One of the clinical specialties that stands out when it comes to professional liability is obstetrics. Nowhere do the clinical stakes and the patient's expectations seem higher. Rarely is the plaintiff in a malpractice trial more sympathetic. This is echoed in the professional liability premiums that obstetricians pay, some of the highest in the industry. In the Harvard medical system, the self-insurance program known as CRICO is pursuing a proactive role in promoting patient safety and improved outcomes. CRICO has begun offering a malpractice premium incentive discount to the OBs it insures. The discount applies if the insured physician meets six criteria, one of which is attendance at a program for team training. One of the team training programs approved by the liability insurer involves a labor & delivery simulator.
"We were particularly interested in the simulator because the simulation scenarios are based on our own malpractice claims."
Jack McCarthy is president of Risk Management Foundation, which oversees the insurance program for the Harvard-affiliated medical institutions.
"We've compiled the medical incidents and then they've been turned into simulation scenarios. So, it gives the providers a very realistic setting to practice in. We became interested in this based on our own claims review in the obstetrical area. As you know, awards and judgments and settlements in obstetrics can be in multiple millions of dollars, so it's a very serious loss area for us. We also noted through the claims review that many times the vulnerabilities in the claims resulted from either poor team coordination or poor monitoring and reaction times by providers when patient vitals showed signs of trouble. So, the simulator really helps to develop teamwork and refine the reaction when the monitoring shows there's a need to intervene."
Dr. Roxane Gardner is an obstetrician who helps run the simulator program for OBs. The facility features a make-believe operating room with a robotic patient and a simulated intensive care unit. A behind-the-scenes control room contains all the computers and audio-visual components that make it look and feel like a labor and delivery suite. Dr. Gardner:
"There are a number of different things that can be done because these types of mannequins can adjust themselves physiologically to whatever is done in a very realistic way. Over the past year we've actually worked on this diligently and have come up with a very credible, realistic way with allowing a vaginal birth to happen so we can create situations that are commonly encountered in vaginal birth—something like shoulder dystocia or imminent delivery that needs to be accomplished with either a vacuum or forceps. We also have a capacity to create a situation that can accommodate a Cesarean section. So, you can go through the motions and make an incision in the abdomen, go down through the layers and eventually get into the uterus that we've created and deliver a baby out of that, as well as its placenta."
Dr. Gardner points out that the training content, more than the equipment, makes the simulation valuable. She says that the issues they review when attendees see videotapes and critique each other's performance are not widely taught in medical school.
"The kinds of things that we're focusing in on are really centered around teamwork and hoping to improve our ability to communicate and share information about what we know about the patient. Often times there are pieces of information that each of the disciplines has acquired through either separate conversations that they've had with the patient, or impressions that they've made from the medical record, or that they've obtained through their colleagues. And sometimes, more often than not, that information doesn't get shared amongst everybody in the team. And if you have the situation that begins to escalate in complexity, then those pieces of information that haven't been shared may actually become critical pieces of information that make or break how smoothly and how well an event is managed."
Entire labor and delivery teams might attend the simulator course at once. Even a clinician attending as an individual will be joining members of other disciplines typically involved in labor and delivery. Dr. Thomas Beatty, chair of the obstetrics and gynecology department at Newton Wellesley Hospital near Boston, was in one of the first classes to complete the simulator requirement for the insurance incentive program.
"The difference was the difference between sort of didactic learning and then learning through experience. So, I was in the experience of a simulated case of shoulder dystocia, which all obstetricians think about at delivery, and so I put in the experience of reacting with the other members of the team and treating the shoulder dystocia and then I had the chance to go back and look and critique, if you will, how we responded. What did we do that worked well? What areas could we have improved?"
Dr. Beatty even shares some insights into what he could improve.
"Sort of the area of clarity: being clear to let someone know that I needed help from them or a particular resource and I was directing my request to that particular person. It's sort of clarity that if I needed someone to help me with this certain maneuver—that I asked them, but also made sure that they responded back that they heard me."
Another attendee was Dr. Jeffrey Ecker, an obstetrician who specializes in high risk cases. He brought his entire care team from Massachusetts General Hospital to the one-day simulator event. Dr. Ecker had expected the course to emphasize facts and specific bits of knowledge. Instead, he says he learned a new appreciation for the value of explicit communication and techniques for sharing information.
"It's very clear that those who have designed it really mean for it to be an education in systems and not particular situations or responding to particular emergencies, but to give people who attend a template for how they can organize their thoughts and forces and resources around any emergency."
Dr. Ecker says his team found that they already shared some strengths. Yet, the simulator experience helped them see the risk in taking anything for granted. Participating in realistic labor and delivery emergencies and the chance to review and analyze the video together afterward reinforced some key team principles.
"One of the things that this simulator makes clear is that when there is an emergency or unexpected event it's both important for people's responsibilities to be clear and often that will include one person being designated as a leader. And the second thing that's important is that nothing should ever be assumed and that it never hurts to make even the most obvious thoughts, or this is what I'm thinking, or this is what we're going to do next explicit, that when you start to assume even things you think everyone knows that there may be someone that has a different assumption. And as a consequence, if someone doesn't say out loud what the next step is, what the plan is, that person may go off in a different direction."
Will the result of such training lead to fewer malpractice claims for Jack McCarthy's company to manage? McCarthy says simulators and other team training programs hold far more potential than other remedies for today's malpractice environment.
"I think that as people look at tort reform many of the proposed solutions are really very narrow in range and will be very short lived. I think insurers must begin to provide education and incentives in the area of patient safety. It's only by making the healthcare system safer will we affect the long-term cost of malpractice coverage."
More information on the CRICO premium discount program for obstetrics can be found here
