Example type
Example
Clinical care: Ineffective (from Hu et al. [22])
Scrub technician: Dr. Smith, would you mind confirming what would you like this specimen labeled?
Surgeon: We already talked about it
Clinical care: Effective (from Hu et al. [22])
Surgeon: You guys are going to put in a central line? Or what do you want to do?
Anesthesia attending: Well, we … I need to talk to you about it. Her INR is 1.4. I’m not a big fan of sticking her neck
Surgeon : Sounds fair to me
Anesthesia attending: So if we do … I’m wondering if we can put in a groin, like if you guys put in a groin line in
Surgeon: So I’ll tell you what … Why don’t we see what you get here? This is going to be one of those situations where we could make an incision and know whether this is going to be hard or not. We wouldn’t want to do anything like a big groin line
Anesthesia attending: Right, and I think that’s right
Surgeon: But we’ll prep everything out and … then if we get in and we decide, “Yeah, this is going to be scarier than we wanted,” we’ll put in a groin line
Anesthesia attending: That sounds great
Surgeon: Sound good?
Anesthesia attending: I think that’s the perfect plan
Surgeon: Okay, perfect
Improvement: Effective
Multiple members of a surgical team have expressed concern at what they feel is an unusually high number of surgical site infections being reported for last quarters’ colorectal cases
The institution has in place a comprehensive unit-based safety program (CUSP) team for its colorectal surgery service line [23]
This multidisciplinary surgical improvement team has decided to address the increased surgical site infection rate for this quarter’s project
A round of brainstorming with surgeons, anesthesiologists, nurses, and scrub technicians is used to generate ideas about what may be contributing to the increased infection rate
Multiple team members mention concerns about “dirty” and “clean” instrument handling
Once surgical instruments are contaminated by stool during the latter half of colon resection, “dirty” items are supposed to be set aside to reduce wound contamination during skin closure where the risk of surgical site infection is highest
Team members note that perhaps the segregation of contaminated instruments is not occurring 100 % of the time
They then find themselves overwhelmed by the number of possible reasons why instruments are being mishandled, which include lack of training, a rushed atmosphere, and inadequate spare instruments
Rather than trying to address all of these reasons individually, the team comes up with a simplified solution that should cover all causes
A small, second sterile surgical “closure tray” will be added to these cases to ensure optimal sterility for final skin closure
The team then enlists the help of their administrative champion to demonstrate the potential cost savings of reduced surgical site infections while advocating for the additional surgical equipment needed for each case
One month later, the closure tray has been added to each colorectal procedure
By the next quarter, surgical site infection rates following colorectal cases are below their pre-intervention baseline
The evidence across disciplines and settings identifies multiple hallmarks of effective teams. These “expert teams ” and effective team members are committed to (1) actively and transparently sharing unique information; (2) developing and maintaining shared similar mental models of the team’s goals, tasks, and interdependencies; (3) backing each other up as appropriate; (4) using strategies that facilitate collective sensemaking and closing the loop to ensure shared understanding of information and tasks; (5) believing in the importance of the team’s goal, believing that teamwork is critical to achieving this shared goal, and taking other’s behavior into account; (6) mutually monitoring the situation and team progress in order to adapt or adjust their collective strategy or individual contributions as needed; (7) discussing interdependencies in order to coordinate their actions and tempos; and (8) mutually trusting that their fellow team members will perform their roles and protect the interests of the team [24, 25]. Additionally, the evidence underscores that generalizable teaming skills and attitudes can be developed through well-executed, systems-oriented team training interventions [26, 27]. In this chapter we summarize the science examining team effectiveness, offering practical strategies for optimizing teaming across the perioperative continuum, and also highlighting where empirical evidence remains sparse.
