enhancing patient safety through teamwork traininglong-term organizational and training investments....

By Judith Barrett, RN,

MS, Carolyn Gifford, RN,

MSN, John Morey, PhD,

Daniel Risser, PhD, and

Mary Salisbury, RN,

MSN Dynamics Research

Corp., Andover, MA

AbstractThe effective reduction of medicalerrors depends on an environment ofsafety for patients in both clinically-based and systems-oriented arenas.Formal teamwork training is proposed asa systems approach that will achievethese ends. In a study conducted by(Dynamics Research Corporation,)weaknesses and error patterns inEmergency Department teamwork were assessed, and a prospectiveevaluation of a formal teamworktraining intervention was conducted.Improvements were obtained in five key teamwork measures, and mostimportantly, clinical errors weresignificantly reduced.

IntroductionPatient safety initiatives are on theforefront of medicine and havemobilized healthcare personnel toidentify and implement a multitude ofstrategies to improve patient outcomesand reduce error. A recent publication

by the Agency for Healthcare Researchand Quality1 has identified 79 clinicaland systems-based strategies that offerhope of improvement. In the lastdecade, recognition of the contributionof systems components to the causalchain of medical errors has broadenedthe basis for incident investigation andsolution identification. Solutions thathave attracted recent attention, such asclosed intensive care units andcomputerized physician order entry, fitwell into the systems perspectivebecause they help establish erroravoidance and error capturing workenvironments for practitioners.Teamwork has also been identified as aneffective, system-based interventionthat has broad implications for patient safety.1, 2

The Joint Commission for theAccreditation of HealthcareOrganizations (JCAHO) recentlypublished new patient safety standards3

that call for a number of initiatives,including standards for formal teamworktraining that fosters a collaborative andinterdisciplinary approach to thedelivery of patient care. This paper will describe a structured teamworkinfrastructure model that supportsimproved patient outcomes and errorreduction. In addition, we will offersuggestions regarding how riskmanagement practices may befacilitated and strengthened byincluding teamwork principles into investigative analysis and thedevelopment of improvement strategies.

61F A L L 2 0 0 1www.ashrm.org

Enhancing Patient Safety Through Teamwork Training

Teamwork as an Infrastructure UpgradeThe word “team” often is used todescribe a group of people workingtogether in a related area or on aspecific project. Most of thesesituations actually represent workinggroups, not teams. Working groups aredifferent from teams in several ways.Groups rely on individual members’contributions and information sharing,but they do not necessarily engage incomplex, real-time decision-making.Teams learn to create a collective effortfocusing on making judgments incomplex situations, resulting in moreeffective outcomes than could beachieved by individual efforts.According to Manion, Lorimer, andLeander,4 team interventions are mosteffective with tasks that require diverseresponsibilities, high-level judgment,complex decision-making, highinvestment in and accountability forthe outcomes.

Critical patient care requires thesecharacteristics and teams are importantin this setting. In healthcare,individuals work together every daywith the common purpose of providinghigh quality patient care, yet often they

have little or no training in effectiveteam behaviors that can improvepatient safety outcomes.

Theoretical and Practical Bases for Teamwork Teamwork theory has been refinedduring the last decade and researchfindings define the core competenciesrequired for effective teamwork.5 Whilea discussion of various teamworktheories is beyond the scope of thisarticle, teamwork theory developmentand practical applications have led to these considerations for teamworktraining:■ Teams are distinguished from

work groups.6

■ Teamwork skills have beenidentified, and these skills arelearnable, observable, andmeasurable.7

■ While the same team behaviorsapply across different teams andteam structures, teamworkinterventions need to be tailored to specific work environments.8

■ Communication and monitoring areessential team actions used togenerate, exchange, and verifyinformation needed by the team.9

■ Teams are especially well-suited to identify, capture, mitigate, andmanage real-time human error.7, 10

These key considerations have guidedthe development of teamwork trainingfor emergency department personnel,and appear to be applicable to otherclinical environments.

