neonatal-Perinatal Medicine, Yale University School of Medicine, New Haven, CT. Address reprint requests to Shad Deering, MD (Obstetrics), Division of Maternal Fetal Medicine, Medical Director, Andersen Simulation Center, Madigan Army Medical Center, 9040 Fitzsimmons Dr, Tacoma, WA 98431. E-mail: [email protected] or Lindsay C. Johnston (Pediatrics), Division of Neonatal-Perinatal Medicine, Yale University School of Medicine, New Haven, CT. E-mail: [email protected]

0146-0005/11/$-see front matter Published by Elsevier Inc. doi:10.1053/j.semperi.2011.01.009

now recognized that a significant number of complications result from team, rather than individual, failures. Indeed, as one author stated, “it has been recognized that individual competence in clinical skills is not enough; team coordination, communication, and cooperation skills are essential to effective and safe performance.”1 In 2004, the Joint Commission issued a Sentinel Alert and noted that most cases of perinatal death and injury are caused by problems with an organization’s culture and communication failures between providers.2 In this same alert, they published the recommendation that hospitals begin to implement teamwork-training programs in an effort to improve outcomes. Many institutions have begun to do this and their malpractice carriers recognize these efforts and are offering discounts of up to 20% off their liability premiums when this training is undertaken.3,4

Background Origins of Team Training The science of team performance training originated from the attempts of commercial and military aviation to improve flight safety. Crew resource management (CRM) focuses on skills, such as communication, leadership, and decision making, of flight crews. It encourages the use of all available resources, including equipment, procedures, and staff, to 89

90 promote safety and enhance efficiency. Initially stemming from a NASA workshop in 1979, where it was noted that human error was the primary cause of most aviation accidents, CRM has since been adapted for use in other high-risk industries.5 The military has also been a major force in the development of effective teams. An evaluation of multiple U.S. Army aviation fatalities in the 1980s revealed that most accidents involved experienced pilots with failures attributable to errors in crew communication, workload management, and task prioritization. A new training system was instituted to address these problems. The U.S. Navy began research in team training after a U.S. naval warship accidentally fired on an Iranian commercial airplane in 1998. As a result, aircrew are now instructed in 8 behavioral skills on the basis of CRM principles, including assertiveness, communication, leadership, and decision-making. The Air Force similarly developed new guidelines for teamwork in the 1990s, which include group problem solving, backing up teammates, and maintaining an atmosphere that encourages teamwork.6 There are a myriad of reasons why errors occur in demanding, time-stressed environments. Crew members are hampered by frequent interruptions, which can shift focus away from critical details, resulting in failure to follow up on important points. Fatigue from working long hours or inadequate staffing can result in loss of vigilance. Inadequate communication is an extremely common contributor to errors, and handoffs of information are times of particularly high risk. Vital information can be lost during such transfers, if not communicated in a clear, effective manner. Errors can also result from the presence of an established hierarchy among members of a team. For example, a pilot just out of training might hesitate to point out deficiencies in the performance of a more senior colleague because of professional courtesy or fear of being reprimanded. Similarly, the judgment of a very well-respected, higher-ranking individual might not be questioned because other team members assume that they won’t make mistakes. Any of the factors listed can contribute to critical details being overlooked, protocols not being followed, or mistakes going by unnoticed. In a high-risk environment, any error has the potential to result in the loss of lives and can lead to substantial costs being incurred. The study of human factors recognizes that most of these errors can still occur in units that are using teamwork. However, effective teams are more likely to notice mistakes earlier and can address them before they lead to harmful outcomes.

Transition of Team Training to Health Care Health care is a prime example of a high-stakes environment in which errors can lead to deleterious outcomes. The issue of medical errors was brought to the forefront of the public’s attention after the 1999 publication of “To Err is Human” by the Institute of Medicine.7 The outcry after this report led to the formation of a task force to develop a strategy to reduce the number and severity of medical errors. Adoption of hu-

