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Improving Teamwork Among Nurses and Physicians

Daniel OConnell, Ph.D. Seattle, WA 206 282-1007

O'Connell 2010

Multiple individuals with specific skills and roles, coordinating their activities towards a mutually understood and agreed upon aim the Red Socks the Transplant Team

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Keys to Teamwork

Acceptance and respect for each members information and contribution

Including the patient and family

Limiting hierarchy to those issues required by scope of practice and responsibility Shared decisionmaking 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 Explicitly calls for teamwork training Communication cited in most sentinel events Team training/crew resource management emerged as solution to many aviation disasters

JCAHO: Patient Safety Plan 2004

25 years of aviation experience

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 teams 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.
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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 patients care Clear understanding of roles & capabilities Standard operating procedures Briefing/huddle before each event allowing Anticipation and adjustment for specific challenges
O'Connell 2010


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

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
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Is Communication matched to purpose and timeliness?

No communication:

No/inadequate referral letter or consult note, discharge summary, progress note, briefing Progress note in chart, referral letter, consult note or one way briefing Conversation in real time intended to clarify, recognize anomalies, surface concerns and make shared decisions
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Serial Monologue

Real time dialogue

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 dont you mind your own business?

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Red Flags

Anomalies and concerns that are recognized before any adverse event

5-7 evident before aircraft incidents RCAs in healthcare routinely find 5+ red flags preceding adverse event Anomalies, deviations from expected are so common that they are not remarkable

Normalization of deviance

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Willingness to assert a position

Why didnt 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 Skills lab, hi/low fidelity enactments with discussion, feedback and correction Devil is in the details
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Simulation/practice for emergencies

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 Performance





Traits & Talents

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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