Working in hospital Teams

1. Working in hospital Teams A/Prof Andrew Dean July 2015

3. Why is this important? • Your experience as a trainee doctor and as a senior doctor will be heavily influenced by your own experience of “teams” • That experience will be mainly positive • Team functioning can be enhanced by understanding how teams work, and the attributes of good teams • The attributes of a good team are those of a good leader • Start learning about what makes a great medical leader now, and aim to become a great medical leader

4. Hospital teams – some theory • Teams in hospitals may be ‘static’, e.g the medical records team, the cleaning staff team, with fairly constant membership who know each other • Or, ‘dynamic’, e.g. the Resusc team, the MET team; the team assembles as needed, with whoever is available, and the members may not be familiar • Hospital teams are often multi-disciplinary • The performance of a team is enhanced when that team have practised as a team previously • We do not always have this luxury in medical teams; we have to make a new team work, in an acute situation

5. What do you think? • “Assertive personalities are needed in all team leaders” • “Junior medical team members know nothing so they should be quiet and just observe the seniors in action” • “Only surgeons should be in charge of an ED trauma team” • “A good leader just delegates, and tells the medical team what she has decided to do” • “Confident leaders never show uncertainty” • True or False?

6. What the evidence suggests • “Assertive personalities are needed in all team leaders” • Good leaders balance assertiveness with team consultation • “Junior medical team members know nothing so they should be quiet and just observe the team in action” • Junior team members have inputs which should be listened to • “Only surgeons should be in charge of a trauma team” • An emergency physician is usually the best team leader in a trauma team • “A good leader just delegates, and tells the medical team what she has decided to do” • Delegation without consultation increases the chance of error • “Confident leaders never show uncertainty” • Good leaders accept uncertainty and selectively utilise the skills and inputs of the whole team, to help them make decisions

7. Medical Team members need to • Understand their role within the team • Continually develop their own knowledge • Understand the values of their organisation (e.g. hospital) • Understand their responsibilities in that organisation (e.g. hospital) • Maintain their medical procedural skills • Agree on the goal of the situation • Have an agreed decision making structure

8. What variables are there? • Teams are made up of humans, with • Different ages • Different seniority • Different past experiences • Different gender • Different cultural backgrounds

9. Inequalities in medical teams • Power • Experience • Responsibility

10. What do you think? • “Good teams don’t have disagreements” • “Good leaders decide quickly” • “Patient relatives should not influence MET team decisions” • “If a team member is disrespectful, be disrespectful back towards them. They deserve it.”

11. Conflict resolution • Professional and mutually respectful discussions about contentious issues are a sign of healthy teams • Ultimately leaders have to make a decision • Failed resolution requires escalating this process to higher arbiturs, e.g. Director of Medical Services, Ethics Committee

12. what do you think? • Excellent teams and leaders have the following balance of (1)Technical and Cognitive Skills (2) Emotional Competence / Emotional Intelligence Skills • 90%: 10% • 75%:25% • 33%:66% • 10%:90%

13. What the evidence suggests

14. Dysfunctional teams • Team members in a dysfunctional team become reluctant to communicate clinical discrepancies in the patient’s condition (red flags) • Transfer of information ‘dries up’ if the communicator is afraid of the response of their ‘senior’ staff colleagues • Stress among team members reduces diagnostic thinking clarity • Anxiety reduces procedural skill performance • Dysfunctional teams have higher staff ‘burnout’ and lower retention of staff (strong evidence base)

15. Disruptive behaviours • Confrontation • Verbal abuse • Physical or sexual harrassment • Unprofessional outbursts • Any other abuse of the ‘power differential’ • Lazy team members • Inconsistent follow-up by leaders of team member behaviour • ‘Heirarchy’ thinking: where one team member is afraid to look incompetent, or is afraid of upsetting a colleague.

16. Successful teams (reference 1) • Open communication • Non-punitive environment • Clear direction • Clear and known roles and tasks • Respectful atmosphere • Shared responsibility for team success • Clear and known decision making process • Clear and known disagreement resolution process • Feedback and evaluation of performance • Adequate resources

17. Successful leaders • Accurately assess their own abilities and skills • Listen • Handle their own emotions • Recognise reduction in their functioning • Are professional at all times • Are in a good mood at work • Encourage input from team members • Make decisions after consultation • Exercise power with restraint • Think of the team in a non-heirarchical manner • Inspire • Market the ‘brand’ at all times • Evaluate outcomes and modify future approach

18. Junior team members • Are the next generation of “leaders in development” • Should try to emulate the leaders they admire • Should be aware of the supports that exist to protect them from disrespectful behaviours

19. Lessons from aviation (Reference 1) • Training used to focus primarily on the technical aspects of flying • 70% of crashes are due to communication failures in the cockpit • Concept of Crew Resource Management (CRM) developed from the 1970s • Parallels in Anaesthesia, Emergency Medicine, Operating Theatres • 70% of Anaesthetic incidents are due to human error

20. Good medical teams • Teach standardisedcommunication systems eg ISBAR • Use Simulation of high risk situations, engaging with multidisciplinary members • Employ team role models as champions for exemplary behaviour • Have robust incidentreporting systems and genuine follow up mechanisms • Regularly meet for non-punitive evaluation of adverse outcomes, near-misses or sentinel events • Formally provide debriefing processes for members, as needed

21. A good team in action

22. references • 1. O’Daniel M, Rosenstein AH. Chapter 33: “Professional Communication and Team Collaboration”. In Patient Safety and Quality: An Evidence-Based Handbook for Nurses. 2008. Editor Hughes RG. Agency for Healthcare Research and Quality, US Department of Health and Human Services, Rockville (MD), USA

23. thankyou