1. Inter-professional Teamwork & Collaboration
Annette Bartley
Director of The Safer Patient Network
Faculty for Healthcare Improvement Wales

2. Session Objectives
Appreciate the inherent clinical value of effective teamwork and communication in providing safe patient care
Understand how communication failures are at the root of the overwhelming majority of unanticipated adverse events
Understand the critical importance of Assertion /Critical Language so providers can speak up reliably when they perceive risk to a patient
Learn about the inherent limitations of human performance and the value of reliable systems to help insure safe care
Describe some tools/techniques that can help enhance teamwork communication
Why communication is the heart of the
matter
• The limits of human performance
• Lessons from high reliability
• Tools and behaviors to achieve effective
teamwork and communication within a
culture of safety
LEADERSHIP

3. Let’s begin with a story
This is a story about 4 people named everybody, somebody, anybody and nobody. There was an important job to be done and Everybody was asked to do it. Everybody was sure somebody would do it. Anybody could have done it but nobody did it. Somebody got angry about that because it was Everybody's job. Everybody thought anybody could do it, but nobody realized that everybody wouldn't do it. It ends up that everybody blames somebody when nobody did what anybody could have done

4. Why is teamwork so important in healthcare?
A healthcare system that supports effective teamwork can improve the quality of patient care, enhance patient safety and reduce workload issues that cause burnout among healthcare professionals
Hospitals historically have relied on a
dedicated and highly skilled professional
workforce to compensate for any
operational failures that might occur during
the patient care delivery process. Great
doctors and nurses, not great organization
or management, have been seen as the
means for ensuring that patients receive
quality care.

5. Teamwork Matters More responsive & patient –centered service
More clinically effective & cost effective care
Avoids duplication & fragmentation
Allows for improved organizational planning
Improves job satisfaction or cross-training
Improves admission, hand-off/ transfer of care & discharge planning

6. Should We Disclose Harmful Medical Errors? If So, How?

7. “ Rather than being the main instigators of an accident, operators tend to be the inheritors of system defects….. Their part is that of adding the final garnish to a lethal brew that has been long in the cooking.”
James Reason, Human Error, 1990
Every system is perfectly designed to get the results it gets…

8. Error is Inevitable Because of Human Limitations
Limited memory capacity – 5-7 pieces of information in short term memory
Negative effects of stress – error rates
Tunnel vision
Negative influence of fatigue and other physiological factors
Cognitive performance after 24 hrs. without sleep equivalent to blood alcohol of .10 ! Dawson et al, Nature, 1997
Limited ability to multitask – cell phones and driving
Structuring the nursing workload-- Big picture or task performance?
Tucker & Spear: Med-surg observation, at least 100 discrete tasks per 8 hour shift:
Average 3 minutes / task
No ability to sequence – juggling, prioritizing tasks
Formally interrupted at least once / hour
Consistent workarounds

9. Criteria for Healthcare Teamwork
Multiple disciplines are involved in care
Disciplines encompass a diversity of distinct knowledge and skills needed for patient care
Plan of care reflects an integrated set of goals
Team members share information and coordinate services
Schmitt, Farrell and Heinemann; 1988

10. Cultivating Teamwork
People are any organization's most valuable assets, but for some reason we keep forgetting this simple point. Instead, we get caught up in the latest system that is going to make everything and everyone more efficient and economical, ignoring the fact that it is people who make systems work.

11. Teamwork- The Sum of the parts is greater than the whole
Healthcare is an extremely complex environment
There are:
Surprises
Uncertainty
Incomplete Information
Interruptions
Multitasking

12. Getting to Goal

13. The Role of Leadership
• Common goal – optimal care, optimal environment for caregivers • Engaging doctors • Understanding and engaging the culture • Effective teamwork and communication • Measurement – show people the benefit • Continuous cycles of improvement

14. Executive Perceptions vs. Frontline Perceptions:
Executives overestimate:
Teamwork Climate 4X
Safety Climate 2.5X
Executive Confidence vs. Executive Accuracy:
-Often wrong but rarely in doubt…
-Currently no incoming data-streams
-Halo Effects
-Frontline data fills the gap

15. When is teamwork most effective
Clear purpose (shared vision)
Good communication;
Co-ordination
Supportive protocols and procedures
Effective mechanisms to resolve conflict when it arises. Active participation of all members is another key feature.
Successful teams recognize the professional and personal contributions of all members; promote individual development and team interdependence; recognize the benefits of working together; and see accountability as a collective responsibility.

