o'connell 2010 improving teamwork among nurses and physicians daniel oconnell, ph.d. seattle,...
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O'Connell 2010
Improving Teamwork Among Nurses and
Physicians
Daniel O’Connell, Ph.D.Seattle, WA
[email protected] 282-1007
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
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
O'Connell 2010
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
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.
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
O'Connell 2010
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
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?)
O'Connell 2010
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
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
O'Connell 2010
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
Standardized info exchange/briefing
SBAR Situation Background Assessment Recommendation
From Kaiser Permanente surgery program
O'Connell 2010
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?”
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
O'Connell 2010
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
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”
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
Role of Leadership
Understand, believe in, model and influence the performance of Team based attitudes, processes, behaviors and incentives
O'Connell 2010
O'Connell 2010
Star Model of PerformanceRoles
Skills
MotivationsTraits & Talents
Systems
Performance
O'Connell 2010
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