Perhaps in the future organized training will be available more often for individuals, especially clinicians, who seek training specifically as team leaders. Blumenthal and colleagues (2012) have called for inclusion of clinical team leadership training in graduate medical education. The recent Institute of Medicine (IOM) report on nursing appeals for teaching leadership at all levels of nursing education (Institute of Medicine, 2011, pp. 221-254). At present, for nurses as well as physicians, leadership training is only very rarely part of entry-level degree programs or residencies, but it is available to practitioners in various free-standing programs. In contrast, colleges of pharmacy have begun to include leadership training in their curricula. In 2009 the Argus Commission of the American Association of Colleges of Pharmacy called for the incorporation of leadership development into pharmaceutical education (Kerr et al, 2009). At least 2 universities have added leadership training to their curricula, one in its Doctor of Pharmacy (PharmD) degree program (Sorensen et al, 2009) and one in its residency program (Fuller, 2012). Of course, team leadership is a standard part of the curriculum for MHA and other degree programs for healthcare administrators.

Healthcare professionals who have not had the benefit of leadership training in person can acquaint themselves with the core concepts through online courses, which are offered by many universities. These courses often lead to a master’s degree or a certificate in healthcare leadership, but some programs will permit students to take selected courses without enrolling in a degree or certificate program. In addition, of course, one can simply read. Table 14–2 contains a focused list of books and articles that team leaders will find useful.

Experiential learning with self-reflection and discussion is an important component of any organized leadership training program, whether it is offered in-house or by a training institution or university. Participants commonly report that this is the most valuable component for them. Both new and experienced team leaders benefit by interpreting their leadership experiences, using concepts of leadership obtained by formal study or reading on their own. Especially helpful is discussion with other leaders or, ideally, with a mentor who is an effective team leader. Self-reflection and discussion generate more clarity of understanding and new insights into how best to lead. At present, most team leaders learn how to perform well in their roles through reading, reflection, and discussion with other leaders or a mentor.

Dr. Mitchell, the pharmacist depicted in the preceding vignette, discussed various training options with several people and in the end decided to read on his own and seek mentoring from his boss and one other leader at the hospital.

TRAINING OF TEAMS

Interprofessional Education in Professional Schools and Colleges

It would be desirable for healthcare professionals to begin their team training when they begin their professional education. Ideally the training would address teamwork within each profession and, more importantly, across different professions, that is, interprofessional teamwork. Unfortunately, in the United States, with very few exceptions, this training is not provided. There have been calls for interprofessional education for several decades, including recommendations from the Institute of Medicine (Institute of Medicine, 2003) and associated committees (Mitchell et al, 2012). Within the past 5 years, progress has been made, but the efforts are still at an early stage (Thibault, 2011). The need for interprofessional education is discussed further in Chapter 19.

Team Training Programs

It was 4:30 p.m. on a winter afternoon. Thirty-five people were assembled in a classroom at Trent Medical Center, a 400-bed, urban hospital. The group included surgeons, nurses, surgical technicians, housekeeping personnel, nurse anesthetists, anesthesiologists, and others. At the front of the room, Derek Cavadov, MD, the Chair of the Surgery Department was speaking to the group about teamwork. He and Mary Peterson, RN, an operating room nurse, collaborated in teaching the 3-hour session.

Four months earlier, Dr. Cavadov had approached the Chief Medical Officer of the hospital to request funds to hire a training firm to teach principles of teamwork to the surgeons, anesthesiologists, and staff at Trent. He and Ms. Peterson had then worked with 2 of the firm’s trainers to customize the material for Trent. Dr. Cavadov, Ms. Peterson, and the trainers thought it would be important for the material to be presented by people with whom the attendees already had working relationships. The trainers coached Dr. Cavadov and Ms. Peterson and served as assistants in the teaching program, distributing materials during the teaching sessions and facilitating discussions when the large group broke into small groups to work on exercises that were included in the curriculum.