A Case for Formal TeamworkTraining: Lessons from AviationSince healthcare organizations operatewith explicit or implicit staff teams, theopportunity exists for formal teamworktraining and teamwork-basedorganizational changes to meet safety

62 JOURNAL OF HEALTHCARE RISK MANAGEMENT

A closed case study covering4.7 million patient visits for an11-year period ending in 1996revealed that teamwork couldhave mitigated or preventederrors in 43% of the 68 closedclaim cases that resulted incash judgments or settlementsto plaintiffs.8 Usingconservative methods, DRCdetermined that $3.45 of thecost of every ED patient visitwas attributable to litigatedcash payouts associated withpoor teamwork.

needs not met by other system changes.9

However, effective teamwork does notspontaneously happen when individualswork together.11 Rather, it requireslong-term organizational and traininginvestments.

One model for improving teamwork in healthcare is drawn from crewresource management (CRM) trainingintroduced by the commercial aviationindustry in the 1980s. At the time,aircraft accident investigations hadrevealed that 80% of accidents werebased on “human error,” but furtherinvestigation indicated that asignificant portion of human error wasin fact attributable to teamwork failuresprimarily associated with inadequatecommunication and coordination.12

Now, the specific behaviors associatedwith communicating and coordinatingthe task work of flying an aircraft aretaught in fifth generation CRMprograms offered to commercial andmilitary aviators.13

Two programs that have adaptedaviation CRM processes to healthcareare anesthesia crisis managementtraining14 and the MedTeams systemdeveloped by Dynamics ResearchCorporation (DRC) for hospitalEmergency Departments (EDs).7, 15

Whereas the anesthesia program focusesexclusively on training the singleanesthesia provider on the operatingroom team, the MedTeams approachfocuses on training all ED staff in acommon set of teamwork behaviors.Experience with the ED interventionsuggests the applicability of teamworktraining to other clinical environmentsas well.

Application of FormalTeamwork BehaviorsTo assess the likelihood that teamworktraining could improve patient safety,DRC examined current weaknesses and

error patterns in emergency careteamwork using malpractice case files.This analysis projected the potentialimpacts of improved teamwork onemergency care cost and performance.A closed case study covering 4.7 millionpatient visits for an 11-year periodending in 1996 revealed that teamworkcould have mitigated or preventederrors in 43% of the 68 closed claimcases that resulted in cash judgments or settlements to plaintiffs.8 Usingconservative methods, DRC determinedthat $3.45 of the cost of every EDpatient visit was attributable to litigatedcash payouts associated with poorteamwork. In addition to the liabilitycosts of poor teamwork, the analysisrevealed specific recurring teamworkfailures. Examples of the most frequentand costly team breakdowns were: (a) failure to identify an establishedprotocol for patient care, or even todevelop a treatment plan, (b) failure toadvocate and assert an alternative planor corrective course of action when aquestion arose about the patient’s care,(c) failure to prioritize caregiver tasksfor the patient, and (d) failure to cross-monitor actions of other team members.Other specific teamwork failures were shown to contribute to medicalmisadventures in the ED, but they did so less frequently.

DRC and ED researchers conducted aprospective evaluation of the trainingintervention called MedTeams fromMay 1998 to March 1999 using a quasi-experimental, untreated control groupdesign with one pre-test and two post-test observation periods. Challengesthat had to be resolved in developing a practical teamwork training systemcentered on (a) defining teammembership and structure, (b)identifying applicable teamworkbehaviors, (c) implementing techniquesfor effective communication, and (d) developing the team-oriented


operational and management leadershipactions necessary to implement thesystem. The training and evaluation wasbased on five Teamwork Dimensionswith 41 associated behaviors (see Figure1) that focus on structure, process andoutcomes of teamwork. For example,key behaviors included callouts,checkbacks and cross monitoring.

Nine civilian and military hospital EDswere assigned to either theexperimental and control group. A totalof 684 physicians, nurses andtechnicians were trained in theexperimental group and 374 physicians,nurses, and technicians were trained inthe control group. The trainingintervention consisted of an 8-hourcourse and practicum. Three outcome


© Dynamics Research Corporation

constructs were assessed: teambehaviors, attitudes and opinions, andED performance. The results, details ofwhich may be found in Morey, Simon,Jay, and others,15 demonstrated theeffectiveness of the teamwork training.Improvements were obtained in theexperimental group for six out of theseven key measures assessed. The mostimportant finding from the study wasthat clinical errors, defined as anyclinical task that actually or potentiallyput a patient at risk, were substantiallyand significantly reduced. Othermeasures indicated that the quality ofteam behaviors improved, teamwork didnot increase workload, staff attitudestowards teamwork were enhanced,preparation of patients for admissionfrom the ED improved, and theproportion of highly satisfied patientsincreased.

