Teamwork and Team Communication Skills

1. Teamwork and Team Communication Skills Brian Ross, MD, PhD Professor, Anesthesia Executive Director, Institute for Simulation and Interprofessional Studies

2. • ‘on the job’ • apprenticeship • see one, do one, teach one ISIS Institute for Simulation and Interprofessional Studies • see one wrong • do 100 wrong • teach 1000 wrong Practice makes Perfect Practice makes Permanent Perfect Practice makes Perfect

3. Tenerife Plane Crash (MHS) • 583 people die when two fully loaded 747s collide on a foggy runway on the small island of Tenerife • Human error caused by defective perception, assumption, poor communication THE SAME TYPE OF ERRORS HAPPEN IN HEALTHCARE EVERYDAY.

4. Good Clinical Care Requires Team Work Good Communication is the Skill Otherwise Patient Care and Patient Safety Will Be De-Railed

5. TeamSTEPPS Strategies and Tools to Enhance Performance And Patient Safety

6. High-Performing Teams Teams that perform well: • Hold a shared mental model • Have clear roles and responsibilities • Use all available resources • Have strong team leadership • Provide and receive feedback well • Develop a strong sense of collective trust and confidence • Create mechanisms to cooperate and coordinate

7. For Good Patient Care Need to Develop a Shared Mental Model Communication Shared Mental Model Leadership/ Teammanship Patient Project Mutual Support Situational Monitoring/Awareness

8. Teamwork Tools Operational Tools • Brief - planning • Debrief – problem solving • Huddle – process improvement • Hand-Off • Situational Awareness • Mutual Respect Communication Tools • SBAR • Cross-Check • Check-Back • Cross-Monitoring • Call-Out • CUS • Tw0-Challenge Rule • I’m Safe

9. What is A Shared Mental Model ?

10. Shared Mental Model The knowledge and understanding of a patient or treatment plan held in common by a patient’s healthcare team. Provides team members with a common understanding of who is responsible for each task. Allows team members to anticipate one another’s needs so they can work synchronously.

11. Shared Mental Model What is happening here ?

12. Shared Mental Model OB – “We need to deliver this baby” NSVD Vacuum/Forceps C/S Regional Crash General Anesthetic ED – “We need to shock this guy” Cardioversion Defibrillation General Surgery – MS3’s, are you ready to round? Information and results Order book Dressing supplies

13. Tenerife Disaster: Sources of error • Perception: I am cleared to take off • Assumption: That other jet is not on the runway • Communication: Turn on the 3rd runway • Halo effect: He’s the chief pilot • Normalized deviance in not following procedure • Loss of situational awareness: Pilots and ATC NO SHARED MENTAL MODEL

14. Why Teams Don’t Perform Well Lack of Coordination and Follow-Up Inconsistency in team membership ** Lack of time Distractions Lack of Information sharing Fatigue Hierarchy Workload Defensiveness Misinterpretation of Cues Conventional Thinking Lack of Role Clarity Varying Communication Styles Delayed Decision Making Conflict ** 32 Anesthesiologists ! 52 Surgeons ! 64 Nurses ! = 3.5 million teams

15. Teamwork Tools Operational Tools • Brief - planning • Debrief – problem solving • Huddle – process improvement • Hand-Off • Situational Awareness • Mutual Respect Communication Tools • SBAR • Cross-Check • Check-Back • Cross-Monitoring • Call-Out • CUS • Tw0-Challenge Rule • I’m Safe

16. Developing a Shared Mental Model • • Rounds • Briefs • • Huddles • • Debriefs • • Transitions in Care

17. Medicine: Post-call rounds • Team: Attending, senior resident, intern, 2 MS3s, pharmacist, discharge coordinator, bedside nurse, and ideally, the patient and family. • Intern or MS3 gives a clear, succinct OCP, emphasizing their assessment and plan • Other team members have a chance to add, clarify, ask questions or raise concerns • Summarize for the patient, family, and the rest of the team: • Plan for the day • Plan for the hospital stay • “Anything else you’re concerned about?”

18. Brief • Briefs are for planning purposes • Information to be discussed: Team membership and roles Clinical status of team’s patients Goals, pitfalls, barriers Issues affecting team operations (i.e. resources) • Very short (5-10 min) • Usually involve multiple patients

19. OB Brief • Find a google image

20. Huddle (remember Dr. Dellinger’s preop huddle video) Huddle: • focused on one patient or clinical event • reinforces the plans already in place for a patient Crash C/S Routine surgery Bedside placement of a central line • allows for information updates • ensures the whole team has a shared mental model

21. De-Brief • Accurate recounting and documentation of key events • Analysis of why the event occurred, what worked, and what did not work • Discussion of lessons learned and how they will alter the plan next time • Establishment of a method to formally change the existing plan to incorporate lessons learned

22. Handoff: Responsibility for Patient Care Transfers to Another Team • Your team is signing out for the night • Patient transfers from OR to PACU • Patient transfers from floor to ICU • Patient discharged from hospital back to PCP “Shake the Yoke”