Dr. Cavadov and Ms. Peterson talked about safety in aviation and drew parallels between cockpit crews and surgical teams. At times they posed questions to the whole group and asked the participants to formulate answers in small groups, which then presented their views for discussion in the whole group. Over the 3 hours, the teachers covered material on communication, the role of the team leader, and other aspects of teamwork. Attendance was required, either as a condition of employment (for example, for the nurses) or as a condition of having privileges to perform surgery at the hospital. For the most part, the members of the class were attentive. At one point, a gynecological surgeon interrupted the flow of the presentation to say that her surgery team already performed very well and that she thought the time spent that afternoon would have been spent better in patient care—although she finished her statement with a mildly positive comment about the interesting stories of aviation accidents that the teachers had presented.

The session described in this vignette is being repeated throughout the United States in various forms. This session was a simple classroom lecture–discussion. Often role-playing or other similar group exercises are also used, sometimes using actors or life-sized dolls (mannequins) to simulate surgical emergencies. Several years ago, hospitals began to provide teamwork training with the intent of improving patient safety. This interest in providing teamwork training was generated by the Institute of Medicine report To Err Is Human (2000). Prior to this report, team training in US health care was rare. Despite the fact that healthcare team training is not yet routinely provided in professional schools, it is widely regarded as necessary for nurses, physicians, pharmacists, and others in clinical practice, and it is available from a number of sources.

TeamSTEPPS

A commonly used training option is the TeamSTEPPS program (King et al, 2008). This program was first developed in the Department of Defense and then adapted by the Agency for Healthcare Research and Quality (AHRQ) for general use in health care. The primary purpose of TeamSTEPPS, as stated by AHRQ, is to improve patient safety. It has been used extensively in hospitals across the United States. Underlying the training is a model of team function with 5 elements: team structure, leadership, situation monitoring, mutual support, and communication. Team structure includes essentially the same items that are listed in Table 6–2 (in Chapter 6), namely, team membership, a clear leader, and so on. Leadership in TeamSTEPPS emphasizes coordination of team members’ activities and assurance of good communication. In other words, as we would describe it, leadership in TeamSTEPPS is more concerned with managing than leading—as is characteristic of leadership in template teams. Situation monitoring means active observation and interpretation of events occurring in the team’s work setting, performed in order to be able to take appropriate action promptly. Mutual support is support by each team member for every other team member as a contributor to the team’s success. One could say that the term mutual support is a gentle label for the actions that are sometimes required by mutual accountability. In other words, mutual support consists of team members helping other team members who cannot perform their assigned tasks because of problems with competence or excessive workload. In an earlier version of the model, mutual support was called back-up behavior (Salas et al, 2005). Finally, communication is the sharing of information among team members.

Several of the 5 elements of TeamSTEPPS training include specific action concepts and tools for use by a team. For example, the leadership module of the program includes information about running brief planning sessions called huddles. In these sessions, team members come together to assure that everyone on the team understands the team’s current situation and plan. Sometimes huddles result in adjustments to the plan. The communication portion of the model includes 3 communication routines that are already widely used in hospital care: the SBAR technique, call-outs, and check-backs. SBAR (pronounced “ESS-bar”) stands for “Situation, Background, Assessment, Recommendation.” The abbreviation provides a sequence for delivering 4 succinctly stated items of information in situations where time is short and immediate action is required for patient care. The person delivering the SBAR message is expected to state the symptom or difficulty of the patient in question (the situation), then to provide the clinical background of the patient, then to state what he or she believes is the problem at hand (the assessment), and, finally, to recommend a course of action. The SBAR technique is particularly useful for nurses speaking to physicians about patient-care problems and recommending action. It can also be used by physicians providing information to each other or by social workers reporting information to nurses or by any pair of healthcare professionals serving the same patient in need of immediate attention. Call-outs, mentioned in Chapter 2, are audible statements of steps in a process or statements of action being taken. For example, the leader of a trauma resuscitation team might call out “Blood pressure 110/70” as a way of notifying the other team members that the patient’s blood pressure has been measured and is within the acceptable range, or a nurse might call out “Unit of packed cells started” to let everyone in the room know that a blood transfusion with packed red blood cells has been started. Check-backs, mentioned in Chapter 6, are audible confirmations that information has been received or that requested action has been taken. For example, a nurse asked to administer a drug intravenously might state aloud the drug and the dose given, confirming to the rest of the team members that the administration of the drug has been completed.

