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Social Science & Medicine 75 (2012) 986e989

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Social Science & Medicine

journal homepage: www.elsevier .com/locate/socscimed

Commentary

Improving teamwork and safety: Toward a practical systems approach,a commentary on Deneckere et al.

Eduardo Salas a,*, Heidi B. King b, Michael A. Rosen c,d

aDepartment of Psychology, and Institute of Simulation and Training, University of Central Florida, 3100 Technology Drive, Orlando, United StatesbUnited States Department of Defense Patient Safety Program, United StatescArmstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, United StatesdDepartment of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, United States

a r t i c l e i n f o

Article history:Available online 8 May 2012

Keywords:TeamworkTeam trainingCare pathwaysPatient safetyWork systemsCommunication

DOI of original article: 10.1016/j.socscimed.2012.0* Corresponding author. Tel.: þ1 407 882 1325.

E-mail address: esalas@ist.ucf.edu (E. Salas).

0277-9536/$ e see front matter � 2012 Elsevier Ltd.doi:10.1016/j.socscimed.2012.02.055

Safety and quality are by no means new concerns in healthcare,but these issues have received increased attention over the pastdecade from researchers, clinicians, governments, funders, andpatients themselves. Due in large part to measurement challenges,the exactmagnitudeof thepatient safety problem is debatable, but itis undeniably larger than practitioners or laypeople imagined justyears ago. Similarly, the ultimate causes of patient harmremain to bethoroughly documented, but are undeniably many and variable innature ranging from deficient infection control practices, to thedesign of medical devices, to organizational culture (Cuong-Phamet al., 2012). Among these varied causes, teamwork and communi-cation failures have been identified as a crosscutting contributoryfactor in many types of adverse events. Consequently, a largenumber of interventions have been developed, implemented, andevaluated to improve teamwork and communication in recent years.These fall into three main categories each addressing distinct yetinterrelated aspects of a complex healthcare delivery system: 1)teamwork training programs which seek to build the competenciesof team members, 2) structured communication protocols (e.g.,briefing and debriefing checklists) which seek to improve the reli-ability of transferring critical information, and 3) organizationalinterventions (e.g.,work andprocess redesign)which seek to change

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work processes and structures so that they support more effectivecommunication (Buljac-Samardzic, Dekker-vanDoorn, van Wijn-gaarden, & van Wijk, 2010). In practice, most teamwork improve-ment initiatives include interventions from each of these categories.

The lessons learned to date in quality and safety improvementindicate that multi-factorial interventions (i.e., those addressingmultiple aspects of care delivery) are likely to be more successfulthan interventions targeting one component of the care deliverysystem in isolation. In their article in issue 75(2) of Social Science &Medicine, Deneckere et al. (2012) provide a thorough review of thecare pathways literature as it relates to teamwork. This is animportant contribution to the literature on care pathways. Addi-tionally, this article is significant as it highlights the interdependentnature of different quality and safety interventions being developedand implemented in healthcare. Care pathways are largely a workredesign intervention wherein principles of high reliability organi-zations are applied to reduce unnecessary complexity and variationthrough standardization of care delivery processes and protocols(Pronovost et al., 2006). Care pathway interventions may providethe opportunity for more effective teamwork, but they are insuffi-cient on their own to guarantee it. As the authors note, more tightlycoupling the care pathway interventions with training interven-tions to improve teamwork competencies will likely provideimproved effectiveness.

In this brief commentary, principles from the organizational andhuman factors literature that can inform the development and

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evaluation of multi-faceted interventions addressing work and taskdesign, technology and information systems, individual and team-level competencies, and organizational culture are presented.These principles summarize pertinent aspects of the well estab-lished multi-disciplinary science of teams and team training.

Teamwork relies on competencies: communication,coordination, and cooperation

Teamwork is not just a concern for healthcare. Many industrieshave recognized the critical role teamwork plays in effectiveoperations, particularly those industries dealing with high risk,safety-critical environments and tasks such as aviation, the mili-tary, and power generation. These practical needs have drivena large body of rigorous research on the nature of effective teams(Kozlowski & Ilgen, 2006). Three key themes from this research arehighlighted below, specifically, the distinction between teamworkand taskwork, theoretical frameworks of team effectiveness, andthe nature of teamwork competencies.