16. Teamwork video clip

17. Patient at the centre
Patients and their families are important team members with an important role in decision-making.
To enable patients to participate effectively, they need to learn about how to participate in the team; how to obtain information about their condition; and how each healthcare professional will contribute to their care.

18. Barriers to Teamwork
Failure to appreciate the value of different roles
Power struggles inhibit communication
The ‘attitude virus’!
Frequent staff changes complicate staff learning
Conflict and compromise may be caused by predominance of less experienced workers
Poor communication
Adapted from Opie, 1997

19. Barriers to Safety Mistakes are seen as episodes of personal failure
Trained to be perfect - knowledge and competence are equated with the absence of error
Mistakes are seen as episodes of personal failure
Catastrophic events are rare-“It won’t happen to me”
Assuming safety, not assuring safety
Focus on individuals, not complex systems
- fix the person and the problem goes away
Tell me
How many of you in direct care roles in the recent past have NOT had the experience of standing at a patient’s bedside seeing something concerning and thinking:
Is it important?
Should I call?
Do they want to know?
What kind of reception am I going to get?

20. Familiarity with others is a critical component of effective teamwork:
74% of all commercial aviation accidents happen on the first day of a crew flying together
Familiarity trumps fatigue
Highlights the importance of predictable patterns of behavior

21. Psychological Safety…
Recognition that human error is inevitable
Complex systems
Inherent Human Limitations – stress, limited memory capacity, fatigue, & multitasking
● Safety is often ASSUMED, not ASSURED
● Culture of the expert of the individual
Solution:
Teamwork & Communication!

22. Fatigue
24 hours without sleep is equivalent to a blood alcohol level of 0.10 – a 30% decrease in cognitive processing
Nurses are 3 times more likely to make mistakes after 12 hours on the job
Junior doctors made 30% more errors in ICU patients when on traditional 24 hour call schedules
The best countermeasure for fatigue is teamwork –more people in the same movie

23. Multitasking, Interruptions, Distractions
Humans are poor multi-taskers
Drivers on mobile phones have 50% more accidents, 25% of traffic accidents are "distracted drivers”
Interruptions and distractions increase error rates
Humans need very formal cues to get back on task when interrupted and distracted

24. Failure of Recognition and Rescue
A very common theme in adverse outcomes
Someone has to recognize the patient is in trouble, AND
The patient has to be rescued from the problem in a timely fashion
Condition H

25. Conflict Resolution in the OR
Conflict was observed in 10% of flights and 10% of surgeries
We simply did not see a lot of briefings in the OR, but more on that in a moment.
We did not see surgical and anesthesia teams treating each other and dynamic components of a single entity, but as separate teams with separate tasks.
Conflict was not common, but interestingly we see it at similar rates in the commercial aviation cockpit -
Important caveat is that the training videos were created to calibrate to a 4 point scale – the scenarios used were based on typical complications you would find locally, and the differences in performance were agreed upon by all our nurse, resident, and attending physician project members.
Get examples of poor and good behavior from archive
Resolved in 80% of instances in cockpit
Resolved in 20% of instances in operating room
Operating Room
n=100
Cockpit
n=3200
Behavior
% of Observations with a rating
OR/Cockpit
% Below Standard
(1 & 2)
% Above Standard
(3 & 4)
Briefings
84% / 85%
90%
10%
23%
77%
Establish team environment
83% / 83%
66%
34% 8%
92%
Inquiry
54% / 59%
55%
45% 9%
91%
Conflict Resolution
10% / 10%
80%
20%
22%
78%

26. Psychological Safety…
Do you know all the names of the personnel you work with?
Safety Briefings= Level the playing field
“Hi, I’m ___. I’m sorry I missed your name.”
“I don’t have any pride invested here. I just want to get it right, so if you think I am doing anything wrong, please let me know.”

