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Service Delivery Innovation Profile

Crisis Management Simulation Course Receives Positive Reviews, Enhances Communication and Teamwork Among Labor and Delivery Practitioners During Crises

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Labor and Delivery Crisis Resource Management courses are two (introductory and advanced), 7-hour, simulation-based teamwork classes for labor and delivery clinicians. Immersed in realistic, simulated obstetric cases, the clinicians learn strategies of crew resource management, a safety program originally developed by the aviation industry that was translated into health care to facilitate improvement of teamwork and communication skills in a real labor and delivery crisis. According to immediate post-course surveys, these courses are highly regarded by the vast majority of participants. Surveys conducted 1 or more years after the introductory course suggest that it produces lasting benefits, including improvements in communication, team leadership, and team performance during crises. Plans are in place to distribute followup surveys after the advanced coursework.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation surveys on how participants feel about the course, including its impact on communication, teamwork, and team leadership during subsequent crises.
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Developing Organizations

Center for Medical Simulation; Harvard Medical School and Harvard Affiliated Hospitals; The Controlled Risk Insurance Company (CRICO), Risk Management Foundation, "CRICO/RMF" of the Harvard Medical Institutions
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Date First Implemented

Piloted in February 2002

Problem Addressed

The prevalence of medical errors and injuries that occur in labor and delivery is high, leading to large numbers of malpractice claims. Many of these errors and injuries are due to preventable problems, including poor teamwork and communication during complex, high-risk deliveries. Most traditional training programs fail to address these teamwork and communication issues adequately.
  • A common, preventable problem: Obstetric emergencies are associated with devastating consequences for the affected baby, family, and providers; for example, obstetric hemorrhage is a leading cause of maternal death.1 In many cases, hemorrhaging and other problems that occur during labor and delivery could have been prevented. For example, analysis of malpractice cases at Harvard suggests that 43 percent of errors are caused by poor teamwork and communication.2
  • Failure to address root causes of the problem: Most traditional training programs focus on procedural issues rather than inadequate communication.1 This lack of focus is owing in part to physicians’ failure to recognize the need for better communication. Although physicians tend to rate themselves highly on communication skills, surveys of nurses suggest that they do not concur with the physicians’ self-ratings. In addition, because labor and delivery crises are often multifaceted and complex, teams may focus on addressing one complication but miss others as they arise.2

What They Did

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Description of the Innovative Activity

