By Frank Federico, Institute for Healthcare Improvement
Frank Federico is a senior patient safety expert and Institute for Healthcare Improvement (IHI) faculty. He is a pharmacist by training and has co-chaired several IHI collaboratives.
Healthcare is complex and complicated. There are multiple people involved in delivering care, no matter the setting you are in, so to be effective and to work together we need to have an effective team that communicates well and resolves conflicts. Simply telling people they are on a team does not a team make. There are certain qualities and activities that teams must perform to build that cohesiveness. They have a common mission, and they understand it, they understand their roles, they have psychological safety, where they question each other and support each other, and they have ways to resolve conflict. You have to ask from the very beginning, what are the norms for this team, who is part of the team, and what are the expected roles for each member of this team? The norms of conduct are that everybody gets a say and everybody gets to contribute. Ultimately the foundation of a good team is non-negotiable respect for each other.
As improvement momentum builds in the Safe Care Collaborative, now is a good opportunity to look at teamwork and communication, one of the interconnect elements in the Institute for Healthcare Improvement’s Framework for Safe, Reliable and Effective Care.
There needs to be a team leader. Hierarchy is not a bad thing, because somebody has to make the final decision. It is how a leader uses their power to engage others that makes an effective team. If a leader dominates the team, then you don’t have a team, you just have a person in charge.
What is ‘teamness’?
Teamness is a term that describes the ability of individuals to work as a team. There is more cohesiveness as a team when people work together frequently because these people already know each other, but there are instances where the group is so large that there isn’t that consistency of the same people frequently working together. In the airline industry there is no guarantee a captain will fly with the same co-pilot each and every time. So no matter who you have sitting with you, you both have to act as members of that team, that is where teamness comes in. For teamness, the same principles of a team apply, that you start working as a team, understand your mission, and what you are trying to accomplish. Everybody gets to contribute, everybody gets to question, someone might say, ‘well I’m not sure if that’s right’, or ‘I think we’re missing something’. Those kinds of discussions only come with psychological safety. And then there is an agreement of how to move forward, so everybody knows what is expected, everybody has contributed to the plan, everybody knows where we are going next. An effective team not only plans and carries out, the members also reflect.
In healthcare the reason we have activities such as huddles is because each one of us contributes what we see as a potential risk, and by that I mean being situationally aware. Do we know where we are? Do we know what the risks are in what we’re doing? When you have effective teamwork, each team member has a different view of the situation which can contribute to helping develop that overall situational awareness. In this case, situational awareness is knowing what are we working to achieve, what could be a problem that we haven’t thought of, and are we going down a rabbit hole?
How can a team improve their communication?
If a team member doesn’t have clarity around what the team is trying to accomplish, then generally the recommended language is ‘for my clarity’ or using some critical language that doesn’t cause offence but opens the door to further discussion. You could say, ‘I’m not clear what that meant, can we go back through that?’ Another option is to perform a read back or teach back and say, ‘what I heard you say was … is that correct?’ This process reinforces psychological safety and keeps people from getting defensive. It’s an effective technique because the response might be ‘that’s not what I intended, here’s what I intended …’.
Briefings, time outs and debriefs are activities teams can use. Just before surgery for example, there is a recommendation to perform a time out. Before the procedure starts, the team stops to identify the patient, identify the procedure, identify the concerns they may have and agree that they’ve addressed everything. Debriefings occur after an event. This could be the aftercare of a patient, or it could be carried out by an improvement team after a small test of change. The debrief is the study part – what did we learn and what will we do better next time?
The other tool recommended for use is SBAR (Situation-Background-Assessment-Recommendation). This was designed to present intended information and a recommendation in a very concise manner. What is the situation we’re dealing with? What’s the background? What do I offer as the assessment of what I think is going on? And what is my suggested recommendation for others?
How is this being used in the Safe Care Collaborative?
In the Safe Care Collaborative, we have improvement teams that must practice these techniques. They in turn are bringing back lessons learned about effective teamwork and communication to their work areas. Having effective teamwork is an integral part of changing culture according to the Framework for Safe, Reliable and Effective Care. You can’t have a good team unless you have psychological safety, but you can’t have psychological safety unless you have a team that has non-negotiable respect for each other. You can’t resolve conflicts if you don’t have good teamwork and good conflict resolution techniques. Accountability is an essential part of having an effective team because in an effective team we hold each other accountable for our behaviours and our actions. When the improvement teams exhibit these behaviours and use these communications tools, then other people start mimicking what’s going on.
Without effective teamwork how can an improvement team actually help guide an organisation towards delivering better care? And without effective teamwork how can we possibly deliver the care that our patients really need?