Key Measures of Teamwork Effectiveness and Error IdentificationAn important measure of teamworkeffectiveness used in the evaluationstudy was the Team Dimension Rating.In this measure, specially trained nursesand physicians observed teamworkfunctioning during high intensitysituations such as cardiac arrest and inother acute episodes of care. Teamworkperformance was rated on a seven-pointscale for each of the five TeamDimensions. Each observation lasted 30to 60 minutes. Observed errors wereclinical errors that were recognizedduring the teamwork observation periodand described on an Observed ErrorRecord form. The study data revealedthat teamwork performance improvedand clinical errors were significantlyreduced.

Consider the following example of an observed error: A burn patient received duplicate administrations of intravenous Morphine when two nursesindependently administered the drugafter a physician gave a verbal order.

The staff realized the overdose whenthe patient’s breathing slowed, at whichpoint they intervened. The patientrecovered but there was clearly ateamwork failure. Systematic use ofcheck backs and cross monitoring,teamwork behaviors taught inMedTeams, almost certainly would have prevented this overdose event.

This example underscores the need for mutual accountability for all teammembers. Mutual accountability foroutcomes is a central element in teams,and represents a significant shift inthinking for healthcare professionals,whose education and training havehistorically focused on fosteringindividual responsibility. In fact,mutual accountability is not a substitutefor individual accountability, butrepresents a developmental step inprofessional accountability. In a high-reliability team, not only doeseach team member accept personalaccountability, but he or she alsobecomes accountable for outcomes ofthe team’s actions measured againstestablished standards.4, 16 Thisrecognition of the team as a safety net,capable of catching individual clinicianerrors, is an important step in the effort to increase patient safety andreduce errors.

Usefulness of Team Concepts to Risk Management When an institution uses a formalteamwork approach and teamwork is considered an element of theoperational infrastructure, risk managershave an additional framework for


In fact, mutual accountability is not a

substitute for individual accountability,

but represents a developmental step in

professional accountability.

evaluating events and proposingmanagement changes. An evaluationinstrument like the Teamwork FailureChecklist6 (see Appendix 1) can be used in a number of ways: as ateamwork failure sub-analysis tool in a root cause analysis, to supportmanagement reviews of teamperformance in specific units, to support institutional trend analysisregarding teamwork breakdowns and to flag important teamworkfailures for reviews (see Figure 2).

With the implementation of astructured teamwork approach likeMedTeams, the risk manager has the means to integrate a teamworkassessment into the root cause analysis.The five Team Dimensions provide the risk manager with a foundation forincident or sentinel event assessmentsand to highlight failures of teamworkbehaviors. Overlaying the TeamDimensions on a traditional root causeanalysis tool assists in the identificationof behaviors that may have contributedto an adverse event. For example, when


© Dynamics Research Corporation

mutual accountability for clinicaloutcomes is a behavioral expectation,shared by all team members, the focusof analysis will shift from what theindividual did wrong to how teamperformance broke down. This broaderview will reveal opportunities forinterdisciplinary coordination strategiesthat have a more lasting impact onpatient safety.

At the organizational level, the RiskManager has a role in working withmanagement to promote and maintainthe concept of teamwork as animportant infrastructure interventionfor error reduction and overallmitigation of liability. Analyzing thetrends related to team performance canidentify teamwork and systemweaknesses that need reinforcementthrough, for example, formal andinformal educational sessions.

At the executive level, the RiskManager also has a role in discussingwith executive leaders the majoroccurrences and trend data thatcontribute to poor outcomes andincrease the potential for liability. Theteamwork perspective is an importantelement of analysis that will provideinformation for strategic initiatives.

Finally, at the healthcare system level,an opportunity exists to study andidentify common teamwork failuresacross multiple organizations using de-identified, aggregate data drawn fromclosed case reviews. These analyses canidentify weaknesses in teamwork skillsthat are causing harm across a wide setof healthcare organizations.

