Facilitators and barriers for high-reliability training in medical centers

Clinical environments are often complex and fast-paced, demanding that individuals work cohesively in teams, follow standard operating procedures, share information within and across disciplines, and make sound decisions using accurate information. Meeting these demands requires good communication and an understanding of human factors principles, emphasizing that while human error is unavoidable, patient harm is not.^[1] Clinical Team Training (CTT), a multidisciplinary program based on aviation’s Crew Resource Management (CRM), was established to improve patient safety at Veterans Health Administration medical facilities, where various teams deliver care within a larger system. CTT seeks to influence the culture of the Veterans Health Administration (VHA) healthcare system, guiding it towards adopting a high reliability mindset. The larger system can be enhanced to manage and trap human error before small errors become bigger problems.

Joint Commission statistics (2004-2013) indicate that approximately 70 percent of the time, communication failures are cited as a significant root cause in reported sentinel events. CTT has demonstrated effectiveness at improving communication and teamwork in the clinical environment. A Veterans Affairs (VA) study found a significant decrease in the annual surgical mortality rate in groups trained in CTT methods as opposed to untrained groups. The 74 facilities in the training program experienced an 18 percent reduction in yearly mortality compared with a 7 percent decrease among the 34 facilities that had not yet undergone training. Two other studies showed further positive results from using CTT methods, such as a substantial decrease in the rate of adverse events and the severity of those events in the operating room. CTT methods were also implemented to improve communication and teamwork in 11 nursing units at nine VA facilities during another training program piloted in 2010. The implementation included a six-hour learning session and two-hour clinical simulations using high-fidelity patient simulators.^{[1, 2, 3]}

Across several studies related to team training, there were demonstrated increases in patient safety as evident by reduced adverse events, such as errors in the operating room due to lack of preprocedural verifications. Along with enhanced teamwork behaviors, these studies showed that team training positively impacted clinical processes and patient outcomes. The significant findings included the importance of leadership involvement and interactions with project champions that positively impacted improved teamwork, ultimately resulting in overall quality improvements. Additionally findings showed evidence that CTT improved intragroup positive relationships, improved communication, and promoted standardization of processes resulting in fewer errors and improved patient outcomes.^{[3, 4]}

There is also discussion in the literature suggesting that leadership responsible for organizational change should consider designing and implementing team training in annual planning events.^[4] A study in 2016 demonstrated that the use of team training during annual planning optimized effectiveness of certain critical areas within healthcare operations settings. Investigators discovered an increase in employee engagement that indicated the same number of staff were able to achieve positive outcomes for patients due to improved working relationships and communication. Additionally, there were signs of significant improvement in organizational learning, supervisor and manager expectations, improved teamwork, a reduction of nosocomial infections, reduced falls, and a decrease in patient safety adverse outcomes. Finally, the study determined that leadership support was critical for this success.^[5]

A notable finding relating to evidence on HRO implementation effects in an acute care study revealed that organizations experienced significant reductions in serious safety events (SSEs) (range from 55% to 100%). These improvements were maintained over a nine-year period. Staff who provided feedback during interviews agreed that leadership rounding is associated with an improved patient safety culture, higher employee engagement, and lower burnout.^[6]

In March of 2021, the National Center for Patient Safety (NCPS) leadership aligned with the enterprise-wide implementation of the CTT program. CTT training can be compared to several quality improvement initiatives within the current literature. CRM, Life Flight and the TeamSTEPPS® Program are examples.^[7] These training goals are very similar: increasing patient safety through improving the physical structure of the work environment, communication, standardizing processes, and open and honest dialogue relating to the human potential for mistakes to reduce harm. Organizations have the opportunity to improve human factors that impact the delivery of care and training, resulting in fewer errors through the use of a formalized safety training program. Nearly all participants reported positive outcomes post-intervention and training of CRM, including improved safety numbers.^[1]

The current study aims to determine the facilitating factors and barriers to conducting large-scale CRM-based training in a national health care system (VHA). While there are some studies on this topic, none review training in a federal system or provide data on changes within the system.^{[1, 3, 4, 5, 7]}

2.1The Veterans Health Administration

2.2The Clinical Team Training Program in VHA

The CTT program allows clinicians to improve patient safety by facilitating clear and timely communication through collaborative teamwork in the clinical workplace.^[9] Principles of aviation’s CRM are introduced in a clinical context to model specific applications in the healthcare environment. CTT requires a coordinated, multidisciplinary approach with top leadership engagement and support.^[2] The initial implementation of CTT in VHA was optional and included on-site training with integrated simulation conducted by experienced National Center for Patient Safety faculty, followed by coaching and monitoring unit-based safety projects over twelve months. Recurrent training was completed one year from the initial learning session to reenforce key CRM concepts in the program. The fundamental paradigm of CTT is that frontline clinicians are taught specific CRM communication behaviors to manage human error before patients are harmed. The core topics taught within CTT include: the concept of High Reliability, leadership strategies, effective communication, Just Culture and psychological safety, Effective Followership, situational awareness, error tolerance, and then instruction on conducting a local High Reliability Organization (HRO) project.

