Health care is provided through the coordinated efforts of interdisciplinary teams that include practitioners from multiple professional specialties. The effectiveness of a health care team improves clinical outcomes, patient safety, the care environment for the patient and his or her family, and the work atmosphere and culture for practicing clinicians (Gorman, 1998; Silver & Antonow, 2000; Weeks, Mills, Dittus, Aron, & Batalden, 2001) Proficient health care teams contribute significantly to the financial health of a health care institution by reducing high staff turnover rates and the need to train new staff and by decreasing the incidence of unanticipated infection, untreated pain, or other poor clinical outcomes that lead to longer hospital stays and increased recovery periods (Heinemann, 2002; Institute of Medicine, 2003b). Effective health care teams increase the diagnostic power applied to challenging medical problems by incorporating input from multiple specialty sources (Gorman, 1998; Institute of Medicine, 2003b) and are more likely to develop new procedures, methods, and tools to improve the provision of patient care (Heinemann, 2002; Omachonu, Ross, & Swift, 2004). Improving team effectiveness makes good sense for health care but requires us to develop those competencies that are required for optimal functionality.
There are a number of ways to improve the effectiveness of teams (Drinka & Clark, 2000), but team training is the most common and is the best documented across multiple domains from business to the military. Team training assumes that members are competent in performing individual task work and typically targets team-based competencies such as situational awareness, knowledge of roles and responsibilities, and strategies for communication and collaboration (Cannon-Bowers, Salas, & Converse, 1993; Salas, Dickinson, Converse, & Tannenbaum, 1992). Optimally, team training that is designed to facilitate specific team competencies has long-lasting and distributed effects on how a team functions.
In health care, the role behaviors of team members in the provision of patient care are important contributors to the team's performance. Roles and responsibilities within health care teams are predominately distributed along professional lines, such that physicians, nurses, allied health providers, and others perform their specific roles integrated with and tangential to each other. Therefore, an explicit understanding of how these roles function within health care teams is central to the development of effective teams and the assessment of associated team competencies. Challenges may arise in team effectiveness because professional preparation of health care practitioners can lead to differences in perceptions and recommendations for patient care as well as communication patterns and protocols (Drinka & Clark, 2000; Institute of Medicine, 2003a, 2003b; Petrie, 1976; Petrioni, 1994). This is in part the result of segregated professional education where discipline-specific perspectives, methods, vocabulary, cultures, and identities become enmeshed in clinical practice and create challenges for interdisciplinary work. Unfortunately, this lack of interdisciplinary experience can lead to chasms where requisite skills are required for the interpersonal behaviors that facilitate optimal team performance in applied practice.
Rentsch and Hall (1994) derived the term team member schema similarity (TMSS) to describe the degree to which team members have similar knowledge structures for perceiving, interpreting, and organizing team-related phenomena. TMSS incorporates schema congruence and schema accuracy among team members, where schema congruence refers to the degree that team members' content and structural schemas match and schema accuracy refers to the degree that team members' schemas match a specific known target, such as a predefined protocol or fact-based content (Rentsch & Woehr, 2004). When team members have accurate schemas of each other, they will be able to correctly attribute behaviors within the team to personal or role constraints rather than to personality problems or other emotionally charged conflicts. Without an accurate shared schema, teammates may find it difficult to avoid emotional conflict that results from misinterpretation of evocative but well-intended behaviors (Rentsch & Zelno, 2003).
Team members develop impressions of their teammates in terms of the team's tasks, teamwork, and interpersonal dynamics that impact team effectiveness through direct or indirect interactions with each other (Rentsch & Woehr, 2004). These impressions about their teammates and themselves include characteristics associated with their competence, cooperativeness, reliability, communicativeness, and interpersonal skills.
For health care teams that are composed of interdisciplinary members who have distinct and embedded professional practices, the challenges associated with achieving schema congruence and schema accuracy among team members are substantial but necessary to attend to. Determining these requisite competencies are the first step in deriving appropriate team development interventions, such as training, that will help achieve this objective. The purpose of this study was to identify the characteristics of health care teams in terms of team membership and associated role behaviors in the provision of patient care across multiple practice areas, with the intent to formulate a model for informing the development of health care teams at a tertiary care academic medical center.
