Optimizing safety, comms, and teamwork in and around the OR
The role of effective teamwork in accomplishing complex tasks is accepted in many domains.
Paul Barach, MD, MPH, Clinical Professor, Wayne State University School of Medicine and Chief Medical Officer, Pegwin, U.S. and Douglas B. Dotan, MA, CQIA, Founder/Chairman/President Pegwin, U.S. | Jan 27, 2020
The role of effective teamwork in accomplishing complex tasks is accepted in many domains. Similarly, there is good evidence that the outcome in trauma care depends on effective surgical team performance. Team training and communication has a proven history in aviation and military organizations. In 1988, after many aircraft accidents, the IATA Technical Committee, the senior international aviation safety agency, recommended that all airlines should establish a safety department managed by a professional safety officer to implement a safety management system with explicit flight safety functions. Prior to 1988, communication between the captain and first officer was more subordination than meaningful collaboration. There was little communication in the cockpit. One pilot would read out the required action and the other pilot would execute and then repeat back confirming the action completed. The aviation industry realized through Crew Resource Management training that meaningful teamwork can only occur when there is truthful, transparent and timely communication between team members. Aviation learned from its mistakes, but it took many incidents, as well as public and regulatory scrutiny, to make flying reliable and safe.
Recently, these experiences and techniques have been applied in healthcare, including in resuscitation and critical care management. Studies of aviation teams revealed failures of coordination, communication, workload management, loss of group situational awareness, and inefficient resource utilization. Thorough investigation of adverse events in hospital care, patient hand-offs, and resuscitation revealed similar failures that, like aviation, tend to be multifactorial and complex.
Healthcare has turned to learn from the aviation industry and developed processes to create a patient safety culture and communicate effectively to achieve reliable and cost-effective patient outcomes. Briefing the team before a procedure, communicating constantly during a procedure so team members know the intended plan, and then debriefing the team to collectively reflect and learn what went well, and what is needed to be improved are essential components of great teams.
The U.S. spends more per person on healthcare than any other industrialized country, yet our health outcomes, including overall life expectancy, are worse. Teams, we know, make fewer mistakes than individuals, especially when all team members know their individual responsibilities as well as those of the other team members. However, simply bringing individuals together to perform a specified task does not ensure that they will function as a team. Teamwork depends on a willingness of clinicians from diverse backgrounds to cooperate toward a shared goal, to communicate, to work together effectively, and to improve.
Each team member must be able to:
- Anticipate the needs of the others
- Adjust to each other’s actions and to the changing environment
- Monitor each other’s activities and distribute workload dynamically
- Have a shared understanding of accepted processes, and the knowledge of how events and actions should proceed (situational awareness)
Turning healthcare experts into an expert team requires substantial planning and practice. There is a natural resistance to move beyond individual roles and accountability to a team mindset. We can facilitate this organizational commitment by:
- Fostering a shared awareness and mind-set of each member’s tasks and role on the team through cross-training and other team-training modalities
- Training members in specific teamwork skills such as communication, situation awareness, leadership, followership, resource allocation, and adaptability
- Conducting team training in simulated scenarios with a focus on both team learning, behaviors and technical skills
- Training clinical team leaders in the core leadership competencies to build and maintain effective teams
- Establishing and consistently utilizing reliable methods of team performance evaluation and rapid feedback
Teams that do not communicate well cannot deliver effective care but are merely groups of individuals working side by side. Effective teamwork and communication are critical to functioning safely in healthcare. They help groups navigate competing priorities, overcome issues associated with human factors, and reduce the risk of error. Surgical training must focus more intently on providing clinicians with the core competencies—the knowledge, skills and attitudes to more effectively communicate with the family and other providers and function as high reliable teams. Continued research on how to improve the safety and quality of perioperative care will be driven by honest and respectful dialogue with providers. This will eventually lead to a deeper understanding of the systemic causes and mechanisms that cause harm and how best to develop resilience to help mitigate this harm and develop more reliable systems of care.
References available on request.