27. Psychological Safety…
Environment of Respect
“A fundamental, non-negotiable respect for every employee, everyday, by everyone”
Their work is recognized and acknowledged

28. Effective Communication Requires
Structure Communication (SBAR)
Assertion/Critical Language (key words)- The ability to speak up and stop the show
Leadership
flat hierarchy
sharing the plan
continuously inviting other team members into the
Conversation
explicitly asking people to share questions or concerns
using people’s names

29. Importance of Communication
Communication failure has been identified as the leading root cause of sentinel events over the past 10 years (Joint Commission)
Communication failure is a primary contributing factor in almost 80% of more than 6000 root cause analyses of adverse events and close calls (VA Center for Patient Safety)
The elevator speech
Supporting info:
The Joint Commission analyzed the sentinel events that were reported to them over the last 10 years and identified communication failure as the leading root cause of sentinel events.
The Veterans Administration (VA) National Center for Patient Safety database shows similar results, with communication failure cited as a primary contributing factor to adverse events and close calls.

30. Effective communication
Have a plan
Hand-offs are dangerous
Recognise the value of a structured process
Structured language / clarity
Who owns the patient?
What are the parameters for increasing the intensity of care?

31. Different Communication Styles
National Culture
Gender
Roles (Physician, Nurse, Manager)
Nurses: narrative & descriptive
Physicians: problem solvers “just give
me the facts”

32. Structured Communication: SBAR
If the phone goes dead in 10 seconds – will the person on the other end know what is needed?
Situation – State what you are calling about (5-10 second punch line)
Background – State what you are calling about (including objective date i.e. vitals, labs)
Assessment – State what you think the problem is (diagnosis
not necessary – include severity)
Recommendation – State what you think
needs to be done for the patient (get a
time frame)

33. Structured Communication
S –Mr. M has sudden onset of radiating chest pain & shortness of breath B – He has a history of MI’s, & his obs are 186/76, 180, 24 & he is on 5L of O2 per nasal cannula sats 84% A – I think Mr. M might be having an MI R – I need you to come evaluate the patient, how soon will you be here?

34. Structured Communication
CUSS to communicate concern
C – “I’m Concerned” or “I need clarity”
U – Uncomfortable
S – Stop the line/procedure
S – Patient Safety is at risk!

35. Assertion Speak up and state your information with appropriate persistence until there is a clear resolution
What is it?
Organized in thought and communication
Valued by the entire team
Looking for clarification & common understanding
What is it not?
Aggressive or hostile
Ridiculing
Confrontational
Ambiguous *

36. Teamwork Improving Quality-How Do We Start?
Create a sense of urgency
Pull together the guiding team
Formulate a change vision and strategy
Communicate your vision for understanding and buy-in
Set aims & use the Model for Improvement
Measurement and feedback loop
Test ‘one’ communication tool on one shift with one team
Test and Learn from it/build upon it and refine the process
We’ll start the process by reviewing the Implementation Guide and materials provided in getting started.
The process recommended is based on Dr. John Kotter’s nationally acclaimed organizational change theory:
Create a sense of urgency
Its important that we identify a need for improved teamwork and the importance of acting now. We need to tie the program to an existing potential problem. We can use organizational data to identify and support the selection of this problem.
Pull together the guiding team
We need to select a powerful group to lead this effort by identifying individuals with leadership authority, credibility, communication ability, analytical skills, and relevant clinical expertise.
Formulate a change vision and strategy
We will identify how fixing this “problem” will change the future such as improved clinical outcomes, staff and patient satisfaction; and safer, more efficient patient care.
We need to ensure that our vision is feasible and we have the necessary resources, information infrastructure, commitment to improvement, and leadership support.
We’ll start with a small unit using one teamwork tool then expand beyond that using lessons learned.
Communicate your vision for understanding and buy-in
We’ll then showcase a successful effort to interest other units in participating and create some buy-in.
We’ll focus on the leadership and staff members who are critical to our success.