First, in order to define, understand, and improve teamwork it isnecessary to distinguish it from taskworkdthe aspects of an indi-vidual team member’s work completed without input from othermembers of the team. Taskwork can be completed in relativeisolation from other team members. In comparison, teamworkconsists of the processes used to manage the interdependentcomponents of team members’ workdthe actions taken by teammembers while communicating, cooperating, and coordinating(Salas, DiazGranados, et al., 2008; Salas, Wilson, et al., 2008). Thisdistinction is useful as it helps to draw boundaries around whatteamwork is and is notda point of departure for the developmentand validation of theories of effective teamwork and ultimatelyimprovement strategies.

Second, many theories and frameworks have been developed todetail the nature of these teamwork interactions, and how a team’sfunctioning determines successful or unsuccessful team outcomes(Ilgen, Hollenbeck, Johnson, & Jundt, 2005; Salas, Stagl, Burke, &Goodwin, 2007). At a high level, team member interactionprocesses can be categorized as action, transition, or interpersonal(LePine, Picoolo, Jackson, Mathieu, & Saul, 2008). Action processesoccur during the periods of time when teams are directly pursuinggoal accomplishment (e.g., direct patient care) and include coordi-nation, cross monitoring, and back-up behavior. Transitionprocesses occur as teams prepare for and reflect on their work andinclude briefing, debriefing, and handoff activities where teammembers analyze the situation, specify goals, and engage in plan-ning. Interpersonal processes can occur at any time as teammembers manage personal relationships with their coworkers andresolve conflict. Just as with individual level taskwork or technicalperformance, a specific set of competencies underlie these team-work processes.

Third, teamwork competencies are the knowledge, skills, andattitudes (KSAs) that each team member must posses in order tointeract in an effective manner. They are what teammembers mustknow, do, and feel in order to effectivelymanage interdependenciesand shared resources with their fellow team members in order toachieve their common goals. Research supports the existence ofa large array of teamwork competencies (Salas, Rosen, Burke, &Goodwin, 2009); however, team training in healthcare mostfrequently targets communication, situational awareness, leader-ship, and role clarity (Weaver et al., 2010). One integrative model ofteamwork, The Big Five Model of teamwork (Salas, Sims, & Burke,2005), has served as the basis for competency models in health-care team training programs including the Team Strategies andTools to Enhance Performance and Patient Safety (TeamSTEPPS�)which targets leadership, situation monitoring, communication,

mutual support, and team structure (e.g., role clarity) teamworkcompetencies. Programs adopting this general competency frame-work have been applied successfully in multiple clinical areasincluding surgery, trauma, and labor and delivery. Differences in thenature of work across clinical domains places different types ofteamwork demands on care providers. For example, some teamsinteract in a tightly coupled manner such as trauma teams whereasothers are distributed more in space and interact less frequently intime such as a care team on an inpatient floor unit. Consequently,contextualized teamwork competency models are being developedto meet the needs of specific clinical domains. These general andcontext specific teamwork competencies are crucial in developingsystematic teamwork training programs, and may be highly rele-vant to care pathway interventions. Specifically, conductinga teamwork needs analysis (i.e., identifying what general or contextspecific competencies underlie a team’s success) will help to ensurethat training interventions pairedwith a care pathway interventionwill target the most critical competencies for a given unit. Addi-tionally, in that a care pathway intervention changes the nature ofthework, it may introduce new interdpendencies and influence thetypes of teamwork behaviors that will lead to effective outcomes.

These teamwork competencies can be systematicallyimproved through training

In addition to the identification of teamwork processes thatreliably lead to improved outcomes and the competencies thatunderlie those processes, the science clearly demonstrates thatteam performance can be systematically improved with training.Good teamwork is not a trait that teams either do or do not posses,but a set of skills that can be developed over time through struc-tured learning opportunities. Team training is a set of theoreticallybased strategies and methods for developing the team-relatedknowledge (e.g., shared mental models), behaviors (e.g., leader-ship, communication), and attitudes (e.g., collective orientation,mutual trust) of team members. It involves the application ofa systems approach to development and implementation, and notjust a single training session. That is, the training is one componentof a constellation of factors that influence team performance, andthe degree to which training is aligned with other components ofthe system, the higher the probability of successful implementation.

