1. What can Healthcare Learn from Team Training and Other Domains? David P. Baker, Ph.D. American Institutes for Research

2. Session Objectives
Demonstrate the importance of teamwork in healthcare
Review the evidence on the effectiveness of team training
Present guidelines for implementing effective team training programs
Describe current initiatives in medical team training

3. Teamwork and Healthcare
In most all cases, the delivery of healthcare involves:
Two or more individuals (RNs, MD, PharmDs, etc.)
Performing distinct tasks
Working interdependently
Ensuring a safe outcome (i.e., common goal)
The delivery of healthcare requires teamwork!
Team members come from different backgrounds, disciplines, and are seldom trained together
The key characteristic that distinguishes teams for groups or collectives of people is TASK INTERDEPENDENCY
Teams performs interdependent tasks!

4. What Do Effective Healthcare Teams Look Like?
…have members who anticipate each other.
…can coordinate without the need to communicate overtly.
…can recognize and adjust their strategy under stress.
…manage conflict well-team members confront each other effectively.
…backup and fill in for each other.

5. What Do Effective Healthcare Teams Look Like?
…communicate often "enough”.
…effectively “span” boundaries with stakeholders outside the team.
…regularly provide feedback to each other, both individually and as a team (“de-brief”).
…have members who understand each others’ roles and how they fit together.

6. Producing Effective Teams
Team membership-selection (Klimoski & Jones, 1995)
Modify team tasks, workflow, structure
(Campion et al, 1995)
Provide support, resources, performance aids
Build team member knowledge, skill, and attitude competencies (KSAs) - TRAINING
(Salas & Cannon-Bowers, 2001)
Selection – Can choose the right team members!
Change the environment by structuring the work differently
Provide tools or other aids to assist with teamwork
Training
Individual members – Individual Level KSA
Intact teams – Team Level KSAs

7. Targets of Team Training
Team Members
Cognitions
Behaviors
Attitudes
Knowledge Competencies—Principles and concepts that underlie a team’s performance (Know what team skills are required)
Skill Competencies—A Learned capacity to interact with other team members at some level of proficiency
Attitude Competencies– Internal states that influences team members choices or decisions.
Two – Levels
1.Individual Level – The KSAs individuals possess to function effectively in a team
2 Team Level – The KSAs that are unique to a team – Knowledge of team member preferences
Knowledge
Skills
Affect
“Think”
“Do”
“Feel”

8. Team Process Developed by Salas and colleagues
Mutual
Trust
Shared Mental
Models
Team
Orientation
Team Leadership
Close Loop
Comm.
Back-Up
Behavior
MPM
Adaptability
THE CORE
Developed by Salas and colleagues
Reviewed the team research – meta analysis – and summarized it into a concise model – compiled all the evidence!
Two components—
The core of teamwork – what teams do
The coordinating mechanisms – the glue that allows team members to coordinate

9. Meta Analysis Results (Salas)
Team Training leads to improvements in:
Attitudes
Knowledge
Skills
Findings consistent across military, aviation, and emerging in healthcare
Cross training, team self-correction, TDT, CRM
Little evidence for organizational impact

10. Guidelines for Effective Team Training in Healthcare

11. Guideline 1 Engage Leadership (Physicians)
If physicians do not believe that teamwork is critical it will be an uphill battle
Physicians need to be included as team members and leaders
Physicians must be champions for teamwork and training
Physicians must value and reinforce team principles

12. Guideline 2 Develop Training Systematically
Training development requires:
Needs analysis
Specification of objectives that are linked to desired outcomes
Content development
Delivery
Evaluation
Preparing the transfer environment

13. Guideline 3 Training Should be Scientifically Rooted
There is a science of team performance and training (Baker et al. 2005, Advances in Patient Safety)
There are principles, tools and strategies that have been shown to work

14. Guideline 4 Determine if Staff are Ready for Training
Teamwork and training must be valued
Trainees must be motivated to learn – negative pre-training experiences increase motivation
Past experiences with training in the organization shape pre-training expectations
Self efficacy is important

15. Guideline 5 Prepare the Learning Environment
The organization must communicate that team training is important
There should be systems in place to:
Reinforce learned principles
Transfer trained skills
Establish coaches at the sharp end of care

16. Guideline 6 Incorporate Opportunities for Practice
Practice is essential when developing team skills
Simulation is an excellent tool for skills practice
Simulation must incorporate sound learning strategies like scenario-based training
Practice must be structured and paired with measurement and feedback to be effective

17. Guideline 7 Evaluate Training at Multiple Levels
Evaluation involves systematic review of the training program to ensure it produces the desired outcome
There are 4 levels of evaluation:
Reactions (Did they like it? Find it useful?)
Learning (What do they know?)
Behavior (What can they do?)
Outcomes (What impact has there been on the organization?)

