Teamwork Training May Improve Patient Safety


WASHINGTON — Patient safety problems in hospitals often stem from a lack of teamwork and poor communication, James Battles, Ph.D., said at a conference sponsored by the National Patient Safety Foundation.

“In health care, if we don't have good teamwork, patients die,” said Dr. Battles, the senior service fellow for patient safety at the Agency for Healthcare Research and Quality (AHRQ).

“Teamwork is not unique to health care, and what we know about teamwork research comes from a number of disciplines, namely the military,” he said.

In the wake of “To Err Is Human,” the 1999 Institute of Medicine report that raised awareness of medical errors and called for better teamwork among physicians, AHRQ partnered with the Department of Defense to develop a teamwork training program. The resulting Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) program was designed to help doctors and hospitals integrate teamwork principles into their daily activities as a way to reduce clinical errors and to improve patient outcomes, patient satisfaction, and hospital staff satisfaction.

Poor communication and other teamwork issues usually are to blame when a serious medical error occurs in a hospital, case studies have shown. “There is a growing scientific body of literature that indicates that medical teamwork can improve the quality of the clinical process,” Dr. Battles said.

One key characteristic of successful teams is a shared mental model, which means that members of the team are “on the same page” and have a mutual sense of trust and a sense of being part of a team working toward a common goal. Each member of a successful team knows his or her role. And the most successful teams have supportive leadership.

Physicians can download materials from the AHRQ Web site and customize them to suit their practices. TeamSTEPPS became widely available in November 2006, and about 50 medical centers across the United States have used the program to improve teamwork and patient safety in their facilities, Dr. Battles said.

TeamSTEPPS offers ways to transform hospital culture by addressing the root causes of serious safety problems, particularly failures of communication.

“The program offers an excellent model and thorough instruction on how an institution can alter [its] culture and support enhanced teamwork,” Dr. Mark V. Williams, professor of medicine at Emory University in Atlanta and director of the Emory Hospital Medicine Unit, said in an interview.

“It especially empowers nurses and other health care staff to speak up and alert their colleagues and physicians when patient safety is at risk,” said Dr. Williams, who is evaluating the TeamSTEPPS program for possible use at Emory.

Key team events that make up the TeamSTEPPS program include briefs, huddles, debriefs, and conflict resolution, Heidi King, director of DOD's Healthcare Team Coordination Program, said at the meeting. A brief is a short gathering of caregivers to review what is scheduled for the day. Topics include assignments, a review of relevant patient data, plans for specific patients, staff availability and workload, and resources.

“The idea is that we are creating words that people can use, when we say 'get together for a brief or a huddle,' everyone knows what is meant,” Ms. King said. “What we call the 'huddle' is for problem solving and to reestablish situation awareness. An example of a huddle: When a core care team, such as a surgical team or ob.gyn. team, meets for a quick review prior to a specific procedure.”

The debriefing is the step in which quality improvement occurs. Team members meet after the procedure or the next day to review events, even if everything went well the previous day. “This is where patient safety needs to take place, on the front lines of patient care,” Ms. King said.

A debriefing may include conflict resolution. The TeamSTEPPS material offers a constructive approach to resolving conflicts among team members in a four-step process called the DESC:

▸ Describe the specific situation or behavior that caused conflict.

▸ Express how the situation made you feel and what your concerns are.

▸ Suggest alternatives and seek agreement.

▸ Consequences should be stated in terms of the impact on team goals.

The outcomes of the training can be measured by improvements in four core skill areas: leadership, situation monitoring, mutual support, and communication. (See box at left.)

Program participants develop a combination of knowledge (of the shared goals), attitudes (of mutual trust and support), and skills (related to accuracy, efficiency, and safety) that ultimately improve patient safety, Ms. King said.

“The big thing is sustaining the changes in attitude,” Ms. King said. “Implement the training in one section of the hospital, start monitoring what is going on, and communicate about what is working and not working, and then expand the training to other areas of the hospital,” she advised.

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