This qualitative study was exempted after an institutional review board review at the University of Michigan. Qualitative methods were selected because the study objective was to understand team dynamics in context-specific settings, without any attempts to manipulate team behaviors in practice (Patton, 2002). The intent of this study was to understand team roles and associated behaviors and to extrapolate those roles and behaviors to form a model for team development, as recommended by Baker, Day, and Salas (2006) and Salas, Rosen, and King (2007), and therefore fit well with qualitative methodology rather than descriptive or quantitative methods. Nonparticipant observation methods were undertaken to obtain precise data on specific role behaviors within interdisciplinary health care teams. A single observer was used to maintain consistency between the observations and to minimize the impact of the observer in the assessed environment. Observer bias is a natural component of qualitative research; however, the observer was not a clinician and therefore had no professional biases influencing the observations associated with role performance in the clinical settings.
A convenience sample of 25 health care teams was selected from interprofessional relationships established by the researcher because observing a team in its course of normal functioning requires trust between the team and the observer. It is important to note that although known to the teams, the observer in this study was neither predicting behavior nor evaluating its quality. Rather, the observer unobtrusively noted what the team members did throughout the course of their work in each of the contexts. In an academic medical center, personnel are routinely observed by patients, students, residents, other faculty, or administrators in clinical contexts, and as such, it is unlikely that the presence of the reviewer significantly altered the roles team members played in the course of their work. The sample included interdisciplinary teams that provide services within or in association with the University of Michigan Health System. Teams were selected to represent patient care in a variety of clinical environments, including health care setting (academic, public, private), patient care area (inpatient hospital, operating theater, ambulatory clinic, etc.), patient population (pediatric, adult), clinical specialty (surgery, primary care, emergency medicine, etc.), and interdisciplinary team composition (MD, RN, Allied Health, Administration, etc.).
Teams were observed in vivo during the routine course of their work over several hours on two occasions. Team behaviors were logged using a check sheet (Figure 1), with a check mark placed when the role behavior was observed for any team member. Categories of role behaviors included administrative, financial, administrative preparation, clinical preparation, clinical procedure, clinical therapeutic, clinical counseling, and psychosocial counseling. These categories were selected from a roster of professional positions published by the Department of Human Resources at the University of Michigan Hospitals and Healthcare Centers and are defined as follows:
* Administrative: any task associated with clerical, functional, or documentary management of the patient within the health care system or clinic (e.g., staffing, scheduling, check-in/out, insurance documentation, form management, messaging, mailing, etc.).
* Administrative preparation: any task associated with documentation or management specific to direct patient care (e.g., informed consent, chart entry, chart management, ordering tests, prescription and medication management, etc.).
* Financial: any task associated with the exchange of money or compensation (e.g., billing, insurance claims, accounting, collections, procurement, payments, etc.).
* Clinical preparation: any task associated with preparing a patient for clinical treatment (e.g., preparation of treatment space, instruments/equipment, and medication/anesthesia; resource allocation; patient preparation; etc.).
* Clinical procedure: any task or group of tasks associated with a medical intervention on behalf of the patient either for diagnosis or for treatment (e.g., surgical procedure, IV placement, intubation, wound closure, etc.).
* Clinical therapeutic: any task or group of tasks associated with nonprocedural medical intervention on behalf of the patient for either diagnosis or treatment (e.g., taking patient history, reading radiology/imaging reports, evaluating laboratory results, etc.).
* Clinical counseling: any task or group of tasks associated with providing medical counsel to the patient and/or his or her family/caregivers (e.g., discussing medication and treatment options, prescribing therapeutic/treatment alternatives, breaking bad news, referrals to specialists/other practitioners, etc.).
* Psychosocial counseling: any task or group of tasks associated with providing psychological or social counsel to the patient and/or his or her family/caregivers (e.g., psychosocial management of chronic diseases, hospice/end-of-life counsel, rehabilitation therapy, addiction/recovery support, etc.).