Labor and delivery providers participate in a 7-hour obstetrical simulation course called Crisis Resource Management based on principles of crew resource management; the course is designed to increase patient safety through improved communication and teamwork. An abbreviated 90-minute, unit-based didactic team training and obstetrics safety drills course has been developed to include labor and delivery support staff members who are unable to attend the full-day session. A second 7-hour course provides more advanced training (see bullet below). Information provided in August 2012 indicates that between 2002 and 2011, the program, which is based at the Center for Medical Simulation, has conducted 201 labor and delivery simulation-based team training courses, 148 level I or "introductory" courses, and 53 advanced courses; corresponding to a total of 1,402 participants, comprised of approximately 200 anesthesiologists, 700 obstetricians, 500 registered nurses and 100 certified nurse midwives. Key elements of the program include the following:
  • Introductory course curriculum: The introductory 1-day, 7-hour course exposes participants to real-life scenarios in a setting that closely simulates an actual labor and delivery environment, including a realistic triage area, labor suite, recovery room, and operating room (complete with mannequins and fetal heart monitors). The course is open to all labor and delivery providers, including perinatal nurses, obstetricians, midwives, residents, obstetrical anesthesiologists, and family physicians. The course is typically taught by a team of instructors and simulation technicians, with participants breaking into multidisciplinary teams of three or more clinicians (typical of a real-world labor and delivery unit). The course includes three simulated crisis scenarios in which participants are videotaped while they manage the clinical event. A skilled facilitator reviews the video with participants and discusses what was done well and what areas need improvement. After the last simulation, participants discuss how their teamwork has improved over the course of the day and how it might have an impact in their everyday work.
    • Unit inservices: In response to challenges in freeing up all members of the labor and delivery staff to attend the full-day course, a modified, 90-minute, unit-based introductory teamwork and communication and obstetrics safety drills course was developed. The unit inservice includes the support staff who are members of the obstetrics team but cannot attend the day-long courses with the nurses, physicians, and midwives. This course is taught by Crisis Resource Management physician champions who have attended train-the-trainer coursework.
  • Advanced course curriculum: Information provided in August 2012 indicates that, following completion of the introductory course, providers may participate in an advanced course that refines the principles of communication and crew resource management. This 7-hour course follows the simulation format of the first course, but includes four simulated obstetric scenarios. The advanced course delves more deeply into the skills involved in asserting oneself in providing feedback to colleagues about the management of cases and other issues of concern. Sample topics include clarifying roles, practicing difficult conversations, managing conflict, ensuring cultural competency when working with patients/families, and practicing teamwork skills.
  • Crew resource management principles: Both courses rely heavily on principles of crew resource management, including the following:
    • Role clarity: Duties, responsibilities, and task assignments are clearly articulated within the team.
    • Event manager: A key element of both courses is the designation of an “event manager” who monitors the critical event, and keeps the team apprised of timing issues, available personnel, and equipment. The event manager also uses the SBAR model (situation, background, assessment, and recommendation) to facilitate structured communication within the team.
    • Resource management: Participants learn to use the equipment and supplies necessary to manage an event.
    • Communication strategies: Team members learn strategies for sharing information with each other, such as:
      • Closed-loop communication: This strategy involves having the speaker give information to the listener, having the listener repeat what he or she heard and understood, and then having the speaker confirm that information.
      • Direct communication: Team members are taught to introduce themselves and direct all communication to specific individuals, ideally by name.
      • Seeking help: Team members are encouraged to “lower the threshold” for when they call for help.
    • Situational awareness: Team members learn to keep abreast of dynamic clinical situations through frequent verbal status reviews by teammates; these reviews help to prevent the team from becoming “stuck” by promoting clarity and encouraging the generation of new ideas, such as a new differential diagnosis, that can help break an impasse.
    • Assertion: Team members are taught to speak out about their concerns, state alternative viewpoints, and/or suggest alternative actions. They are encouraged to be persistent in clearly stating their opinion, particularly related to something they believe to be unsafe. If responses to expressed concerns are not satisfactory and unsafe situations continue, individuals are taught to escalate the concern by bringing in other clinicians.
    • Review of barriers: Factors that can be detrimental to long-term vigilance are reviewed, including production pressures, excessive fixation on an issue, hubris, and fatigue.
    • Debriefing and error disclosure: Strategies for debriefing events and disclosing medical errors are also reviewed, including how to speak with the patient and his or her family and how to manage difficult conversations.
  • Reduction in malpractice insurance premiums: Information provided in August 2012 indicates that CRICO/RMF (the patient safety and medical malpractice company owned by and serving Harvard-affiliated health care organizations) has confirmed a consistent decline in malpractice claims among those obstetricians who participate in CRICO Patient Safety's Ob Risk Reduction Program activities, including simulation-base team training coursework. As of January 1, 2011, CRICO Patient Safety replaced the 10 percent premium discount program with a two-tiered premium program such that obstetricians who complete CRICO Patient Safety's Ob Risk Reduction Program activities maintain the lower tier premium class, corresponding to a premium that is 16 percent less than the higher tier premium class.

