Beth Israel Deaconess Medical Center in Boston, Massachusetts had been working on teaming training and crew resource management strategies since 2001 when a serious adverse event underscored the need for improved communication to the Labor and Delivery team. This initiative was led by Drs. Benjamin Sachs, Susan Mann, Ronald Marcus and Stephen Pratt and was subsequently followed-up with a Department of Defense contract to study their team-training model with a cohort of civilian and military hospitals. The model has a quantitative component tracking the frequency and severity of adverse events before and after training through calculation of three indices: Adverse Outcome Index, Weighted Adverse Outcome Score and Severity Index. The results of this study and their model were reported on in detail in The Joint Commission Journal on Patient Safety and Quality (September, 2006 Volume 32, Number 9).
Dr. Sachs and his colleagues offer their team training model: Team Performance Plus™ under the Harvard Risk Management Strategies Foundation.
Team Performance Plus™ (TPP™) is a comprehensive program-by clinicians, for clinicians-that provides interdisciplinary team-training, for obstetricians, midwives, nurses, and anesthesia providers to:
- Ensure safer deliveries
- Reduce the occurrence of preventable errors
- Minimize litigation exposure
In December 2005, NPIC/QAS became the data partner for the Harvard Risk Management Strategies Foundation Team Performance Plus™ (TPP™) team-training program. All hospitals participating with TPP™ submit data to NPIC/QAS for the calculation of their indices.
NPIC/QAS works closely with TPP™ to refine and update the calculation of the AOI, WAOS and SI using administrative data.
Our contract with TPP™ allows NPIC/QAS to use the most current algorithm to provide an AOI Report to member hospitals outside of a contract with TPP™. This enables hospitals that are engaged in similar team training or simulation projects to have a baseline and follow-up quantitative component to their training activities. For those hospitals that are thinking of initiating a team-training program, a baseline report gives them a picture of their "starting point".
» Download a Sample AOI Report