18. Guideline 8 Training is not a One-Time Event
Refresher training is required
Medicine is an evolving field
More and more research is focused on healthcare teams
New training strategies are being develop, tested and validated
Want to produce a learning organization

19. Guideline 9 Training Must be Aligned
Team training will reduce but not eliminate error
Human failure is inevitable
Team training must align with the organization’s broader patient safety program

20. TeamSTEPPSTM Scientifically rooted Customizable Publicly available
Evidenced – based
Scientifically rooted
Customizable
Publicly available
Multiple strategies
Evaluation tools

21. Advocacy and Assertion
Course Summary
BARRIERS
Inconsistency in Team Membership
Lack of Time
Lack of Information Sharing
Hierarchy
Defensiveness
Conventional Thinking
Complacency
Varying Communication Styles
Conflict
Lack of Coordination and Follow-Up with Co-Workers
Distractions
Fatigue
Workload
Misinterpretation of Cues
Lack of Role Clarity
TOOLS and STRATEGIES
Brief
Huddle
Debrief
STEP
Cross Monitoring
Feedback
Advocacy and Assertion
Two-Challenge Rule
CUS
DESC Script
Collaboration
SBAR
Call-Out
Check-Back
Handoff
OUTCOMES
Shared Mental Model
Adaptability
Team Orientation
Mutual Trust
Team Performance
Patient Safety!!

22. Three Critical Phases Pre-Training Assessment-Readiness
Kick-Off plan
Senior Leadership involvement
Executive Sponsor & Change Team Mentor and Role-model Behaviors
Training Classes
Metric Reinforcement through Post-training Assessment
Essentials course for support staff
Web-based teamwork updates
Learning Action Network for follow-up and Information Sharing
Pre-Training Assessment-Readiness
Train-the-Trainer:
Train the Participants
Implementation & Sustainment
Selection of Instructors/Coaches
Supporting training materials provided
Train-the-Trainer
Fundamentals Course
Implementation Workshop
Culture Change Workshop
Practice teaching
Establishment of Training and Implementation Timelines
Implementation Roll-out Plan
Observation Toolkits
Site assessment
AHRQ Hospital Survey on Patient Safety Culture
Executive Brief to gain Senior Leadership buy-in
Selection of Executive Sponsor and Change Team Members
Establishment of Goals/Values
Communication Campaign
Pre-training (baseline) Assessment
Implementation plan

23. TRANSFORMATIONAL CHANGE FACTORS Leadership Level Individual Level
Org Level
Safety Culture
Transparency/Trust
Systems-Efficacy
Learning Environment
“Report Card”
Leadership Level
Lead the Way
Establish the Sense of Urgency
Create a Vision or Gain-Plan & Prepare
Develop a Coalition-Assess Environment
Communication Process
Enable Change to Last
Improve Systems and
Structures
Improved
Patient
Outcomes
Improved Staff
and Patient
Satisfaction
Processes
Staff
Retention
Individual Level
Self Efficacy Training Motivation
Pre-training Experience
Level IV Evaluation
Intervention
Sentinel Event
Pre-Training Measurement
-Knowledge -Skills -Attitudes
Post-Training Measurement
-Knowledge -Skills -Attitudes
Training Transfer
To be understood and evaluated, these recommendations for leaders and staff had to come together into one cohesive yet dynamic model. The purpose of a model is to:
Provide a shared mental model for an evidence-based, evaluation driven, heuristic system for change
Pull together the theories of leading team and culture change researchers (Salas, Kirkpatrick, and Kotter)
Pull together the input and lessons learned of leaders and staff training and implementing behaviors on site
Remain sufficiently broad and flexible to adapt to a variety of settings and specialities yet
Remain focused enough to effectively train individuals to the specific behaviors shown to improve outcomes in aviation
Provide process and outcomes founded on core leader and staff actions necessary to train, implement, and sustain
Undergo 4 level - whole organization - evaluation
The top (big box) establishes the three levels within the org where change needs to occur and the essential actions each must assume. At the level of the organization patients and staff must feel the system (of safety) is transparent and trustworthy. The leadership level identifies the accountabilities and responsibilities for a culture change and at the individual level the real work is to deliver excellent clinical out of the context of the behaviors and attitudes essential to teamwork. The bottom of the graphic illustrates the intervention and evaluation that occur and are necessary to make all this happen.
Tools
Methods
Level II Evaluation
Level II Evaluation
Level III Evaluation
Training
Training Objectives
Competencies
-Knowledge -Skills -Attitudes
Level I Evaluation

24. American Institutes for Research 1000 Thomas Jefferson Street, NW
David P. Baker, PhD
American Institutes for Research
1000 Thomas Jefferson Street, NW
Washington, DC 20007