Medical Team Training at VHA reduces rate of adverse events

Reported adverse events decreased from 3.21 to 2.4 per month

A recent follow-up study in the Archives of Surgery shows that improvement in patient safety has resulted from the implementation of Medical Team Training at a number of Veterans Health Administration (VHA) hospitals.

The report shows a decrease in adverse events and harm at VHA hospitals over a three-year period. It found a significant decrease in the number of adverse events reported per month from July 2006 through December 2009, compared to a study conducted from 2001 to mid-2006 (2.4 vs. 3.21). The authors attributed the decline to a greater emphasis on safety, team training and communication. They also identified 237 incidents, 101 of which were adverse events and 136 of which were "close calls."1

VHA began implementing Medical Team Training (MTT) in March 2005 to improve patient outcomes through more effective communication and teamwork among providers in critical care areas. Since then, the training program has facilitated 217 learning sessions that have involved 15,470 caregivers at VHA facilities nationwide.

"Eliminating wrong-site surgery has been a real challenge for the health care field," notes Julia Neily, RN, MS, MPH, associate director, National Center for Patient Safety (NCPS), Field Office, and lead author of the Archives study. "It seems people can't get to zero; we're really pleased about the fact that we saw a decrease."

Following aviation's model

According to the Department of Veterans Affairs (VA), the idea for MTT came from the realization that many safety issues in health care are related to miscommunication and the failure of groups to operate as effective teams. The aviation industry recognized this problem 30 years ago and developed Crew Resource Management (CRM) to address communication failure in the cockpit. (CRM is defined as using all available sources — information, equipment, and people — to achieve safe and efficient operations.)

NCPS began developing the MTT program in 2003. Phase I focused on operating room and surgical intensive care unit staff. It was rolled out in March 2005 and ended June 2009. Phase II extended the program to non-operating room clinical areas and began in July 2009. In a final Phase I update report, dated Aug. 30, 2010, teams from 121 VA medical centers provided this additional insight into the program's effect in the operating room:

  • Sixty-nine percent reported improved teamwork.
  • Sixty-six percent indicated improved efficiency (better equipment use; improved first-case on-time starts).

"The goal and mission of the program are to improve outcomes for veterans by enhancing teamwork and communication skills of providers," says Douglas E. Paull, MD, FACS, FCCP, director of Patient Safety Curriculum for NCPS.

The first phase, he explains, includes preparation and planning. "It starts with a leadership call — engaging facility leadership in the project. If they are on board, our own publications disclose a four-fold increase in the success of a process improvement being sustained one year later."

"About three months prior to the learning sessions we did our pre-work, which included developing an inter-disciplinary team — thinking about what they wanted to work on, and which specialty they wanted to start improvement in," adds Neily. "That way we already had some buy-in on what they wanted to improve."

Local champions and implementation teams were selected by each local VA facility clinical area, Paull continues. So, for example, the chief of surgery would be a champion, and in turn would select frontline staff and administrators to join him or her on the implementation team. The local champions and their implementation teams would then select from among the six available patient safety projects: checklist-guided preoperative briefings and postoperative debriefings; SBAR handoffs; interdisciplinary administrative briefings; interdisciplinary patient centered rounds; code debriefings; and fatigue management. Many sites selected a second project, Paull notes.

The second phase, says Paull, was the on-site training itself. "This was heavily influenced and based on CRM communication techniques," he notes. The peer-to-peer training was multidisciplinary and interactive, Paull says.

The final phase, follow-up, involved sharing of lessons learned, troubleshooting, PDSA (Plan Do Study Act) cycles, and celebrating successes.

Gaining staff buy-in

When addressing staff buy-in, "we are really talking about patient safety culture here," says Paull. "They want best outcomes for veterans and superior working relationships with their colleagues. They design their own projects, checklists, and which patient safety issues are tackled. They own their projects."

Paull shared initial MTT results in improvements in efficiency and success stories with teams early on, he notes. "Tracking outcomes data that is already collected made it easier for implementation teams," says Paull. "Providing support in the way of a website, a listserv, monthly calls, follow-up interviews and coaching aided the cause."

While certain standardized approaches were employed, each facility made adaptations to their environment. "We felt that helped the buy-in of folks from all different levels; we honored their system," says Neily. "It also helped with implementation."

In terms of implementation, notes Paull, from about 2003-2009 MTT focused largely on the OR and the ICU. "Because of acuity and complexity of care, errors that occur in these arenas can have serious consequences for patients," he says. "Also, studies have demonstrated that MTT and CRM training are particularly effective in these micro-systems." The VA undersecretary mandated MTT for every Veterans Affairs medical center conducting surgery, "so we enrolled and trained each facility, about 129 or so," he says. Each of these facilities initiated checklist-guided preoperative briefings; Veterans Health Administration policy now requires such a process for all invasive procedures. "Implementation has moved forward, and now teams from cardiology, endoscopy, ER, and medical surgical floors are involved in voluntary MTT," he says.

One of the most important things Neily teaches staff members is to speak up if they have a concern about care. "We developed a process to support that, which includes pre-operative briefings and post-op debriefings," she says. "We taught surgical teams to talk about the case beforehand, guided by a checklist — a template people can use." The aforementioned national directive, she adds, made the 12 critical elements of the briefing mandatory, "so we not only taught about it, but it was embedded into the national directive." (The national directive can be found at

For the training sessions on these briefings, the OR was closed. "The message we sent was that everyone was important — scrub techs, nurses, CRNs," Neily says. "Second, we wanted everyone included in the briefing. Through various activities, we encouraged people to get know each other by name. One of the things we said was, 'we want you to develop a briefing tool to guide your discussion; here are some templates to use.'" While the template had to be followed, she adds, the ultimate tools were developed so they would work in the specific environment of the facility.

Other results

A number of additional "successes" have been published in the VHA's online quarterly newsletter, "Briefings and Debriefings," says Paull. They include the following:

  • Circulating nurses do not have to leave the OR to gather equipment as often.
  • OR cases are more likely to start on time.
  • Patients are more likely to receive antibiotics or DVT prophylaxis.
  • Staff members are more satisfied with their professional lives.
  • There is less nursing turnover.
  • Morbidity and mortality rates are lower.

"Is this a safer healthcare organization because of MTT? Yes it is," says Paull. "MTT is an evidence-based improvement strategy for all healthcare organizations in fulfilling the IOM's vision of safer healthcare."


  1. Neily et al. Incorrect Surgical Procedures Within and Outside of the Operating Room — A follow-up report. Arch Surg. Published online July 18, 2011. doi:10.1001/archsurg.2011.171.

[For more information, contact:

  • Julia Neily, RN, MS, MPH, Associate Director, National Center for Patient Safety, Field Office. Phone: (802) 295-9363 ext. 6417. E-mail:
  • Douglas E. Paull, MD, FACS, FCCP, Director, Patient Safety Curriculum, National Center for Patient Safety, Department of Veterans Affairs, 24 Frank Lloyd Wright Drive, Suite M 2100, Ann Arbor, MI 48106-0486. E-mail:]