), Team effectiveness in complex organizations. ), Pushing the boundaries: Multiteam systems in research and practice. Second, nurses tended to ask for help from those socially close to them; this allowed nurses to help preserve their reputation regarding his or her competence at handling the daily rigors of nursing (p. 61). The publisher's final edited version of this article is available at. Leadership must model and support desired team competencies within health care workers. However, few studies examine the impact of virtuality on teamwork processes and patient outcomes. A more precise understanding of how within team, and between team processes interact to impact outcomes. Ge Y, Ahn DK, Unde B, Gage HD, & Carr JJ (2013). OGrady ET (2008). Salas E, Rosen MA, Burke CS, & Goodwin GF (2009). For example, in these contexts, expertise is often highly distributed, formal leadership (e.g., attending physicians), and team membership changes often, leadership styles may differ among formal leaders, and communication across specialties or interdependent units is often informal, unstandardized, and fragmented. In addition to gauging perceptions of overall safety, these surveys measure constructs related to communication, leadership, and coordination and collaboration within and across units. In short, teams in health care span the full spectrum of team taxonomies. Determine what attributes of the measurement system produce the most valid and reliable ratings with the lowest level of logistical costs. the contents by NLM or the National Institutes of Health. Communication failures: An insidious contributor to medical mishaps, Improving teamwork in healthcare: Current approaches and the path forward. Interventions to improve team effectiveness: A systematic review. Teamwork quality impacts patient, staff, and organizational outcomes. Correspondence concerning this article should be addressed to Michael A. Rosen, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, 750 East Pratt Street, 15th Floor, Baltimore, MD 21202. Debriefing affords a valuable learning opportunity for teams to discuss their performance with the expectation to improve during the next performance period. Toward a definition of teamwork in emergency medicine. There is a wide variety of team types and configurations across the health care industry. Supporting involved health care professionals (second victims) following an adverse health event: A literature review. To err is human: Building a safer health system, Difficulties in collaboration: A critical incident study of interprofessional healthcare teamwork, Interactions within groups and subgroups: The effects of demographic faultlines. Early models of nontechnical skills in anesthesia, surgery, and similar care contexts evolved mainly from models of teamwork in other high-risk industries, including aviation, military operations, and energy production (e.g., Yule, Flin, Paterson-Brown, & Maran, 2006). Keebler JR, Dietz AS, Lazzara EH, Benishek LE, Almeida SA, Toor PA, Salas E (2014). Regardless of our future careers we are all likely to experience some sort of teamwork requirement even if it is as simple as getting . Gilson LL, Maynard MT, Jones Young NC, Vartiainen M, & Hakonen M (2015). Lack of trust: Communication is the process of transferring ideas, thoughts, and knowledge from a sender to the receiver. Health care team training competencies can be systematically improved. Marks MA, Mathieu JE, & Zaccaro SJ (2001). Daugherty Biddison EL, Paine L, Murakami P, Herzke C, & Weaver SJ (2015). Organizational culture provides the operating conditions (e.g., norms of interaction; Edmondson, Bohmer, & Pisano, 2001) that promote effective teamwork. Research on teams and teamwork processes within health care is important for two main reasons. Discovery 2 pertains to the formal definitions of teamwork KSAs (inputs in the IMO framework) and their identification as targets for intervention, particularly for training interventions. Criticai incident studies demonstrated overiap between the nontechnical competencies that these settings required and those identified in models developed for surgery, anesthesia, and aviation, but they also pointed to several key differences (Reader & Cuthbertson, 2011). A large-scale survey by the U.K. National Health Service revealed that degree to which health care workers reported conducting their work in effective teams was associated with a range of patient outcomes, including rates of errors, and patient mortality (Lyubovnikova, West, Dawson, & Carter, 2015). Specifically, we highlight evidence concerning (a) the relationship between teamwork and multilevel outcomes, (b) effective teamwork behaviors, (c) competencies (i.e., knowledge, skills, and attitudes) underlying effective teamwork in the health professions, (d) teamwork interventions, (e) team performance measurement strategies, and (f) the critical role context plays in shaping teamwork and collaboration in practice. Defining the prehospital care multiteam system In Keebler JR, Lazzara EH, & Misasi P (Eds. Hospital survey on patient safety culture. government site. Discovery 4 focuses on how team processes are measured, and Discovery 5 on how competencies and processes are improved. Health care personnel at the university hospital did more often than personnel in county hospitals refer to absence of key professionals (17% vs 7%, p = 0.04). Electronic Health Records (EHRs) are a recent standard in most care delivery systems, yet limited research examines HIT as an agent-based team member, coordination mechanism, or artifact of team cognition. Your workplace becomes more enjoyable and productive when you are able to operate as a team. Table 1 provides a summary of key discoveries and associated future directions for research. Tucker and Edmondson (2003) conducted a study on hospital nursing care processes and