It is increasingly clear that future improvements in health care will depend progressively more on our ability to promote excellent teamwork and effective communication across the spectrum of clinical care. Our technology infrastructure, now on a fast track deployment of electronic medical records and the spread of computerized physician order entry, is ultimately an enabler to the “peopleware,” the clinicians who must translate such information into clinical practice, and comprise the teams effectively applying protocols and guidelines in the care of patients. Currently, we can assure our patients that their care is always provided by a team of experts, but we cannot assure our patients that their care is always provided by expert teams. There are two components required to successfully train and implement effective teamwork and communication in clinical practice. First, there are critical tools and behaviors that support effective collaborative work. At a minimum, structured language, effective assertion/critical language, psychological safety, and effective leadership are required components. The second aspect is the use of medical simulation to embed and practice such skills. The current question is how to most practically teach and practice such skills so they become embedded in the delivery of patient care systematically and in a manner that provides value to patients, clinicians and institutions. Teamwork requires learned skills in leadership, group participation, and communication—but such skills cannot be fully implemented by those who have them unless co-workers have been afforded similar new insights and language. The time has come to evaluate the efforts underway in our numerous simulation centers and educational departments, and to strategically define how to bring excellent teamwork and communication consistently into our hospitals. We can reasonably expect that an investment in teamwork and communication strategies will do more than improve quality and safety. The efforts are also likely to decrease patient harm, potential malpractice suits, and increase patient satisfaction. There is extensive experience in other high reliability industries, like commercial aviation, the military, etc., that we can draw on.
We have at our disposal today three main mechanisms to teach teamwork and effective communication skills (), and as a result of extensive teamwork training in other industries we can define the most useful components.
The spectrum of teamwork training
Visible Leadership Involvement
To successfully apply and sustain effective teamwork and communication requires three components: visible and consistent senior leadership involvement, clinical physician leadership, and embedding the tools and behaviors in clinical work that people do every day. The key and consistent message by senior leaders must be that these efforts are important, and appropriate resources will be available to support them. In the culture of medicine, with physicians being de facto leaders, respected physicians as champions is critical. This requires physicians who are willing to publicly commit their support among their peers and express the importance of such efforts. They must also be willing to openly deal with resistance from their colleagues in an open, constructive manner. When clear physician support is lacking, and it is left to nurses and others to deal with physician resistance, the results will be suboptimal.
Practically applying the tools and behaviors needed for effective teamwork and communication is challenging because clinicians are busy and not terribly interested in more work to do. Framing the adoption of such techniques as practical tools to make one's day simpler, safer and easier is a good approach. Being seen as practical and relevant to the clinical work makes it far easier to embed the changes so they become the way care is routinely delivered.
Teaching Tools and Behaviors of Effective Teamwork and Communication
The basic core skills are structured language (SBAR, which stands for situation, background, assessment, and recommendation), effective assertion, critical language, psychological safety, and effective leadership. Situational awareness and debriefing are also valuable.
Structured language increases predictability and provides a common template for communication. Communication styles are personality dependent, and effective communication is affected by factors such as the confidence and skill of a nurse and how receptive a physician is to the communication. SBAR is a situational briefing model adopted from the U.S. Nuclear Navy that helps providers organize their thoughts and communications to increase the likelihood of a mutually understood and agreed upon conclusion.
Assertion/critical language is a core element of effective teamwork, as it provides a mechanism that allows any team member to voice a concern relative to patient care and trigger active communication among the team about the expressed concern. Having structure to this process is quite important, as we know from risk management data that often people speak up softly, indirectly, or not at all.
Psychological safety means that one can voice a concern or ask for help and know that the response will always be respectful. Unless this environment of respect is consistently present, and a basic property of the organizational culture, people will hesitate to express concern and avoidable harm will occur.
Effective physician leaders actively work to flatten the existing hierarchy, share the plan of care with other team members, actively and repeatedly invite others into the conversation, and create familiarity by knowing the names of individual team members. Some doctors naturally have these skills. Many do not, and we have not systematically taught leadership skill in medical education.
