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SPECIAL ISSUE ON TEAMWORK
Building high reliability teams:
progress and some reflections
on teamwork training
Eduardo Salas,
1
Michael A Rosen
2
1
Department of Psychology,
Institute for Simulation &
Training, University of Central
Florida, Orlando, Florida, USA
2
Department of Anesthesiology
and Critical Care Medicine,
Armstrong Institute for Patient
Safety and Quality, Johns
Hopkins University School of
Medicine, Baltimore, Maryland,
USA
Correspondence to
Dr Eduardo Salas, Institute for
Simulation & Training, University
of Central Florida, UCF, Orlando,
FL 11111, 32826 USA;
esalas@ist.ucf.edu
Received 20 March 2013
Accepted 20 March 2013
Edited by Eduardo Salas and
Michael Rosen in collaboration
with Elizabeth Hunt (Johns
Hopkins University, School of
Medicine, Division of Pediatric
Critical Care Medicine,
Baltimore, USA) and Pamela R
Jefferies (The Johns Hopkins
University, School of Nursing,
Baltimore, USA)
To cite: Salas E, Rosen MA.
Quality and Safety in Health
Care 2013;22:369–373.
ABSTRACT
The science of team training in healthcare has
progressed dramatically in recent years.
Methodologies have been refined and adapted
for the unique and varied needs within
healthcare, where once team training
approaches were borrowed from other industries
with little modification. Evidence continues to
emerge and bolster the case that team training is
an effective strategy for improving patient safety.
Research is also elucidating the conditions under
which teamwork training is most likely to have
an impact, and what determines whether
improvements achieved will be maintained over
time. The articles in this special issue are a strong
representation of the state of the science, the
diversity of applications, and the growing
sophistication of teamwork training research and
practice in healthcare. In this article, we attempt
to situate the findings in this issue within the
broader context of healthcare team training,
identify high level themes in the current state of
the field, and discuss existing needs.
Teamwork training has been heralded as
a transformative method for improving
safety and quality in healthcare.
1
Not too
long ago, the argument for team training in
healthcare relied heavily on the experiences
of other industries: aviation, nuclear power
generation and the military for example.
Now, the story is different. We know that
teamwork impacts clinical performance,
2
and teamwork training can improve the
teamwork of clinicians
3
and even clinical
outcomes.
4
Evidence from a diverse range
of sources, including reviews of adverse
events and incidents of patient harm,
5
reviews of closed claims malpractice cases,
6
descriptive studies across clinical contexts
7
and cross-sectional survey studies
8
all high-
light the pervasiveness of communication
failures in healthcare. Comprehensively
addressing breakdowns in communication
requires a full systems approach, including
the analysis and redesign of work processes
and information technology.
9
Such changes
notwithstanding, the teamwork competen-
cies of healthcare workers constitute a crit-
ical component for any efforts to reduce
communication failures. Yet, the develop-
ment of teamwork competencies has not
been addressed in a systematic way by edu-
cational institutions, professional organisa-
tions or healthcare systems to date.
The articles in this special issue clearly
demonstrate the extent to which a body
of knowledge on teamwork in healthcare
exists and upon which educational and
training efforts could draw. The achieve-
ments detailed here are remarkable and
encouraging. In this article, we take stock
of what we know, what works, what are
the insights and what needs to be done
about the design, delivery and implemen-
tation of team training. These reflections
encompass not only the articles included
in the special issue but the broader scien-
tific literature on team training and simu-
lation as well as our own experience.
TEAM TRAINING WORKS
The data are compelling and convincing. It
is not perfect, but clearly team training
impacts important processes and outcomes.
These data come not only from the articles
in this special issue, but from a growing lit-
erature base, which includes increasingly
rigorous approaches to evaluation.
910
Like
many safety and quality interventions,
evaluation of team training in healthcare is
not easy. The unit of analysis for a team-
work training intervention is not typically a
patient or even staff team, but an entire
unit. The effects of teamwork on patient
and safety outcomes are frequently indirect.
COMMENTARY
Salas E, et al.Quality and Safety in Health Care 2013;22:369–373. doi:10.1136/bmjqs-2013-002015 369
Despite these challenges, the emerging picture clearly
demonstrates that healthcare providers have positive
reactions to teamwork training (ie, they believe it is
important, relevant to their work and they intend to
apply it in their practice), learn the concepts and use the
new behaviours on the job. These multi-level training
evaluations are important pieces of the puzzle as they
outline all of the links in the chain of effects necessary to
achieve the ultimate results desired. However, these are
not the truly compelling issues. Team training must
impact patient safety and quality of care. We now know
that this is true. Teamwork training is associated with
improvements in clinical performance
2
and other
important organisational outcomes (eg, efficiency,
culture).
3
Most importantly teamwork training improves
patient outcomes.