found that nurses, key members of the interprofessional health care team, engaged in certain strategies when solving problems that they encountered. A growing body of literature links the quality of teamwork to the quality and safety of health care delivery (Schmutz & Manser, 2013). Advanced practice registered nurses: The impact on patient safety and quality In Hughes RG (Ed. Principles for measuring teamwork: A summary and look toward the future In Brannick MT, Salas E, & Prince C (Eds. The coordination and delivery of safe, high-quality care demands reliable teamwork and collaboration within, as well as across, organizational, disciplinary, technical, and cultural boundaries. Cannon-Bowers J, Tannenbaum S, Salas E, & Volpe C (1995). Aaron S. Dietz, Johns Hopkins University School of Medicine. . Dutton RP, Cooper C, Jones A, Leone S, Kramer ME, & Scalea TM (2003). Team leadership and cancer end-of-life decision making, Introduction: Advances and challenges in care of older people with chronic illness. However, across industries, there is a strong tendency to emphasize the division of labor and ignore mechanisms of coordination and integration (Heath & Staudenmayer, 2000). Through coordination, communication . Other frameworks defined nontechnical competencies in care contexts that called for managing interdependent work over longer periods of time in looser team structures. Further, these systems may be more or less appropriate for measuring teamwork depending on the (a) specificity of team performance expectations, and (b) physical distribution of team members (Rosen et al., 2015). Impact of relational coordination on quality of care, postoperative pain and functioning, and length of stay: A nine-hospital study of surgical patients. (2016) showed that training impacts all four criteria. Communication failures in the operating room: An observational classification of recurrent types and effects. It gives a patient access to an entire team of experts. An official website of the United States government. Sallie J. Weaver, National Cancer Institute, Rockville, Maryland. Bogdanovic J, Perry J, Guggenheim M, & Manser T (2015). The KSAs underlying teamwork in health care settings are identifiable. We introduce a comprehensive framework for team effectiveness. 8600 Rockville Pike Scarce research investigates teamwork over longer time frames in complex MTS structures. Poor communication can result in misunderstandings, misdiagnoses, and delays in care. Develop trust between members. Evidence derived from studies of lab, military, and aviation teams identified team/collective orientation, mission analysis and planning, mutual performance monitoring, backup behavior, adaptability, and leadership as critical teamwork competencies (Salas, Rosen, Burke, & Goodwin, 2009). For example, teleconsults and virtual participation in multidisciplinary treatment planning is expanding, particularly in rural and low-resource care delivery settings. Before Communication failures often have a negative effect on patient and staff satisfaction. Johns Hopkins University School of Medicine. This would inform evidence-based IPE practices for students and practicing health care professionals, as well as multilevel intervention strategies to improve multidisciplinary care. Component team (CT) 1 and CT 2 exhibit intensive coordination, such as a primary care team and group of consultants working collaboratively on diagnosis and treatment planning; CTs 1, 3, and 5 exhibit sequential interdependence, such as care teams within a preoperative surgical clinic, operating room, and recovery unit caring for surgical patients; CTs 3 and 4 exhibit reciprocal interdependence, such as physical therapy and nursing teams working to ambulate patients within an inpatient care unit. First, they did whatever it took to continue the patient-care task, and they did this without probing into what caused the problem. Academics, policymakers, and the public are increasingly aware of the magnitude of preventable patient harm in U.S. health care, which may exceed 250,000 deaths per year (Makary & Daniel, 2016). Teams in organizations: From input-process-output models to IM0I models, Measuring the impact of interprofessional education on collaborative practice and patient outcomes. If the team members feel that they have a strong say in major decisions, then they can resist higher level directives, because they feel the team's solution is better. It can get political. Unique and complex team configurations, as well as ongoing transformations in health care delivery systems, provide wide-ranging opportunities about which team researchers can work to generate new knowledge. Bowers L, Nijman H, Simpson A, & Jones J (2011). Similarly, medical residents involvement in medical errors is associated with decreased quality of life, increased burnout, and increased odds of screening positive for depression (odds ratio = 3.29, 95% CI [1.90, 5.64]; West et al., 2006). For example, clinical care in critical care or floor units of a hospital, long-term care, or rehabilitation often unfolds over multiple days, or months, and involves a core team of clinicians delivering the majority of bedside care (i.e., nurses, technicians, attending physician) and a medium to large number of consuiting clinicians who join the care team during brief episodes centered around specific tasks (e.g., rounds) or for specific purposes (e.g., consults, rehabilitative or therapeutic services). Educate different professions as early as students to promote interprofessional collaboration. In order to optimize OR teamwork in a targeted and evidence-based manner, it is first necessary to conduct a comprehensive, theory-informed assessment of barriers and . These are considered inputs in our IMO framework. Many processes take much longer when there's a team involved. Estimating health care-associated infections