Emergency medicine, perhaps more than any other specialty, has been charged by the Joint Commission on Accreditation of Healthcare Organizations, the Institute of Medicine, and the public to address reliability and patient safety problems in our departments. In previous columns, I have looked at the science of reliability and how reliability tools can help us provide the right care for the right patient in the right time frame at every patient encounter.
Past columns have looked at medical error from the perspective of human cognition, and talked about creating a better environment for reducing cognitive errors. Another area seeing a revival of interest as we tackle patient safety is the medical team approach, also called crew resource management.
Other industries such as aviation and nuclear power and places such as aircraft carrier flight decks and military medical units have already embraced this ideology. In the late 1990s, medical team training was making its way into emergency departments, operating rooms, and labor and delivery, but for reasons which are unclear, the concepts never became mainstream. The early data suggested promise for these principles in medical settings so it is no surprise that clinicians interested in improving health care delivery and patient safety are returning to the area.
Dynamics Research Corporation and investigators from Brown University and Madigan Army Medical Center looked at team behavior in different legal cases. Most were a chain of errors involving poor organizational structure, poor task prioritization, poor communication, and a lack of cross-monitoring of other caregivers' work. They identified 8.8 team errors (mostly in communication) per case. They concluded that 50 percent of the harm done in such cases could have been averted with medical team training and implementation. In subsequent studies, they observed an 80 percent decrease in observed errors and fewer cases referred to risk management after medical team training. A fiscal analysis suggested that $4 per patient could be immediately saved if medical team training were implemented. (Ann Emerg Med 1999;34:373.)
In 1978 a report by the Military Inspector General identified poor teamwork as a factor in many aircraft accidents. In 1979 a NASA workshop looking at the problem coined the term crew resource management. In 1980 United Airlines became the first airline to develop a crew resource management training program for its flight crews. By 1989 all three branches of the U.S. military had developed crew resource management training. Finally, in 1997, the Federal Aviation Administration required all airline carriers to provide crew resource management training to all flight crews.
The data from the military on the effectiveness of crew resource management in reducing errors are compelling and lead to efforts at implementation in various health care settings. With its needs for quick decision-making using incomplete data and demand for effective coordination of groups of caregivers for rapid care delivery, emergency medicine has much in common with aviation. Armed with a large government grant, Morey et al in 2002 embarked on an ambitious study that was modeled after the aviation experience. The year-long multicenter study included 684 physicians, nurses, and technicians who received formal crew resource management training (the Emergency Teams Training course) and who were assigned to work teams in nine teaching and community hospital EDs. Patients and staff were asked to fill out surveys to assess teamwork behavior prior to training and at four- and eight-month intervals after training. Clinical errors also were tracked.
A statistically significant improvement in team behaviors was noted during the study period, and the clinical error rate fell from 30.9 percent to 4.5 percent. The subjective workload did not change, but the study participants' attitudes about teamwork improved. (Health Services Research 2002;37:1553.)
The medical team project demonstrated that team behaviors and skills can be taught, but it cannot be assumed that teamwork behaviors are understood by all staff. Superb individual clinical skills do not signify good teamwork skills, and while teamwork skills do not replace clinical skills, they can augment them. It is obvious that certain clinical silos of care (the emergency department, the operating room, and labor and delivery) lend themselves to team care and therefore team behaviors. Many hospital-based units with higher intensity of care, multiple caregivers, and many interventions in a short period of time benefit from the rigor a medical team approach can bring.
To begin, it's important to define terms, and in this case, a team is two or more people who achieve a mutual goal through interdependent and adaptive actions, and a group is two or more individuals who achieve a goal through individual independent contributions.
In understanding team behaviors, it is critical that the reader understand the differences between a team and a group. In most organizations, indeed in most emergency departments, personnel function reasonably well as a group. Individuals working at defined independent tasks ultimately achieve a goal. The difference with team functioning is that the tasks are more interdependent and adaptive, and the work of the team is dynamic and flexible. This adaptation and flexibility lends itself to managing the work load, planning, problem solving, and developing team improvement strategies. Essential elements of a team include a common purpose and shared goals, interdependent actions, communication, accountability, and collective effort.
The medical teams approach differs from the traditional structure of group care in other ways, too. On medical teams, members are taught a high level of situation awareness and to be in tune to the idiosyncrasies and aberrancies in patient care. Team members are taught to balance immediate tasks with situation awareness and to monitor the work of other team members to ensure smooth health care delivery. The teamwork system is designed to improve care delivery and reduce the number of clinical errors. It encourages team members to coordinate and support each other actively in clinical tasks by using the structure of work teams. A basic advantage of this paradigm is the ability to manage workloads more effectively.
A last important feature of the medical team approach involves communication. Medical teams are taught to communicate using rigorous communication tools like SBAR (situation, background, assessment, recommendation). Callouts are frequent and followed by callbacks. The two-challenge rule is also taught and encouraged. (When a staffer suspects that a physician has made an error, the staffer asks the physician to clarify. If the staffer still suspects an error, he queries again — the second challenge: “Dr. Jensen, are you sure you want to give that lady 100 mg of morphine?” Nowhere is communication more critical than during hand-offs, so the communication is very systematic and rigorous there, too.
Dr. Welch is the quality improvement director in the emergency department at LDS Hospital in Salt Lake City, a clinical faculty member at the University of Utah School of Medicine, faculty at the Institute for Healthcare Improvement and the Urgent Matters Project for the Robert Woods Johnson Foundation, a quality improvement consultant to Utah Emergency Physicians, and a member of the Emergency Department Benchmarking Alliance.
CREW RESOURCE MANAGEMENT
▪ Teamwork behaviors are teachable.
▪ Team behaviors do not replace clinical skills.
▪ Superb individuals may not perform well in teams.
▪ ED staff may not be skilled in team behaviors.