S. Deering, L.C. Johnston, and K. Colacchio man factors training, such as CRM, was recommended to improve the performance of health care providers. The MedTeams project began in 1996 as a means to deliver aviation CRM training to emergency department staff organized into caregiver teams. This program resulted in a statistically significant improvement in the quality of observed team behaviors, a decrease in the clinical error rate of 56%, and increase in staffs’ attitudes towards teamwork.8,9 It has since been expanded to include labor and delivery units, operating rooms, and intensive care units. Team strategies and tools to enhance performance and patient safety (TeamSTEPPS) was developed by the Department of Defense’s patient safety program in collaboration with the Agency for Healthcare Research and Quality to extend the military’s research on team performance to health care. An essential set of interrelated knowledge, skills, and attitude competencies was identified, which includes critical aspects of teamwork, including leadership, mutual performance monitoring, mutual support, and communication. TeamSTEPPS is designed to create and sustain a culture of safety by producing highly effective medical teams that optimize resources, increasing team awareness, resolve conflicts, and eliminate barriers to quality and safety.10-12 In 2005, an article in JAMA indicated that, despite a great increase in focus on patient safety, there had not been a decrease in the death rate as the result of medical errors. However, there were reductions in certain kinds of errorrelated deaths, including a 50% reduction in poor outcomes of preterm infants when Labor and Delivery staff had participated in team training.13

Basic TeamSTEPPS/CRM Concepts and Definitions When talking about teamwork and communication issues, it is important to have a basic understanding of the key concepts and terminology. These concepts apply to both routine and emergency situations but are often more noticeable in the latter. Although there are many different programs available, each with slightly different verbiage, the same basic tenants apply across all of them. Leadership Leadership is the ability to coordinate the activities of team members by ensuring that the plan of care is understood, changes in information are shared, the environment allows all team members to do their best work, and to provide necessary resources. This does not mean that the leader will always be a physician. In fact, the leader may change during an event. As an example in obstetrics, if there is an umbilical cord prolapse and the nurse is the initial staff in the room, she/he must assume a leadership role (ie, situational leadership) until the physician who can perform the cesarean delivery arrives. Another example is a neonatal resuscitation in which the delivering provider may initiate treatment and then turn this over to a pediatrician when they arrive. Regardless of who is or should be the leader during an emergent event, it is critical that this is apparent and that there is role clarity such that care and directions can be given in an effi-

Multidisciplinary teamwork and communication training cient manner that will reduce confusion and unnecessary interventions or delays (Role clarity refers to the degree to which it is obvious to all members of the team what each person’s role is, such as the leader, assistant, etc.). Situational Awareness It is always important for providers to be aware of all aspects of care being delivered to the patient. Each individual must communicate and share observations with others so that they can maintain more global situational awareness. When the key leadership has situational awareness, they can help to ensure that others are apprised of what is going on with other patients and how these factors may affect them, resulting in a shared mental model. By definition, a shared mental model is the perception of, understanding of, or knowledge about a situation or process that is shared among team members through communication. Practical ways that this can be accomplished include tools, such as a brief with both physicians and nursing staff at the beginning of a shift, and team huddles as situations change. Mutual Support All members of the team must look out for one another to ensure the best care and patient safety is achieved. One way that this is accomplished is through a process called cross monitoring. This is defined as monitoring the actions of other team members for the purpose of sharing the workload and reducing or avoiding errors. Mutual support protects team members from work overload situations that may reduce effectiveness and increase the risk of error. When they work together to support each other, team members foster a climate in which it is expected that assistance will be actively sought and offered as a method for reducing the occurrence of mistakes. Communication This is the process by which information is clearly and accurately exchanged among team members, including the patient. Some common barriers to effective communication include inconsistency in team membership, varying communication styles, distractions, fatigue, and misinterpretation of cues. For communication to be effective, it must be complete (including all relevant information), clear (in a manner that is plainly understood), brief (given in a concise manner), and timely (offered in an appropriate time frame when effective clinical actions can be taken). Some strategies for this include a standardized way to present patient information, one of which is the SBAR (ie, Situation/Background/ Assessment/Recommendation) format. Other ways include call outs (verbalizing information that is important to the entire team, especially during emergencies), check backs (repeating back information that was given, such as medication dose and route, to prevent errors), and ensuring handoffs are complete and accurate. A more comprehensive list of the key teamwork concepts and tools can be found in Table 1.

