Developing a culture of safety is a core element of many efforts to improve patient safety and care quality. This systematic review identifies and assesses interventions used to promote safety culture or climate in acute care settings. The authors searched MEDLINE, CINAHL, PsycINFO, Cochrane, and EMBASE to identify relevant English-language studies published from January 2000 to October 2012. They selected studies that targeted health care workers practicing in inpatient settings and included data about change in patient safety culture or climate after a targeted intervention. Two raters independently screened 3679 abstracts (which yielded 33 eligible studies in 35 articles), extracted study data, and rated study quality and strength of evidence. Eight studies included executive walk rounds or interdisciplinary rounds; 8 evaluated multicomponent, unit-based interventions; and 20 included team training or communication initiatives. Twenty-nine studies reported some improvement in safety culture or patient outcomes, but measured outcomes were highly heterogeneous. Strength of evidence was low, and most studies were pre-post evaluations of low to moderate quality. Within these limits, evidence suggests that interventions can improve perceptions of safety culture and potentially reduce patient harm.

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Promoting a culture of safety as a patient safety strategy: a systematic review.

Objectives To review important patient safety practices for evidence of effectiveness, implementation, and adoption. Data sources Searches of multiple computerized databases, gray literature, and the judgments of a 20-member panel of patient safety stakeholders. Review methods The judgments of the stakeholders were used to prioritize patient safety practices for review, and to select which practices received in-depth reviews and which received brief reviews. In-depth reviews consisted of a formal literature search, usually of multiple databases, and included gray literature, where applicable. In-depth reviews assessed practices on the following domains: • How important is the problem? • What is the patient safety practice? • Why should this practice work? • What are the beneficial effects of the practice? • What are the harms of the practice? • How has the practice been implemented, and in what contexts? • Are there any data about costs? • Are there data about the effect of context on effectiveness? We assessed individual studies for risk of bias using tools appropriate to specific study designs. We assessed the strength of evidence of effectiveness using a system developed for this project. Brief reviews had focused literature searches for focused questions. All practices were then summarized on the following domains: scope of the problem, strength of evidence for effectiveness, evidence on potential for harmful unintended consequences, estimate of costs, how much is known about implementation and how difficult the practice is to implement. Stakeholder judgment was then used to identify practices that were "strongly encouraged" for adoption, and those practices that were "encouraged" for adoption. Results From an initial list of over 100 patient safety practices, the stakeholders identified 41 practices as a priority for this review: 18 in-depth reviews and 23 brief reviews. Of these, 20 practices had their strength of evidence of effectiveness rated as at least "moderate," and 25 practices had at least "moderate" evidence of how to implement them. Ten practices were classified by the stakeholders as having sufficient evidence of effectiveness and implementation and should be "strongly encouraged" for adoption, and an additional 12 practices were classified as those that should be "encouraged" for adoption. Conclusions The evidence supporting the effectiveness of many patient safety practices has improved substantially over the past decade. Evidence about implementation and context has also improved, but continues to lag behind evidence of effectiveness. Twenty-two patient safety practices are sufficiently well understood, and health care providers can consider adopting them now.

Making health care safer II: an updated critical analysis of the evidence for patient safety practices.

The objective of this study was to conduct a systematic review and meta-analysis of teamwork interventions that were carried out with the purpose of improving teamwork and team performance, using controlled experimental designs. A literature search returned 16,849 unique articles. The meta-analysis was ultimately conducted on 51 articles, comprising 72 (k) unique interventions, 194 effect sizes, and 8439 participants, using a random effects model. Positive and significant medium-sized effects were found for teamwork interventions on both teamwork and team performance. Moderator analyses were also conducted, which generally revealed positive and significant effects with respect to several sample, intervention, and measurement characteristics. Implications for effective teamwork interventions as well as considerations for future research are discussed.

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The Effectiveness of Teamwork Training on Teamwork Behaviors and Team Performance: A Systematic Review and Meta-Analysis of Controlled Interventions