Defining Teams, Teamwork, and Multi-Team Systems
A team is defined as an identifiable group of two or more people working interdependently toward shared, mutual goals that could not be accomplished effectively, if at all, by a single person. [28, 29]. Teamwork refers to the behaviors (e.g., communicating and sharing information, checking for mutual understanding), attitudes (e.g., belief in the collective ability of the team and need for teamwork), and cognitions (e.g., shared mental models) teams use to communicate, coordinate, and collaborate their efforts to achieve shared, collective goals. Studies of teamwork in surgery and other domains of care reflect the heterogeneity of teams and teaming in practice. Teams can be defined in terms of patient population (e.g., pediatric surgical teams) [30], disease or procedure types (e.g., colorectal surgery teams, surgical oncology teams), professional identity (e.g., surgical ICU nursing teams), setting (e.g., ambulatory/day surgery team), and crisis scenarios (e.g., rapid response teams) [31].
Teams can also vary in the degree to which the roles contributing to team goals and the individuals filling each role remain stable over time. A simple 2 × 2 typology of healthcare team composition developed by Pamela Andreatta [32] is helpful for understanding and comparing teams with (1) stable roles and stable personnel; (2) stable roles, but variable personnel; (3) variable roles, yet stable personnel; and (4) variable roles combined with variable personnel. For example, surgical teams may be static or dynamic (i.e., ad hoc), with more handoffs occurring among dynamic teams that, in turn, demand more explicit communication and coordination to be optimally effective [33]. Different people may switch into and out of the same role during a defined period of time (e.g., a new relief circulator may join a case while others go to lunch or break) and different roles may join or leave as needed (e.g., a specialist may participate in a portion of a case). Across the perioperative care continuum teams can also address different types of tasks. For example, team-based work can focus on (1) advice and involvement (e.g., unit, service line, or departmental patient safety or quality improvement teams), (2) production and service (e.g., central sterile processing teams), (3) projects and development (e.g., research teams focused on innovation), and (4) action and negotiation (e.g., direct care team involved in a particular case, rapid response teams) [34]. Surgical teams in the operating room are most often discussed as action teams, defined as “highly skilled specialist teams cooperating in brief performance events that require improvisation in unpredictable circumstances” ([34], p. 121). However, it is critical to remember that direct care is not the only type of team-based work important for safe, high-quality, high-value surgical care. Clinicians, nonclinical perioperative staff, and administrators also participate in project teams and advice/involvement teams dedicated to improving care safety, quality, and value.
While many generalizable teaming processes are important across different team types and different types of team-based work, these typologies are helpful for considering situations or team configurations in which some team behaviors, attitudes, or cognitions may need more (or less) attention in practice. For example, teams that vary in roles or personnel must consider allocating slightly more time and attention to developing and reestablishing shared mental models about the strategies that will be used to coordinate their actions compared to relatively more static teams. Conversely, while highly stable teams working together over time can develop the shared cognitive structures and behavioral norms that enable them to adapt efficiently when needed, they can also become overly reliant on implicit coordination strategies, missing opportunities to explicitly verify information or shared understanding which can lead to glitches and unintended errors [35].
While a co-located multidisciplinary team may complete a particular surgical procedure, a micro-systems-oriented lens emphasizes thinking of the perioperative continuum of care as the work of a team of teams [36]. Effective, efficient, and safe surgery often requires the collective efforts of five to six different teams plus individual collaborators. For example, care transitions across a preoperative clinic team, a preoperative evaluation or testing center, a prep area or regional anesthesia team, an intraoperative team, a PACU team, and a postoperative floor care team. Intraoperative surgical teams depend on teams working in central sterile processing and supply chain teams for the tools and materials they need to complete their work. These teams, in turn, depend on the intraoperative team to send back tools and alert them when changes in kits or supplies are needed. Collectively, all of these teams are working toward the shared, mutual goal of providing highest quality, safe care for each individual patient. However, the interdependencies among the multiple players that must align their efforts to carry out a single case are often underappreciated and not clearly understood in practice.