37. What is TeamSTEPPSTM? An evidence-based teamwork system
Designed to improve:
Quality
Safety
Efficiency of health care
Practical and adaptable
Provides ready-to-use materials for training and ongoing teamwork
Evidence-Based Teamwork System
TeamSTEPPS is a teamwork system based on 20 years experience and lessons learned from High-Reliability Organizations (HROs) (for example, military operations, aviation, community emergency response services, and nuclear power industries). These types of organizations have been conducting extensive research on how teams work, what makes them effective and how to enhance their performance. This research is directly relevant to health care because delivering effective care requires teamwork.
Designed to Improve Team Effectiveness
TeamSTEPPS has incorporated the best practices from this research into a program to improve the quality, safety, and efficiency of health care by improving communication and other teamwork skills. These skills lead to important team outcomes like enabling the teams to:
Adapt to changing situations.
Have a shared understanding of the care plan.
Develop positive attitudes toward and appreciate the benefits of teamwork.
Provide more safe, reliable, and efficient care.
Practical and Adaptable
Designed with input from the medical community, it is an initiative that will work within the daily functioning of our organization (it is practical) and can be customized (adapted) to meet our organization’s needs. For example, we could identify an appropriate teamwork tool/process to help address a known problem (from a variety of options) that will best work within a specific department and focus time on training the team to use that tool.
[Note: If you have a specific “problem” that a department or the organization is struggling with , use it as the example here; it will have more impact and focus the discussion/presentation on specific issues that are relevant to your senior leadership.]
Ready-to-Use Materials
The TeamSTEPPS program provides materials to integrate teamwork principles into all areas of our health care system (for example, medical and support areas) so that everyone is focusing on teamwork, and the ongoing support to keep teamwork as the focus during daily work. The success of this program depends on enhancing the culture of our organization to focus on teamwork.

38. Why Use TeamSTEPPS?
Goal: Produce highly effective medical teams that optimize the use of information, people and resources to achieve the best clinical outcomes
Teams of individuals who communicate effectively and back each other up dramatically reduce the consequences of human error
Team skills are not innate; they must be trained
Note: Review the goal statement
health care systems, like many HROs, depend on the coordinated interactions of care providers working in an environment that is:
Dynamic
Complex
High risk
TeamSTEPPS provides the resources to optimize team performance across our organization.
Human factors research has shown that even highly skilled, motivated professionals are vulnerable to error due to human limitations.
But research has also shown that:
Teams that communicate effectively and back each other up reduce the potential for error, which results in enhanced safety and improved performance.
For example, the Joint Commission analyzed the sentinel events that were reported to them over the last 10 years and identified communication failure as the leading root cause of sentinel events.
TeamSTEPPS improves communication and other teamwork skills (e.g., backup behaviors) that help an organization move toward attaining this goal. This is important because teamwork is not innate; it must be learned.

39. Teams STEPPS- What Teams Learn?
Teamwork principles and training techniques apply to our organization as well as every other health organization.
If we implement TeamSTEPPS, our teams will learn about the four competency areas that lead to improved team performance, safer practices, and change in culture:
Leadership – how to direct and coordinate, assign tasks, motivate team members, facilitate optimal performance.
Situation monitoring – how to develop common understandings of team environment, apply strategies to monitor teammate performance and maintain a shared mental model.
Mutual support – how to anticipate other team members’ needs through accurate knowledge and shift workload to achieve balance during periods of high workload or stress.
Communication – how to effectively exchange information among team members, regardless of how it is communicated.
They will also learn about specific tools and strategies that can be implemented in our units that support these competencies. Some of these tools and strategies include:
Briefings
Team Huddles
Two-challenge rule
SBAR
Check back
The end result will be a higher-performing team, where members:
Share a clear vision of the plan
Utilize concise, structured communication techniques
Adapt readily to changing situations
Maximize the use of information, skills, and resources for optimal outcomes
TeamSTEPPS understands the dynamics that can occur when teams consist of physicians, nurses, and technicians. The initiative focuses on gaining the support of both physicians and nurses to enhance teamwork. To support this, one of the two trainers for the program should be a physician or non-physician medical provider.

40. What Can TeamSTEPPS Do for Us?
Clinical Units in a Medical Center2
After implementation of SBAR to improve communication among clinical caregivers:
• Reduced rate of adverse drug events (from 30 to 18 per 1,000 patient days).
• Improved medication reconciliation at patient admission from 72% to 88% and at discharge from 53% to 89%.
Emergency Department1
After implementation of multiple medical
team training programs:
Improved observed team behaviors.
Enhanced staff attitudes toward teamwork.
Reduced observed clinical errors.
These are real examples that provide evidence of significant improvements in patient safety, clinical outcomes, and cost after implementing team training or specific elements within TeamSTEPPS.
One of the anecdotal benefits of the initiative is that it “re-energizes” medical professionals to be interested in and proud of their profession.
[Note: based on your knowledge of your leadership and your organization, you might find it useful to select and present just a few of these examples from this and the next two slides.]
Morey, JC, Simon, R, Jay GD, et al. Error reduction and performance improvement in the emergency department through formal teamwork training: Evaluation results of the MEdTeams project. Health Serv Res. 37: , 2002.
Haig, K. Sutton S., Whittington, J. SBAR: A shared mental model for improving communication between clinicians. JL Comm J Qual Patient Saf 32(3):167-75, March 2006.
Morey, JC, Simon, R, Jay GD, et al. Error reduction and performance improvement in the emergency department through formal teamwork training: Evaluation results of the MedTeams project. Health Serv Res. 37: , 2002
Haig, K., Sutton S, Whittington, J. SBAR: A shared mental model for improving communication between clinicians. JL Comm J Qual Patient Saf 32(3):167-75, March 2006.