Who Should Be Involved in Teamwork Training? To be maximally effective, teamwork training must include all personnel and providers who care for the patient. In the

91 perinatal environment, this requires multiple services and specialties caring for mother and infant. Although it is important to remember all the nursing and physician providers, many other people, such as the receptionist at the front desk who may be responsible for paging people and the scrub technician who is needed for urgent operative procedures, should be included. A potential list can be seen in Table 2.

Evidence for Team Training There is a good amount of evidence from multiple specialties that teamwork training can improve clinical outcomes and both the Institute of Medicine and the Agency for Healthcare Research and Quality suggest that patient safety can be improved by the use of teamwork training in health care. In addition, it has been shown that teamwork training leads to improvement in communication, decision-making, and providing feedback.14 The Institute for Healthcare Improvement also published a white paper in 2005 entitled “Idealized Design of Prenatal Care” and in this important publication, they strongly argued that teamwork strategies be applied to perinatal medicine.15 Even the American Congress of Obstetricians and Gynecologists has recently offered guidance recommending teamwork training for obstetrics stating that “Training in teamwork and communication techniques is increasingly being recognized as a cornerstone of a robust patient safety program.”16

Obstetrics In 2007, a randomized study was published that involved 15 institutions and randomized them to either teamwork training or no intervention.17 The primary outcomes for this study used the Adverse Outcomes Index (AOI), which was composed of specified adverse maternal and neonatal outcomes. In this study, the authors did not find a difference in the AOI between the institutions. Although there was no difference noted in the AOI in this study, when the authors reviewed the methods of this study, data were collected in the posttraining period for only 5 months, which may be too short a period to evaluate when attempting to introduce true culture change. In their secondary outcomes, however, they did notice that the decision to incision time for cesarean sections was significantly shorter (33.3 min vs 21.2 min, P ⫽ 0.03) after teamwork training. In a more recent article, Pettker et al18 reviewed the impact of a comprehensive patient safety strategy on adverse obstetrical events, with teamwork training being a major component of the intervention. In their study, they also used the AOI as their primary outcome and demonstrated a significant improvement after the implementation of program that involved standardizing care protocols, teamwork training, and requiring all providers to pass a fetal heart rate monitoring course to improve communication about fetal tracings. Surgical errors are another area that must be considered in modern obstetrics because Cesarean delivery is major abdominal surgery and the national Cesarean delivery rate is more than 30% in the United States. Although there are no

S. Deering, L.C. Johnston, and K. Colacchio

92 Table 1 Key TeamSTEPPS Concepts and Skills/Tools Concept Leadership

Skill/Tools Role clarity Resource management Conflict Resolution

Teamwork behaviors

Communication

SBAR

DESC

Two-challenge rule

Check back

Call out

Situation monitoring

Situational awareness Shared mental model

Mutual support

Task assistance Advocacy Feedback

Description The leader is responsible for making sure that all members of the team understand their roles and responsibilities Resources and workload are appropriately allocated to ensure patients are not placed at risk The leader must assist in resolving both interpersonal or medical care conflicts using the chain of command and appropriate conflict resolution strategies in a timely manner The leader will ensure that essential teamwork activities, such as team meetings, briefings, and debriefings occur and that lessons learned are shared A structured technique for quick, clear, and concise presentation of relevant patient information (Situation/Background/Assessment/ Recommendation). A conflict resolution tool that addresses the behavior in a factual and structured manner (Describe the behavior/Express concerns/Specify a course of action/obtain Consensus on next steps). The concept that a provider should verbally express concern about an order or plan that they feel may compromise patient safety at least twice if it is not acknowledged the first time The practice of repeating an order or instructions back to the person giving them to ensure that the one receiving the orders has understood them correctly The calling out of important events (such as vital signs, laboratory values, fetal heart rate), especially during emergency situations to facilitate anticipation of potential interventions The practice of constantly scanning the unit/surroundings and being aware of what factors may affect the delivery of safe patient care Ensuring that all providers are aware of the pertinent information regarding a patient and have a shared understanding of the plan of care Offering or asking for assistance when a team member is overloaded and has too many tasks to complete A form of verbal support from a healthcare provider that requires them to advocate for patient safety if identify a potential issue The practice of providing a review of performance with the goal being to improve outcomes