23. Handoff - “I PASS THE BATON” 4-P’s Introduction: Introduce yourself and your role/job (include patient) Patient: Identifiers, age, sex, location Assessment: Present chief complaint, vital signs, symptoms, and diagnosis Situation: Current status/circumstances, including code status, level of uncertainty, recent changes, and response to treatment Safety: Critical lab values/reports, socio-economic factors, allergies, and alerts (falls, isolation, etc.) THE Background: Co-morbidities, previous episodes, current medications, and family history Actions: What actions were taken or are required? Provide brief rationale Timing: Level of urgency and explicit timing and prioritization of actions Ownership: Who is responsible (nurse/doctor/team)? Include patient/family responsibilities Next: What will happen next? Anticipated changes? What is the plan? Are there contingency plans? Patient Problem Plan Precautions/Issues Question, Clarify, and Confirm

24. Handoff: MS3 signing out patient to intern

25. Handoff: MS3 contacting PCP at hospital discharge

26. Handoff: OR to PACU

27. Develop a Shared Mental Mode Through Communication Leadership/ Teammanship Patient Mutual Support Situational Monitoring/Awareness

28. Leadership vs ‘Teamanship’

29. Crew Resource Management "Oh I believe in resource management all right......... You are the resource and I'm the management!"

30. ‘Expert Team’ ‘Team of Experts’

31. Team Leader Three types of leaders: • Designated: The person assigned to lead and organize a designated core team, establish clear goals, and facilitate open communication and teamwork among team members • Situational: Any team member who has the skills to manage the situation-at-hand • Default: Occasionally it is the ‘Shared Mental Model’ that is the team leader

32. Expected Team Behaviors Leadership Behaviors: • SBAR • Requests • Call-Outs • Cross-Checks (cards) • “Shake the Yoke” • Task Prioritization • Situational Awareness • Mutual Support • Briefs/Huddle/Debriefs • Hand-Offs • Expect Teammanship Behaviors Teammanship Behaviors: • SBAR • Call-Outs • Check-Backs • Cross-Monitoring • Cus’ ing • Two Challenge Rule • Mutual Support • Requests Help • I’m Safe

33. Leadership Behaviors Requests : Directed to Individuals – no “King County” Make Eye Contact Point at Individual Use Their Name Expect Parroting

34. Leadership Behaviors Task Prioritization: Importance of tasks Balance of Workload

35. Develop a Shared Mental Mode Through Communication Leadership/ Teammanship Patient Mutual Support Situational Monitoring/Awareness

36. How Situational Monitoring Helps Teams • Process of actively scanning behaviors and • actions of other team members to assess • elements of the situation or environment • • Fosters mutual respect and team accountability • • Provides safety net for team and patient • • Includes cross monitoring

37. Situational Monitoring • You are rounding with your general surgery team. You discuss STAT coag studies for a patient who needs to go back to the OR. Your intern writes the order but answers a page and doesn’t turn it in, and rounds continue. • Your team sits a patient up to listen to his lungs, putting the side rails down and moving the phone, call light and bedside table out of the way. He lies back down and after asking if he has any questions, the team prepares to leave. Offer to find the patient’s nurse and pass on the order Put everything back so the patient doesn’t fall

38. Situational monitoring • You are rounding with your medicine team, and notice that the elderly wife of a patient looks a bit confused and uncertain as the team discusses the plan Go back after rounds and check in with the patient and wife.

39. Develop a Shared Mental Mode Through Communication Leadership/ Teammanship Patient Mutual Support Situational Monitoring/Awareness

40. Communication LH CG Effective Communication must be: • complete: relevant information avoiding unnecessary detail • clear: standard terminology, minimize an acronyms • brief: be concise • timely: avoid delays, verify, validate or acknowledge

41. SBAR SBAR: is a communication technique which provides a standardized framework to communicate about a patient’s condition. (Can also be referred to as ISBAR, where I stands for introductions) Situation: what is happening with the patient Background: what is the clinical background – other relevant info for current problem or other hx that may impact current prob Assessment: what do I think the problem is Recommendation: what would I recommend Practice

42. Case #1: SBAR

43. Case #2: SBAR

44. Call-Out Call-Out: is a tactic used to communicate or share information with the whole team, often directed at a specific individual (often the team leader); frequently unrequested information • Two meanings: • Team member alerting others that they arrived at the scene • Example: • Anesthesiologist entering room saying: • “Anesthesia is here, etc” • Request for data/information and Response to the request: • Example: • Leader: “Airway status?” • Resident “Airway clear” • Leader: “Breath Sounds?” • Resident: “Breath Sounds decreased on right”

45. Cross-Check Pilot: “ Flaps at …” Co-Pilot: “Flaps at …”

46. Cross-Check Cross-Check: is a closed-loop communication strategy used to verify a request is received. Sender initiates request or message, receiver confirms he/she has received the request CROSS-Check: Validating a request by the team leader of team member Example: Bob the Team Leader says: “Joe, get me a blood gas.” Joe the Team Member says: “Bob, I will get the blood gas.”

47. Check-Back CHECK-BACK: A communication loop involving a sender initiating the message, a receiver accepting the message and providing feedback that the task has been completed. Example: Resident asks the nurse: “ Bill, Call anesthesia.” Nurse confirms by saying: “Calling for Anesthesia.” Nurse checks back: “I have contacted Anesthesia"

48. Check-Back is… Sender initiates message Receiver accepts message, provides feedback confirmation Receiver confirms action was completed

49. Cross-Monitoring CROSS-MONITORING: Validating or challenging a team member's action, diagnoses, assessment, or treatment plans. Example: Team Leader: “I think this is 2o block. Team ?: (what do you think ?) Member B: “I agree … or … I actually think it is 3o block.”

50. CUS Please Use CUS Wordsbut only when appropriate! I Need Clarification “Stop the Line !”