Creating a Culture of Teamwork to Save Lives: What Does it Take? Eduardo Salas, Ph.D. Department of...

Creating a Culture of Teamwork to Save Lives:

What Does it Take?Eduardo Salas, Ph.D.Department of Psychology &Institute of Simulation & TrainingUniversity of Central Floridaesalas@ist.ucf.edu

This Morning…

We are taking “a trip”… Why you should care about

teamwork… What team science tells us

about teamwork… Give you some advice… What does it take…

Going to Mars…2035

…An expert team

Long Duration…Confine Environment…

This Team Needs To Be…

Reliable, no errors… Resilient, deal with novel

events… Adaptive, change due to

conditions… Self-correcting, no time for

outside intervention…

This Team Needs To Be…

Decisive, make quick & robust decisions…

Cohesive, get along… Safe, errors could cost their

lives… Teamwork, coordinate,

cooperate & communicate…

And So Does Patient Care!!!!

I. What is the State of the Science? What Matters in Teams?

What is the State of the Science?

How Do We Turn a Team of Experts into an Expert Team?

What is the State of the Science? Theoretically-driven (170+ models!)

“Nothing more practical than a good theory.”

It’s a multi-disciplinary field Explosion of empirical work! Studying real teams; performing real

tasks “Teams in the Wild” Simulations

Experts as participants

What is the State of the Science? Hundreds of teams!

Aviation Healthcare Military Corporate world

Teams defined Task interdependency Distributed expertise Hierarchical organized Member Fluidity

What is Teamwork? It is the actions, events and

behaviors, cognition, feelings taken to accomplish a team goal.

It is about… …taskwork skills (i.e., own task). …teamwork skills (i.e., how to work together). …building and maintaining both.

What Matters…

The 7 C’s of Teamwork…

COMMUNICATION

TEAMWORK

Organizational &

Individual Outcomes

Cooperation… Attitudes & Beliefs:

Team Orientation Collective Efficacy Mutual Trust Openness to Experience

Good Teams… Develop collective efficacy Have strong team orientation

Coordination… Behavioral Mechanisms:

Mutual Performance Monitoring Back-up Behavior/Supportive Adaptability/ Flexibility

Good Teams… Self-correct Employ huddle, debriefs

Communication… Information exchange protocols:

Close-loop communication Precise, Timely, Clarity Appropriate terminology

Good Teams… Share unique information

Cognition… Shared understanding:

Roles & Responsibilities Knowledge of team mission; Objectives,

Norms, & Resources Familiarity with Teammates

Good Teams… Have clear roles Team norms are clear

Coaching… Leadership:

Team Leadership Promotes teamwork Cares about team members Sets ground rules

Good Teams… Have coaches Set expectations Clarify roles

Conflict… Conflict resolution strategies:

Interpersonal skills Psychological safety

Good Teams… Deal with conflict, confront it Coaches create psychological

safety

Conditions… Supportive context

Good performance recognized & reinforced

Access to resources Information needed available

Policies, procedures & incentives aligns

Leadership sends “signals” that teamwork matters

II. Ten Characteristics of Effective Teams…

Ten characteristics of effective teams…1. Clear roles & responsibilities

…have members who understand each others’ roles and how they fit together.

2. Compelling purpose – goal, vision …have a clear common purpose. …energized by their shared mission. …can evaluate current status in terms of a

destination.

Ten characteristics of effective teams…3. Team coach (leader) – promotes,

develops, reinforces …leaders that directly intervene to enact

teamwork processes. …have team members who believe the leaders

care about them. …provide situation updates. …set expectations. …self-correct first. …clarify roles. …solicit ideas and observations from team

members. …seek out opportunities to reinforce effective

teamwork.

Ten characteristics of effective teams…4. Mutual trust – familiarity

…manage conflict well—team members confront each other effectively.

…have a strong sense of team orientation. …trust other team members’ “intentions”. …strongly believe in the team’s collective

capability to succeed. …develop collective efficacy.

Ten characteristics of effective teams…5. Team norms – clear, known &

appropriate …what is acceptable “around here”.

6. Shared understanding of task, mission & goals – hold shared mental model …have members who anticipate each

other. …can coordinate without overt

communication.

Ten characteristics of effective teams…7. Self-correct – huddles, debriefs

…regularly provide feedback to each other, both individually and as a team (“de-brief”).

…establish and revise team goals and plans. …differentiate between higher and lower

priorities. …have mechanisms for anticipating and

reviewing issues/problems of members. …periodically diagnose team "effectiveness”,

including its results, its processes, and its vitality (morale, retention, energy).

Ten characteristics of effective teams…8. Set expectations (and are

managed) – clear, understood9. Shared unique information –

efficient information protocols …huddles, debriefs can help.

