1. Pulling it All Together
Summary
Pulling it All Together
“The truth of the matter is that you always know the right thing to do. The hard part is doing it.”
–Norman Schwarzkopf

2. Day 1 Objectives
Explain the theoretical framework and evidence base that supports the use of team skills to improve safety culture.
Learn the team skills that enhance performance and patient safety.

3. The Theory Team Effectiveness Salas, Sims, Burke. Is there
Mutual
Performance
Monitoring
Team
Leadership
Team
Orientation
Back-up
Behavior
Shared Mental
Models
Mutual
Trust
Adaptability
Teams provide organizations with a greater ability to adapt and learn than do individuals. However, just because groups of people call themselves a team doesn’t mean that they are truly a team. Based on an extensive review of the literature, Eduardo Salas and colleagues published this framework/model —called the big 5 of teamwork—in The purpose of the model is to identify the core concepts that enable groups of people to work together, to collaborate, to adapt to changing circumstances, and effectively work toward a common goal. The diagram illustrates that when team leaders direct and coordinate the activities of other team members by clarifying roles, establishing goals & expectations, and organizing meetings for planning and feedback, they provide the opportunity for team members to communicate, collaborate, and cooperate. It is during these meetings—in TS we learned to call them briefs, huddles, and debrief—that team members communicate what they have learned by monitoring others, a new shared mental model of how to reach a goal emerges, and team members offer back up or mutual support to achieve that goal. When team members trust each other, value team goals above individual goals, and use closed loop communication, they have the ability to be adapt, manage complex systems & patients and learn from experience.
Team
Effectiveness
Big 5
Salas, Sims, Burke. Is there
a “Big Five” in teamwork?
Small Group Research. 2005; 36:
Coord.
Mechanism
Closed Loop
Communication

4. The Framework: What Comprises Team Effectiveness?
Knowledge Cognitions “Think”
Attitudes Affect “Feel”
The TeamSTEPPS triangle logo is a visual model that represents some basic but critical concepts related to teamwork training as explained below.
Individuals can learn four primary trainable teamwork skills. These are: 1.  Leadership. 2.  Communication. 3.  Situation monitoring. 4.  Mutual support.
If a team has tools and strategies it can leverage to build a fundamental level of competency in each of those skills, research has shown that the team can enhance three types of teamwork outcomes: 1.  Performance. 2.  Knowledge. 3.  Attitudes.
For example, if every member of the team has basic competency in situation monitoring and communication, it is incumbent upon them to build shared mental models more effectively. Improved outcomes beget greater proficiency (improved teamwork skills) and a desire to be a part of the team (attitudes). Such is the reciprocal relationship between skills and outcomes.
…team performance is a science…consequences of errors are great…
Skills Behaviors “Do”

5. More Evidence Exploding Literature
Patient Care Team + Evidence-Based Practice = 1,128
Patient Care Team + Evaluation Studies = 843
Studies in diverse patient populations demonstrate relationship between teamwork and
Improved clinical processes
Reduction in medical errors
Improved surgical team performance
Increased adherence to guidelines
Decreased length of stay
Increased functional status
Decreased mortality
Salas et al. What are the critical success factors for team training in
health care? Jt Comm Jrnl Qual Safe. 2009;35:

6. The Bottom Line….
The knowledge, skills, attitudes, language, and coordinating mechanisms inherent in teamwork1 create the flexibility team members need to manage complexity2 and learn from experience.3-5
Salas E, Sims DE, Burke CS. Is there a "Big Five" in teamwork? Small Group Research. 2005;36:
Cannon-Bowers JA, Salas E. Team performance and training in complex environments: Recent findings from applied research. Curr Dir Psychol Sci. 1998;7:83-87.
Senge PM. The Fifth Discipline: The Art & Practice of the Learning Organization. New York, NY: Doubleday; 1990.
Edmonson AC. Learning from failure in health care: Frequent opportunities, pervasive barriers. Qual Saf Health Care. 2004;12(Suppl II):ii3-ii9.
Salas E, Rosen MA, Burke CS, Goodwin GF. The wisdom of collectives in organizations: An update of the teamwork competencies. In: Salas E, Goodwin GF, Burke CS, eds. Team effectiveness in complex organizations: Cross-disciplinary perspectives and approaches. New York, NY: Routledge/Taylor & Francis Group; 2009:39-79.

7. Barriers, Tools/Strategies, Outcomes
Inconsistency in Team Membership
Lack of Time
Lack of Information Sharing
Hierarchy
Defensiveness
Conventional Thinking
Complacency
Varying Communication Styles
Conflict
Lack of Coordination and Follow-Up with Co-Workers
Distractions
Fatigue
Workload
Misinterpretation of Cues
Lack of Role Clarity
TOOLS and STRATEGIES
Brief
Huddle
Debrief
STEP
I’M SAFE Checklist
Cross Monitoring
Feedback
Advocacy and Assertion
Two-Challenge Rule
CUS
DESC Script
Collaboration
SBAR
Call-Out
Check-Back
Handoff
OUTCOMES
Shared Mental Model
Adaptability
Team Orientation
Mutual Trust
Team Performance
Patient Safety!! Team Goals

8. The Constraints Complexity of patients and systems
Competing Values & Expectations
Limited resources
Complexity of patients and systems
Behavioral Choices of Fallible Human Beings
Desired Outcomes

9. Identifying Opportunities to Use TeamSTEPPS Tools and Strategies
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10. Discussion What were the barriers to communication?
Lack of information sharing, lack of follow-up, lack of role clarity, misinterpretation of cues, workload
Which TeamSTEPPS tools and strategies could have been used? (Consult your Pocket Guide)
STEP, huddle, SBAR
What is the biggest issue in terms of teamwork skills?

11. Using TeamSTEPPS Tools and Strategies
Vig 2bLg001
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12. Case Analysis Divide yourselves into groups of 4 - 5
Discuss the scenario in your team
Identify the barriers to teamwork that occurred
Identify tools, strategies to address the barriers
Report out to the whole group

13. Summary
During this training, we learned that teamwork strategies and tools—
Create a safety net for fallible human beings (human factors)
Do not come naturally…must be learned (evidence-based training)
Create the flexibility we need to manage complexity and learn from experience
What we didn’t learn… for Master Trainers
One shot didactic lectures can not change people’s behavior
Human beings and organizations adopt new behaviors in stages as a result of a change strategy

14. “To improve teamwork in support of patient safety, what small change can you commit to?”
“The achievements of an organization are the results of the combined effort of each individual.”
–Vince Lombardi