A/Prof Andrew Dean

July 2015

WORKING IN HOSPITAL TEAMS

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 positiveTeam functioning can be enhanced by understanding

how teams work, and the attributes of good teamsThe attributes of a good team are those of a good

leaderStart learning about what makes a great medical

leader now, and aim to become a great medical leader

WHY IS THIS IMPORTANT?

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-disciplinaryThe performance of a team is enhanced when that

team have practised as a team previouslyWe do not always have this luxury in medical teams;

we have to make a new team work , in an acute situation

HOSPITAL TEAMS – SOME THEORY

“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?

WHAT DO YOU THINK?

“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

WHAT THE EVIDENCE SUGGESTS

Understand their role within the teamContinually develop their own knowledgeUnderstand the values of their organisation (e.g.

hospital)Understand their responsibilities in that organisation

(e.g. hospital)Maintain their medical procedural skillsAgree on the goal of the situationHave an agreed decision making structure

MEDICAL TEAM MEMBERS NEED TO

Teams are made up of humans, withDifferent agesDifferent seniorityDifferent past experiencesDifferent genderDifferent cultural backgrounds

WHAT VARIABLES ARE THERE?

PowerExperienceResponsibility

INEQUALITIES IN MEDICAL TEAMS

“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.”

WHAT DO YOU THINK?

Professional and mutually respectful discussions about contentious issues are a sign of healthy teams

Ultimately leaders have to make a decisionFailed resolution requires escalating this process to

higher arbiturs, e.g. Director of Medical Services, Ethics Committee

CONFLICT RESOLUTION

Excellent teams and leaders have the following balance of (1)Technical and Cognitive Skills

(2) Emotional Competence / Emotional Intelligence Skills

a) 90%: 10%b) 75%:25%c) 33%:66%d) 10%:90%

WHAT DO YOU THINK?

Technical Knowledge and Cognitive SkillsEmotional Compe-tence and Non-technical Skills

WHAT THE EVIDENCE SUGGESTS

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 performanceDysfunctional teams have higher staff ‘burnout’ and

lower retention of staff (strong evidence base)

DYSFUNCTIONAL TEAMS

ConfrontationVerbal abusePhysical or sexual harrassmentUnprofessional outburstsAny 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.

DISRUPTIVE BEHAVIOURS

Open communicationNon-punitive environmentClear directionClear and known roles and tasksRespectful atmosphereShared responsibility for team successClear and known decision making processClear and known disagreement resolution processFeedback and evaluation of performanceAdequate resources

SUCCESSFUL TEAMS (REFERENCE 1)

Accurately assess their own abilities and skillsListenHandle their own emotionsRecognise reduction in their functioningAre professional at all timesAre in a good mood at workEncourage input from team membersMake decisions after consultationExercise power with restraintThink of the team in a non-heirarchical manner InspireMarket the ‘brand’ at all timesEvaluate outcomes and modify future approach

SUCCESSFUL LEADERS

Are the next generation of “leaders in development”

Should try to emulate the leaders they admireShould be aware of the supports that exist to

protect them from disrespectful behaviours

JUNIOR TEAM MEMBERS

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

LESSONS FROM AVIATION (REFERENCE 1)

Teach standardised communication systems eg ISBARUse Simulation of high risk situations, engaging with

multidisciplinary membersEmploy team role models as champions for exemplary

behaviourHave robust incident reporting systems and genuine

follow up mechanismsRegularly meet for non-punitive evaluation of adverse

outcomes, near-misses or sentinel eventsFormally provide debriefing processes for members,

as needed

GOOD MEDICAL TEAMS

A GOOD TEAM IN ACTION

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

REFERENCES

THANKYOU