A high variety of team interventions aims to improve team performance outcomes. In 2008, we conducted a systematic review to provide an overview of the scientific studies focused on these interventions. However, over the past decade, the literature on team interventions has rapidly evolved. An updated overview is therefore required, and it will focus on all possible team interventions without restrictions to a type of intervention, setting, or research design. To review the literature from the past decade on interventions with the goal of improving team effectiveness within healthcare organizations and identify the “evidence base” levels of the research. Seven major databases were systematically searched for relevant articles published between 2008 and July 2018. Of the original search yield of 6025 studies, 297 studies met the inclusion criteria according to three independent authors and were subsequently included for analysis. The Grading of Recommendations, Assessment, Development, and Evaluation Scale was used to assess the level of empirical evidence. Three types of interventions were distinguished: (1) Training, which is sub-divided into training that is based on predefined principles (i.e. CRM: crew resource management and TeamSTEPPS: Team Strategies and Tools to Enhance Performance and Patient Safety), on a specific method (i.e. simulation), or on general team training. (2) Tools covers tools that structure (i.e. SBAR: Situation, Background, Assessment, and Recommendation, (de)briefing checklists, and rounds), facilitate (through communication technology), or trigger (through monitoring and feedback) teamwork. (3) Organizational (re)design is about (re)designing structures to stimulate team processes and team functioning. (4) A programme is a combination of the previous types. The majority of studies evaluated a training focused on the (acute) hospital care setting. Most of the evaluated interventions focused on improving non-technical skills and provided evidence of improvements. Over the last decade, the number of studies on team interventions has increased exponentially. At the same time, research tends to focus on certain interventions, settings, and/or outcomes. Principle-based training (i.e. CRM and TeamSTEPPS) and simulation-based training seem to provide the greatest opportunities for reaching the improvement goals in team functioning.

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Interventions to improve team effectiveness within health care: a systematic review of the past decade

Recognizing the importance of teamwork in hospitals, senior leadership from the American College of Physician Executives (ACPE), the American Hospital Association (AHA), the American Organization of Nurse Executives (AONE), and the Society of Hospital Medicine (SHM) established the High Performance Teams and the Hospital of the Future project. This collaborative learning effort aims to redesign care delivery to provide optimal value to hospitalized patients. With input from members of this initiative, we prepared this report which reviews the literature related to teamwork in hospitals. Teamwork is critically important to provide safe and effective hospital care. Hospitals with high teamwork ratings experience higher patient satisfaction, higher nurse retention, and lower hospital costs. Elements of effective teamwork have been defined and provide a framework for assessment and improvement efforts in hospitals. Measurement of teamwork is essential to understand baseline performance, and to demonstrate the utility of resources invested to enhance it and the subsequent impact on patient care. Interventions designed to improve teamwork in hospitals include localization of physicians, daily goals of care forms and checklists, teamwork training, and interdisciplinary rounds. Though additional research is needed to evaluate the impact on patient outcomes, these interventions consistently result in improved teamwork knowledge, ratings of teamwork climate, and better understanding of patients' plans of care. The optimal approach is implementation of a combination of interventions, with adaptations to fit unique clinical settings and local culture.

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Interdisciplinary teamwork in hospitals: a review and practical recommendations for improvement.

BACKGROUND:
Effective collaboration and teamwork is essential in providing safe and effective care. Research reveals deficiencies in teamwork on medical units involving hospitalists.

OBJECTIVE:
The aim of this study was to assess the impact of an intervention, Structured Inter-Disciplinary Rounds (SIDR), on nurses' ratings of collaboration and teamwork.

METHODS:
The study was a controlled trial involving an intervention and control hospitalist unit. The intervention, SIDR, combined a structured format for communication with a forum for regular interdisciplinary meetings. We asked nurses to rate the quality of communication and collaboration with hospitalists using a 5-point ordinal scale. We also assessed teamwork and safety climate using a validated instrument. Multivariable regression analyses were used to assess the impact on length of stay (LOS) and cost using both a concurrent and historic control.

RESULTS:
A total of 49 of 58 (84%) nurses completed surveys. A larger percentage of nurses rated the quality of communication and collaboration with hospitalists as high or very high on the intervention unit compared to the control unit (80% vs. 54%; P = 0.05). Nurses also rated the teamwork and safety climate significantly higher on the intervention unit (P = 0.008 and P = 0.03 for teamwork and safety climate, respectively). Multivariable analyses demonstrated no difference in the adjusted LOS and an inconsistent effect on cost.

CONCLUSIONS:
SIDR had a positive effect on nurses' ratings of collaboration and teamwork on a hospitalist unit, yet no impact on LOS and cost. Further study is required to assess the impact of SIDR on patient safety measures. Journal of Hospital Medicine 2010. © 2010 Society of Hospital Medicine.

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Improving teamwork: Impact of structured interdisciplinary rounds on a hospitalist unit

Importance Though interprofessional bedside rounds have been promoted to enhance patient-centred care for hospitalised patients, few studies have been conducted in adult hospital settings and evidence of impact is lacking.