Human errors are trapped before they reach the patient through effective teamwork, communication, and higher levels of team situational awareness. ^[10] With the implementation of VHA’s HRO journey in the past 5 years, CTT was required in all clinical areas at each facility and local facility leadership are required to block staff to for attendance. The program used a Train the Trainer model to develop facility-level Master Trainers to implement CTT in 2018. As the implementation spread, NCPS leadership received feedback from the field on multiple challenges in implementing the CTT training and required quality improvement projects. The training started with a video of a poignant patient safety incident involving a routine surgery where complications arose during anesthesia induction. It highlights the tragic consequences of communication failures within the medical team, leading to an inability to adequately address an obstructed airway, ultimately resulting in a preventable death. The following questions were developed to test the participants knowledge and understanding of the principles of Team Training: Who was the leader? What did you think about the communication? What was the team dynamics like? Did they have a sense of urgency or situational awareness? Is this style of leadership Concern for People or Concern for Task? What are the 3 Ws? (What I see, What I’m concerned about, What I think we should do). What are the components that define situational awareness?

Initially, high-level strategic planning meetings between NCPS and the National Center for Organization Development (NCOD) offices were held to discuss reports of local reaction and reception to CTT by VA medical center leadership. More specifically, there were reports of disruptive behavior events being reported during the training and subsequent project implementation of CTT. For example, some clinicians did not think team training would be helpful and did not engage in the training, while other, non-clinicians felt the training was not germane to their work. Consequently, a workgroup within NCPS was formed to: (1) Measure the reaction and reception to CTT training across VA medical centers; (2) Develop a response to any negative reception, including disruptive behaviors to CTT, and (3) Implement and share the developed response(s) to appropriate NCPS leadership and VA medical center leadership.

The multi-professional workgroup was comprised of 11 NCPS team members, including Subject Matter Experts (SMEs) related to CTT, education, analysis, coordination support, and office leadership. Additionally, two NCOD staff were consulted during this program stage to facilitate discussion and guide the development of evaluation and response tools. The multi-professional group met weekly to review CTT materials and known responses from the field. It was decided that further evaluation of the responses from critical VHA medical center staff was needed. A subgroup was formed to host semi-structured focus groups to measure that feedback.

The four focus group facilitators participated in two coaching sessions from NCOD on conducting focus groups. Facilitators were divided into two groups ensuring diversity of backgrounds and facilitation experience. Focus group content was developed iteratively by the subgroup and NCOD consultants with the intent to produce a non-punitive and psychologically safe structured interview to use in the focus groups.

The focus groups targeted VA medical center CTT Points of Contact (POC), HRO Leads and CTT Master Trainers. These positions were thought to have the best exposure and perspective to their local VAMC staff’s reaction and reception to CTT training and project implantation. NCPS sent a request to participate to all VHA CTT POC, HRO Leads, and 60 random CTT Master Trainers from every VA medical center. Forty-eight of the 138 CTT POC and HRO leads (response rate 35%) and 11 of the 60 CTT Master Trainers (response rate 18%) responded. Six of the 48 CTT POC and HRO leads, and 8 of the 11 CTT Master Trainers participated. They were grouped by CTT POC/HRO Lead and CTT Master Trainers, then by date and time preference.

Responses were collected live and presented to all participants in each focus group session to ensure participant comfort and accuracy. All subgroup leaders agreed on iteratively and qualitatively reviewing participant responses from the four open-ended and three poll questions. Each subgroup leader was assigned a question to conduct a preliminary review of participant responses. After the initial review, a second leader then re-reviewed the participant responses. Over multiple iterations, themes emerged and were formalized by the team (see Figure 1 for focus group questions and response themes).

Figure 1.

Focus group questions and response themes

Overall, the focus groups revealed that Leadership engagement in cultural change is imperative. The focus groups also identified that language and examples used in the curriculum may have inadvertently marginalized individuals by making some non-clinical team members feel excluded as part of the team. In addition, some participants felt that the use of the term “Projects” created a negative connotation for the required quality improvement project on each unit and instead preferred the terms “micro-project,” “safety strategy,” or “quick wins.”