TeamSTEPPS also includes content on change management in order to elicit support from frontline team members for widespread adoption of the teamwork principles that are covered in the 5 principal elements of the program. Actual use of the principles of change management falls to senior leaders in the organization rather than to the frontline team members to whom TeamSTEPPS training is directed.

AHRQ has developed an extensive array of training materials, for example, slides, pocket-sized memory aides, instructions for training exercises, and questionnaires used to measure team members’ attitudes toward teamwork. These materials are in the public domain and are available without charge (Agency for Healthcare Research and Quality, 2012). The TeamSTEPPS team assessment questionnaire is discussed in Chapter 13. Various consulting and training firms have also elaborated on the TeamSTEPPS materials to produce additional materials, some of which are tailored to teams with particular purposes, for example, emergency cesarean delivery teams.

TeamSTEPPS is especiallly suitable for template teams. It is particularly appropriate for teams that must contend with high risk of injury to patients, must operate under intense time pressure, and must cope with turnover of personnel from one patient-care episode to the next. The method used in TeamSTEPPS for achieving improvement in safety is standardization of behavioral expectations and communication. As the use of huddles, check-backs, and other routines becomes habitual, everyone participating in the teams in a given department or hospital comes to expect these items of behavior, and any awkwardness in the new behavioral routines dissipates over time. The standardization enables successive template teams (for instance, surgical teams or resuscitation teams) to continue to behave in the prescribed manner even though team members change from team to team.

This standardization ordinarily would not be useful in true teams, where it would be constraining and artificial. Teams with stable membership operating without intense time pressure have the opportunity to develop more varied and nuanced behavior and communication processes.

However, several components of TeamSTEPPS have wide application, including application to true teams. For example, huddles can be used to advantage in many healthcare settings. Some primary care teams use a huddle every morning as the day starts. Interprofessional teams on rounds in a hospital can use huddles before seeing all patients or before seeing selected patients whose situations are especially complicated. Also, the SBAR technique can be used in almost any transfer of clinical information aimed at forming a plan, regardless of whether the planning is urgent or not. Call-outs and check-backs are useful in any team coping with time pressure and high risk, regardless of whether the team is a template team (for example, an emergency department team) or a true team (for example, a stable emergency rescue team that is called into action repeatedly over long periods of time).

Anesthesia Crisis Resource Management

The first medical specialty to engage in systematic team training was anesthesiology, beginning in about 1990. The model for this training came from aviation. In about 1980, responding to the need to decrease or eliminate commercial air crashes, airlines began to use a training method called Crew Resource Management (CRM) (Hamman, 2004). Pilots, flight attendants, and aircraft dispatchers participating in a CRM program learn teamwork skills such as communication, conflict resolution, and workload management. The teaching methods used include conventional classroom teaching coupled with exercises in handling simulated in-flight emergencies. Flight simulators provide an artificial cockpit space that mimics the real world—with familiar seats and other equipment, instrument panels, and even simulated views into the space ahead of and around the airplane. Carefully orchestrated disaster scenarios are conducted in the simulator. The scenarios are controlled by the instructors, who are able to provide the trainees with flight experiences such as loss of engine power, an electrical fire, and so on. The trainees practice working together to handle these unexpected events. The exercises include follow-up debriefing, feedback, and coaching.

Gaba and colleagues developed a method for training operating room teams in the same way that airlines train cockpit crews (Gaba et al, 2001). Fully equipped, fully functional, simulated operating rooms are used. The patients are elaborate mannequins constructed to mimic human anatomy and physiology with high or low blood pressure, normal or abnormal heart rhythms, an airway (throat) into which a tube can be inserted to provide oxygen to the lungs, and other bodily features relevant to the training exercises. Emergency scenarios are played out in the training venue. The events are videotaped, and the team members go through careful debriefing as a group after the exercise. The debriefings are led by trained instructors. The training method is called Anesthesia Crisis Resource Management (ACRM). It is now widely used throughout the United States and Canada.

Simulation

ACRM has provided a precedent that has been adapted for use in many other settings in health care (Eppich et al, 2011). For example, CRM-like team training using simulation is now used in obstetrical units (Clark et al, 2010) and pediatric trauma teams (Hunt et al, 2007). In these settings too, life-like venues and mannequins are used to enable teams to learn teamwork skills and to be able to handle unusual adverse events. Hospitals and universities across the country have established simulation centers so that the quality of team training can be advanced.