41. Focus on the common goal
Anchor the work where we have common agreement (PFCC)
Avoid judgment and 1st person / 2nd person dialogue
Basic tenet of negotiation theory – it is much easier to have the 3rd person conversation when discussing how to do the work

42. Doctor Engagement in Quality and Safety
Challenges:
Doctors are busy
They’ve been trained as individual experts
They are very goal oriented and want to see results
Traditionally, we haven’t taught them about human factors, teamwork and system error – a different way of thinking

43. Doctors & Nurses Nurses are trained to be narrative and descriptive
Doctors are trained to be problem solvers
– “what do you want me to do?”
– “just give me the headlines”
Complicating factors: gender, national culture, the pecking order, prior relationship
Perceptions of teamwork depend on your point of view

44. Understanding culture is essential
What are your social metrics?
How do people perceive teamwork in the
environment – are staff hesitant to speak up?
Safety climate? Do staff believe their
concerns would be acted upon?
What is their level of threat awareness? High
workload, fatigue, multi-tasking?

45. A Good Approach SBAR to communicate Assertion/ critical language
Psychological Safety / Effective Leadership
Rapid Response Teams
Leadership Walk Rounds

46. Putting the Pieces Together
Culture – leadership, safety culture, teamwork
Reliable Processes – embed teamwork practices in these
Cycles of Improvement – build a learning organisation with continual improvement

47. The Five Filters What are the 5 medications that put our
patients at risk? Warfarin, insulin, narcotics etc.
What are the 5 lab tests we can’t afford to lose?
What are the 5 diagnoses we can’t afford to miss?
What are the 5 places things fall through the cracks?

48. Crew Resource Management
Focus on teamwork, communication, flattening hierarchy, managing error, situational awareness, decision making
Non-punitive reporting of near misses, 500,00 reports over 15 years
Very open culture with regard to error and safety

49. High Reliability
Preoccupation with failure – When someone raises a concern, the problem exists until proven otherwise
Reluctance to simplify – Errors and close calls are
reflections of deeper system flaws
Commitment to resilience – Knowing there will be
problems and flaws, the job will get done
Deference to expertise – The person most qualified does the job
Sensitivity to operations – Flexing resources to deal with demand or workload

50. Red Flags – Loss of Situational Awareness
Ambiguity
Reduced/Poor communication
Confusion
Trying something new under pressure
Deviating from established norms
Verbal violence
Doesn’t feel right
Fixation / Boredom / Task saturation
Being rushed / Behind schedule

51. Debriefing -An opportunity for individual, team and organizational learning
The more specific, the better
What did we do well? What did we learn?
What would we do differently next time?
Take a minute or two to learn when it’s
fresh in everyone’s head

52. Teamwork & Vitality Ideas generations- Snorkel together
Use data to motivate and drive teams for better results
STUDY RESULTS TOGETHER
Celebrate Successes
Star Awards/rewards

53. Key Take Home’s Respect the wisdom of the front line workers
Culture is related to clinical and operational outcomes
Culture is local – work unit culture trumps hospital culture
Lots of variability across work units
Familiarity improves predictable patterns of behavior (improves performance)
Perceptions of teamwork differ by role, whereas perceptions of safety climate are consistent within a work unit
Senior leader contact with front-line workers is key to improving perceptions of safety climate
Frontline providers have demonstrated a striking ability to improve culture in an relatively short time, when they are leading the effort
Answer the question: “Are We Safer than Last Year?”

54. Remember every system is perfectly designed to get the results it get

55. The Blue Angels