Teamwork Training in Healthcare: More Than Just Kumbaya

One of the central tenets of the patient safety movement is that modern medicine is a team sport. Unfortunately, its players – particularly physicians – were trained and socialized to be free-spirited individualists. We need the Celtics of the 80s; what we have is a collection of young John McEnroes.

While this theory has been generally accepted, there is less agreement regarding how to change things. When I speak about safety culture, many of the questions I’m asked focus on how we are going to train future generations of medical students and residents to be “different” (translation: not like the prima donnas I have to deal with in my daily practice). It’s as if people are fatalistic about the ability to transform the culture of today’s practitioners; perhaps the next crop of physicians will do, and be, better.

Those of us who aren’t resigned to a biological solution to this problem have been enthusiastic about teamwork training and crew resource management programs for years. These programs are modeled on similar programs introduced in aviation in the 1980s after it was discovered that several tragic crashes had their roots in remarkably poor teamwork and communication. The programs bring together multidisciplinary groups to learn habits of clear communication and teamwork, and to be trained in the use of tools to employ when the going gets tough – such as, say, when a flock of Canadian geese flies into your jet’s engines.

Five years ago, with funding from the Moore Foundation, we implemented such a program on the medical services at UCSF and at two nearby hospitals. Unfortunately, while the program’s participants believed that it made care safer, our relatively small numbers of patients and providers left us unable to show improvements on hard outcomes like mortality. Other studies have had similarly mixed results – enough to keep the candle burning for those of us who believe that culture is critical and that teamwork training is the likeliest way to improve it, but not enough to catalyze a national movement for more. And, because it is expensive (the outlays for the trainers are only a small fraction of the costs – the real costs are the lost productivity of scores of nurses and doctors taking a day away from their regular jobs), teamwork training has mostly remained a novelty, implemented by a few cutting edge institutions and true believers.

In this week’s issue of JAMA, Neily and colleagues report the results of a teamwork training program implemented in 74 VA facilities. They found that the intervention (not just teamwork training, but more on this later) was associated with a 50% reduction in post-operative mortality, when compared to a contemporaneous control group of 34 facilities that had not yet implemented this training. While the raw mortality reduction is impressive, the finding of a dose-response curve (for each additional quarter-year of training, there were 0.5 fewers deaths for every 1000 procedures) makes the results all the more convincing.

I think pressure will now mount for healthcare organizations to institute teamwork training programs, particularly in their high risk, error-prone areas such as the OR and labor and delivery. As usual, the question will be, Where the money will come from? While our initial UCSF teamwork training program was grant-funded, the real test will be whether organizations will spend their own money for these programs. My guess is that most will not. This, of course, raises another question: Should regulators and accreditors now require teamwork training? Eventually, yes, but not just yet. I worry that an imposed solution will lead to half-hearted programs and resentful participants. This is the kind of complex, socio-cultural intervention that I’d love to see grow organically out of an organization’s recognition of its own needs. At the same time, it would be reasonable for the Joint Commission and other accreditors to mandate that every healthcare organization perform safety culture assessments, and that units with poor culture take active steps, such as a VA-like program, to address it. And, just as pilots are all required to undergo teamwork training to receive and maintain their license, such training should become a feature of every medical school and residency curriculum, and ultimately should be required by certifying boards.

We are still learning the best ways to teach teamwork: there is good team training and not-so-good team training. Some of the lessons we learned from our experience were: a) everybody needs to participate; nobody can be allowed to opt out (some ORs now require that surgeons and the other members of OR crews participate in teamwork training to maintain their staff privileges, and their hospitals shut down their ORs for a day to allow the training to be conducted with full participation); b) the training must be intensely multidisciplinary (i.e., you need to get docs, nurses, pharmacists, and others sitting together, working through clinical scenarios – teaching teamwork to separated cohorts of physicians or nurses is a perversion of the concept); c) the use of high-tech simulation can help by amping up the drama, but it isn’t crucial; d) leadership endorsement and support of the program is essential; and e) while there are many companies that can be brought in to help design and implement teamwork training programs (many of them staffed by former or active pilots), programs need to be localized and delivered, at least in part, by folks known and respected by the staff, not by outside consultants. Moreover, we learned that a single training program of 4-8 hours, while helpful, won’t have lasting impact unless it is followed by ongoing efforts to reinforce the lessons and the tools. The initial training is like a vaccination; the effect erodes if it isn’t followed by the appropriate boosters.