Role behaviors for each team member were noted using the check sheet throughout the period of observation, including collaborative and communal activities. No patient-specific details were noted or recorded. Because it was not possible for the researcher to directly observe all team members at every moment, each member was asked by the researcher to clarify his or her professional position, duration as a team member, work schedule, team role(s), and teammates' role(s). These data provided supplemental information to substantiate, to clarify, and to verify observations.
All data were aggregated for each team and analyzed using constant comparative methods of categorization. A matrix of behaviors by professional role was created for each team to evaluate frequency and distribution patterns for both the team and its constituent members. The matrix included each team member's ID, consistency of the member's presence on the team, his or her role, and observed behaviors. A pattern of variability in both specific personnel and their associated role behaviors emerged from the data for each team. For example, although a team role was consistent (e.g., RN), the individual serving that role varied over a period (e.g., Nurse A was present for a period, Nurse B for another). Similarly, a role behavior performed by one person (e.g., RN placing Foley catheter) varied with contextual factors (such as the experience level of the person performing the behavior) such that another person might perform the behavior instead (e.g., Specialist MD placing Foley catheter).
A second level of analyses was then conducted to examine the distribution of variability within and between the teams for role behaviors and the personnel associated with those roles. A code was assigned to each team to indicate whether the individuals comprising the team were consistent (stable/variable) and whether their specific roles behaviors were consistent (stable/variable). For example, a team with consistent people always performing the same role behaviors was assigned the code SRSP for stable role, stable personnel. After analyzing each team, a table was created for all teams listing patient care areas and their associated team code to determine if there were any patterns or commonalities between the team types.
Examination of trustworthiness and credibility of findings is an important aspect of ensuring the reliability of qualitative research (Lincoln & Guba, 1985). For this study, evidence is supported by the convergence with other sources of data including repeated observations within each team, observations of multiple and variable teams, interviews, and existing literature about the importance of team roles in practice as well as by the divergence of the end outcome (multiple team types) from initial expectations (single team type; Buchel, 2000). Additional evidence is provided by the complete categorization of all data within the framework with no outliers, indicating the consistency of the data, the convergence of those data from multiple and different sources of information, and the resulting data categories that form the resulting model (Creswell & Miller, 2000).
Analyses of the data yielded four distinct types of health care teams (Figure 2): stable role, stable personnel (Type SRSP); stable role, variable personnel (Type SRVP); variable role, stable personnel (Type VRSP); and variable role, variable personnel (Type VRVP). An example of a Type SRSP team was found in a private practice pediatric medicine group that provided well and sick child medical care in ambulatory care clinic. The team members included reception and administrative staff, physicians, and nurses, all of whom were consistent (SP) and performing consistent roles (SR) on a routine basis. Another private practice team providing physical medicine and rehabilitation therapy services was categorized as Type VRSP. This team provided home care therapy for adults with physical disabilities and/or ambulatory limitations and included physical and occupational therapists, therapy aids, and administrative staff. Although the team members were consistent, each member frequently performed role behaviors beyond their professional designations depending on the needs of the patient, for example, nursing, social work, advocate, personal care, and so forth.
Examples of teams where personnel variability was routine were found in many patient care areas. One example of a Type SRVP team was in the general surgery operating theater at an academic medical center. This team provided in-hospital surgery for adult patients. The surgical team members included surgeons, surgical residents/fellows, nurses, anesthesiologists, anesthesiology residents, operating room technicians, and medical students, all of whom served consistent roles; however, some of the individuals performing those roles varied, sometimes even during a procedure.
An emergency flight team providing urgent care and/or air transport of emergent and/or critical care patients to a tertiary care academic medical center was an example of a Type VRVP team. Team members included physicians, residents/fellows, nurses, pilots, and technicians. Because of transport restrictions, no more than six team members could participate on a flight, and the mix of team members for an event varied depending on situational requirements and member availability. Team members were required to fulfill the roles of missing members as needed. Only two roles remained consistent for all team missions: pilot and nurse.