4
TEAM TRAINING WORKS, BUT IMPLEMENTATION
STRATEGIES AND ORGANISATIONAL CONDITIONS
MATTER
And these conditions matter more than we typically
think. The conditions set the climate for how teamwork
is perceived; for how it is reinforced; and for how it is
valued. The signals that organisations send about what
behaviours, attitudes or cognition are appropriate and
accepted in the workplace will determine whether physi-
cians, nurses, students and staff will exhibit them. It is
clear that organisations get the behaviours, cognition
and attitudes they reinforce.
11
For example, in a
follow-up article to the widely cited WHO safer surgery
checklist study,
12
almost 50% of the reduction in mor-
tality and complications observed after implementing
the checklist was associated with the pre-existing safety
culture of the facilities where the checklist was imple-
mented.
13
Facilities high in safety culture realised much
more benefit from the intervention than facilities with
lower safety culture. This is rational, predictable and
consistent with theories of organisational culture. An
organisation’s safety culture consists of the aggregate
attitudes and values of its members. It reflects the
degree to which individuals prioritise safety in relation
to other competing demands (eg, financial and produc-
tion pressures). If an organisation’s members prioritise
safety, they will more likely see the value of collaborat-
ing and invest effort in changing their own behaviours
and patterns of interactions on the job.
In this special issue, Jones et al
14
found that certain
aspects of organisational structure and leadership mod-
erated the relationship between teamwork training and
cultural change. Specifically, the impact of teamwork
training decreased if the organisation did not have a
functioning error reporting system in place, leaders did
not understand or reinforce the value of teamwork,
and teamwork concepts were not institutionalised into
job descriptions, or evaluation and promotion criteria.
Taken as a whole, these characteristics indicate the
degree to which the organisation takes teamwork train-
ing seriously. Do staff perceive the training as a ‘one
and done’episode, or as a part of the organisation’s
true values? To realise long-term and sustained change,
organisations must provide the supportive context for
teamwork and pervasive reminders that teamwork
matters to the organisation.
15
TEAM TRAINING WORKS, BUT METHOD
OF DELIVERY MATTERS
And practice is best. Guided practice. In contrast to
other topics in healthcare education, traditional
information-based methods of training delivery can
improve teamwork in healthcare.
16
The effectiveness of
didactics and reading materials may reflect the fact that
the content of teamwork training (ie, teamwork knowl-
edge, skills, and attitudes) may be easier to learn relative
to complex clinical topics. Or, perhaps, the novelty of
the topic engages learners. Nonetheless, applying team-
work principles on the job remains challenging. It
involves breaking old habits of communication and
interaction, much of which we do under time pressure
and without much conscious deliberation. Thus,
practice-based training significantly enhances impact on
the acquisition, application and retention of teamwork
skills in healthcare.
17
In this special issue, there are
several examples of the use of simulation to improve
teamwork and safety including the work of Patterson
et al
18
in the paediatric emergency department and the
work of Brock et al
19
in interprofessional education.
TEAM TRAINING IS A CULTURAL INTERVENTION
AND DEPENDENT UPON LEADERSHIP SUPPORT
AT ALL LEVELS
While behavioural and knowledge competencies are crit-
ical for effective teamwork, attitudinal competencies
matter as well. These include belief in the importance of
teamwork, mutual trust and comfort with taking inter-
personal risks. These characteristics are tied to organisa-
tional climates and cultures, which are heavily
influenced by leadership at all levels. Emerging evidence
indicates that, much like other organisational change
interventions in healthcare, the degree of leadership
support for teamwork training in healthcare impacts sus-
tainment.
20
For example, when senior leaders attend, if
only briefly, teamwork training sessions, sustainment of
those interventions is markedly better than in facilities
where leadership support is less visible.
21
As discussed
above, teamwork is tightly intertwined with culture, and
leadership is perhaps the single most important driver of
what an organisation’s culture looks like.
TEAM TRAINING IS BEST PAIRED WITH OTHER
METHODS OF IMPROVING TEAMWORK
Team training represents just one of three main types
of intervention that can improve teamwork in health-
care. The two others consist of standardised commu-
nication protocols (eg, briefing and debriefing
checklists, and handoff protocols) and interventions at
the structural level (eg, changes to team composition,
Commentary
370 Salas E, et al.Quality and Safety in Health Care 2013;22:369–373. doi:10.1136/bmjqs-2013-002015
information systems and support tools, role structure
clarification).
22
Each of these approaches has value in
its own right, but each complements the others.
23
With appropriate organisational design and communi-
cation protocols, the work environment supports
rather than inhibits effective communication, coordin-
ation and collaboration. In this issue, Bunnell et al
24
demonstrated significant impact on care processes as
well as staff and patient reported outcomes. They
achieved this benefit by pairing teamwork training
with a workflow analysis and redesign for specific
care communication challenges faced in outpatient
oncology. General teamwork training combined with
specific communication tools is an effective strategy,
as the training provides a broad rationale for team-
work and general competencies while the tools
provide scaffolding, support and reminders for using
teamwork skills on the job.