Objective To evaluate the effect of patient-centred bedside rounds (PCBRs) on measures of patient-centred care.

Design and setting Cluster randomised controlled trial involving four similar non-teaching hospitalist service units in a large urban hospital.

Participants Hospitalised general medical patients.

Intervention We assembled working groups on two intervention units, consisting of professionals and patient/family members, to determine the optimal timing, duration and format for PCBR. Nurses and hospitalists rounded together in PCBR using a communication tool to provide a framework for discussion and unit leaders joined PCBR to provide coaching during initial weeks of implementation.

Main outcomes Using patient interviews, we assessed preferred and experienced roles in medical decision-making using the Control Preferences Scale, activation using the Short Form of the Patient Activation Measure, and satisfaction. We also compared postdischarge patient satisfaction survey items related to teamwork, involvement in decisions and overall care. We assessed nurses’, physicians’ and advanced practice providers’ (APP) perceptions of PCBR using a survey developed for this study.

Results Overall, 650 patients were approached for structured interview during hospitalisation: 284 were excluded because of disorientation, 54 were excluded because of non-English language, 72 declined to participate and 4 withdrew from the study after enrolment. Interview data were available for 236 (122 control and 114 intervention unit) patients, and postdischarge satisfaction survey data were available for 493 (274 control and 219 intervention unit) patients. We found no significant differences in patients’ perceptions of shared decision-making, activation or satisfaction with care. Results were similar in analyses based on whether PCBR had been performed (ie, per protocol). We also found no difference in postdischarge patient satisfaction items. Results were similar in multivariate analyses controlling for patient characteristics and clustering of patients within study units. A majority of nurses (78.6%), but only about half of hospitalist physicians and APPs felt that PCBR improved communication with patients (47.4%). A minority of nurses (46.4%) and physicians and APPs (36.8%) agreed that PCBR had improved the efficiency of their workday.

Conclusions PCBR had no impact on patients’ perceptions of shared decision-making, activation or satisfaction with care. Additional research is needed to identify optimal approaches that can be reliably implemented in hospital settings to improve patient-centred care.

https://qualitysafety.bmj.com/content/qhc/early/2015/12/01/bmjqs-2015-004561.full.pdf

Effect of patient-centred bedside rounds on hospitalised patients' decision control, activation and satisfaction with care

Non–housestaff medicine services are growing rapidly in academic medical centers (AMCs), partly driven by efforts to comply with resident duty hour restrictions. Hospitalists have emerged as a solution to providing these services given their commitment to delivering efficient and high-quality care and the field's rapid growth. However, limited evidence is available on designing these services, including the similarities and differences of existing ones. We describe non–housestaff medicine services at 5 AMCs in order to share our experiences and outline important considerations in service development. We discuss common challenges in building and sustaining these models along with local institutional factors that affect decision making. Keys to success include ensuring an equitable system for scheduling and staffing, fostering opportunities for scholarly activities and academic promotion (defining the “academic hospitalist”), and providing compensation that supports recruitment and retention of hospitalists. With further work hour restrictions expected in the future and increased requests for surgical comanagement, the relationship between AMCs and hospitalists will continue to evolve. To succeed in developing hospitalist faculty who follow long careers in hospital medicine, academic leadership must carefully plan for and evaluate the methods of providing these clinical services while expanding on our academic mission. Journal of Hospital Medicine 2008;3:247–255. © 2008 Society of Hospital Medicine.

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Non-housestaff medicine services in academic centers: models and challenges.

We were pleased to read the letter from Drs Merchant and Federman as we had hoped that our study would prompt deeper thought and further discussion about interprofessional bedside rounds.1 Like Drs Merchant and Federman, we were disappointed that the intervention used on our study, patient-centred bedside rounds (PCBR), did not result in improved patients’ perceptions of shared decision making, activation or satisfaction with care. Merchant and Federman state that prior studies have shown that patients prefer their team conduct rounds at the bedside. We wish to point out that the studies cited …

https://qualitysafety.bmj.com/content/qhc/early/2016/02/28/bmjqs-2016-005371.full.pdf

Hiren M Shah

Papers

Improving teamwork: Impact of structured interdisciplinary rounds on a hospitalist unit

Effect of patient-centred bedside rounds on hospitalised patients' decision control, activation and satisfaction with care

Non-housestaff medicine services in academic centers: models and challenges.

Response to the letter to the editor by Drs Merchant and Federman