Quality Quarterly

Teamwork: The Road to Respect, Reliability, and Resilience

Everyone in health care is in the business of saving lives, whether you are a front line caregiver, an equipment supplier, an environmental engineer, an executive, an analyst, or any other position that touches the processes, systems, environment, or evaluation of health care. We are all in the business of saving lives, and we must function with reliability every day. It is not “OK” in health care to do a better job on some days, more than others. We have to get it right — provide the highest quality of care, and prevent harm and medical errors — all day, every day. 

But we are human beings, right?

Exactly. That’s why we need a systematic approach that acknowledges human factors, a quality and safety culture, and a supportive team environment all humming in harmony. If you place these three concepts in a Venn diagram, the overlapping center segment will be high reliability. Becoming a high-reliability organization (HRO) is among every provider’s strategic initiatives. But how do we get there? What does that look like? What does that sound like? And why aren’t we “there” yet? I believe it is because we pay more attention to the science (evidence-based strategies and human factors), than we do to the people we are asking to practice them — the team.

More attention to the team is conveyed in communication — speaking, listening, questioning, observing non-verbal cues, and learning each other’s perceptions. Ineffective communication is the number one factor at the root of most medical errors and adverse events, so that is a great place to focus your steps on your journey to high reliability. 

Much of the danger zone in our health care environment lies just below the surface, like the larger part of an iceberg. We are wise to be alert to identify and learn from the near misses that lie just above the surface, so that we prevent more devastating damage. There are several teamwork training models available to health care organizations, but they all revolve around these core concepts: situation awareness, mutual support, leadership, and speaking up.

Taking five minutes to communicate better, to have an exchange about what we are seeing and thinking in a given situation, will not just save time in the long run —it may even prevent an adverse event. We must take one step back, slow the momentum in a difficult situation, and listen to our teammates.

You have probably seen pictures or images cleverly designed to appear as two different things at the same time. These are often used in teamwork discussions to help participants understand that two of us may be looking at the very same thing, but we see it differently. We must take a moment, listen to each other to get on the same page, with all the pertinent facts, to move forward with a shared mental model. 

Many tools and strategies can be taught and practiced to hone a team’s skills in supporting each other and maintaining effective (and life-saving) communication on a daily basis.  Let’s review just five, with an emphasis on communication exchange:

  1. “Check Back” facilitates understanding and allows for the receiver of a message to repeat to the sender their understanding of an order, a suggestion, or request, and opens the door for a concern or question in that exchange. Then the initial sender confirms  the receiver has it right, or takes the opportunity to clarify, correct, or change the request.
  2. Briefs are essential to help all team members get on the same page at the beginning of a shift or before a procedure or intervention. The key is to create an exchange, not have one person conduct a “report” while others simply listen. Draw out any questions or concerns the team members might have. Encouraging that exchange creates the “safe space” for another team member to speak up on another day.  Promoting psychological safety in the easy or routine situations will help to assure it in the difficult ones. Speaking up saves lives.
  3. Huddles are quick and effective exchanges to help team members all get up to speed on changes in a patient’s condition, or on changes in the environment of care. You want your team members to feel comfortable requesting a huddle, not always leaving it up to the designated leaders.
  4. Debriefs can be very helpful at close of shift and need not take more than a few minutes. The team gets a chance to thank each other, respect each other, mention whether a piece of equipment needs attention, comment on whether the workload seemed out of balance (to be addressed in more detail by a few after the debrief or on the following day) and best of all, is an opportunity to describe any “near miss” that occurred.
  5. “Stop the Line” can be the most difficult strategy, if organizational leadership does not support its use. This tool takes a little more training so that those who use it and those who hear it can get on the same page.  The CUS acronym is an effective script for this: “I am concerned about …, I am uncomfortable with xyz contributing factors… I don’t think it is safe to continue.” The person on the receiving end of that phrase learns that these three words require him or her to stop, listen, and discuss the situation to assure a shared mental model and the best course of action, together.  Your team can develop a different phrase, but make sure it is widely practiced (soft simulation), so that everyone understands its value.

These practices will not only help us become HROs by preventing medical errors, but will also help us pursue the Quadruple Aim:  improving care, promoting health, reducing cost, and enhancing joy and meaning in work as we learn to function better as a team.  We are not only saving the lives of our patients every day, we are strengthening each other’s resilience.

For more information about team training resources, contact Julia Slininger, vice president, regional quality network, at (213) 453-4519.