studies specific to obstetrics, a retrospective cohort study by Neily et al19 reported on the implementation of a team training program for their operating room teams in the Veterans Health Administration, the largest national integrated health care system in the United States. In their study there was an 18% decrease in observed mortality for the institutions that Table 2 Personnel to Consider, Including in Teamwork Training Programs: Obstetrical staff providers (obstetricians/family medicine/ midwives) Pediatrics Anesthesia Residents (all specialties that participate on labor and delivery) Nursing staff Operating room technicians/assistants Administrative support personnel (front desk, reception) Pathology (blood bank personnel for hemorrhage protocols)

implemented the training, which was an almost 50% greater decrease than the untrained group. In contrast to the aforementioned studies, where the main intervention was general teamwork training for the entire unit and the outcomes examined were more global in nature, authors of other studies have evaluated the effect of teamwork training for specific obstetrical emergencies that have been traditionally identified as contributing to poor outcomes. Some of these emergencies include umbilical cord prolapse and shoulder dystocia, postpartum hemorrhage, eclampsia, and neonatal resuscitation. A study from a maternity unit in the SouthWest of England reported on their clinical outcomes after making annual team training for the care of an umbilical cord prolapse mandatory.20 Training was part of a 1-day course and was mandatory for all midwifery and obstetrical staff. In their findings, the authors demonstrated that the diagnosis to delivery interval for emergency Cesarean deliveries as the result of umbilical cord prolapse after this specific team training was implemented decreased from 25 to 14.5 minutes (P ⬍ 0.001).

Multidisciplinary teamwork and communication training Another study was performed after this training program was implemented, and the authors demonstrated a significant decrease in the incidence of low Apgar scores (⬍6) and hypoxicischemic encephalopathy that was sustained over the posttraining time period.21

Pediatrics Pediatrics team training with simulation has been studied and reported most frequently with regards to neonatal resuscitation. Team training can be used to both improve teamwork and to practice specific skills necessary for pediatric caregivers to acquire during their training. As the field of neonatology advances, so does knowledge of effective techniques used to assist caregivers in achieving and maintaining the technical and behavioral skills necessary for successfully resuscitating a newborn. Through the use of simulation-based training, a high-fidelity mannequin can mimic the real environment of a delivery room, eliciting realistic responses from trainees. By providing scenarios coupled with debriefings, units can provide a rich learning experience similar to that of the real clinical environment.22 In a study done at the University of Texas Health Center, incoming pediatric interns and other subspecialties rotating through the pediatric wards were randomized to learn the Neonatal Resuscitation Program by the use of either highfidelity simulators with team training or low-fidelity manikins in the control arm. Blinded observers videotaped the resuscitations for teamwork and resuscitation quality and measured both the number of predefined teamwork behaviors exhibited and the time of resuscitation. The high-fidelity training group exhibited more frequent teamwork behaviors and better workload management than control subjects. In addition, the behaviors persisted when subjects were followed 6 months after completing the training. This indicates that including team training into the Neonatal Resuscitation Program curriculum was an effective way to teach teamwork skills.23 Similarly, a recent study at Children’s Hospital of Philadelphia assessed the effect of high-fidelity simulation on cognitive performance after a training session involving several mock resuscitations designed to teach and reinforce pediatric advanced life support algorithms. The subjects (51 pediatric residents) were randomized to either a high-fidelity simulation, or the standard mannequin simulation group. Subjects completed 3 phases: (1) assessment of baseline performance; (2) a didactic session reviewing pediatric advanced life support algorithms; (3) repeated mock code exercises to assess performance. The phases were measured by a scoring instrument designed to measure cognitive performance. The baseline performance was similar between groups, and both groups demonstrated improvement during the mock code exercises. However, the subjects in the high-fidelity simulation group showed greater improvement in their cognitive performance.24 Most of the evidence behind team training with simulation has occurred in simulation centers as opposed to in situ training in an intensive care unit or pediatric ward. The advantage

93 of the latter is the ability to create a more engaged learning experience with the complexities of clinical settings without the hazards of real life. In situ simulation can recreate stressful critical events in a safe setting. In one pilot study of more than 700 participants conducted by Fairview Health Services in Minneapolis, MN, researchers were able to evaluate the use of team behaviors and competencies, including situational awareness, closed-loop communication, hand off tools, shared mental models, and leadership transfer.25