Such complex networks of teams, known as multi-team systems (MTSs) , are defined by two or more component teams that work interdependently and interface directly in order to achieve at least one overarching shared goal that any one of the individual teams could not achieve on its own [37, 38]. Each component team works toward its own proximal goals in addition to the overarching, more distal MTS goal(s), and sometimes team goals may compete with the overarching MTS goal [39]. For example, team scientists parsimoniously describe the work of an MTS responding to a car accident, including a fire crew, emergency medical team, surgical team, and postsurgical care team as core component teams working interdependently to achieve their mutual distal goal, survival of the patient, while also working toward their own proximal goals (e.g., stabilizing and transporting the injured person) [37]. The MTS concept is helpful in considering teamwork in surgery given the number of teams and players that must align their efforts and information in order to achieve safe, effective, efficient care for each patient undergoing surgery. Studies of MTSs also highlight key teaming processes that are even more critical in such contexts. For example, boundary spanning—actively reaching out and interacting across team boundaries—is a critical skill for teams working as part of an MTS. Explicit forms of coordination and communication also become more important in MTS settings given that only a few members of each component team may ever directly interact with one another.
Models of Teams and Teamwork
Numerous models in the social and organizational sciences describe teams, their development, processes, and factors that influence their effectiveness. It is outside the scope of this chapter to offer a thorough history of team performance models; however, understanding the theoretical foundations of healthcare team processes and performance is critical for developing the skills and interventions that support expert teams (for comprehensive reviews see Mathieu [40] and Cannon-Bowers [41]).
Early thinking about teamwork was largely linear, evidenced by conceptual models adopting what is known as an input-process-output (IPO) approach to depicting teamwork performance effectiveness. Inputs were defined as antecedents or contextual factors (e.g., characteristics of individual members, the practice environment, or organization) that impact the affective, behavioral, and cognitive teaming processes believed to be the mechanisms through which teams achieve collective outcomes.
Although a useful starting point for understanding and describing teamwork, the traditional IPO model does not adequately capture the dynamism and adaptive nature of teamwork over time [42]. Furthermore, conceptualizations of teamwork processes were vague, leading Marks, Mathieu, and Zaccaro [43] to formally define them as “members’ interdependent acts that convert inputs to outcomes through cognitive, verbal, and behavioral activities directed toward organizing taskwork to achieve collective goals” (p. 357). Yet, this definition still failed to account for the affective (e.g., trust) and cognitive (e.g., shared awareness) drivers of teamwork. Marks et al. [43] termed these mechanisms emergent states and defined them as “properties of the team that are typically dynamic in nature and vary as a function of team context, inputs, processes, and outcomes” (p. 357).
Building on these conceptual advancements, Ilgen and colleagues [44] introduced the input-mediator-output-input (IMOI) model of team performance, which differed from IPO models in two major ways. First, process is replaced with mediator, which subsumes both emergent states and processes as defined by Marks et al. [43]. Second, the IMOI model acknowledges that team performance can be episodic and recursive [43] such that outcomes from past performance periods can influence subsequent performance. Take as an example an uncommon but critical surgical emergency like cardiac arrest during an otherwise uneventful low-risk cholecystectomy. The well-trained operating room team performed all of the routine portions of the surgical encounter correctly (e.g., “time out” to review surgical plan, close oversight of the sterile field, good communication between surgeon and anesthesiologist), but early into the case it was noted that the patient was hypotensive and lost his pulse. Every member of the team scrambled into action to perform CPR and reestablish circulation. Although the patient survived, team members later shared that the disruptive event illuminated multiple issues that had gone previously unnoticed (e.g., the “crash cart” was not stored in its appropriate place in a hallway alcove; roles were not clearly assigned in the transition from routine operating roles to arrest team; postarrest infusions were not readily available). In preparation for the next intraoperative arrest, the members of the team initiated a quality project with the OR team nurse educator to develop a daily checklist to ensure that equipment, roles, and medications were available at all times. As a result of these efforts, the surgical team felt that it was more effectively ready to handle the next intraoperative emergency.