Another lesson, one emphasized by the JAMA authors and by Pronovost and Freischlag in their superb accompanying editorial, is that teamwork training is one of several interventions, and it is the combination that matters. Read the paper closely: while everyone is talking about the Crew Resource Management component, the actual program included pre-op briefings and post-op debriefings, the use of coaches, implementation of checklists, and several other tools. The risk here is that someone who hears about the VA study in passing might believe that implementing a one-and-done day of teamwork training will achieve the remarkable results described by Neily. This is analogous to the checklist experience, in which many people misinterpreted the Michigan ICU results as being simply the result of a checklist (how simple is that!). As Bosk and the Hopkins team that implemented the Michigan Keystone project later wrote in the Lancet,

“If we just tell the workers to use checklists, we will have solved the problem of catheter-related blood stream infections” is quite simply the wrong conclusion to draw from the Keystone study. The “simple checklist” stories in the press created excitement about progress in achieving patients’ safety and reassurance for the public and policy makers, but the real story of Keystone is messier and more complex. Although we all hope for the simple solution that with ease and no additional expense makes a stay in the ICU safer, there is some danger in mistaking hope for reality. The answer to the question of what a simple checklist can achieve is: on its own, not much.

And so it is with teamwork training: necessary but not sufficient.

The recent tenth anniversary of the safety field occasioned lots of chatter regarding how little progress has been made in preventing medical errors. While I share some of this disappointment, I also think that changing behavior and culture is not a sprint. It’s a marathon. This week’s JAMA study proves that culture can be modified with a feasible set of interventions, and that these efforts not only make providers feel warm and fuzzy, they also save lives.

If I were a patient in need of surgery, I’d want to know my surgeon’s outcomes and pedigree, to be sure. But I’d also want to know about the quality of the teamwork. Since there is no way for me to find this out, I’d be satisfied knowing that the members of my surgical team had participated in a robust team training program, along the lines of that reported by the VA. If they hadn’t, I’d look elsewhere. It’s that important.

Robert Wachter, MD, is widely regarded as a leading figure in the modern patient safety movement. Together with Dr. Lee Goldman, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine. His most recent book, Understanding Patient Safety, (McGraw-Hill, 2008) examines the factors that have contributed to what is often described as “an epidemic” facing American hospitals. His posts appear semi-regularly on THCB and on his own blog, Wachter’s World.

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17 replies »

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  3. Great Blog.I have great respect for the Docs in practice today. They do many things very well.They are not all great or even good managers and that’s where they need to be.The most important aspect of health care that needs reform is that physicians need an attitude that allows them to be team leaders. Until that happens all other reforms are only bandaids.

  4. It’s disappointing how defensive most of the responses are.
    My point, and certainly Bob’s point, was not that only MDs are at fault, but that in an environment in which some part of the chain can’t be corrected or over-ruled when a safety violation is detected, quality is going to suffer, and checklists (and evidence-based protocols of any kind) are going to have disappointing results. Most often, I think a barrier in these cases is the physician/surgeon, but there are other barriers as well, including administration. Ultimately, you might say that it is the culture of the institution that is at fault rather than single out any one part of it. What is needed is a Safety Culture. As AHRQ defines it:
    Safety culture and culture of safety are frequently encountered terms referring to a commitment to safety that permeates all levels of an organization, from frontline personnel to executive management. More specifically, “safety culture” calls up a number of features identified in studies of high reliability organizations, organizations outside of health care with exemplary performance with respect to safety.(1,2) These features include:
    1, acknowledgment of the high-risk, error-prone nature of an organization’s activities
    2. a blame-free environment where individuals are able to report errors or close calls without fear of reprimand or punishment
    3. an expectation of collaboration across ranks to seek solutions to vulnerabilities
    4. a willingness on the part of the organization to direct resources for addressing safety concerns (3)
    If you want to know who is more at fault at any given institution (doctors or administration), look to who wants to create a safety culture and who resists it.
    A question for those like Samuel Stenes who say IT is the problem for safety: what is the evidence that hospitals with more pervasive use of IT have worse communications, more dropped hand-offs, more unforced errors, etc.? Other than anecdotes (I hear UPMC raised a lot in this context), I think you have none.
    Nobody denies that IT can get in the way sometimes, especially when it is done poorly. But only blowhards and Luddites at this point argue that IT is making quality of care worse in general. There is no evidence for it, especially since quality of care isn’t going down while use of IT is certainly going up. And integrated systems, like the VA, Geisinger, InterMountain and Kaiser, seem to be making IT work very well for them in the area of quality (and yes, I’m aware that there have been major IT snafus in the history of each of these institutions, with the possible exception of Geisinger).

  5. All this teamwork and check list stuff is pedantic, but people are making big names for themselves reinventing the wheel. Communication is the key. The reason why we need all of these artificial prompts to remember to communicate IS because of the illness in the system exacerbated by HIT devices. NO ONE has the time to talk when thjey are clicking away on user unfriendly devices.

  6. “Exactly right jd. What nurse or tech is going to call out an arrogant rainmaker surgeon who makes it clear that he does not appreciate being contradicted or criticized? ”
    Barry, it depends on the doctor’s results. Often, those in charge of peer review are suckups to the administration enabling the administrators to control the doctors with the bullying tactics described above. If the arrogant doctor’s results are not outliers, the doc mist know something. The empowerment of staff is useless unless there is a complaint group that will counterbalance the weight and arrogance in the CEO’s offices.

