Australasian Anaesthesia 2011 - Australian and New Zealand ...

Teamwork: hard facts, soft skills. 189Teamwork: hard facts, soft skills.JENNIFER WELLER, MD, MCLINED, MBBS, FANZCA, FRCASpecialist Anaesthetist and Head of Centre for Medical and Health Sciences Education, Faculty of Medical andHealth Sciences, University of Auckland, New ZealandA/ Prof Weller is an anaesthetist and head of the Centre for Medical and Health Sciences Education at the Universityof Auckland. Her research interests include simulation-based learning, patient safety and medical error, teamworkand interprofessional collaboration, and performance assessment.INTRODUCTION“A team refers to two or more individuals each with specific roles, working toward a common goal, and with concreteboundaries. Teams work on complex tasks requiring dynamic exchange of resources (e.g. information), coordinationof effort and adaptation to changing situational factors. Teamwork is the vehicle through which such coordinationoccurs. It is defined in terms of the behaviours (e.g. closed loop communication) cognitions (e.g. shared mentalmodels) and attitudes (e.g. collective efficacy, trust) that combine to make adaptive interdependent performancepossible.” 1The days of the heroic, individualist doctor are over. Organisational and structural changes in the way patientsare cared for in hospital, and increasingly complex interventions means no one person takes responsibility for thetotal care of a patient. The patient relies on a team of health professionals – hospital specialists, nurses, allied healthprofessionals – to deliver their care. There is overwhelming evidence that failures of teamwork result in medicalerrors. Medical error has been called the new epidemic, reportedly the biggest killer next to cancer and heartdisease. 2 Rather than focussing only on technical proficiency, new knowledge and increasingly sophisticatedequipment and interventions, the medical profession may need to take a look at some hard facts about teamwork.This chapter will consider some evidence on teamwork and patient safety, present empirical data on how effectiveteams operate and describe some practical approaches to improve teamwork and patient safety in the operatingtheatre.Over the last decade there have been increasingly pressing calls from patient safety bodies, health commissionersand government agencies for improved collaboration between health professionals. Consumers and providers havethe expectation that the health professionals responsible for patient care will collaborate with each other to deliverthe most effective and efficient service. 3,4 In the United States, the Institute of Medicine published a recommendationfor interdisciplinary training of medical teams as one of their key strategies for reducing medical errors. 5 Educationand training bodies, including the Australian and New Zealand College of Anaesthetists, have responded to theproblem by explicitly including communication and collaboration as key domains of medical education and clinicalpractice. 6,7National level projects have been launched to improve teamwork. The Agency for Healthcare Research andQuality launched TeamSTEPPS, 8 a national programme to improve communication and teamwork skills amonghealth care professionals (http://teamstepps.ahrq.gov/abouttoolsmaterials.htm ). The NHS launched “The ProductiveOperating Room” (TPOR) project to improve quality and deliver care more efficiently to surgical patients (http://www.institute.nhs.uk/quality_and_value/productivity_series/the_productive_operating_theatre.html ).One module in this programme addresses teamwork. The TPOR programme has been adopted in a number ofNew Zealand district health boards, funded by the NZ Ministry of Health. The WHO Surgical Safety Checklist (http://www.who.int/patientsafety/safesurgery/tools_resources/SSSL_Checklist_finalJ un08.pdf), now widely adoptedinternationally by many hospitals, includes elements to promote information sharing and collaboration between theoperating room team.CHALLENGES FOR OPERATING ROOM TEAMSAnaesthetists work in a fast-paced, high pressure environment where errors can have immediate and devastatingconsequences for patients. Of all medical environments, the operating room requires optimum and finely tunedcommunication and collaboration between members of the team to avoid error and optimise care. And yet thereare a number of factors in the operating theatre that challenge effective teamwork: teams are “unstable”; there isan established culture of parallel teams; and there is a strong hierarchical structure.The membership of the operating room team is unstable, with constantly changing membership on any day,and over the course of the day. Surgeons, nurses and anaesthetic staff may be uncertain about the roles andcapabilities of others. Much of the literature on teams is derived from stable teams, but a fundamental requirementin the operating theatre will be adaptability in the face of changing team membership.While the staff working together on a surgical list on any one day may be expected to work as a single operatingroom team, they may not conceive of themselves as a team, but rather a collection of different teams based ontheir different professional identities. The operating room maintains the appearance of three parallel teams: thesurgical team; the nursing team; and the anaesthetic team. These three groups have their own established professionalidentities, and have biases and stereotypes affecting their perceptions of and interactions with members of othergroups. These differences are established in basic medical education. With little evidence of combined educationalevents, specialist training programmes and ongoing continuing professional development can further entrenchprofessional isolation. Even initiatives in teamwork have, surprisingly, often remained uni-disciplinary.While collaboration between anaesthetists and their anaesthetic assistants may have improved over the last decade