Health care in general, and surgical care specifically, is a team sport. To provide optimal patient care and enjoyment at work, teamwork and communication within surgical services benefit from deliberate development. This chapter describes the characteristics of highly effective health care teams and what is required of team members. Overall team performance is affected by the skills of members, the clarity of the team’s goals, and the effectiveness of the interlaced activities of members. Teams practice and learn. Effective teams provide safer care.
In addition to the capabilities of teams, the system(s) in which the teams work and the culture of the workplace directly affect team performance and their patient care outcomes. This chapter provides an overview of the systems and culture as they affect teams and describes an approach to measurement of team communication and safety culture that goes beyond the assessment of the collective technical competence of the team. The authors describe their experience in using the Safety Attitudes Questionnaire and the NOTECHS nontechnical skills framework to assess the culture of the surgical environment and surgical teams.
KeywordsTeamwork, Safety attitudes questionnaire, Teaming, Teams, Competence, Collective competence, Culture, Nontechnical skills, NOTSS, NOTECH
Expert Teams 80
What Is a Team and What Does It Do? 80
Team Behavior and Surgical Outcomes 82
The System(s) in Which Teams Work 84
Influencing for Good or Ill—The System’s Culture 86
Teams and Culture—Nontechnical Skill Assessment 86
The Impact of Culture 87
Culture and Nontechnical Skill Performance 89
Authors’ Biography 94
Surgery and health care, in general, depends on quality teamwork. Highly functioning teams are not born but are built. In high-functioning and effective teams, members have a shared understanding of purpose, the system(s) in which they are to function, and the cultural norms that define acceptable behavior. The accomplishments of a team exceed the accomplishments of its members. A team learns and exhibits collective competence.
The purpose of this chapter is to describe characteristics of expert teams, and the sociocultural environment and systems in which teams function in the context of surgical safety. It discusses aspects of both technical and nontechnical aspects of surgical performance using clinical examples from experience in British Columbia.
Every day, we see expert teams working, whether they are astronauts working together on the international space station using the CanadaArm to launch or retrieve satellites, construction workers building the next skyscraper, our favorite sports team, or emergency responders. In each situation, a group of individuals, each with specific skills, have come together to perform a task, a task that any one member would not be able to achieve on her or his own.
The concepts underpinning expertise in teams and team behavior have only recently been studied in medicine. The need for effective teamwork and effective communication has been recognized by many reports and reports describing the safety of health care around the world, such as the Canadian Adverse Event Study and the report on Adverse Events among Children in Canadian Hospitals. These reports and others, such as To Err Is Human and Crossing the Quality Chasm, have surfaced the concrete connection between teamwork and increased patient safety and quality of care. Moreover, they highlighted the many contributing factors that facilitate quality human and team performance in health care.
What Is a Team and What Does It Do?
A team can be defined as a group of two or more individuals who share a common goal, composed of members, each having specific skills and roles to perform in order to attain a known goal successfully. Team members rely upon each other. Teams as a whole and their members adapt to changes in the context or situation in which they find themselves. Baker and colleagues describe these characteristics as the “specific knowledge, skills, and attitudes” that team members must possess.
Effective teams embody a collective approach and action, composed of interdependent tasks to achieve the goal. The members of a team and the team possess specialized knowledge and skills, and make decisions and trade-offs while executing the collective action. They learn from experience so that performance can be improved. Often, teams work under conditions of high demand and stress, and in situations where the consequences of failure can be profound such as in health care.
To be most effective, a team must be directed by a common and understood goal. To achieve that goal, the members must share a common mental model of both the goal and the task(s) required to achieve it. “When teammates hold similar cognitive representations, they are better able to anticipate one another’s needs and actions, to engage in more efficient searches for information, to jointly interpret cues in their environments, and to negotiate solutions to problems encountered.” Members share a “team orientation”; “we can only achieve our goal together, otherwise we fail.”
To build the team orientation, members must establish mutual trust. This is done by training and working together, supporting each other and learning from experience as they participate in the authentic situations that the team is intended to address. They know each other and the tasks. They monitor each other’s performance and provide backup support when needed. They are effective verbal and nonverbal communicators, balancing voicing and listening.
What teams do, specifically the “activity of working together,” has been described by Edmonson as “teaming”. Teaming is “a dynamic state, not a bounded static entity.” “Teaming blends relating to people, listening to other points of view, coordinating actions and making shared decisions. Effective teaming requires everyone to remain vigilantly aware of others needs, roles and perspectives.” Teaming embodies cognitive and affective skills in the members and the team. It does not require a stable structure. Teaming is the “engine of organizational learning.” Through “repetitive cycles of communication, decision making, action and reflection, with each cycle informed by the result of the previous cycles until the outcomes are achieved.” During this process, the differences between the knowledge and skills of members become clear, effective communication leads to improved coordination, and effective interdependent actions develop.