The complete sample distribution by team typology is presented in Table 1. All Type SRSP teams were from ambulatory care areas, whereas all Type VRVP teams were from emergent or critical care areas. Most of the teams were Type SRVP, which included multiple patient care areas and specialties. Given the nature of health care delivery-with multiple shifts, high turnover, and rotating schedules-it makes sense that the most pervasive team was Type SRVP, with stable roles but variable personnel performing those roles. The single Type VRSP team was the only home health team in the sample; this likely reflects sample bias rather than the actual prevalence of this type of team in practice.
The most important finding yielded by these data was that health care teams appear to be much more complex than teams in other domains that are composed of consistently stable personnel functioning in consistently stable roles (Type SRSP). In contrast, health care teams comprise both variable and stable personnel and roles, and most health care teams in the sample had variable personnel serving at any given time. This was especially evident in the areas of critical care and urgent care practices.
There are numerous team competencies identified in other professional domains that have been proposed for health care teams. Examples include leadership, coordination, feedback, planning, communication, assertiveness, common attitudes, situational awareness, decision making, performance monitoring, information processing, shared expectations, interpersonal relations, adaptability, and team cognition (Baker, Gustafson, Beaubien, Salas, & Barach, 2003; Dunnington & Williams, 2003; Howard, Gaba, Fish, Yang, & Sarnquist, 1992; Morey et al., 2002; Shortell et al., 1994). Competencies such as monitoring performance and following communication protocols are conceptually straightforward and provide reasonably derived training and assessment. For example, crew resource management training initiated for cockpit crews in aviation uses performance checklists and communication protocols to reduce human error (Helmreich, Merrit, & Wilhelm, 1999). Other competencies, such as situational awareness or team cognition, are more nebulous and challenging to train and assess.
On the surface, it seems reasonable to apply team models derived from other professions to health care; however, these examples underscore the difficulty of defining exactly what contributes to an effective health care team and how best to facilitate the acquisition of those specific competencies. Most team models assume Type SRSP team stability; however, 76% (19/25) of health care teams observed in this study were not Type SRSP. Therefore, team models and associated competencies from other domains may not wholly transfer to health care or adequately inform training specific to the challenges of interdisciplinary teamwork in health care. In particular, emergency and critical care teams were primarily Type SRVP and Type VRVP. Team effectiveness is imperative for these types of teams because of the high impact that error has on patient safety and well-being, and indeed these teams are most frequently targeted for team training and development in health care institutions. If team competencies and associated training are derived from a Type SRSP model, they may not meet the true needs of the team.
Team competencies may vary by team type; that is, what may be perceived as a critical competency for one type of team may be less important or not at all important for another type. For example, overlapping knowledge and skills within the team may be a required competency for Type VRVP, and cross-training team members to perform functional responsibilities and developing situational awareness to respond to environmental circumstances would be reasonable training strategies. These same competencies and associated training would likely be ineffective for Type SRSP, where the ability to perform a role other than your own is not necessary, and training associated with providing feedback and developing interpersonal relationships may be more desirable.
It is likely that critical competencies for a specific health care team are a function of the team itself, influenced by the degree of required cross-functional coordination of role behaviors and variably dependent on contextual aspects of the patient care environment. The ability and the willingness of a team to determine its own set of competencies for optimal performance may be a competency in and of itself, a subset of what Cooke, Salas, Kiekel, and Bell (2004) refer to as team cognition. Team cognition emerges from the interaction of each team member's knowledge and the communication, coordination, and other process behaviors that produce team performance. Hence, competencies for effective teamwork may be specific to the team itself (Cannon-Bowers & Salas, 1997; Cannon-Bowers, Tannenbaum, Salas, & Volpe, 1995).