Context of the Innovation

The Center for Medical Simulation was created to improve patient safety by using medical simulation to recreate emergency situations so that providers have an opportunity to practice delivering safe patient care. The Center for Medical Simulation is a not-for-profit organization that is affiliated with Harvard Medical School and Harvard Medical School–affiliated hospitals (e.g., Massachusetts General Hospital and Brigham and Women's Hospital). After an analysis of closed malpractice cases indicated that 43 percent of labor and delivery claims were related to teamwork and communication problems, leaders at Harvard's medical malpractice company, CRICO/RMF, decided they needed to provide training to increase provider competence in these areas. CRICO/RMF approached the Center for Medical Simulation about developing a formal course in this area that incorporates realistic simulations of actual labor and delivery crises.

Did It Work?

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Post-implementation surveys show that the course is highly rated by the vast majority of participants; surveys conducted 1 or more years after the course suggest that it produces lasting benefits, including improvements in communication, team leadership, and team performance during crises.
  • Positive feedback from initial pilot tests: A total of 36 clinicians participated in six pilot courses conducted between February and October 2002. The 35 participants who completed the survey all rated the course favorably (either “excellent” or “very good”) and believed that it had a positive impact on teamwork and communication skills. Participants generally found the simulated scenarios to be realistic, with 31 of the 35 responding participants rating them as very realistic; views on the scenarios were similar regardless of whether the course was taught in a real labor and delivery unit or the simulation center.3
  • Continued positive feedback from subsequent tests: Between September 1, 2003 and July 20, 2005, a total of 308 labor and delivery clinicians participated in the course, with 307 completing an immediate postcourse evaluation. Of these, 99 percent rated the course as excellent or very good, and 98 percent rated the quality of the scenarios as excellent or very good.3
  • Lasting benefits: A survey completed in 2006 by 58 (out of 176 total) individuals who took the course in 2004 suggests that the program has had a lasting benefit related to the quality of communication, teamwork, and team leadership during crises.
    • Better communication: More than three-fourths (77 percent) of respondents reported that communication had significantly or somewhat improved during the most difficult or critical event they have experienced since completing the course.
    • Better team leadership and performance: Nearly 64 percent of respondents reported that team leadership had significantly or somewhat improved during management of the aforementioned crisis event, whereas 67 percent reported that overall team performance had improved.
    • Useful principles: Most survey respondents who experienced a difficult or critical clinical event strongly or somewhat strongly agreed that Crisis Resource Management principles are useful for obstetrical faculty (86 percent) and that they had learned things during the course that have subsequently proved to be useful in practice (88 percent).
    • Positive change in practice: Most survey respondents (53 percent) reported that the course has led to changes in their obstetric practice.
  • Reduction in malpractice claims: Information provided in June 2010 indicates that the training has resulted in a reduction in the total number of obstetrical claims and the number of claims for high-severity events. A total of 53 obstetrics-related claims associated with a cost of $62.6 million occurred across the Harvard system during the 4-year period before the intervention. In comparison, only 31 obstetrics-related cases associated with a cost of $44.7 million occurred during the 4-year period after the training.4
  • Positive recommendation for others and desire to repeat course: Most (86 percent) individuals completing the survey 1 or more years after taking the course would recommend it to their colleagues. Roughly two-thirds of those completing immediate postcourse evaluations in 2004 recommended that the course be repeated at least yearly. Enthusiasm for repeating the course was somewhat lower among those completing the survey 1 year or more after the course, with only 28 percent making this recommendation.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation surveys on how participants feel about the course, including its impact on communication, teamwork, and team leadership during subsequent crises.

How They Did It

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Planning and Development Process

Key steps in the planning and development process include the following:
  • Course development based on existing model: The course was modeled after the very successful Crisis Resource Management anesthesia course offered by the Center for Medical Simulation since 1994.
  • Identification of real-life scenarios for simulations: The Center for Medical Simulation developed real-life scenarios, taken directly from closed malpractice claims, to be used as simulated cases.
  • Cultivating physician champions: The chiefs of labor and delivery services from Harvard Medical School–affiliated hospitals participated in the course, also received the 10 percent annual discount in malpractice premiums, and became strong advocates for the program after taking the course.

