O'Connell 2010

Improving Teamwork Among Nurses and

Physicians

Daniel O’Connell, Ph.D.Seattle, WA

danoconn@uw.edu206 282-1007

TEAM

Multiple individuals with specific skills and roles, coordinating their activities towards a mutually understood and agreed upon aim

the Red Socks the Transplant Team

O'Connell 2010

Keys to Teamwork

Acceptance and respect for each member’s information and contribution Including the patient and family

Limiting hierarchy to those issues required by scope of practice and responsibility

Shared decision–making is preferred mode for resolving concerns

Civility/collegiality is highly valued and “defended”

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Impetus for Team Training

Institute of Medicine 2000 Errors caused by communication and coordination failures Aviation style team training recommended

JCAHO: Patient Safety Plan 2004 Explicitly calls for teamwork training Communication cited in most sentinel events

25 years of aviation experience Team training/crew resource management emerged as

solution to many aviation disasters And we are already having success with this in

healthcare ER, OB, anesthesia

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A Shift Across Industries

“Team training represented a move away from autocratic and individualistic styles of aircraft command to one that is more team based, with mutual interdependence and shared responsibility.”

In a safety context, the team’s role is to avoid errors, trap them before they have consequences and minimize the consequences that do result

Musson and Hemlreich (2004) Team training and resource management. Harvard Health Policy Review 5(1) Spring 25-35.

Trading Autonomy for Reliability

Standard work wherever possible Agreed upon protocols and processes

Toyota Lean Production, High Reliability Orgs.)

Plan, broadly shared and agreed upon Predict/anticipate Coordinate, Manage resources Recognize and Recover Review, Improve, Disseminate Best Practice

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AD hoc teams

Come together for limited time, for specific tasks and then are reformulated Flight crews, endo suite, OR, multiple clinicians

managing a patient’s care Requires

Clear understanding of roles & capabilities Standard operating procedures Briefing/huddle before each “event” allowing Anticipation and adjustment for specific

challenges

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Teamwork Solutions in Healthcare Establish the protocol or plan Communicate to all team members,

hold briefings and ad hoc team meetings Team members ask for help in timely manner Check-backs for accurate understanding SBAR as example of information exchange in the team Cross-monitor actions of others Assertive communication skills

a concern, clinical information or corrective action Team members accountable for technical and interpersonal

behavior (emotional intelligence) Simulate/ practice emergency procedures

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Establish Plan or Protocol

Variation among providers/staff creates poor ability to anticipate and coordinate E.g., Problem of preference cards

Need not wait for “best practices” in order to agree on standard practice

Trade off of autonomy for reliability Team coordination depends on increased predictability

Supplies, staffing, coordinating, anticipating, catching

How will this “best practice/agreed upon practice” be negotiated and enforced? (ad hoc?, universal?)

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Communicate to all team members

Situational awareness requires broader sharing of information/thought processes & plans

Anticipating additional resources that may be needed and priming them

Value of the pre-procedure briefing/huddle to plan, anticipate, coordinate and apply to the specific situation in the moment

Ex. Mini team meetings could be called by any member throughout the shift

Is Communication matched to purpose and timeliness?

No communication: No/inadequate referral letter or consult note,

discharge summary, progress note, briefing Serial Monologue

Progress note in chart, referral letter, consult note or one way briefing

Real time dialogue Conversation in real time intended to clarify,

recognize anomalies, surface concerns and make shared decisions

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Check backs for Accurate Understanding

Receiver gives brief summary and speaker confirms, corrects Reduces chances of inaccuracy or inattention not

being detected and corrected Formalized in the airline industry

Key information repeated to assure accuracy and response between aircraft and tower

Common in restaurant industry Uncommon in healthcare

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Standardized info exchange/briefing

SBAR Situation Background Assessment Recommendation

From Kaiser Permanente surgery program

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Cross-Monitoring Situational Awareness

Be aware of the actions of others And comment when safety concerns arise!

Make others aware of the steps they are planning/taking to increase effectiveness of cross-monitoring

Requires trust, openness to feedback and flexibility about hierarchy and role Opposite of, “Why don’t you mind your own

business?”

Red Flags

Anomalies and concerns that are recognized before any adverse event 5-7 evident before aircraft incidents RCA’s in healthcare routinely find 5+ red flags

preceding adverse event “Normalization of deviance”

Anomalies, deviations from expected are so common that they are not remarkable

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Willingness to assert a position

“Why didn’t you/I speak up?” What is “professional” advocacy and assertiveness?

Airlines learned that professional/appropriate assertiveness must be taught and reinforced

SBAR with agreed upon escalators “Stop the assembly line” (Toyota Lean Production)

Otherwise, correctable red flags and errors go uncorrected until harm is imminent

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Practice for emergencies

Emergencies must be anticipated and prepared for in advance High risk/low incidence

Adequate resources for emergencies Staffing at a level that emergencies/urgencies can be

handled safely Simulation/practice for emergencies

Skills lab, hi/low fidelity enactments with discussion, feedback and correction

“Devil is in the details”

Choose the Middle Way

Avoid extremes of “Captain of the ship” on the one hand, “Mutiny on the Bounty” on the other

Agreed upon protocols for discussing and resolving disagreements in the moment

Agreed upon processes for reviewing situations afterwards Including both technical and interaction Issues

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Role of Leadership

Understand, believe in, model and influence the performance of Team based attitudes, processes, behaviors and incentives

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Star Model of PerformanceRoles

Skills

MotivationsTraits & Talents

Systems

Performance

O'Connell 2010

Hold team members appropriately accountable

Behavior in teams includes Technical skills /clinical judgment Emotional intelligence (see next slides)

Hire, train, reward, promote, transfer and dismiss to build these capabilities