ACRM and similar training programs have substantial benefits, but there are limits to the application of aviation CRM methods to health care. For example, while CRM training is relevant to care provided in intensive care units (ICUs), there are several differences between intensive care and aviation that call for differences in the approach used in the 2 settings (Reader and Cuthbertson, 2011). In ICUs, the decision makers commonly deal with multiple patient-care situations unfolding simultaneously while air crews (like surgical teams) deal with one situation at a time. And the work of ICU teams, including diagnosis, treatment, counseling families, and other activities, is more varied than that of aviation crews.

Use of simulation has also been extended to settings that are not characterized by high risk or the need for immediate action, for example, primary care. In some training programs, medical students, nurses, and social workers participate in simulations of interviewing patients or delivering bad news to patients and their families. Either real or simulated physician office rooms are used. Actors are cast as patients, using scripts. The actors are instructed to vary their behavior in specific ways that depend on what the students choose to do.

TeamSTEPPS, although based on teamwork principles that derive from CRM in aviation, does not have a simulation component. However, since TeamSTEPPS is in the public domain, some training firms have used the TeamSTEPPS program and added simulation exercises to it.

High Reliability Organizations

The aim of simulation training programs focused on safety improvement is to enable teams to emulate the performance of high reliability organizations (HROs) (Roberts, 1990). HROs are organizations that routinely function under demanding conditions and yet perform with extraordinarily low rates of mishaps. Examples are air traffic control centers, nuclear power plants, aircraft carriers, and electrical power grid operations centers. Weick and Sutcliffe have identified 5 traits that characterize HROs: (1) preoccupation with failure, (2) reluctance to simplify interpretations, (3) sensitivity to operations, (4) commitment to resilience, and (5) deference to expertise (Weick and Sutcliffe, 2001, pp. 1-23). HRO workers who are preoccupied with failure are not pessimistic; the phrase “preoccupied with failure” is misleading. Workers with this trait cultivate a thorough-going thoughtfulness about what might go wrong so that they can anticipate mishaps and either design them out of the system or recognize and correct them promptly. Reluctance to simplify interpretations means that the organization’s members accept the complexity of its operations and avoid simplistic explanations of mishaps, thereby avoiding distortions in their understanding of events. Sensitivity to operations means that members of the organization pay close attention to what actually happens in their operations, noting minor unexpected events and changes in circumstances that might signal vulnerability to mishaps. This sensitivity at an organizational level requires psychological safety (explained in Chapter 6) for the individuals working in the organization because a sense of safety is necessary if people close to unexpected events and changing circumstances are to report their observations and voice their concerns, thus enabling action to be taken. Commitment to resilience means determination to identify mishaps promptly and to limit the damage or correct it. Deference to expertise does not mean deference to people with high status and high levels of expertise in their fields. It means deference to those people who have the most knowledge about the issue at hand. If the issue is surgical instrument sterilization, then the expertise lies with those who sterilize the instruments. If the issue is surgical technique, then the experts are surgeons. HROs do not tolerate decisions made by people with high rank who do not have knowledge of the particular areas affected by their decisions.

Although the concept of HROs pertains to whole organizations, all of the characteristic HRO traits are desirable in healthcare teams, especially teams that must contend with high risk and time pressure. And all of the traits are compatible with the characteristics of effective teams presented in Chapter 6. In fact, some of the characteristics of effective teams are necessary for a team to be highly reliable, for example, psychological safety and pursuit of systematic performance improvement.

The Joint Commission (which accredits and certifies healthcare organizations and programs in the United States) is a promoter of high reliability in health care. It hosted its fifth conference on HROs in 2012. The support of The Joint Commission for the concept of HROs is hastening the development of team training and the use of simulation centers.

Other Team Training Programs

Several other formalized team training programs have been developed over the past 10 years. Some of these programs have been summarized by Baker and colleagues (2005). With rare exceptions, they are especially suitable for template teams working in high-risk areas of hospitals such as operating rooms, emergency departments, obstetric departments, adult intensive care units, and neonatal care units. Some of the programs use simulation, and some do not. A list of several sources of training appears in Table 14–3. To date most organized healthcare team training has been centered on improving safety.

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