ConclusionAlthough the benefits of teamworkseem intuitive to healthcare providers,little formal training of the requiredskills or assessment of the effectivenessof teamwork exists. Fully understandingand implementing a teamwork model isthe basis for studying and understanding

clinician error chains, and consequentlyproviding a methodology for correctiveactions for continuous qualityimprovement. It also helps to fulfill theintent of the JCAHO requirement thatcalls for teamwork training and effectivecommunication in the patient caredelivery process. Using a structuredteamwork system enables seniorleadership and members of the Board of Directors to track tangible andmeasurable indicators of teamworkimprovement and assess patient careperformance change.

1. Markowitz, A., editor. AHRQEvidence Report/TechnologyAssessment. Number 43.Rockville, MD: AHRQ Publication01-E058, July 2001.

2. Kohn, L.T., Corrigan, J.M.,Donaldson, M.S., editors. To Err isHuman: Building a Safer HealthCare System. Washington, DC:National Academy Press, 1999.

3. JCAHO, Revisions to JointCommission Standards in Support of Patient Safety and Medical/Health Care Error Reduction.www.jcaho.org/standard/fr_ptsafety.html. 2001.


Fully understanding and implementing a

teamwork model is the basis for studying

and understanding clinician error chains.

4. Manion J., Lorimer, W., Leander,W.J. Team-based Health CareOrganizations: Blueprint forSuccess. Gaithersburg, MD: AspenPublishers, 1996, pp. 6-9.

5. Salas, E., Cannon-Bowers, J. A.“The Science of Training: ADecade of Progress. Fiske, S. T.,Schacter, D. L., Zahn-Waxler, C.,editors.” Annual Review ofPsychology, Palo Alto, CA: AnnualReviews, 2001, pp. 471-499.

6. Katzenbach, J. R., Roberts, D. K.The discipline of teams. HarvardBusiness Review. 71: pp. 111-120,March-April, 1993.

7. Risser D. T., Simon R., Rice M. M.,et al. “A Structured TeamworkSystem to Reduce Clinical Errors.”Spath P.L., editor. Error Reductionin Health Care. San Francisco:Jossey-Bass, 1999, pp. 235-278.

8. Cannon-Bowers, J.A., Tannenbaum,S. I., Salas, E., Volpe, C. E.“Defining Competencies andEstablishing Team TrainingRequirements.” Guzzo, R. A., Salas, E., et al. Team Effectivenessand Decision Making inOrganizations. San Francisco:Jossey-Bass, 1995, pp. 333-380.

9. Risser, D. T., Rice, M. M., Salisbury,M. L., et al. “The potential forimproved teamwork to reducemedical errors in the emergencydepartment.” Annals of EmergencyMedicine. 34: 373-383, 1999.

10. Helmreich, R. L., Wilhelm, J. A.,Klinect, J. R., Merritt, A. C.“Culture, Error, and Crew ResourceManagement.” Salas, E., Bowers, C.A., Edens, E., editors. ImprovingTeamwork in Organizations.Mahwah, NJ: Lawrence ErlbaumAssociates, 2001, pp. 305-331.

11. Sexton, J. B., Thomas, E. J., andHelmreich, R. L. “Error, stress, andteamwork in medicine and aviation:cross sectional surveys.” BMJ. 320:745-749, 2000.

12. Taggart, W.R. “Crew ResourceManagement: Achieving EnhancedFlight Operations.” Johnston N.,McDonald N., Fuller, R., editors.Aviation Psychology in Practice.Brookfield, VT: Ashgate PublishingCompany, 1994, pp. 309-339.

13. Helmreich, R. L., Merritt, A. C.,Wilhelm, J. A. “The evolution ofcrew resource management trainingin commercial aviation.” TheInternational Journal of AviationPsychology. 9 (1): 19-32, 1999.

14. Gaba, D. M., Fish, K. J., Howard, S. K. Crisis Management inAnesthesiology. Philadelphia:Churchill Livingstone, 1994.

15. Morey, J. C., Simon, R. S., Jay, G.D., Wears, R. L., Salisbury, M. L.,Dukes, K., Berns, S. “ErrorReduction and PerformanceImprovement in the EmergencyDepartment through FormalTeamwork Training: EvaluationResults of the MedTeams Project.”Paper submitted for publication.

16. Katzenbach, J. R., Smith, D.K.Wisdom of Teams. NY, NY: Harper Business Book, reissue 1999, pp 60-61


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