Resources Used and Skills Needed

  • Staffing: Staffing will vary with the scope, goals, and objectives of the project. The Center for Medical Simulation employs about seven full-time staff. A hospital-based program may employ one or two part-time nurses and/or physicians to champion the project. Course participants attend the 7-hour course during the regular workday.
  • Costs: Creating the Center for Medical Simulation cost several hundred thousand dollars, including development of the high-tech simulated operating room, a multipurpose clinical room, and a conference room. Would-be adopters could begin on a smaller scale, potentially using unoccupied rooms within the hospital, thus reducing this cost.
    • Physical space: The Center for Medical Simulation developed a dedicated simulation center for the course. However, a standard operating room can also be used, or a room within the hospital that can be adapted and used exclusively for training.
    • Equipment: An unsophisticated birthing pelvis typically costs less than $1,000, whereas more advanced birthing simulators can cost anywhere from $4,000 to $40,000, depending on the model selected. The simulation center uses low-tech part-task trainers (low-cost devices that represent a body part or internal organ on which health care providers can practice a medical task, surgical technique, or obstetrical procedure), technologically advanced mannequins, and medical equipment that replicates what is found in a typical labor and delivery setting and operating room.
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Funding Sources

Initial funding came from CRICO/RMF. Participants now pay a fee to attend the course at the Center for Medical Simulation.end fs

Tools and Other Resources

Blum RH, Raemer DB, Carroll JS, et al. Crisis resource management training for an anaesthesia faculty: a new approach to continuing education. Med Educ. 2004;38(1):45-55. [PubMed]

Howard SK, Gaba DM, Fish KJ, et al. Anesthesia crisis resource management: teaching anesthesiologists to handle critical incidents. Aviat Space Environ Med. 1992;63(9):763-70. [PubMed]

Knox GE, Simpson KR, Garite TJ. High reliability perinatal units: an approach to the prevention of patient injury and medical malpractice claims. J Healthc Risk Manag. 1999;19(2):24-32. [PubMed]

Shapiro MJ, Morey JC, Small SD, et al. Simulation based teamwork training for emergency department staff: does it improve clinical team performance when added to an existing didactic teamwork curriculum? Qual Saf Health Care. 2004;13:417-21. [PubMed]

Adoption Considerations

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Getting Started with This Innovation

  • Involve organizational leaders: Involve leadership from the beginning, and find physician champions who can become catalysts for changing traditional practices. As noted, after chiefs of the various labor and delivery departments took the course, they became champions for use of Crisis Resource Management principles by their departments.
  • Ensure that training is multidisciplinary: Use multidisciplinary teams during the training, as these teams provide the most robust experience for all involved, especially with respect to teaching teamwork and communication.
  • Involve medical residents: Encourage residents to participate, as the course provides an opportunity for them to work side-by-side with attending physicians, midwives, and nurses.

Sustaining This Innovation

  • Offer shorter course options: Offer abbreviated onsite courses. It is unrealistic to rely exclusively on offsite training alone because of the challenges of getting providers to spend a whole day away from the hospital. Many practical lessons can be learned from participating in brief, unit-based simulated scenarios and/or safety drills.
  • Update training materials: Continually update the Crisis Resource Management training course to incorporate new material, including human factor analysis. Provide regular feedback to course participants.
  • Market the course: Sustain interest in the course through periodic internal marketing, such as newsletter articles and flyers.
  • Use real data to illustrate problems: Relate root cause analysis of errors and near-misses to issues related to teamwork and communication.
  • Incorporate training into credentialing: Consider incorporating simulation into credentialing and/or competency assessment, especially for postgraduate training and new employee orientation.
  • Monitor team performance: Monitor adverse events and near-misses to identify opportunities to improve and/or reward team performance. Consider training observers to objectively observe and rate team performance during simulation-based training and safely drills to identify opportunities to improve and/or reward team performance.5