Using Simulation to Help with Team Training Teamwork training concepts are most often taught by standard didactic presentations and lectures. This approach presents the inherent challenge in that the providers must then translate these concepts into action in the clinical setting. Simulation, which can be used to allow the providers to practice the concepts they have learned in a safe environment, has the potential to help in both the initial instruction and reinforcement of the concepts. In addition, if done in situ in the labor and delivery ward, simulation may be useful to assess teamwork and communication after the training and identify actual communication and systems issues. Another reason that simulation is well suited to team training is that it allows the entire team to practice obstetrical and pediatric emergencies in a no risk environment. It is doubly beneficial because it provides the opportunity to address both gaps in medical knowledge as well as target common mistakes in communication, teamwork, and conflict resolution rather than just talking about them in a classroom setting or waiting for them to occur in real life when a mother and/or baby are at risk. After these exercises, performance is reviewed in the form of a debriefing. Debriefing is a critical time during simulation training where lessons are learned and shared with the participants. Although there is much about debriefing that is something of an art form, there are basic tenets that can be learned and practiced which will provide better results.26 Many of the previously discussed studies that evaluated the effects of team training were conducted using simulation. Currently, the Agency for Healthcare Research and Quality is developing a specific training guide for instructors that will assist them to integrate simulation into teamwork training. A list of some commonly used simulators can be seen in Table 3.

Where Should Simulation Training for Teamwork Training Be Performed? Teamwork training with the use of simulation can either occur in a simulation center or “in situ,” referring to training occurring in the learner’s usual clinical environment. There are distinct advantages and disadvantages to each location. Training in a dedicated simulation center or simulation laboratory has several advantages. First, the environment is tightly controlled, which standardizes the experience for all

S. Deering, L.C. Johnston, and K. Colacchio

94 Table 3 Simulators for Obstetrical and Pediatric Team Training Simulator

Company

NOELLE Birthing Simulator Gaumard Scientific, Miami, FL (http://Gaumard.com) PROMPT birthing trainer Limbs & Things, UK (http://limbsandthings.com) PEDI Blue Neonatal Gaumard Scientific, Miami, FL Simulator (http://Gaumard.com) Newborn HAL Gaumard Scientific, Miami, FL (http://Gaumard.com) Premie HAL Gaumard Scientific, Miami, FL (http://Gaumard.com) SimNewB Laerdal Medical, Stavanger Norway (http://www.laerdal.com/)

learners. Skilled facilitators develop and oversee the sessions, operate the simulation equipment, and preside over the debriefings. Technicians with extensive knowledge of the simulators are available to assist with any malfunction of the equipment, reducing the number of sessions delayed or canceled as the result of technical difficulties. Simulation centers often have dedicated educators who are well-versed in principles of adult learning and who can be used to optimize the benefits to the trainees. Audio-visual recording systems are integrated into the simulation rooms, and the recordings allow the learners to benefit from watching their own actions during the debriefing. Finally, large numbers of learners from different centers can potentially train at a simulation center using a particular module or curriculum, and the data collected can be used for research purposes. Limitations to team training occurring in a simulation center include frustration of the learners by the limitations of the standardized environment, such as unfamiliar equipment or lack of their usual colleagues. Learners may need to travel off campus to attend a course, and high demand for sessions can make scheduling more difficult. Perhaps most importantly, the simulation center may not offer equal opportunities to identify and fix “systems” problems inherent in each individual’s clinical environment, such as issues with the physical space or ancillary support. To address these concerns, simulations were developed to occur “in situ,” in the learner’s typical clinical environment. This should alleviate anxiety about unfamiliarity with the equipment and the layout in the artificial world of the simulation center. It also allows for multidisciplinary learning among people who actually make up a patient care team, ideally improving communication and enhancing patient safety. Simulators used “in situ” can be used during follow up drills or “mock codes.” This review of concepts is paramount to help reinforce information learned during the initial training session, and prevents loss of knowledge over time. “In situ” simulation is ideal for the identification of “system” problems that are more difficult to detect during “off site” training in a simulation center.25,27 Several authors have published work on the effectiveness of using “in situ” simulations of high risk

Description Full-body birthing simulator

Approximate Price US$3,995-37,995

Female lower torso birthing simulator US$4,425-7,125 Infant resuscitation simulator