  7. Barry Carol is deceiving himself and the readers to imply it is the doctors who breach safety. The breaches start at the top, the top-down phenom.
    In the days of yore, we lowly doctors were trained to do the right thing and to communicate with eachother, from the room cleaners to the administrative leader of the hospital. As the corner suite people have become intent on profit and maintaining their multi million dollar salaries, example Pittsburgh, the care suffers.
    The genesis of the vacancy of teamwork is the bullying tactics of hospital administrators, who feign their interest in safety, when it is, actually, profits only. They fefensively lie, deceive, and misrepresent the truth as to how dangerous the care is. They always state that “patient care was not affected”, no matter what the disaster with their wiring of their records. The patients suffer the consequences.
    The Joint does nothing to discipline the disruptive administrators, who daily, violate the JC Standards.
    These dictators act as bullies to depreciate the morale of their staff and physicians and are deaf to complaints about safety breaches.Their BODs are disinterested.

  8. Traditional communication has been distorted and disrupted in an environment in which all health professionals are poring over their terminals, oblivious to everything else going on around them. I agree with one of the comments above, CPOE is an impediment to requisite teamwork and require workarounds because of its defects as a team player. It needs too much attention and it can not be trusted.

  9. “Checklists don’t matter if nurses and other support staff are afraid to speak up when one of the steps isn’t followed. In order for them to be willing to speak up or stop the procedure, they need institutional support.”
    Exactly right jd. What nurse or tech is going to call out an arrogant rainmaker surgeon who makes it clear that he does not appreciate being contradicted or criticized? Why should they risk incurring his wrath and possibly losing their job? How many hospital CEO’s would be prepared to fire such a surgeon or remove his admitting privileges knowing that the hospital would lose lucrative business when it may already be only marginally profitable at best? Everyone knows what the right thing to do is but it’s easier said than done.
    At the VA, by contrast, it’s not so easy to get a nurse or tech fired. They have civil service job protections and they know it. At the same time, the surgeons are government employees who can’t just take their business elsewhere. It’s a vastly different world compared to the commercial hospital sector.

  10. Nice post. Checklists don’t matter if nurses and other support staff are afraid to speak up when one of the steps isn’t followed. In order for them to be willing to speak up or stop the procedure, they need institutional support. It doesn’t just take a team. It takes a village (go ahead, groan).
    Craig, if you are part of a team employed by a hospital or integrated delivery system, the malpractice responsibility and cost is assumed to a greater extent by the institution. It’s as a freelancer that responsibility rests largely on your shoulders. Or is being an employee as a doctor totally different from being an employee as a lawyer or executive?

  11. See the excellent book “On The Mend.” Contains illuminating case studies of their successful “collaborative care model.”

  12. In this modern world of HIT, the EHRs and OEs must be part of the team. Paradoxically, they are not part of the team, and no one can train them to be. Coming in as a consultant “the famous second opinion” after the patient has been hospitalized for 2 weeks is an exercise in futility. Trying to find out how the patient got to where h/she is today using any one of the OE and EHR products is tedious, if not impossible.
    Why, you may ask? Read this: http://portal.acm.org/citation.cfm?id=1196138
    The equipment is flawed as a team player. The entire medical care team needs to radically alter its “playing” style to to put up with the diruptive and virally toxic impact that this one palyer has on cognitive processes and care provision.
    These devices have not gotten proper training to be drafted on to the medical team, yet the sellers and Congressional trough feeders are in to writing lucrative contracts for players that are inferior and insufficient to help the entire effort. Thus, the entire team goes down, outcomes are no better, and medical care is slowed and inefficient. There you go!

  13. Attitude of the team IS imperative to good care, but technology is also one of the keys to great care too. How can management keep moral high, mistakes and overhead low while also providing great care to patients?

  14. I can’t help but rise to this one. All sorts of people want us to share our authority, but nobody wants to share the responsibility with us. Hmmm…..

  15. One of the things that is very important in healthcare is the attitude of the people involved in dealing with the patients. It is not just about the technology that matters a lot but moreover the right practice of the medical practitioners as well as the medical staffs. Doctors are like chief captain that also acts as leaders to their patients. They must offer reliability in order for them to be followed by their patients. Also, they must also act as a great motivator to the patients in dealing and fighting with their battles of sickness in a rightly and a very positive manner.
    Cardiac Care

  16. Great Blog. I have great respect for the Docs in practice today. They do many things very well. They are not all great or even good managers and thats where they need to be. The most important aspect of health care that needs reform is that physicians need an attitude that allows them to be team leaders. Until that happens all other reforms are only bandaids.