Additional Considerations

A growing body of evidence from other settings suggests that simulation training can be effective. For example, lower malpractice claim experiences among anesthesia faculty completing simulation training (compared to those not participating in this kind of training) led to a recent increase in the discount (i.e., credit) offered to course participants, rising from 6 to 19 percent between 2006 and 2007; this discount remains in effect.6 A retrospective cohort study in the United Kingdom found that simulation-based training can make a difference in perinatal outcomes, leading to statistically significant improvements in 5-minute Apgar scores for full-term babies and appreciable but not statistically significant reductions in the occurrence of hypoxic-ischemic encephalopathy.7 Other recent studies have shown that simulation-based training is useful for identifying pitfalls in obstetrical management.8 Experiences published by other centers have reported lower obstetric malpractice exposure and improved patient safety profiles when their obstetrical providers participate in obstetrical risk reduction activities that include obstetrical simulation-based team training.9,10 Continued research is needed to determine whether obstetrical simulation-based team training definitively translates into lives saved, reduced malpractice exposure and sustained improvements in patient safety profiles.

More Information

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Contact the Innovator

Roxane Gardner, MD, MPH, DSc
Labor & Delivery Course, Co-Director
Center for Medical Simulation
65 Landsdowne Street
Cambridge, MA 02139
Phone: (617) 768-8900

Toni Walzer, MD
Labor & Delivery Course, Co-Director
Center for Medical Simulation
65 Landsdowne Street
Cambridge, MA 02139
Phone: (617) 768-8900

Innovator Disclosures

Dr. Gardner and Dr. Walzer have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Information about the labor and delivery simulation courses offered by Harvard's Center for Medical Simulation is available at: (information added in June 2010).

Shannon DW. How a Captive Insurer Uses Data and Incentives to Advance Patient Safety. Patient Safety & Quality Healthcare. November/December 2009. Available at:

Gardner R, Walzer T, Simon R, et al. Obstetric simulation as a risk control strategy: course design and evaluation. Simul Healthc. 2008;3:119-27.


1 Novello A, King J. Health advisory: prevention of maternal deaths through improved management of hemorrhage. New York State Department of Health; August 12, 2004. Available at:
(If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)
2 Case Study: The Harvard Center for Medical Simulation's Labor and Delivery Crisis Resource Management Course. The Commonwealth Fund; March 30, 2005.
3 Gardner R, Walzer T, Simon R, et al. Obstetric simulation as a risk control strategy: course design and evaluation. Simul Healthc. 2008;3:119-27. [PubMed]
4 Shannon DW. How a Captive Insurer Uses Data and Incentives to Advance Patient Safety. Patient Safety & Quality Healthcare. November/December 2009. Available at:
5 Rosen MA, Salas E, Wilson KA, et al. Measuring team performance in simulation-based training: adopting best practices for healthcare. Simul Healthc. 2008;3:33-41. [PubMed]
6 McCarthy J, Cooper JB. Malpractice insurance carrier provides premium incentive for simulation-based training and believes it has made a difference. Anesthesia Patient Safety Foundation Newsletter. 2007;22(1):17. Available at:
7 Draycott T, Sibanda T, Owen L, et al. Does training in obstetric emergencies improve neonatal outcome? BJOG. 2006;113(2):177-82. [PubMed]
8 Maslovitz S, Barkai G, Lessing JB, et al. Recurrent obstetric management mistakes identified by simulation. Obstet Gynecol. 2007;109(6):1295-300. [PubMed]
9 Pettker CM, Thung SF, Norwitz ER, et al. Impact of a comprehensive patient safety strategy on obstetric adverse events. AJOG. 2009;200(5):492.e1–492.e8. Available at:
10 Grunebaum A, Chervenak F, Skupski D. Effect of a comprehensive obstetric patient safety program on compensation payments and sentinel events. AJOG. 2011;204 (2):97-105. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: July 07, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: August 13, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: August 07, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.