Where the Idea Originated
The idea for Medical Team Training (MTT) came from the realization that many safety issues in health care are related to a failure in communication.
The aviation industry recognized this problem 25 years ago and developed Crew Resource Management (CRM) to address communication failure. CRM is defined as using all available sources (information, equipment, and people) to achieve safe and efficient operations.
The focus of CRM is the safety, efficiency, and morale of humans working together.
Since health care has many features in common with aviation (high profile, complex technology, well educated professionals, and significant risk), NCPS hypothesized that CRM principles would have applications in health care — and they do!
Why it is Important
Studies continue to show that a majority of adverse medical events involve communication failure.
NCPS has developed an internal, confidential, non-punitive system — the Patient Safety Information System (nicknamed “SPOT”). More than 15,000 root cause analysis (RCA) reports and nearly 700,000 safety reports have been recorded in SPOT since NCPS was established.
Upon review of 5,511 of these RCA case reports from VA Medical Centers throughout the United States, 78 percent of the cases identified communication failure as at least one root cause contributing factor in the reported adverse event or close call.
Specifics About the Program
The MTT program was developed in 2003-2004 to improve outcomes of patient care through more effective communication and teamwork among health care providers.
During Phase I of the program, NCPS has conducted 160 MTT Learning Sessions, involving 144 facilities, and targeting more than 12,000 caregivers. The focus of Phase I was to improve patient outcomes through more effective communication and teamwork among providers in critical care areas, such as the operating room and intensive care unit.
Implementation teams from 110 VA medical centers that completed the MTT program in March 2009 provided insight into the program’s impact in the operating room:
- 82 percent reported improved teamwork
- 78 percent indicated improved efficiency
MTT Phase II is underway and focuses other clinical areas, such as cardiac catheterization labs, endoscopy units, and primary care clinics.
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Medical Team Training