In discussing the nuances of team cognition (Rentsch & Woehr, 2004), include aspects of the social relations model of perceptions, metaperceptions, and meta-accuracy in social interactions (Kenny, 1994). Metaperception is the ability of an individual to perceive another person's perception of someone else and is analogous to metacognition (the ability of an individual to monitor and regulate his or her own cognitive activities). Meta-accuracy refers to an individual's ability to accurately determine how he or she is perceived by others. When integrated with TMSS, the framework provides a foundation for analyzing the interpersonal dynamics that occur in teams by examining the potential for misinterpretations of intent at dyadic and aggregate levels of communication. Such is useful for developing team-specific strategies for improving effectiveness. The team typology proposed herein can be used as a guide for selecting the optimal strategies for a given health care team and when coupled with the model proposed byRentsch and Woehr (2004) provide a foundation for determining optimal team competencies and training objectives that target potentially challenging aspects of team-specific performance. For example, Type SRSP and Type VRSP teams might benefit from training efforts that serve to develop an understanding of each other's task-related knowledge and skills as well as personality-related characteristics that may be lead to potentially misinterpreted behaviors without a shared and accurate understanding of each other's intentions (schema congruence and schema accuracy).
Although constructive conflict is an important aspect of highly effective teams because it provides checks and balances for task work and serves to initiate innovation to manage challenging situations, emotional conflict is a detriment to effective team performance. Optimally, teams have high team member schema congruence and schema accuracy that facilitates the ability to engage in the type of constructive conflict that improves team performance. By helping team members to understand their teammates' task-related expertise and associated task-related constraints, it may be possible to minimize the intrateam conflicts that are detrimental to team effectiveness and to facilitate optimal team processes and achievement (Rentsch & Zelno, 2003). Competencies in these areas would be advantageous for Type SRVP teams because they focus on the task-related behaviors of a role, not on the individual. Therefore, team-training strategies targeting the development of these competencies would likely be more effective than strategies that serve to build interpersonal relationships on the basis of understanding team members' personalities.
The willingness of team members to share information, to express opinions, to raise doubts, to object, to challenge ideas, and to evaluate the performance of others is critical to team effectiveness, yet the openness of teammates to do so is related to how the individual team members manage team-related conflict (Amason & Sapienza, 1997). If openness behaviors are not interpreted as well intended, they may cause anxiety-arousing situations within the team that diminishes its effectiveness. Team members who believe that their own goals are congruent with those of their teammates are more likely to engage in constructive team behaviors rather than avoiding or misinterpreting the behavior of teammates as threatening. Helping team members to commit to cooperative goals and be open to providing and receiving feedback toward achieving those cooperative goals can provide the contextual foundation for trust among team members, which is related to constructive teamwork behaviors (Fiore, Salas, & Cannon-Bowers, 2001). These types of competencies would likely facilitate optimal team-based behaviors in Type VRVP teams where the individuals and the roles they serve within the team may be in flux at any given time, with only the underlying goal of the team's work being constant. Team members of newly formed teams are not likely to enact the type of openness behaviors that are positively related to the constructive conflict that spurs team effectiveness to avoid or to minimize the potential for uncomfortable interpersonal dynamics within the team. Team-training strategies that support optimal systems for collaborative work in this context would likely serve the development of these competencies rather than strategies that target personality-driven or role-specific behaviors.
Compositional factors affecting team performance may also vary by team type. The professional culture, the experience levels of team members, the team's history, the hierarchical structure, the member seniority and duration on the team, and the availability of resources all differentially affect team attitudes and performance (Drinka & Clark, 2000; Gorman, 1998; Heinemann, 2002). A Type SRVP team-where the individual performing a consistent role varies-may perform well within a hierarchical leadership structure because there are clear definitions of role behaviors but uncertainty about the particular individuals serving those roles. In this context, clear definition of team roles and leadership are critical to the coordination and implementation of team activities because they represent the only common factors. However, a Type VRSP team that includes consistent people performing different roles depending on the needs of the environment may do better with a shared governance model of leadership, where team members coordinate task work based on shared knowledge of each other's capabilities and strengths and the needs of the environment. Both teams may benefit from leadership training; however, the associated competencies and form that training takes would depend on the team type. Identifying those factors that impact a particular team is therefore crucial to selecting appropriate training methods and assessment approaches for that team.
Results suggest that a singular model to inform best practices for health care team development may not adequately address the specific performance challenges of each team type. Adaptable development strategies for each type of team and its associated role membership may be required to optimize team performance. This is an important implication because the costs associated with team development efforts, whether through training or other methods, are substantial. Packaged team development curricula can help to offset those expenses by providing a common framework; however, if the focus of the selected curriculum does not match the specific needs of the team type, it may be ineffective.