There is a large and growing literature documenting the effec-tiveness of teamwork training programs in improving teamworkcompetencies, transferring learned competencies to the workenvironment, and important organizational outcomes includingsafety and quality within healthcare as well as refinements in thetraining content and methods used (Buljac-Smardzic et al., 2010).More recently, studies have begun to show an impact of teamworktraining programs on safety and quality metrics. For example, theVeteran’s Affairs Medical Team Training program has decreasedpreoperative delays (from 16% to 7% of cases), increased antibioticprophylaxis compliance (from 85% to 97%), decreased equipmentissues (from 24% to 7% of cases), decreased handoff issues (from5.4% to 0.3% of cases), and most notably reduced mortality (Neilyet al., 2010; Paull et al., 2009; Wolf, Way, & Stewart, 2010).

These findings illustrate a pattern consistent with the broaderliterature evaluating team training programs. Specifically, meta-analytic synthesis indicates that team training can account for upto a 20% improvement in team performance (Salas, DiazGranados,et al., 2008; Salas, Wilson, et al., 2008). However, the remaining80% of a team’s performance is attributable to a variety of sourcesincluding organizational and work design characteristics. Thisfinding has implications for care pathways as it suggests an additiveeffect for teamwork training when applied in conjunction with thework redesign and standardization involved in a care pathway

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intervention. Deneckere et al. (2012) concur with this interpreta-tion, and provide an overview of several key team training strate-gies that have been documented to be effective. In addition to theseresources, there is a broad and deep literature available on how toeffectively develop high performing teams, which can be used tobolster care pathway interventions. Future research is needed tobetter understand how to pair team training strategies with carepathway interventions.

Context, constraints, and conditions moderate teamwork:tasks, tools, and organizational factors matter

As described above, teamwork depends on the competencies ofteam members: on what they know, feel, and do. However, themembers of a team are situated within complex organizations andfeatures of the organizational context, work processes and tasks,and information technology and tools can all support or hindervarious aspects of teamwork. Specifically, the science indicates thatteams perform better when their tasks are designed to promotehigher levels of autonomy and task meaningfulness amongmembers (Stewart, 2006). Additionally, organizational policies andstructures such as reward and incentive systems are critical driversof teamworkbehaviors aswell (e.g., are teammembers rewarded forindividual performance alone, teamperformance, or amixof both?).Additionally, some teams may be set up for success, and others forfailure regardless of how well they work together as a team. Forexample, the ability to rapidly detect and correct errors before theytranslate into patient harm is one of the most frequently citedbenefits of good teamwork (e.g., assertive communication fromproviders at all levels of the traditional power hierarchy whenunsafe conditions are perceived). However, like all human abilities,there are limitations to this team-level capacity and even highperforming teams working in poorly designed systems thatgenerate large numbers of errors can become overwhelmed andbreak down. Consequently, developing care pathway interventionsand team training programs concurrently could lead to gains ineffectiveness given the interdependent nature of tasks, tools, orga-nizational characteristics, and effective team behaviors. Deneckereet al. (2012) indicate that the current state of care pathway inter-ventions typically involves a training component, but there is noreference to systematic needs analyses being used, a shortcomingcommon to most stand-alone team training interventions inhealthcare as well (Weaver et al., 2010). Formal methods for theconcurrent design of work standardization and training are needed.

Teamwork is not just about standardization; teamwork isabout adaptation

Much of the teamwork and communication improvementefforts in healthcare have emphasized standardized communica-tion protocols for critical interactions such as checklists for pre-procedure briefings and debriefings, and handoffs. This is appearsto be the logic behind why care pathways would lead to improvedcommunication and teamwork. However, this is only one aspect ofteamwork, and increasingly, teamwork is required for catching andcorrecting non-routine events and solving novel problems. In thesecases, good teamwork involves combining multiple sets of exper-tise in collaborative problem solving and innovation. This type ofteam performance requires a different set of competencies beyondeffective information transfer. It is unclear whether or not carepathways will influence this type of teamwork. This is perhaps oneof the areas in need of the most research. Specifically, how can anorganization work to improve the reliability of it’s processesthrough standardization while retaining or improving an ability toadapt, innovate, and react efficiently and effectively when the

situation calls for it? As Deneckere et al. (2012), standardization isa central feature of care pathway interventions. While this isa valuable strategy, there are shortcomings to all approaches, andcreating and sustaining mindful reliability with a reluctance tosimplify and adaptation are no small challenges. This need is beingaddressed through research into collaborative problem solving andmacrocognition in teams (Fiore et al., 2010).

