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 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 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-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 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 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 MEDICAL TEAM MEMBERS NEED TO

 Teams are made up of humans, with  Different ages  Different seniority  Different past experiences  Different gender  Different cultural backgrounds WHAT VARIABLES ARE THERE?

 Power  Experience  Responsibility 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 decision  Failed 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?

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 performance  Dysfunctional teams have higher staff ‘burnout’ and lower retention of staff (strong evidence base) DYSFUNCTIONAL TEAMS

 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. DISRUPTIVE BEHAVIOURS

 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 SUCCESSFUL TEAMS (REFERENCE 1)

 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 SUCCESSFUL LEADERS

 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 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 ISBAR  Use Simulation of high risk situations, engaging with multidisciplinary members  Employ team role models as champions for exemplary behaviour  Have robust incident reporting 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 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 Editor Hughes RG. Agency for Healthcare Research and Quality, US Department of Health and Human Services, Rockville (MD), USA REFERENCES

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