An example of a team-training curriculum targeting health care is the TeamSTEPPS (2009) program. TeamSTEPPS provides an instructional framework built around four team competencies: leadership, situation monitoring, mutual support, and communication. The curriculum describes these competencies within the structure of a generalized health care team and prescribes a set of tools for use in optimizing team performance across the competencies. The TeamSTEPPS program explicitly states that "Emphasis is placed on defining team skills, demonstrating the tools and strategies team members can use to gain proficiency in the competencies/skills, and identification of tools and strategies that can be used to overcome common barriers to achieve desired outcomes" (p. 10). Although comprehensive and well intended, the TeamSTEPPS training program illustrates the difficulty with a one-size-fits-all concept of health care teams-the actual training materials do not account for the team variability. For example, a hierarchical model of either designated or situational leadership is presented for all teams. As previously noted, this model may not be most effective for all team types. Likewise, situation monitoring will likely be much more important for Type VRVP teams in a surgical intensive care unit than it would be for Type SRSP teams in a dermatology ambulatory care office. This is not to assert that the TeamSTEPPS competencies are not important or relevant to health care teams but rather to assert that the relative importance of these competencies and how associated training materials and assessment metrics are derived and implemented would best be determined by the type of team for which they are being selected. It may be that a subcomponent of a packaged curriculum like TeamSTEPPS is sufficient for one team, the entire curriculum is required for another team, or a different curriculum entirely is appropriate for another team type. In this way, health care can begin to disassemble the entrenched results of a hierarchical system where discipline-based decision making prevails in the provision of patient care (Hall & Weaver, 2001) rather than the "high levels of cooperation, coordination and standardization to guarantee excellent, continuity, and reliability" envisioned by the Institute of Medicine Crossing the Quality Chasm report (Institute of Medicine, 2001).
The intention of this study was to identify the characteristics of health care teams in terms of team membership and associated role behaviors in the provision of patient care across multiple practice areas, with the intent to formulate a model for informing the development of health care teams at a tertiary care academic medical center. The team typology that resulted from this work may provide a guide for selecting or developing appropriate team development strategies, define associated team competencies, and optimize training materials for each type of health care team. By increasing the effectiveness of health care teams through targeted development rather than one-size-fits-all solutions, clinical outcomes, patient safety, and the care environment for patients and their clinicians may all improve (Gorman, 1998; Heinemann, 2002; Institute of Medicine, 2003a, 2003b; Omachonu et al., 2004; Silver & Antonow, 2000; Weeks et al., 2001). Although patient outcomes are influenced by many variables and variable interactions that are difficult to control for in the applied health care environment, quantitative studies examining the impact of team behaviors on patient outcomes for each type of team would provide insight into what factors are most important to develop for specific teams. The team typology model provides a framework for beginning these empirical studies and to help streamline team development efforts.
There are several limitations of this work as it relates to the broader health care community. Although large and diverse in structure and composition, nonetheless a single institution was used to derive the resulting typology. In addition, one team per patient care area was evaluated as representative, and the role behavior categories (administrative, clinical counseling, etc.) were relatively broad and determined a priori rather than inducted from pure observation. Health care teams based in rural communities were not observed, many of which may be Type VRSP teams because of the limitations on medical resources in remote areas. However, the consistency of the results within the sample and its inclusiveness of all permutations of observed teams suggests that the typology has acceptable transferability and may be useful for describing health care teams and for providing a framework for understanding how to optimize team development strategies. Additional research in validating this model through its implementation with a variety of health care teams at other institutions and in other health care communities would be beneficial to develop important aspects of interdisciplinary team effectiveness and derive associated competencies for each team type. In doing so, we can empirically determine the best development strategies for each team type and establish a foundation for advancing the effectiveness of interdisciplinary health care teams.
The author thanks Larry Gruppen, PhD, and Casey White, PhD, for their support in the preparation of this manuscript.
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