[ Editorials | Signature Series | Index ]

Editorial NOVEMBER 2007

Improvement for Improvement’s Sake?

Ronald T. Burkman, MD

In the area of team/crew resource training we participated as one of the control groups in a randomized study evaluating the effects of such training in a labor-and-delivery setting.2 The training focused on the use of various clinicians (eg, OB/GYNs, anesthesiologists, midwives, nurses) to work in teams to manage the labor-and-delivery unit on a daily basis and to respond to emergencies as needed. The study also involved the use of better communication techniques to convey information more effectively, empowering all persons working on the unit to raise concerns about issues affecting patients.

Most of the participants in the trial had high expectations that it would demonstrate better outcomes in hospitals undergoing the intervention. However, the study showed no significant impact of the training on the measured outcomes, except for a shorter decision-to-incision time for immediate cesarean delivery. Both the intervention and control groups showed an improvement in outcomes during the study; indeed, the control group tended to perform better, albeit not to a statistically significant degree. This latter result may have occurred because all of the control hospitals were also focusing on improving clinical outcomes, and may have introduced process changes other than team training that affected the study outcomes.

This study underscores the need for evidence-based research on such interventions. Although the intervention may have value, the study at the very least indicated a need for refinement.1 For example, without a better understanding of what is needed to make the intervention succeed, many hospitals may expend significant amounts of resources on a strategy that is likely to fail.

In my opinion, many view team training as intuitive and simple. In fact, it is far more complex than it seems. To be successful, participants need to overcome hierarchal barriers in the health care delivery system that have existed for generations, in effect accomplishing a cultural shift. Unless everyone involved “buys into” the idea, the training is unlikely to achieve its goals. Given the novelty and complexity of such training, perhaps most institutions should concentrate on task-specific team training for emergencies (eg, shoulder dystocia, postpartum hemorrhage) until training approaches are refined. The team concept may also be inappropriate for small hospitals, where physicians may not be in constant attendance while patients are in labor.

Many institutions are also embarking on the use of simulation. Some simulations are fairly simple (eg, a drill for managing shoulder dystocia). Other simulations may involve the use of complex, expensive aids such as programmable mannequins or virtual-reality equipment (eg, operative laparoscopy). Although laparoscopy simulators have demonstrated improvement of skills with increased use of the simulator, there is less evidence to show whether the learner therefore becomes a better surgeon.

For simulations that involve multiple individuals and the use of a programmable mannequin (eg, postpartum hemorrhage), there is no objective system for determining how successfully the group performs, or whether they subsequently perform better when the real problem arises. As most of these latter simulations involve only a handful of physicians and nurses, how should the training be implemented at larger institutions? Should all of the physicians, midwives, and nurses undergo simulation training (at a relatively prohibitive cost) or will a few suffice, assuming a subsequent “Hawthorne effect”? As large institutions encounter such emergencies on a relatively frequent basis, do they gain less from simulating the problem compared with a small, low-volume hospital? That is, due to the infrequency of these events at a smaller hospital, might not the care providers there benefit more? In addition, who should provide this training, and how will its effectiveness be measured?

These are only a few thoughts about two of the newer approaches intended to improve clinical outcomes. Certainly, everyone wants to reduce hospital error rates and improve issues that adversely affect quality of care. Everyone would prefer to be proactive, rather than reactive. However, as noted by Auerbach et al, “Although the scope of the problems may seem to favor action over knowledge, quality improvement is on common ground with the rest of biomedicine.”1 In other words, the approach to quality-improvement projects must be as evidence-based as possible, or we risk the distinct possibility that many will be ineffective and wasteful of time and money.

back to top

Ronald T. Burkman, MD, Associate Editor

References

1. Auerbach AD, Landefeld CS, Shojania KG. The tension between needing to improve care and knowing how to do it. N Engl J Med. 2007;357(6):608-613.
2. Nielsen PE, Goldman MB, Mann S, et al. Effects of teamwork training on adverse outcomes and process of care in labor and delivery: a randomized controlled trial. Obstet Gynecol. 2007;109(1):48-55.