Improving Organizational Culture of Accountability Through "Just Culture" and TeamSTEPPS© to Improve Obstetric Sepsis Outcomes

Introduction: Healthcare’s promise to the public is to provide evidence-based patient and family-centered care by applying the most up-to-date research findings for optimal patient outcomes. With such a huge promise to patients, evidence-based practice continues to lag as many as 17 years from emergence by bench scientists to the point of care delivery (Morris et al., 2011). Sepsis presents further challenges in detection and treatment. Sepsis leads to sudden cardiac death if undetected and untreated with evidence-based interventions. Imagine being an emergency department nurse and knowing an acute abdomen has led to sepsis after delivery of a new beautiful baby girl. The obstetrician does not listen to pleas for treatment and attention for what kills more obstetric patients second only to hemorrhage—sepsis. The words spoken are, “Take me to the Emergency Room. They will know how to take care of me!” Sepsis and recognition were both present. Sepsis was present due to an overwhelming abdominal infection and the patient who practices as a professional nurse recognized she was septic, yet a colleague and obstetric caregiver did not listen to pleas for lifesaving treatment and emergent interventions because she failed to recognize sepsis and need for treatment. Imagine delivering a baby on March 22^nd via Cesarean section and dying on April 18^th, just one month and two days after turning 34 years of age in Alberta, Canada. Caregivers failed to keep the public promise to listen to concerns and deliver timely evidence-based care interventions. In March 2016, the septic patient’s sister began working as a Risk Management nurse in an acute care hospital located in the southwestern United States with the goals of improving system failures, communication breakdowns, and organizational cultures leading to the death of her sister across the North American continent and others globally.

Purpose: The purpose of implementing evidence-based teamwork tools through TeamSTEPPS^© (Team Strategies and Tools to Enhance Performance and Patient Safety) and behavior evaluation algorithms to guide a “just culture” assessment of human error versus system failures were to shift focus from blame and judgment to the severity of actions impacting septic obstetric patient clinical outcomes.

Aim: The aim of this project was to improve clinician proficiency in communication, teamwork skills, and organizational culture in an acute obstetric care unit located in the southwestern part of the United States to optimize patient outcomes for those who develop severe sepsis or septic shock.

Significance: TeamSTEPPS^© represents an evidence-based framework to address four key skills needed for optimal teamwork. The four opportunities for improvement in teamwork between caregivers in four acute care obstetric units addressed by TeamSTEPPS^© tools and strategies revolved around leadership, situation monitoring, support, and communication.

Methods: In December 2016, four hour TeamSTEPPS^© classes were provided to all nursing, non-nursing, and medical personnel working with obstetric patients in an acute care facility with antepartum, mother/baby, labor and delivery and obstetric acute care units. The training was mandatory for all fulltime, part-time, and on call employees. Classes were co-taught by a nurse and physician to promote and role model interdisciplinary teamwork and collaboration. Additionally, all newly hired nurses were introduced to risk and safety initiatives followed by organizational sepsis initiatives during new nurse orientation. The Risk Management nurse who lost her sister to sepsis began telling her sister’s story after the Risk Management presentation to introduce the Sepsis Coordinator’s sepsis presentation. The principles of “just culture” were incorporated into policies and processes for nurse escalation of sepsis care concerns in real time. Nurses were empowered to discuss any concerns not resolved using TeamSTEPPS^© strategies and tools with any member of the healthcare leadership team to promote timely and appropriate care.

Results: In May and August of 2018, two direct care nurses working in the Obstetric Acute Unit independently reported care concerns using TeamSTEPPS^© strategies and tools. Each of the two nurses attended new nurse orientation after inclusion of the case study presentation between the risk/safety section and sepsis presentation. Both nurses were comfortable escalating care concerns to the unit’s nursing management team and Sepsis Coordinator. One nurse stated, “After taking my concerns to the Sepsis Coordinator, Chief Nursing Executive, and Chief Medical Officer, I felt as if my voice had been heard and that they were genuinely concerned about nurse and patient safety.” The other nurse notified her nurse manager she would not attend the Root Cause Analysis (RCA) regarding her patient’s situation without the Sepsis Coordinator in attendance too. The same physician was involved in both patient care situations leading to obstetric nurses reporting concerns over patients’ care leading to emergent transfer to the Surgical Intensive Care Unit. Both obstetric patients survived septic shock. The obstetric physician underwent physician peer review when “just culture” identified reckless behavior to be at the core of placing patients at-risk for harm and raising nursing safety concerns.

Discussion: Through deployment of evidence-based strategies such as TeamSTEPPS^© and “just culture”, healthcare organizations can create a culture of accountability. Employees feel empowered to promote organizational goals and responsible for clinical outcomes. Nurses and physicians work as an aligned team towards organizational and clinical results by doing whatever it takes to ensure the highest quality results. A commitment to teamwork and “just culture” may lead to increased employee morale, organizational commitment, and patient satisfaction.

Conclusion: Solid and consistent application by organizational leadership of TeamSTEPPS^© and “just culture” concepts build trust and empower nurses to speak up. Holding caregivers accountable to organizational core values flattens the pyramid of traditional patriarchal healthcare communication, thus replacing traditional focus on chain of command with patient- and family-centered care.