Effective teams are competent; their members are competent at the individual level and the team is collectively competent. Commonly, individual competence is conceived of as a quality that the person develops, acquires, or possesses; a state achieved. Collective competence differs; it is a characteristic of a team. It is only achieved by participating in the authentic situations that the team is intended to address. Team competence is distributed across the network of individuals and is consistently evolving because of the interconnecting behaviors enacted in time and space between the members of the team.
Characteristics of Effective Team Members
Clarke has described the characteristics that effective members in health care teams possess. These include an individual commitment to safety combined with the ability to effectively communicate (accurately, unambiguously so that the meaning is understood). Team members make sense of the situation as it unfolds while attending to his or her own activities and those of others. The individual’s tasks are known, understood, and rehearsed. Backup plans are developed and contingencies formulated for when they might be needed.
The Formula 1 Pit Stop
Catchpole et al. reported the application of teamwork techniques derived from Formula One pit stops and aviation to patient handover between the operating room and the intensive care unit. The foundational activities seen in the Formula One pit stop that they deemed relevant to handovers in health care include a clearly defined goal supported by leadership. The effectiveness of the pit stop was dependent upon a comprehensive shared understanding of the component tasks and their sequencing.
Individual members of the team knew their own roles and tasks and how these tasks fit together. Each member required individual discipline and composure allowing them to perform under critical time pressures. Beyond their own tasks, team members were aware of and, as needed, responsive to circumstances about them. Team members learned together during training and rehearsal. Pit stop crews debriefed and learned from the “real-life lived” experience. Debriefing and learning created the opportunity for the team to understand where, when, and how tasks and processes could (or did) fail and what the performance strengths and weaknesses were, both for individual members and the team as a collective.
Team Behavior and Surgical Outcomes
Team behaviors in surgery have been the subject of many studies describing the relationships between teamwork, clinical judgment, communication, and clinical quality. Gawande, while studying wrong site surgery and errors reported by surgeons, found that failures of teamwork and judgment were common. Interruptions in the operating room were related to teamwork breakdown and communication breakdowns played a role in surgical errors.
Early work by McDonald et al. described psychological characteristics of surgeon excellence using a retrospective interview technique. They found that surgeons undertaking high-risk procedures self-identified commitment, self-belief, positive imagery, mental readiness, full focus, controlling distractions, and constructive evaluation (i.e., learning from previous cases) as characteristics of excellence in the surgeon.
However, individual excellence and perspective is only one aspect of a highly functioning team. Carthey et al. assessed pediatric cardiac surgery for behaviors and surgical events (errors) in the United Kingdom while using a literature informed, behavioral marker framework. The framework used describes behavioral characteristics at both the individual and team levels.
As described by Clarke and Catchpole earlier, Carthey found that team members needed to have the technical skills necessary to undertake the task required of them, as well as to be mentally prepared and cognitively flexible to allow adaption and awareness of the tasks and the surroundings. Surgeons who scored highest on the behavioral scores were best able to compensate successfully for surgical errors and overall had the lowest number of major or minor events (errors). For surgeons who scored lower on the behavioral scales, negative influences of teams and organizational factors were noted.
Carthey found that teams bring additional skills to the task, beyond those of any one individual. Individuals on a team must be safety aware to mobilize the team should a concern arise and be effective communicators in articulating concerns. Teams learn through planning, repetition, deliberative practice, coaching, review, and analysis. This insight and practice helps teams build the adaptability of team members and creates and coordinates redundancy for times of failure.
The relationship of surgical team behaviors and patient outcomes has been reported in the literature. Mazzocco et al. studied the relationship between surgical team behaviors and patient outcomes using an observational methodology and an instrument addressing six behavioral domains: briefing, information sharing, inquiry, assertion, vigilance and awareness, and contingency management. The patient’s American Society of Anesthesiologists (ASA) Physical Status classification system (ASA) score was used to adjust for patient factors. Outcomes were measured at 30 days postoperatively. Complications were higher in those cases when information sharing was less frequent, during the preoperative briefing, during the procedure, or in the postoperative handover. The behavioral marker risk index across all operative phases was significantly associated with complication or death.
Neily et al. studied the effect of team training on surgical outcomes in Veterans Health Administration facilities. This study assessed a team training program comprising briefings pre- and postoperatively and checklists. The training included preparation, a conference, and four quarterly coaching sessions. One hundred eight facilities (74 underwent training) and 182,409 procedures were studied using outcomes from the VA Surgical Quality Improvement Program. Surgical mortality in both the trained and untrained facilities dropped over the course of the study; however, using propensity matching, trained groups showed a 50% greater drop in mortality. Sustainability of ongoing performance was dependent on continued team training.