The Spectrum of Teamwork Education
Teamwork training falls along a spectrum from interactive classroom training to full-bore simulation where skills can be practiced in realistic scenarios, evaluated, and debriefed. Low fidelity simulation models include table-top simulations or simply walking through the steps of a process. Although there is a tradeoff with regard to realism and complexity, the advantage is low cost and flexibility. Mid-range simulation is done with computerized mannequins that allow multiple protocols and provide a dynamic response depending on the effectiveness of the team in responding to the situation. Another advantage of this mode of simulation is that training can be done in the clinical units where people regularly deliver care, so it is quite realistic and often system weakness is readily uncovered. High fidelity simulators provide a great degree of realism and are very effective. The potential limiting factor is they are resource intensive by their very nature. They are also generally removed from the clinical care units. Historically, these devices originated medically in the domain of anesthesia and operating rooms. They have become quite sophisticated and are now applied in cardiac catheterization techniques, surgical skills, and other domains.
As the pyramid in suggests, the number of individuals an organization is likely to be able to teach using interactive classroom training is significantly higher than in the high fidelity simulators, which are much more costly, and are not as easy or simple to access.
Interactive classroom training requires a curriculum, as noted above, and a skilled facilitator who is able to combine didactic material with audience engagement and role playing. Multidisciplinary classes are essential but no specific technology is required. This teaching should incorporate an explanation of each of the components of teamwork, how human factors knowledge identifies why they are critical to delivering safe care, and how they may be implemented. Fully robust interactive classroom trainings would likely be taught by a clinician known to, and respected by, the group being trained, repeated on a regular basis, and required of all the disciplines in a unit who work together. For example, on an obstetric floor, the group attending a session would include an anesthesiologist, obstetrician, neonatologist, nurse, nurse midwife, secretary, and cleaning staff—and all would be required to, together, attend these sessions.
Each simulation modality has a valuable role to play in a robust teamwork and effective communication development plan, but to understand their roles, it is useful to examine the history of high fidelity training, specifically to appreciate that high fidelity simulators have been available to health care for many years and have had, at best, limited impact. Why? High fidelity simulators, beginning with anesthesia simulation, have played a major role in improving the safety of surgical procedures. Participants come away with awareness that a different set of skills is required to manage available resources than is required to manage the concomitant clinical problems. An anesthesiologist or surgeon may have the clinical knowledge necessary to stop massive blood loss or control an intraoperative cardiac arrhythmia, but to actually do so also requires an ability to maintain oversight of the emergency, and direct others to work collaboratively and effectively with regard to specific task and communication. Jeff Cooper and David Gaba's sentinel efforts in the development and implementation of these simulators into health care has been a significant factor in saving untold lives in our operating rooms and elsewhere (Cooper, Gaba 2002
; Lighthall et al. 2003; Gaba 2004
). However, for all its positive benefit, the acceptance of simulation into health care training has been slow at best, and in the initial evaluations of patient safety, beginning in 1999 with the IOM report, the role of simulation was not highlighted, nor suggestions made at that point to extensively incorporate simulation. There are a few plausible answers as to why.
Simulation: Strengths and Weaknesses
Simulators have been expensive to buy and maintain, and the need for actors, technicians, and facilitators to run them meant with each training ongoing expense were upwards of a few thousands dollars for a day's training of 10 or 12 individuals. Second, while almost every clinician who has trained in a simulator appreciates the new insights they gain, they do not necessarily enjoy the experience. Physicians do not usually comfortably or willingly “suspend disbelief” when acting out a simulated scenario, and often find the experience inherently uncomfortable even before the scenario exposes their knowledge limitations and forces them, as a teaching process, to fail. More problematic, and an essential drawback that is less a fault of simulation than of the health care profession as a whole, is that the select group that is trained often go back to work in hospital environments with other providers who neither understand or appreciate the lessons learned. This can make the training difficult to use, and until very recently hospital leaders have not fully appreciated how better teamwork lessens error and improves the reliability of care. Hospital leaders often have not felt capable of influencing their providers, specifically physicians, to participate. None of these qualities endear simulation to its participants. Lastly, a single day's simulation training, as powerful as the experience might be, still has limitations, encapsulated by one observer who stated, “It was like watching a religious conversion because the experience was powerful enough to generate in a single day whole new insights in each person about the importance of Team Behavior and how to manage resources in a crisis, but the problem was that the conversion was solely of each individual, not the group. Very few left the sessions with enough understanding of the concrete behaviors to utilize in the clinical care setting, nor did they really understand the concepts or theories that would make sense of the behaviors. Each individual knew, and most importantly believed, that when they went back to work they needed to do something differently, but not necessarily exactly what, with whom, or how” (Maynard 2005
). A great credit to these simulations is that they create the environment to generate wholesale conversion of skeptics into believers in less than a full day, but then there is not enough time to also expand the new belief into usable knowledge. This comment leads back to the overall issues of strategy, structure, and implementation.
