As with many healthcare quality outcomes, studies have found disparities in adverse safety events between cultural and racial/ethnic groups in the United States. Safety outcomes in which certain groups experience disproportionately high adverse events include: healthcare-associated infections, diagnostic errors, adverse birth outcomes, medication errors (e.g., polypharmacy and adverse medication events), inappropriate care transitions; and failure to obtain patient directives. One study found that 49.1% percent of adverse events for Limited English Proficient (LEP) patients resulted in physical harm, whereas 29.5% of adverse events for patients who speak English resulted in harm. 134 Patient–provider communication challenges and cross-cultural issues are at the root of many adverse events. Conversely, patients of physicians reporting greater cultural competency were more satisfied, and reported seeking and sharing more information during the medical visit. In one study, provider cultural competency was linked to higher prescribing of antiretroviral medications, patient medication adherence, and viral suppression in non-white HIV patients. 135 Tools specifically developed to mitigate potential adverse events, such as patient suicide, may be more effective when tailored to a patient’s culture, and language services and language concordance between providers and patients have been associated with improved patient outcomes. Implementation: challenges Several barriers to implementing cultural competency practices have been identified, including translating training into practice and understanding the best methods for providing performance feedback to physicians. Another challenge is identifying patients’ language needs. A specific implementation issue is the underuse of professional interpreters in the clinical setting. This is despite the fact that language services are legally mandated and that providers have reported a preference for working with professional interpreters over ad hoc interpreters (family, friends, or untrained staff). There are structural and provider-level reasons for underuse of interpreters, such as the fact that not all states provide reimbursement. For example, pediatricians in states with reimbursement had twice the odds of using a formal interpreter versus those in non-reimbursing states (odds ratio [OR] 2.34; 95% CI 1.24 to 4.40). 136 Barriers to interpreter use at the clinician level include lack of convenience and time pressures, as well as concerns about the quality of interpretation and resource constraints. While physicians have expressed a preference for in-person interpreters, use of telephone and video conferencing increases efficiency and may help to increase use of interpreters. To improve utilization, some have called for organizational resources and guidelines that are consistent with institutional policies and professional norms. Additionally, educational campaigns could help shift clinician culture away from ad hoc interpreters. Despite the cost of interpreter services, studies show that,
ultimately, providing the service is cost-effective in terms of improved care. . Sharing of resources across organizations has helped some facilities to overcome cost barriers. Finally, to address need, more effort could be made to recruit bilingual clinicians with appropriate training and certification. Teamwork and team training Failures in communication and teamwork have been identified as contributing factors in approximately 68% of adverse events. 11 Considerable effort has been made to improve teamwork within healthcare settings through the use of team training programs and performance support tools. Team-training is defined as a constellation of content (i.e., specific knowledge, skills, and attitudes (KSAs) that underlie targeted teamwork competencies, tools (i.e., team task analysis, performance measures), and delivery methods (i.e., information, demonstration and practice-based learning methods) that together form an instruction strategy. Some of the earliest healthcare team training programs were based on Crew Resource Management (CRM), an established and validated strategy within the aviation community. Subsequently, the Veterans Health Administration introduced its own team training program, called Medical Team Training. Similarly, AHRQ partnered with the Department of Defense to develop a team training program specifically designed for healthcare providers called Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS). Introduced in 2006, TeamSTEPPS aims to improve a common set of team KSAs that providers can apply when working in any healthcare team. 137 Four specific, trainable skills are highlighted in the program: leadership, situation monitoring, mutual support, and communication. Since its inception, TeamSTEPPS has become the national standard for team training in healthcare. In 2015, it was estimated that over 1.5 million individuals had been trained in TeamSTEPPS. One reason for this uptake is that TeamSTEPPS concepts are applicable across healthcare environments and the training (and associated support tools) are easily adaptable. Moreover, evaluation data collected on TeamSTEPPS and other team training programs have demonstrated positive results. Team training programs such as TeamSTEPPS also include a variety of tools to help ensure that teamwork skills are transferred from the training environment and integrated into daily practices. Toward that end, performance support tools such as checklists, briefings, and huddles have been implemented to increase communication and teamwork in a variety of healthcare environments. Crew resource management CRM Training was originally developed to improve teamwork within the aviation community. CRM programs focus on improving attitudes toward and knowledge about teamwork, as well as increasing the use of teamwork skills. CRM programs generally follow a workshop format (i.e., classroom training)
that includes a didactic lecture, demonstration of both positive and negative examples of teamwork, hands-on practice using teamwork skills (e.g., in role play exercises or simulation exercises), and feedback regarding the effectiveness of teamwork skills demonstrated by participants. A considerable amount of research on improving teamwork and communication within healthcare has applied CRM as an instructional strategy. The systematic review of team training conducted by Weaver et al. (2014) included nine studies of CRM. 138 Four CRM studies in that review measured results through the collection of various clinical process and outcome measures. They reported that CRM was associated with improvements in clinical management scores, decreases in adverse outcome index (i.e., composite score of clinical outcomes), increases in standards in care (e.g., speed and completeness of resuscitations in the emergency department), and increased patient satisfaction. Overall, results demonstrated positive results on process measures. Specifically, trainees reacted positively to the CRM training across studies, improved their knowledge of teamwork, and reported greater confidence in using teamwork skills. Importantly, data also indicated that trainees increased their use of team KSAs back on the job. TeamSTEPPS® training TeamSTEPPS is a team training program developed specifically for healthcare providers by the U.S. Department of Defense in collaboration with AHRQ. TeamSTEPPS training focuses on four trainable teamwork behaviors: communication, leadership, situation monitoring, and mutual support. The training imparts information on these behaviors, incorporates videos demonstrating positive and negative examples of the skills being used, and provides multiple tools that can be used to increase teamwork behaviors in healthcare settings. Although the TeamSTEPPS program has evolved over the years to include multiple settings (e.g., office-based care, long-term care), as well as online training modules, the studies in the current review followed the traditional TeamSTEPPS program for hospital settings. MTT In 2007, the Veterans Health Administration (VA) introduced its own team training program, MTT. MTT focuses on improving communication through a training workshop, as well as on the job through the implementation of team briefings before and after surgical cases. One study included in Weaver et al.’s (2014) systematic review found significant improvements in teamwork climate items reported for physicians and nurses. 138 Team simulation Simulation is another method used to improve teamwork skills. Simulation provides teams with realistic scenarios that they may face, either routinely or in emergencies. These scenarios allow participants to practice critical teamwork behaviors and receive feedback.
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