Donna O. Farley - Achieving Strong Teamwork Practices in Hospital Labor and Delivery Units

TECHNICAL
REPORT

Achieving Strong
Teamwork Practices
in Hospital Labor and
Delivery Units

Donna O. Farley, Melony E. Sorbero, Susan L. Lovejoy, Mary Salisbury

Prepared for the Office of the Secretary of Defense

Approved for public release; distribution unlimited

Center for Military Health Policy Research

A JOINT ENDEAVOR OF RAND HEALTH AND THE
RAND NATIONAL DEFENSE RESEARCH INSTITUTE

The research reported here was sponsored by the Office of the Secretary of Defense (OSD). The research was conducted jointly by the Center for Military Health Policy Research, a RAND Health program, and the Forces and Resources Policy Center, a RAND National Defense Research Institute (NDRI) program. NDRI is a federally funded research and development center sponsored by the OSD, the Joint Staff, the Unified Combatant Commands, the Navy, the Marine Corps, the defense agencies, and the defense Intelligence Community under Contract W74V8H-06-C-0002.

Library of Congress Control Number: 2010938595
ISBN: 978-0-8330-5055-7

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The U.S. Department of Defense (DoD) Patient Safety Program Office of the TRICARE Management Activity (TMA) provides training and support for the health-care facilities operated by military services to help strengthen their use of effective teamwork practices. In 2002, TMA funded a study aimed to assess the effects of teamwork training for labor and delivery teams on patient safety and other outcomes for mothers and newborns (Nielsen et al., 2007). The study presented in this report is a successor to the 2002 study, with the goal of addressing a number of the issues raised from the earlier studys findings. Using a case-study design, this study has focused on learning from the experiences of five labor and delivery units in implementing teamwork practices for the staff working in their units. Through a combination of process and outcome assessments, using site visits, interviews, staff surveys, and analysis of patient outcomes, the study sought to understand what is required for health-care organizations to achieve effective and sustainable teamwork practices.

The contents of this report will be of interest to national and state policymakers, health-care organizations, health researchers, and others involved in efforts to improve teamwork practices in health-care organizations.

This research was sponsored by Patient Safety Program Office of the Assistant Secretary of Defense/Health Affairs TRICARE Management Activity and conducted jointly by RAND Healths Center for Military Health Policy Research and the Forces and Resources Policy Center of the RAND National Defense Research Institute (NDRI). The Center for Military Health Policy Research taps RAND expertise in both defense and health policy to conduct research for the Department of Defense, the Veterans Administration, and non-profit organizations. RAND Health aims to transform the well-being of all people by solving complex problems in health and health care. NDRI is a federally funded research and development center sponsored by the Office of the Secretary of Defense, the Joint Staff, the Unified Combatant Commands, the Navy, the Marine Corps, the defense agencies, and the defense Intelligence Community.

For more information on the Center for Military Health Policy Research, see http://www.rand.org/multi/military/ or contact the co-Directors (contact information is provided on the web page). For more information on the Forces and Resources Policy Center, see http://www.rand.org/nsrd/about/frp.html or contact the Director (contact information is provided on the web page).

CHAPTER ONE
Introduction and Background

CHAPTER TWO
Study Design and Methods

CHAPTER THREE
Findings Regarding Teamwork Implementation

What Training and Actions Are Required to Achieve a High Level of Teamwork in the
Labor and Delivery Process?

How Strongly Do Self-Reported Experiences in Implementing Teamwork Improvements
Correlate with Actual Levels of Teamwork as Measured by Direct Observation of the
Labor and Delivery Process?

CHAPTER FOUR
Effects of Teamwork Improvement on Unit Staff and Patient Outcomes 55

How Does Achieving Effective Teamwork Affect the Perceptions and Experiences of Staff
Working in Labor and Delivery Units?

What Effects Does Effective Teamwork Have on Labor and Delivery Outcomes for Mothers
and Newborn Infants?

CHAPTER FIVE
Synthesis of Findings and Conclusions

APPENDIXES
A. Tools and Strategies for Teamwork

S.1. Summary of Results Regarding Implementation Progress and Outcome Changes,
by Site xix

2.4. Process Evaluation: Better Understand the Conditions and Actions Required for
Hospital Labor and Delivery Units to Achieve Effective and Sustainable Teamwork Practices 14

2.5. Outcome Evaluation: Assess the Extent to Which Successful Adoption of Teamwork Practices May Influence the Experiences of Staff Working in the Units and
Outcomes for Patients 18

2.7. Correlations of the Items in the Quality-of-Work-Life Composite to Each
Composite in the Labor and Delivery Unit Staff Survey 21

2.8. Response Rates for the Participating Labor and Delivery Units, Staff Surveys at
Baseline and End of Study 22

2.9. Measures of Maternal and Neonate Outcomes Used to Assess Effects of Teamwork
on Patient Outcomes 24

3.1. Basic Organization and Strategy for Teamwork Improvement of the Labor and
Delivery Units 32

3.3. Achievement of Teamwork-Practice Internalization Reported by the Labor and
Delivery Units 35

3.5. Challenges Reported by the Participating Labor and Delivery Units, by Time
Period 38

4.10. Results of Logistic Regressions That Tested Trend Changes in Adverse-Outcome
Index, by Site 68

5.1. Summary of Results Regarding Implementation Progress and Outcome Changes,
by Site 72

G.1. Regression Results for Staff Perceptions of Teamwork in the Labor and Delivery
Unit 116

G.2. Regression Results for Staff Perceptions of Communication Openness in the
Labor and Delivery Unit 117

G.3. Regression Results for Staff Perceptions of Teamwork Climate in the Labor and