Teamwork: Strategy, Structure, and Implementation
The high fidelity simulators are a component of the structure and implementation of teamwork—but their power to effect change is thwarted if they are not part of a health care-wide organizational teamwork and communication educational strategy. That is, a strategy with thematic content taught through physician credentialing, nursing competency, and new-hire orientation that is repeated appropriately and evaluated periodically with surveillance and audit. The evolution of thinking about patient safety is leading organizations to think more globally about this issue, and to consider how the extraordinary teachings promulgated by Gaba, Cooper, Salas, Simon (Salas and Cannon-Bowers 2001
), Helmreich (Helmreich 2000; Helmreich
, Musson 2000
), and others may be more widely disseminated into the health care environment. This will require an organization wide coordinated effort of interactive classroom training coupled with periodic low fidelity skill drills, managed cohesively by clinical chairs and hospital administrators, and supported by facilitators who will likely be trained in the high fidelity simulated environment. In conjunction with and linked to this organizational effort, specific high fidelity skills training will need to be available in the student period of training (i.e., medical and nursing school environments), the specialty period of training (residency programs) and, afterwards, as a part of specialty recredentailing. There are so many nascent efforts in these areas; the time to develop this strategy is now—before the small projects become better formed and less malleable.
Leadership by our trustees, CEOs, and physician leaders is the single most important success factor to turning the barriers of diminished awareness, accountability, ability, and action into accelerators of performance improvement and transformation (Denham 2005
). Awareness is the first critical dimension of innovation adoption. Leaders must be aware of performance gaps before they can commit to adoption of any innovation. Few leaders are fully aware of the magnitude of the problem common to organizations like their own. Fewer still are aware of the performance gaps at their own organization that can only be defined by direct measurement and communication to leadership teams.
Accountability of leaders for closing performance gaps is critical. For innovation adoption to occur, leaders need to be directly and personally accountable to close the performance gaps. Although initiatives like pay for performance are re-calibrating many to focus on quality as a strategic priority, few leaders are directly accountable for specific patient safety performance gaps, especially in the difficult to measure arena of “culture.” Organizations must also be accountable to their patients, their communities, and the national community through public reporting.
Leaders can be aware of performance gaps and accountable for those gaps; however, they will fail to close them if their organizations do not have the ability to adopt new practices and technologies. The dimension of ability may be measured as capacity. It includes investment in knowledge, skills, compensated staff time, and the “dark green dollars” of line item budget allocations. Finally, to accelerate innovation adoption, organizations need to take explicit actions toward line of sight targets that close performance gaps that can be easily scored. Miscommunication, for example, is a component of almost every adverse event, but difficult to measure. Barriers exist along each of these dimensions. Such barriers can often be converted into accelerators by specific performance improvement interventions (Denham 2005
It is clear that leaders drive values, values drive behaviors, and behaviors drive performance of an organization. The collective behaviors of an organization define its culture (Rhoades 2005
). Without the right values supported by robust structures and systems established and sustained by the governance boards, senior administrative leaders, and clinical leaders it will be impossible to become a high reliability organization that embodies a true culture of patient safety.
A Just Culture, the engagement of leadership in safety, and good teamwork and communication training, are critical and related requirements for safe and reliable care. Developed and applied concurrently they weave a supporting framework for the effective implementation of new technologies and evidence-based practices. The mechanisms and tools now exist to do this work. We are late in development and implementation because we have relied too heavily on technology-based solutions and the broad expectation that every clinical project, even those based on social science, must have numerically measurable results. Numerical results for these endeavors are indirectly attainable (through outcome-based projects) if appropriate effort is apportioned to developing mindfulness through the tools described.