and deaths in US hospitals, 2002. How can team performance be measured, assessed, and diagnosed In Salas E & Flush K (Eds. Salas E, DiazGranados D, Klein C, Burke CS, Stagl KC, Goodwin GF, & Halpin SM (2008). How does virtuality influence the sharing of novel information, dissenting opinions, voice, and, in turn, the quality of decision making? For example, how can the complex MTS structure in which care is delivered for a patient with multiple chronic conditions be validly characterized? Discovery 5 pertains to interventions designed to improve teamwork competencies (inputs) or mediators in the IMO framework. According to Aiken et.al (2002), 42% of nurses dissatisfied with their jobs intend to leave within 12 months compared with 11% of nurses with high job satisfaction. Units with poor teamwork tend to have staff with higher levels of fatigue with their roles. How can health care providers develop a sense of MTS membership, and how does their interpretation of MTS goals (e.g., overarching patient goals and priorities related to quality vs. quantity of life) and local team-level goals (e.g., condition specific treatment goals) influence care processes and outcomes? When each person knows that there is . Diagnostic errorsThe next frontier for patient safety. Team performance measurement systems in health care also need to keep pace with the evolving nature of compositional and interdependency structures; they need to be more practical without sacrificing psychometric rigor. Team sizes range from dyadic (e.g., care providers and patients involved in shared decision making) to extensive multiteam systems (MTSs; e.g., quality and safety in improvement teams within a health system; Weaver et al., 2014). However, teamwork serves an additional role in health care. Safety culture surveys with strong psychometric evidence include the Hospital Survey on Patient Safety Culture (Agency for Healthcare Research and Quality, 2016) and the Safety Attitudes Questionnaire (Sexton et al., 2006). In some cases, poor communication can even lead to medical errors. Themes that emerged from the workshop demonstrated the . As detailed in Figure 1, Panel A, this review is guided by the input-mediator-output framework (Ilgen, Hollenbeck, Johnson, & Jundt, 2005) and our collective experience conducting research and applied teamwork improvement projects in health care. As a result, significant efforts have been dedicated to providing health care workers opportunities to systematically build teamwork competencies. Team composition influences teamwork processes and outcomes through surface-level or deep-level constructs. A negative work environment has also been linked to lower HCAHPS scores which will result in . Reactions refer to the affective and utility judgments of participants after completing a training program (Alliger, Tannenbaum, Bennett, Traver, & Shotland, 1997). The teamwork and communication challenges in health care manifest the problem of coordination neglect in organizational systems (Heath & Staudenmayer, 2000). Suicide is a disproportionately high cause of death for physicians in the United States when compared with the population as a whole or other professions, and suicidal ideation among surgeons is almost twice as likely (odds ratio = 1.87, p < .001) in the 3 months following involvement in an incident of preventable patient harm (Shanafelt et al., 2011). Initial literature defines MTSs (DiazGranados et al., 2014; DiazGranados, Shuffler, Savage, Dow, & Dhindsa, 2017; Weaver et al., 2014), but studying health care delivery through this lens can advance our understanding of how MTSs perform, the competencies that matter in an MTS, how MTSs should be developed and sustained, and the contextual and structural issues impacting MTS effectiveness. Each of these opportunities is elaborated on in the following two sections. Although patient satisfaction has always been considered important, it has recently been connected to hospital reimbursement. Gordon M, Baker P, Catchpole K, Darbyshire D, & Schocken D (2015). The care that provided to the patient is more safe and efficient if it is given through the teamwork. Example Teamwork Competency Frameworks for Health Care Professionals. These protocols encourage greater information exchange and improve patient, provider, and organizational outcomes (Keebler et al., 2016). Though still evolving in response to healthcare reforms, the Patient Centered Medical Home (PCMH) holds promise as a transformative model for delivering primary care toward improving the quality of care and health outcomes among the U.S. population while containing costs as stated in the "Triple Aim". The TeamSTEPPS framework draws from the Big Five model of team performance developed by Salas and colleagues (2005) to identify four core teamwork skill domains, including communication, leadership, situation monitoring, and mutual support. We draw from recent and comprehensive empirical and narrative reviews of the science of teams in health care published between December 2000 and December 2017 that were identified through keyword searches of PubMED and PsycINFO to synthesize what is known about the team inputs (i.e., structure and context, teamwork competencies), team processes, measurement and improvement strategies, and, ultimately, the impact these things have on care delivery outcomes. Role boundary conflicts can emerge when teamwork is poor (e.g., team members overstepping professional boundaries; Kvarnstrm, 2008). The KSAs underlying teamwork in health care settings are identifiable: Undergraduate, graduate, and continuing education competency models in healthcare include teamwork-oriented domains (e.g., communication, situation monitoring, mutual support, a team orientation), though most evaluation has occurred in acute, rather than chronic care, contexts. Learning refers to whether trained KSAs