Providing safe health care depends on highly trained individuals with disparate roles and responsibilities acting together in the best interests of the patient. Communication barriers across hierarchies, failure to acknowledge human fallibility, and lack of situational awareness combine to cause poor teamwork, which can lead to clinical adverse events.
The aviation industry has long recognized that safety requires crew members to receive specific training in working as a team, in addition to technical training. Several studies have documented poor levels of teamwork in medicine. A classic study that compared perceptions of teamwork between operating room personnel and flight crews found that attending surgeons were significantly less likely to acknowledge fatigue or accept suggestions from junior staff than were pilots.
Growing recognition of the need for teamwork has led to the application of teamwork training principles, originally developed in aviation, to a variety of health care settings. While there is no single standardized teamwork training program for health care, all programs stress several key concepts. Teamwork training attempts to minimize the potential for error by training each team member to respond appropriately in acute situations. Teamwork training thus focuses on developing effective communication skills and a more cohesive environment among team members, and on creating an atmosphere in which all personnel feel comfortable speaking up when they suspect a problem. Team members are trained to cross-check each other's actions, offer assistance when needed, and address errors in a nonjudgmental fashion. Debriefing and providing feedback, especially after critical incidents, are essential components of teamwork training.
Teamwork training also emphasizes the role of human factors—for example, the effects of fatigue, expected or predictable perceptual errors (such as misreading monitors or mishearing instructions), and the impact of different management styles and organizational cultures. Teamwork training may be purely classroom-based or accompanied by simulations of specific scenarios such as cardiopulmonary resuscitation, "crash" Caesarean section, or multiorgan trauma.
Implementation and Effectiveness
Specific teamwork training programs in health care include TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety)—a program collaboratively developed by the US Department of Defense and the Agency for Healthcare Research and Quality—and MedTeams. These programs have been implemented in several environments, including the emergency department, operating rooms, obstetrics units, and outpatient primary care clinics.
Teamwork training is conceptually attractive, and the evidence supporting the benefits of such programs in health care is growing. A landmark study conducted in the Veterans Affairs hospital system demonstrated a significant reduction in surgical mortality associated with implementation of the Medical Team Training program. Other studies have consistently demonstrated improvements in participants' knowledge of teamwork principles, attitudes toward the importance of teamwork, and overall safety climate; though these have not necessarily translated into durable behavioral changes or improved skills. The effectiveness of teamwork training may depend on baseline perceptions of safety culture as well as the intensity and duration of the intervention.
All military health facilities participate in the TeamSTEPPS program, and the Medical Team Training program is being widely implemented in Veterans Affairs facilities. However, teamwork training is not required for other health care facilities. The Joint Commission's Universal Protocol for preventing wrong-site surgery mandates a preoperative "time out," based on teamwork training principles, in which all team members review the details of the surgery to take place. Many organizations are now coupling teamwork training programs with more specific efforts to structure communication, such as SBAR (situation, background, assessment, recommendation) training. Successful organizational approaches to improving safety, such as the Comprehensive Unit-Based Safety Program, also explicitly incorporate teamwork training principles.
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JOURNAL ARTICLEEffects of teamwork training on adverse outcomes and process of care in labor and delivery: a randomized controlled trial.
Nielsen PE, Goldman MB, Mann S, et al. Obstet Gynecol. 2007;109:48-55.
The collapse of sensemaking in organizations: the Mann Gulch disaster.
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Enhancing Patient Safety During Hand-Offs: Standardized communication and teamwork using the 'SBAR' method.
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Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the MedTeams project.
Morey JC, Simon R, Jay GD, et al. Health Serv Res. 2002;37:1553-1581.
Error, stress, and teamwork in medicine and aviation: cross sectional surveys.
Sexton JB, Thomas EJ, Helmreich RL. BMJ. 2000;320:745-749.
Association between implementation of a medical team training program and surgical mortality.
Neily J, Mills PD, Young-Xu Y, et al. JAMA. 2010;304:1693-1700.
Medical team training and coaching in the veterans health administration; assessment and impact on the first 32 facilities in the programme.
Neily J, Mills PD, Lee P, et al. Qual Saf Health Care. 2010;19:360-364.
TOOLS/TOOLKITTeamSTEPPS: Strategies and Tools to Enhance Performance and Patient Safety.
Department of Defense and the Agency for Healthcare Research and Quality. Rockville, MD: Agency for Healthcare Research and Quality; 2006.
LEGISLATION/REGULATIONUniversal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery.
The Joint Commission.
Last Updated: October 2012