Table 1 displays the focus group responses by question. Themes are displayed with examples of each theme (see Table 1). For the first question (What, if anything, has stood out to you with people’s reactions either during the teaching of CTT, project selection, or project implementation), the major positive themes were: The training has helped, leadership support is important, and conducting a project is worthwhile. There were also several suggestions for improvement of the program. In addition, the major negative themes included: questions about the validity of the training, problems conducting a project, staff feeling intimidated or overwhelmed, staff feeling skeptical about the training, problems tracking the results, issues with virtual training during the COVID-19 pandemic, and low “buy-in” from staff.

For the second question (Do any notable behaviors stand out to you for units that have completed CTT and are starting, or have completed, the Unit-Based Safety Project) the major themes were: The majority reported success, leadership “buy-in” is needed for success, projects can be too broad or the wrong focus. In addition, for the third question, which was a poll on the use of resources supplied by the CTT program, we saw that most of the participants reported using most or all of the resources provided. The resources provided to the field included CTT Instructor Supplement, CTT Project Unit-Based Safety Project Implementation Packet, and CTT Unit-Based Safety Project Options Table (see Table 2).

For the fourth question (What resources or tools do you feel would be beneficial to support your efforts in either teaching CTT or facilitating project selection and implementation that are not currently available?), the major themes were: Do more to include nonclinical staff, make more video training, have longer sessions and manage disruptive behavior during training; develop online training, provide more information about conducting the projects, use adult-learning concepts more, provide examples of unit projects, and more information about who the mentors for the project should be.

For the fifth question (Is there anything you would like to share that was not covered in the above questions?), the major themes were: positive aspects of CTT, more suggestions for improvement, and the importance of early and ongoing education about the CCT program to the entire facility.

The aim of this study was to investigate the implementation of CTT, a well-studied method for promoting the safeguarding of healthcare against unintentional error.^{[2, 4, 5, 7]} The ongoing enterprise-wide implementation of CTT is now mandatory for all VHA staff on clinical units, representing a significant investment of time and resources. Therefore, a thorough evaluation of its effectiveness, impact on patient safety and care outcomes, and the identification of best practices are essential for ensuring a successful and sustainable integration of HRO principles throughout the organization.

Our qualitative investigation provides insights into frontline perceptions of CTT implementation, reinforcing existing literature on barriers to effective team training efforts while also advancing the field with new findings. Specifically, our results support commonly cited required change effort components, including the need for highly visible leadership engagement, adequate time to undertake and complete projects, and overcoming skepticism.^[2] For example, successful teams reported having senior leaders addend the training session and provide reasons why the training was important.

CTT master trainers and coordinators noted that a significant barrier to the implementation of the required CTT projects was the term “project” itself. During focus groups, many CTT faculty reported that the term had a negative connotation, given that in the VHA, “project” is usually used in the context of much larger change efforts. To address this hesitancy, teams adopted terms such as “micro-project,” “safety strategy,” or “quick wins,” which were reported as successful methods for overcoming the negative connotation associated with the term.

Team training efforts in the VHA were originally designed based on Medical Team Training, which focused heavily on medical teams. CTT has evolved to expand beyond the narrow focus of medical teams and incorporate a diverse range of clinical, support staff and administrative teams encountered in healthcare organizations. While earlier versions of the training curricula were limited by their clinical focus, CTT has expanded to address this limitation.

The VHA HRO Journey seeks to change cultural norms across the largest integrated healthcare network in the United States, promoting high-quality and safe care for all Veterans who seek care in the VHA. However, achieving cultural change requires more than simply adapting new training tools or materials into the current cultural milieu. It involves transforming and reintegrating mindsets, behaviors, and interactions among individuals and teams within the organization, ultimately leading to a more effective, safety-oriented, and collaborative work environment. Therefore, it is crucial for CTT to impart a lasting impression on how individuals and teams work or respond.

4.1Changes made in VHA as a result of the focus group feedback

4.2Limitations and future directions

Regina Knowles – original concept, writing and editing. Carol M. Jones – writing and editing. Blake Webb, MD – writing and editing. Deborah Welsh, MS – data analysis, writing and editing. Peter D. Mills, PhD, MS – figures, writing and editing, submitting paper for publication.

Informed patient consent was not required because no patient clinical or identity data was collected, and no patient interventions were completed during the course of study. Therefore ethical review board approval was not required and waived.

This work has no external financial support.

The author declares that there is no conflicts of interest.

The Publication Ethics Committee of the Sciedu Press. The journal’s policies adhere to the Core Practices established by the Committee on Publication Ethics (COPE).

Not commissioned; externally double-blind peer reviewed.

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

No additional data are available.