changed because of participating in training. DiazGranados D, Dow AW, Perry SJ, & Palesis JA (2014). Gully SM, Incalcaterra KA, Joshi A, & Beaubien JM (2002). However, this body of work also highlights that health care teams, like other teams operating in high-risk, dynamic environments with rapid and dynamic performance cycles, engage in (a) adaptive coordination (Bogdanovic, Perry, Guggenheim, & Manser, 2015); (b) critical task execution while learning and synthesizing new or emerging information (Schraagen, 2011); (c) intentional listening, translation of information coming from disciplines with highly specialized languages, and explicit reasoning (Tschan et al., 2009); and (d) speaking up deliberately in contexts in which psychological safety may be low and hierarchical norms strong (Nembhard & Edmondson, 2006). Analysis of errors reported by surgeons at three teaching hospitals. However, we know that there is an unacceptable rate of unintended patient harm, and much of this is attributed to failures in communication between health professionals. Despite the amount of measurement tools available, there is a dearth of criterion validity evidence (Havyer et al., 2014); the science of team measurement in health care needs to prioritize how well specific measures are predictive of patient and organizational outcomes (Havyer et al., 2014). 4) Promote safe and efficient patient care delivery. Hospitals in which staff report higher levels of teamwork (i.e., clear roles and mindful management of interdependencies) have lower rates of workplace injuries and illness, experiences of workplace harassment and violence, as well as lower levels of staff intent to leave the organization (Lyubovnikova et al., 2015). A review of the literature. Real-time measurement can also prompt immediate self-correction or external interventions to enhance performance. Interventions that address IPC problems have the potential to improve professional practice and healthcare outcomes. Identifying and assessing competencies necessary for multiteam systems, virtual teams, and with health information technology, as well as managing disciplinary/other fault lines, and impact on patient and provider outcome, Teamwork processes in healthcare include rapid learning, listening intently, adapting, and speaking up among clearly defined team members and loose collaborators, Observational and interventional studies reinforce that many of the affective, cognitive, behavioral processes that matter for other types of teams operating in high-risk, dynamic environments also matter for teams delivering clinical care (e.g., adaptive coordination, group-level learning while executing, translating and synthesizing new information, explicit reasoning, and speaking up, Identifying interventional strategies beyond training that facilitate these processes among larger MTSs and looser collaborators over time, Team performance can be validly measured across complex settings. Although earlier calls exist, a report by the Institute of Medicine Committee on the Health Professions Education Summit (2003) legitimized teamwork competencies as a standard component of graduate and continuing professional education in the health professions. Applying organizational science to health care: A framework for collaborative practice. Managing complex work usually involves breaking it into tasks and delegating components of the work. The conceptual basis for interprofessional collaboration: Core concepts and theoretical frameworks. Adaptive coordination in surgical teams: An interview study. Kohn LT, Corrigan JM, & Donaldson MS (Eds.). The Interprofessional Education Collaborative (IPEC), a consortium of health profession educational associations, issued a revised report identifying overarching domains and subcompetencies that collectively comprise the core competencies for interprofessional collaborative practice (see Table 1; IPEC, 2016). Specifically, by strengthening our understanding of teams and teamwork processes in more complex organizational systems (e.g., MTSs) that must work interdependently over longer time horizons we will be better able to manage care in these settings; for example, understanding how to build teams to manage the transition to palliative care for terminal patients (Waldfogel et al., 2016) or better integrating mental health services into primary care in rural care settings in which clinical team members may not be physically colocated with patients or one another (Grumbach & Bodenheimer, 2004). (2015). Case studies of EHR implementation (Gross et al., 2016), analyses of EHR mediated electronic referrals for specialty care (Hysong et al., 2011), studies examining interoperability (or lack thereof) among HIT systems (Samal et al., 2016), and studies of patient portals (Ge, Ahn, Unde, Gage, & Carr, 2013) indicate a need to better understand team resilience during change and how to coordinate, communicate, and develop (and update) accurate shared mental models in a distributed, asynchronous fashion. LePine JA, Piccolo RF, Jackson CL, Mathieu JE, & Saul JR (2008). A limiting factor of survey research, however, is the respondent biases that may influence findings. Implementation of surgical briefings and debriefings illustrates this clearly. Telemedicine promises to enhance access to multidisciplinary care and address the severe shortages in specialist and primary care clinicians. Devising a consensus definition and framework for nontechnical skills in healthcare to support educational design: A modified Delphi study. Keers RN, Williams SD, Cooke J, & Ashcroft DM (2013). Mishra A, Catchpole K, & McCulloch P (2009). An affiliation with a larger nonprofit healthcare services organization may have some disadvantages. These findings have been replicated and extended in the health care context, focusing on important value-based health transformation outcomes.