Teams and Teamwork

Now that we have reviewed the first three IPEC competencies related to valuing team members, understanding team members’ roles and responsibilities, and using structured interprofessional communication strategies, let’s discuss strategies that promote effective teamwork. The fourth IPEC competency states, “Apply relationship-building values and the principles of team dynamics to perform effectively in different team roles to plan, deliver, and evaluate patient/population-centered care and population health programs and policies that are safe, timely, efficient, effective, and equitable” (Interprofessional Education Collaborative, 2016). See the following box for the components of this IPEC competency.

Developing effective teams is critical for providing healthcare that is patient-centered, safe, timely, effective, efficient, and equitable (Interprofessional Education Collaborative Expert Panel, 2011). Healthcare professionals collaborate with the interprofessional team by not only assigning and coordinating tasks but also by promoting solid teamwork in a positive environment. A healthcare leader, such as a charge tech, identifies gaps in workflow, recognizes when task overload is occurring, and promotes the adaptability of the team to respond to evolving patient conditions. The qualities of a successful team are described in the following box.

TeamSTEPPS

TeamSTEPPS® is an evidence-based framework used to optimize team performance across the healthcare system. It is a mnemonic standing for Team Strategies and Tools to Enhance Performance and Patient Safety. The AHRQ (2012) and the Department of Defense (DoD) developed the TeamSTEPPS® framework as a national initiative to improve patient safety by improving teamwork skills and communication.

Team structure

A healthcare leader establishes team structure by assigning or identifying team members’ roles and responsibilities, holding team members accountable, and including patients and families as part of the team.

Communication

Communication is the first skill of the TeamSTEPPS® framework. As previously discussed, it is defined as a “structured process by which information is clearly and accurately exchanged among team members” (AHRQ, 2014). All team members should use these skills to ensure accurate interprofessional communication:

• Provide brief, clear, specific, and timely information to other team members.
• Seek information from all available sources.
• Use ISBAR (Identify, Situation, Background, Assessment, and Recommendation) and handoff techniques to communicate effectively with team members.
• Use closed-loop communication to verify information is communicated, understood, and completed.
• Document appropriately to facilitate continuity of care across interprofessional team members (AHRQ, 2014).

Leadership

Leadership is the second skill of the TeamSTEPPS® framework. As previously discussed, it is defined as the “ability to maximize the activities of team members by ensuring that team actions are understood, changes in information are shared, and team members have the necessary resources” (AHRQ, 2014). An example of a healthcare team leader in an inpatient setting is the charge technologist.

Effective team leaders demonstrate the following responsibilities:

• Organize the team.
• Identify and articulate clear goals (i.e., share the plan).
• Assign tasks and responsibilities.
• Monitor and modify the plan and communicate changes.
• Review the team’s performance and provide feedback when needed.
• Manage and allocate resources.
• Facilitate information sharing.
• Encourage team members to assist one another.
• Facilitate conflict resolution in a learning environment.
• Model effective teamwork (AHRQ, 2014).

Three major leadership tasks include sharing a plan, monitoring and modifying the plan according to situations that occur, and reviewing team performance. Tools to perform these tasks are discussed in the following subsections.

Sharing the plan

Healthcare team leaders identify and articulate clear goals to the team at the start of the shift during inpatient care using a “brief.” The brief is a short session to share a plan, discuss team formation, assign roles and responsibilities, establish expectations and climate, and anticipate outcomes and contingencies (AHRQ, 2014)

Monitoring and modifying the plan

Throughout the shift, it is often necessary for the team leader to modify the initial plan as patient situations change on the unit. A huddle is a brief meeting before and/or during a shift to establish situational awareness, reinforce plans already in place, and adjust the teamwork plan as needed (AHRQ, 2014). Read more about situational awareness in the “Situation Monitoring” subsection below.

Reviewing the team’s performance

When a significant or emergent event occurs during a shift, such as a “code,” it is important to later review the team’s performance and reflect on lessons learned by holding a “debrief ” session. A debrief is an informal information exchange session designed to improve team performance and effectiveness through reinforcement of positive behaviors and reflection on lessons learned (AHRQ, 2014).