Change and improvement requires a long-term vision andvigilance

Improving teamwork involves changing patterns of socialinteraction among care providers. These types of behavior arerooted in social norms, professional role identities, and localhistory. Consequently, improving teamwork is a cultural interven-tion, and culture can be resistant to change. This challenge is notunique to teamwork training interventions. Even the adoption ofsimple evidence based clinical guidelines is driven by local orga-nizational culture. Ultimately, the success of care pathwaysdepends on changing the culture of units, particularly the attitudesof staff members around using standardized solutions.

Additionally, as the authors noted, some of the unexpectednegative consequences of introducing care pathways (e.g., increasedworkload) were likely due to difficulties managing organizationalchange, and not with the actual care pathway intervention itself.This is a recurring theme from the team training literature aswell asother improvement interventions. For example, the introduction ofcomputer physician order entry systems has been associated withsevere unintended and negative consequences; however, many ofthese issues were attributable to the management of the imple-mentation process, particularly during the transition from paper toelectronic systems.

In sum, teamwork training implementations can work (i.e.,change behavior in clinical practice), but 1) may not always workdue to characteristics of the organization (e.g., existing culture andhistory, leadership support) or features of the implementation (e.g.,was a needs analysis performed? How was training delivered?),and 2) if it does work, improvements may not be sustained due toreversion to earlier cultural norms and other factors (e.g., staffturnover). Consequently, team improvement interventions are not‘one shot deals’. They should not be viewed as training, but asa long-term cultural change initiative. The role of team coaches inthis process has been highlighted as a critical success factor inbridging the gap between learning and performance in actual workenvironments. In addition to high levels of teamwork competency,team coaches also have specialized skills for developing effectiveteams such as evaluating team behaviors and providing feedbackon teamwork competencies. These individuals provide stable andconsistent on the job feedback and set expectations about thenature of effective teamwork on the units.

Change requires leadership at all levels

A long-term strategy that engages key personnel from all levelsof the organization is required, particularly leaders from thefrontline to the executive offices. Leadership is a shared process. Atsome time, most staff members fulfill some type of leadership role.From a change management perspective, leaders are critical as theynot only help with gaining resources needed for an implementa-tion, but for communicating the values of the organization.Members of an organization take their cues about what is valuedwithin an organization in large part by listening towhat leaders sayand more importantly how they behave. Leaders can set the tonefor teamwork (and other types of safety related behaviors) throughrole modeling and sending consistent and regular messages about

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the importance of teamwork. For example, the presence of leadersin teamwork training sessions is predictive of transfer and sus-tainment of teamwork changes in a unit.

From programs to systems: a comprehensive approach willaddress people, tasks, and tools concurrently

In sum, clinical pathway interventions are one of multiplestrategies available for improving teamwork and safety. Teamworktraining can produce better team performance processes as well asimportant safety and clinical outcomes. Additionally, tasks andwork processes can be redesigned to support better teamwork andmore reliable care delivery processes, and well-designed informa-tion systems are required to manage patient information acrosscare settings and time. However, it is uncommon for these threeaspects of the healthcare system (i.e., the competencies of teammembers, the nature of work tasks, and the information tools usedto support them) to be systematically analyzed, designed, orimproved in isolation let alone concurrently. However, as theeffectiveness of these layers of the healthcare delivery system areintertwined, that is precisely what needs to be done. Changing thenature of the task will change the nature of the teamworkcompetencies required and the types of information tools that cansupport clinical work. Consequently, a more holistic approach toimproving healthcare would, ideally, consider multiple compo-nents of the system as well as the interactions of these components.The improvement of teamwork, and more generally safety andquality, needs to adopt a systems-based perspective where theinteractions between people, tasks, and technology as well as thebroader organizational context are managed for long-term andsustained improvement.

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