10. Launched correctly Kick-off meeting

III. Seven Pieces of Advice…

Some Advice… 1. Ensure all team members are trained

on team-based KSA’s…around six of the C’s… Team training ≠ Team building Information, demonstration, practice &

feedback, key elements Scenario carefully crafted Event-based approach

Does Team Training Work?

YES!!!

Team Training Works! Compared with current training,

enhanced training resulted in (see Cannon-

Bowers & Salas, 19981): 45% improvement in Mission

Performance. 33% improvement in Tactical Decision

Making Performance. 25% improvement in Communication

Efficiency. 10-34% improvement in Team

Coordination. In the aviation environment (Salas et al.,

19992): 6-20% improvement in Teamwork

Behaviors.

1Cannon-Bowers, J. A., & Salas, E. 19982 Salas, E. et al 1999

Does Team Training Work? Team training significantly

improves team3:

Cognition (ρ = .42) Shared mental models

Behavioral process (ρ = .44) Communication, coordination,

collaboration Affect (ρ = .35)

Mutual trust, collective efficacy Performance outcomes (ρ = .37)

Task outcomes, satisfaction, viability 3Salas et al., 2008

Does Medical Team Training Impact Clinical Outcomes?

State of the Science of Medical Team Training… 106 Independent Samples, 93 studies were

included in the meta-analysis Military clinicians-3 Nonmilitary clinicians-79 Students-20 Mix-4

Most team training programs were developed in house (38.68%)

Most teams trained are interprofessional (72.64%) but interdisciplinary teams were minority (26.42%)

Communication was the competency most commonly trained (31.66%)

What Did We Find?

Outcome K1 N2Corrected

dRM3

Variance accounted for

Overall 106 19700 .65* 9.5%

Reactions 3 66 0.65* 9.6%

Learning 58 5489 .83* 14.67%

Behaviors 47 7727 0.58* 7.29%

Organizational Outcomes 29 5591 0.30* 2.19%

Patient Outcomes 16 9350 0.43* 4.42%

1. K is the number of effect studies analyzed for this outcome2. N is the number of individuals evaluated in this outcome3. Corrected dRm is the corrected effect size estimate*Statistically significant; confidence interval excludes zero

What Do the Data Mean? Team training improves overall outcomes by 9.5% Team training is well-liked and perceived as useful

9.5%. Team Training accounts for 14.67% of learning 7.29% of improvement of on-the-job performance

-This includes both task and team performance Team training accounts for 2.19% of improvement

in organizational outcomes (e.g., culture, turnover, financial)

Team training accounts for 4.42% of improvement in patient outcomes (e.g., infection, mortality, complications)

Some Advice… 2. Teach how to Debrief and Huddle!-

Simple, Powerful, & Underutilized What worked? What can be improved? Focus on as many C’s as possible. Debriefing works! (Tannenbaum & Cerasoli,

2012) 25% Performance improvement

Some Advice… 3. Use Simulation!

Games, role plays Accelerates expertise Embedded instructional features

Some Advice…4. Develop team coaches, leaders…5. Measure & Reinforce teamwork!6. For sustainability…create

conditions needed… …continuous process …seek supervisory support …not an event, journey …physicians must engage …CFO/CEO/CMO must see value, business

case

Some Advice… 7. See if you can use this statement:

“Am Dr. ____, I am a good surgeon but I am vulnerable to error so you are here to help me take care of this patient– we are a team.”

IV. What Does It Take…

Success Factors1. Leverage pre-existing team training

programs (e.g., TeamSTEPPS, CRM)…Adapt to needs!

2. Need to understand the coordination

demands in your units…Not all teams created equal…Task interdependence matters…

3. Need to focus on teamwork-related KSAs…

4. Prepare the organization, supervisors, leaders and trainees for team training…

Success Factors5. Create conditions - A support

system that facilitates the application of the trained skills back on the job… …Supervisory support… …Opportunity to practice… …Providing tools for teamwork &

collaboration -- checklists, debriefs, huddles, teamwork aids…

… Team coaching…

Success Factors6. …An organizational commitment

(CEO, CFO, CMO)– leadership support to do things differently… Long-term culture change efforts… Resources allocated…

7. …A cadre of organizational mechanisms to promote & reinforce teamwork…creating the conditions for sustainability… Measure & reinforce teamwork… A journey, not an event…

Success Factors8. …Continuous learning &

educating…Support IPE…Start early…

9. …Discipline in using performance support tools – debriefing, huddles, simulation…

10. …Physicians on-board, supporting…champions…

V. Final Thoughts…

Final Thoughts… Effective teamwork is the foundation

for effective patient care. Teams can learn to be more effective

and save lives. The science of teamwork

Remember the 7 C’s of teamwork and the patterns of effective teams.

As of July 1, 2015

Eduardo Salas, Ph.D.Professor of Psychology

Department of PsychologyRice University

Houston, TX

How Can I Help?