Situation Monitoring

Situation monitoring is the third skill of the TeamSTEPPS® framework and is defined as the “process of actively scanning and assessing situational elements to gain information or understanding, or to maintain awareness to support team functioning (AHRQ, 2014). Situation monitoring refers to the process of continually scanning and assessing the situation to gain and maintain an understanding of what is going on around you. Situation awareness refers to a team member knowing what is going on around them. The team leader creates a shared mental model to ensure all team members have situation awareness and know what is going on as situations evolve. The STEP tool is used by team leaders to assist with situation monitoring (AHRQ, 2014).

STEP

The STEP tool is a situation monitoring tool used to know what is going on with you, your patients, your team, and your environment. STEP stands for Status of the patient, Team members, Environment, and Progress toward goal (AHRQ, 2014).

Cross-monitoring

As the STEP tool is implemented, the team leader continues to cross-monitor to reduce the incidence of errors. Cross-monitoring includes the following:

• Monitoring the actions of other team members.
• Providing a safety net within the team.
• Ensuring that mistakes or oversights are caught quickly and easily.
• Supporting each other as needed (AHRQ, 2014).

I’M SAFE checklist

The I’M SAFE mnemonic is a tool used to assess one’s own safety status, as well as that of other team members in their ability to provide safe patient care. See the I’M SAFE Checklist in the following box (AHRQ, 2014). If a team member feels their ability to provide safe care is diminished because of one of these factors, they should notify the charge tech or other imaging supervisor. In a similar manner, if a MRT notices that another member of the team is impaired or providing care in an unsafe manner, it is an ethical imperative to protect clients and report their concerns according to agency policy (AHRQ, 2014).

Mutual Support

Mutual support is the fourth skill of the TeamSTEPPS® framework and is defined as the “ability to anticipate and support team members’ needs through accurate knowledge about their responsibilities and workload (AHRQ, 2014). Mutual support includes providing task assistance, giving feedback, and advocating for patient safety by using assertive statements to correct a safety concern. Managing conflict is also a component of supporting team members’ needs.

Task assistance

Helping other team members with tasks builds a strong team. Task assistance includes the following components:

• Team members protect each other from work-overload situations.
• Effective teams place all offers and requests for assistance in the context of patient safety.
• Team members foster a climate where it is expected that assistance will be actively sought and offered (AHRQ, 2014).

Feedback

Feedback is provided to a team member for the purpose of improving team performance. Effective feedback should follow these parameters:

• Timely: Provided soon after the target behavior has occurred.
• Respectful: Focused on behaviors, not personal attributes.
• Specific: Related to a specific task or behavior that requires correction or improvement.
• Directed towards improvement: Suggestions are made for future improvement.
• Considerate: Team members’ feelings should be considered and privacy provided. Negative information should be delivered with fairness and respect (AHRQ, 2014).

Advocating for safety with assertive statements

When a team member perceives a potential patient safety concern, they should assertively communicate with the decision-maker to protect patient safety. This strategy holds true for all team members, no matter their position within the hierarchy of the healthcare environment. The message should be communicated to the decision-maker in a firm and respectful manner using the following steps:

• Make an opening.
• State the concern.
• State the problem (real or perceived).
• Offer a solution.
• Reach agreement on next steps (AHRQ, 2014).

Two-challenge rule

When an assertive statement is ignored by the decision-maker, the team member should assertively voice their concern at least two times to ensure that it has been heard by the decision-maker. This strategy is referred to as the two-challenge rule. When this rule is adopted as a policy by a healthcare organization, it empowers all team members to pause care if they sense or discover an essential safety breach. The decision-maker being challenged is expected to acknowledge the concern has been heard (AHRQ, 2014).

CUS assertive statements

During emergent situations, when stress levels are high or when situations are charged with emotion, the decisionmaker may not “hear” the message being communicated, even when the two-challenge rule is implemented. It is helpful for agencies to establish assertive statements that are well-recognized by all staff as the implementation of the two-challenge rule. These assertive statements are referred to as the CUS mnemonic: “I am Concerned – I am Uncomfortable – This is a Safety issue!” (AHRQ, 2014).

Using these scripted messages may effectively catch the attention of the decision-maker. However, if the safety issue still isn’t addressed after the second statement or the use of “CUS” assertive statements, the team member should take a stronger course of action and utilize the agency’s chain of command. For the two-challenge rule and CUS assertive statements to be effective within an agency, administrators must support a culture of safety and emphasize the importance of these initiatives to promote patient safety.