Healthcare Specific Models
Despite burgeoning interest, well-developed, yet practically relevant models of healthcare teamwork delineating critical antecedents, processes, and outcomes across the care continuum are still rare [45]. One example is the integrative (healthcare) team effectiveness model (ITEM) [31]. This model depicts contextual factors (e.g., team training) as critical inputs that influence elements of team task characteristics, including task type (e.g., project vs. patient care), team features (e.g., level of interdependence), and team composition (e.g., discipline, tenure), which in turn drive team processes and emergent states. It notably includes forces external to the organization, such as social, regulatory, and policy factors, that affect mediators of team performance. Furthermore, team outcomes are distilled into a 3 × 2 framework that encompasses the level of analysis (e.g., patient, team, and organizational) and the nature of the measure (e.g., objective vs. subjective). Reflecting the same limitation of other IPO models, ITEM is linear in nature and therefore does not fully represent the progressive nature of teamwork. This problem would be easily solved with the inclusion of a feedback loop. Moreover, it seems unlikely that some external factors demonstrate a direct relationship to task design characteristics.
Other healthcare teamwork models are limited to specific contexts as a result of the difficulties with creating practical models that span the generalities of very different healthcare teams. For example, after a systematic review of 35 peer-reviewed articles investigating teamwork in the ICU, Reader and colleagues [46] presented a framework of ICU team performance. The framework centers on team processes such as communication, leadership, and coordination, and connects them to patient- and team-focused outcomes. Consistent with IMOI models, the authors note that psychosocial factors (i.e., emergent states) influence team outcomes and include a feedback loop linking outcomes to inputs.
In an effort to integrate aspects of both within- and between-team interactions while acknowledging the dynamic, episodic nature of team performance, Weaver et al. [45] advanced a model of healthcare teamwork for patient safety (Fig. 5.1). This model shows how macro (e.g., national, organizational), meso (e.g., department, and unit), and micro (e.g., individual patients or providers) level factors, such as environmental characteristics (e.g., social policy and regulatory programs), organizational characteristics (e.g., physical layout, management structure, technology), patient characteristics (e.g., comorbidities, knowledge, attitudes, and behaviors), task characteristics (e.g., interdependencies, procedural steps), and individual team member characteristics (e.g., education, previous experience, personality), influence within- and between-team performance and effectiveness. Although depicted as individual boxes for the sake of parsimony, these characteristics should be considered in singularity but rather as a constellation of factors that shape the context in which teamwork occurs. The pattern of these factors has a much stronger influence than any one factor by itself.
Fig. 5.1
An integrated model of team effectiveness for patient safety in healthcare, Weaver et al. [45]. Reprinted with permission from Oxford University Press, USA
Moderators, such as team training and culture (i.e., shared, multidimensional values, believes, and perceptions of the work environment), are also shown to influence the relationship between inputs and team processes. Moderators are inputs that can change the nature of a relationship between two other factors. For example, training team members in generalizable teamwork competencies can help ad hoc teams overcome the disadvantages associated with a lack of previous experience working together [47].
One aspect of Weaver et al.’s model is that inputs are shown to affect both intra- and inter-team processes and emergent states, which subsequently impact intra- and inter-team outcomes. The model is one of the first to address care as the work of an MTS. Weaver et al.’s model demonstrates the complexity of these systems and showcases inter-team processes (e.g., boundary spanning, entrainment, collaborative sensemaking) needed in order for multiple teams to collaborate together successfully.
Practical Principles for Effective Teaming in Surgery
In the surgical suite, patient care requires vigilant synchronization of efforts in a team with fluid membership, including highly specialized clinicians with diverse knowledge, skills, and attitudes (KSAs) [48]. Most surgical procedures require at least four multidisciplinary team members: an anesthesia provider, a surgeon, a circulating nurse, and a scrub nurse or technician [49]. Each is responsible for a specific role necessitating unique educational background and experience. Despite these differences, they must be able to effectively perform interdependently to ensure safe and successful surgery.