$1,995

Term infant resuscitation simulator

$18,995

Preterm infant resuscitation simulator $15,995 Term infant resuscitation simulatior

$15,795-$24,000

events to identify problems in the clinical environment, such as administration of in-hospital cardiopulmonary resuscitation28 or the identification of latent environmental threats on a labor and delivery unit.29 Teamwork and communication are essential in high risk situations, and repeated practice of these skills should serve to improve patient outcomes and satisfaction. There are some limitations of “in situ” simulation training. To effectively institute a new teamwork training curriculum, it is essential to train all staff in a clinical environment in a timely manner. This presents the difficulty of scheduling each course to include a complement of staff from every necessary discipline, including physicians, nurses, practitioners, and respiratory therapists, all of whom work on different schedules and shifts. Perhaps even more difficult is incorporating consulting and ancillary staff, those who do not have a primary clinical unit but interact with clinicians in many different areas of the healthcare facility. There is an inherent difficulty scheduling people to participate in teamwork training while providing clinical care, as they may be required to leave to care for a patient. Conversely, people may be resistant to come in for training during their own time unless they are financially compensated, leading to further expense for the hospital. In a large unit or one that operates 24 hours a day, such as an intensive care unit or an emergency department, there is a challenge to identify and train enough facilitators to educate the entire staff, including those working “off-peak” hours. Facilitators must be educated in the foundations of teamwork training, adult education, and the basics of operating the simulators. Next, technical difficulties may occur more frequently when the simulators are being repeatedly moved to new locations. Finally, setting up audio-visual equipment for recording simulations may be more difficult in various clinical environments, and participants may miss out on this valuable learning tool. There is currently little published material on the comparison of the outcomes of teamwork training held in a simulation center versus that conducted “in situ” on the clinical units, but this is an important question requiring further study.

Multidisciplinary teamwork and communication training Table 4 Common Barriers to Implementation of a Team Training Program Failure to perform a comprehensive assessment before implementation Incomplete support from leadership Failure to create a sufficiently powerful change team Not truly integrating the vision Allowance for obstacles Declaring victory too soon Poor coordination Failure to provide sustainment training and focus

Instituting a Teamwork Training Program Although the concepts of teamwork training are relatively straightforward, and the need for it obvious in the perinatal setting, the implementation of a comprehensive teamwork program can be a complex and lengthy intervention. Because the goal of the program is to effect a true change in culture, simply requiring online training or making all staff and providers attend mandatory briefings is very unlikely to result in significant change. As with many areas of medicine, the key place to begin is with the leadership of the institution. After leadership has decided that this is a worthwhile endeavor, the first step is to perform a site assessment and often this will involve administering a culture survey. The results of this first stage are then used to create an action plan. This will involve identifying the key personnel to train and creating a schedule. As discussed previously, simulation training can be a useful adjunct and which scenarios are chosen will depend on cost and the number of people to be trained. There are several options available to institutions to teach teamwork training, some at no cost. One of the most wellknown and studied is the TeamSTEPPS curriculum, which was created by developed by the Department of Defense and the Agency for Healthcare Research and Quality. This is an evidence-based curriculum that is available at no charge to organizations that wish to implement it. Information can be found at the following Web site: http://teamstepps.ahrq.gov. Other simulation-based programs that may be utilized for medical team training include Anesthesia Crisis Resource Management (ACRM), http://med.stanford.edu/VAsimulator/acrm/ and Team-Oriented Medical Simulation. When training is completed, it is important for leadership to maintain emphasis on the behaviors as they enter the sustainment phase. A list of common obstacles to implementation can be found in Table 4.

Conclusions Teamwork training is a critical part of any comprehensive safety plan; however, it is not something that can be effectively accomplished in a few hours of lecture. Improving teamwork, communication, and clinical outcomes requires culture change, and this is not something that comes without an institutional commitment to the goals.

95 Simulation training provides a readily available platform with which to train and reinforce both teamwork and technical skills in obstetrics and pediatrics with a nearly endless variety of scenarios that can be adapted to address events specific to the institution. It allows physicians, nurses, and ancillary staff to train together and hone their communication skills for the uncommon yet life-threatening emergencies with absolutely no risk to a patient. This training is becoming more widely accepted and publications are beginning to demonstrate its potential to save lives and improve outcomes.

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