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Evaluation of a Measurement System to Assess ICU Team Performance*

Dietz, Aaron S., PhD1,2; Salas, Eduardo, PhD3; Pronovost, Peter J., MD, PhD, FCCM1,2; Jentsch, Florian, PhD4; Wyskiel, Rhonda, RN, MSN1; Mendez-Tellez, Pedro Alejandro, MD2; Dwyer, Cynthia, RN5; Rosen, Michael A., PhD1,2

doi: 10.1097/CCM.0000000000003431
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Objective: Measuring teamwork is essential in critical care, but limited observational measurement systems exist for this environment. The objective of this study was to evaluate the reliability and validity of a behavioral marker system for measuring teamwork in ICUs.

Design: Instances of teamwork were observed by two raters for three tasks: multidisciplinary rounds, nurse-to-nurse handoffs, and retrospective videos of medical students and instructors performing simulated codes. Intraclass correlation coefficients were calculated to assess interrater reliability. Generalizability theory was applied to estimate systematic sources of variance for the three observed team tasks that were associated with instances of teamwork, rater effects, competency effects, and task effects.

Setting: A 15-bed surgical ICU at a large academic hospital.

Subjects: One hundred thirty-eight instances of teamwork were observed. Specifically, we observed 88 multidisciplinary rounds, 25 nurse-to-nurse handoffs, and 25 simulated code exercises.

Interventions: No intervention was conducted for this study.

Measurements and Main Results: Rater reliability for each overall task ranged from good to excellent correlation (intraclass correlation coefficient, 0.64–0.81), although there were seven cases where reliability was fair and one case where it was poor for specific competencies. Findings from generalizability studies provided evidence that the marker system dependably distinguished among teamwork competencies, providing evidence of construct validity.

Conclusions: Teamwork in critical care is complex, thereby complicating the judgment of behaviors. The marker system exhibited great potential for differentiating competencies, but findings also revealed that more context specific guidance may be needed to improve rater reliability.

1The Armstrong Institute for Patient Safety and Quality, The Johns Hopkins University School of Medicine, Baltimore, MD.

2Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD.

3Department of Psychology, Rice University, Houston, TX.

4Department of Psychology, and Institute for Simulation & Training, University of Central Florida, Orlando, FL.

5Surgical Intensive Care Unit, Johns Hopkins Hospital, Baltimore, MD.

*See also p. 2045.

This work was performed at the Johns Hopkins University. Portions of the data collection and analyses that are reported were a part of Dr. Dietz’s dissertation work.

The views presented in this article are those of the authors and do not necessarily reflective of the Johns Hopkins University, Johns Hopkins Hospital, Rice University, the University of Central Florida, or the Gordon and Betty Moore Foundation.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (

Supported, in part, by grants from the Gordon and Betty Moore Foundation (grant number: 3186.01).

Dr. Dietz and Ms. Dwyer’s institutions received funding from the Gordon and Betty Moore Foundation. Dr. Mendez-Tellez received support for article research from the National Institutes of Health. Ms. Dwyer received support for article research from the Gordon and Betty Moore Foundation. Dr. Rosen’s institution received funding from the Gordon and Betty Moore Foundation (grant number: 3186.01), Agency for Healthcare Research and Quality, Centers for Disease Control and Prevention, and Jhpiego - Global Health Services, Treatment & Prevention; and he disclosed that he is a co-investigator on a project funded through the National Aeronautics and Space Administration. The remaining authors have disclosed that they do not have any potential conflicts of interest.

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