MEASUREMENT DRIVEN FEEDBACK DRIVES
IMPROVEMENT
Feedback is essential to learning and improvement,
specifically diagnostic feedback—information that
helps team members understand the causes of effect-
ive and ineffective performance.
25
But, measuring any
type of process in healthcare is a challenge. The bar-
riers and constraints are no different for teamwork
measurement. Several robust measurement systems
have been developed for teamwork in specific clinical
areas.
26 27
However, large gaps remain in the tools
available for guiding learning in training events and
on the job. In this issue, Grand et al
28
provide a
general teamwork measurement framework as well as
a process for developing and validating measures for
specific contexts and purposes. This approach of
adapting an overarching measurement framework to
multiple uses is a strong contribution as it is unlikely
there will be a single global tool useful for measuring
teamwork across all settings.
BECOMING AN EXPERT TEAM PLAYER IS A
CAREER-LONG JOURNEY
Currently, team training programmes target practicing
clinicians and last only a few hours.
29
While this
amount of training has proven effective, it is also
unlikely that 2–4 h of training will equip a clinician
with all of the teamwork skills he or she will need
throughout their career. The interprofessional educa-
tion movement emphasises teamwork among health-
care workers from the earliest stages of education, and
alignment of team training programmes conducted in
the operational setting with these early opportunities
to learn will no doubt enhance their effects.
Additionally, these competencies need to be integrated
into ongoing continuing education programmes.
30
Brock et al
19
illustrate how a team training pro-
gramme designed for practicing clinicians can be
effectively implemented with medical, nursing and
pharmacy students. Their work clearly demonstrates
impact on teamwork attitudes and knowledge in these
students, an experience they will hopefully carry
forward in their professional development.
TEAM TRAINING IS A SOLUTION TO PATIENT
SAFETY, NOT THE SOLUTION
Teamwork training attempts to break the mythology
of individual heroism in medicine, and broaden the
views of clinicians to understanding and managing
interdependencies between individuals. The emphasis
on individual expertise and accountability in health-
care is critical and inspiring, but it is also limiting.
The nature of work in healthcare demands a team
approach to coordinate the diverse expertise of clini-
cians as well as better involving patients and their
families in care processes and decisions.
31
However,
truly managing care in a coordinated and collaborative
fashion requires more than good teamwork skills. The
built environment, information systems, devices and
work processes all influence the care provided. There is
workload involved in coordinating with others and
every human has inherent workload capacities and lim-
itations. The work systems that reduce extraneous work-
load (eg, inefficient and duplicative documentation,
overwhelming monitoring false alarms) provide more
opportunities for healthcare workers to coordinate with
one another and with patients and their families.
32
Teamwork training alone will not resolve these issues, of
course. The more fundamental and underlying physical,
device, task and information system issues need to be
addressed concurrently with teamwork training.
SUSTAINABILITY: THE NEXT FRONTIER
If team training is viewed solely as training, real change
is not likely to happen and it is less likely to persist
over time. As previously discussed, what happens in
training sessions matters (eg, use of practice-based
strategies, diagnostic measurement and feedback) but
what happens after training is equally as important and
frequently more challenging to manage. Brodsky
et al
33
demonstrated the long-term impact of a team
training programme in neonatal intensive care on staff
perceptions of teamwork and job fulfilment. Their
approach involved focusing on teamwork training and
including work process changes (ie, team meetings) to
make enacting teamwork in the workplace easier for
staff to accomplish. Thomas and Galla
34
document a
series of lessons learnt in a multi-year effort to spread
and sustain teamwork training efforts throughout a
large hospital system. These include building in
accountability into the training plan for various roles
and responsibilities, embedding the teamwork con-
cepts into organisational policies and practices,
engaging physician leaders as active partners in the
training, and planning for refresher trainings.
Commentary
Salas E, et al.Quality and Safety in Health Care 2013;22:369–373. doi:10.1136/bmjqs-2013-002015 371
CONCLUSIONS
Team training is no longer an approach that healthcare
has adopted from other industries without careful
adaptation. The articles in this special issue and the
broader literature illustrate great maturation in design-
ing, delivering and evaluating teamwork training in a
way that reflects the unique needs of healthcare.
However, we still have much to learn. There remain
open questions about how to make team training
work best. Issues of duration and timing of the train-
ing, how much practice is required, how frequently
should refreshers occur, and many other practical con-
siderations involved in integrating teamwork into the
fabric of educational and operational institutions
remain unanswered to the degree necessary to fully
guide practice. Additionally, further advancements in
rigorous yet practically feasible methods of measure-
ment and evaluation that can drive diagnostic feed-
back at the individual, team, unit and higher levels of
analysis are needed.
Contributors Both authors equally contributed to the
writing of this paper.
Funding This research received no specific funding.
Competing interests None.
Provenance and peer review Commissioned; internally
peer reviewed.
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