Improving Teamwork Among Nurses and Physicians

1. Improving Teamwork Among Nurses and Physicians Daniel O’Connell, Ph.D. Seattle, WA danoconn@uw.edu 206 282-1007 O'Connell 2010

2. 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

3. 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” O'Connell 2010

4. 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 O'Connell 2010

5. 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. O'Connell 2010

6. 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 O'Connell 2010

7. 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 O'Connell 2010

8. 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 O'Connell 2010

9. 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?) O'Connell 2010

10. 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 O'Connell 2010

11. 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 O'Connell 2010

12. 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 O'Connell 2010

13. Standardized info exchange/briefing SBAR • Situation • Background • Assessment • Recommendation From Kaiser Permanente surgery program O'Connell 2010

14. 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?” O'Connell 2010

15. 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 O'Connell 2010

16. 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 O'Connell 2010

17. 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” O'Connell 2010

18. 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 O'Connell 2010

19. Role of Leadership Understand, believe in, model and influence the performance of Team based attitudes, processes, behaviors and incentives O'Connell 2010

20. Star Model of Performance Roles Systems Skills Performance Motivations Traits & Talents O'Connell 2010

21. 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 O'Connell 2010