Research on teamwork has amassed a vast body of literature describing a wide array of shared KSAs necessary for teams to accomplish their task(s) [50]. Many reviews exist to address the different factors that can impact teamwork [34, 40, 41, 51, 52]. However, few offer practical guidance needed by surgeons and other medical professionals to enact and optimize effective teamwork [53]. Salas and colleagues [45, 54, 55] sought to create a parsimonious summary of our current knowledge about teamwork and package it in a way that would be more practically useful than previous frameworks. The result was the “Cs of Effective Teamwork,” a simple framework describing a set of critical considerations for teamwork. The Cs include processes and emergent states (e.g., cooperation, conflict, coordination, communication, coaching, cognition) as well as influencing conditions (e.g., composition, culture, and context) that impact the aforementioned processes. See Salas et al. [55] for complete discussion of the framework’s development.
The Cs heuristic is a useful tool for organizing what healthcare leaders and team members need to know to practice effective teamwork. Adaptations of the Cs heuristic has already been applied to the medical context in order to explain team effectiveness for patient safety [45] and as a framework for guiding the planning and development of interprofessional medical education [54]. Table 5.2 defines each component of the framework and provides an example of how it can manifest within a surgical team.
Component | Definition | Clinical context | Example |
---|---|---|---|
Cooperation | The motivational drivers of teamwork. In essence, the attitudes, beliefs, and feelings of the team that drive behavioral action | Surgeons, nurses, and OR staff bring unique skill sets and perspectives to the care of patients | An effort to improve patient flow in the OR focuses on better integrating the anesthesia, surgical, and nursing needs of the patients from contributions of each team member |
Conflict management | Proactively managing perceived incompatibilities in the interest, beliefs, or views held by one or more team members | Different team members’ unique viewpoints and training make conflicting beliefs likely in the OR | While preparing a difficult surgical field involving a patient’s complete upper extremity, a surgeon and circulator nurse reconcile different approaches to sterile preparation of patients |
Coordination | The enactment of behavioral and cognitive mechanisms necessary to perform a task and transform team resources into outcomes | OR teams maintain well-established workflows so that standardized processes proceed with limited oversight | An OR completing a case pages overhead, “OR6 out, moderate turnover” and all processes required to clean the room with the appropriate thoroughness, prepare for the next patient, and obtain any special equipment occur automatically within a prespecified time period |
Communication | A reciprocal process of team members’ sending and receiving information that forms and re-forms a team’s attitudes, behaviors, and cognitions | OR teams iteratively share and receive both old information and any new changes while patients are proceeding through a surgical workflow to ensure that all team members remain well informed | During a “time out” procedure, a patient’s identification, existing medical problems, surgical plan, special precautions, and team introductions are formally reiterated to confirm full team agreement |
Coaching | The enactment of leadership behaviors to establish goals and set direct that leads to the successful accomplishment of these goals | Effective OR teams include responsive third-party support that can intervene when necessary | The OR charge nurse performs further information-gathering with other OR teams when a circulator nurse reports that case carts are being sent to rooms without complete instrument trays |
Cognition | A shared understanding among team members that is developed as a result of interactions including knowledge of roles and responsibilities; team mission objectives and norms; and familiarity with teammate knowledge, skills, and abilities | OR teams have narrowly defined roles with minimal overlap to ensure focus on critical safety-related activities | Anesthesia care of the surgical patient proceeds with virtually no intervention from the surgeon because the guidelines for safe anesthesia care and triggers for further intervention have already been agreed upon at the institutional level |
Composition | Individual factors relevant to team performance; what constitutes a good team member; what is the best configuration of member knowledge, skills, and attitudes; and what role diversity plays in team effectiveness | Roles in the OR are specific and each representative member of the team is specifically assigned to effectively provide their role in patient care | Scrub assistants are assigned to cases appropriately based on their experiences with the instruments and equipment necessary for a particular case |
Context | Situational characteristics or events that influence the occurrence and meaning of behavior, as well as the manner and degree to which various factors impact team outcomes
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