The importance of teamwork on patient safety in healthcare has been well established. However, the theory and research of healthcare teams are seriously lacking in clinical application. While conventional team theory assumes that teams are stable and leadership is constant, a growing body of evidence indicates that most healthcare teams are unstable and lack constant leadership. For healthcare organizations to reduce error and ensure patient safety, the true nature of healthcare teams must be better understood. This study presents a taxonomy of healthcare teams and the determinants of high reliability in healthcare teams based on a series of studies undertaken over a five-year period (2005–2010).
References
[1]
Shortell, S.M.; Zimmerman, J.E.; Gillies, R.R.; Duffy, J.; Devers, K.J.; Rousseau, D.M.; Knaus, W.A. Continuously improving patient care: Practical lessons and an assessment tool from the national ICU study. Qual. Rev. Bull. 1992, 18, 150–155.
[2]
Zimmerman, J.E.; Shortell, S.M.; Rousseau, D.M.; Duffy, J.; Gillies, R.R.; Knaus, W.A.; Devers, K.; Wagner, D.P.; Draper, E.A. Improving intensive care: Observations based on organizational case studies in nine intensive care units: A prospective, multicenter study. Crit. Care Med. 1993, 21, 1443–1451.
[3]
Shortell, S.M.; Zimmerman, J.E.; Rousseau, D.M.; Gillies, R.R.; Wagner, D.P.; Draper, E.A.; Knaus, W.A.; Duffy, J. The performance of intensive care units: Does good management make a difference? Med. Care 1994, 32, 508–525.
[4]
Institute of Medicine. To Err is Human; National Academies Press: Washington, DC, USA, 1999.
[5]
Institute of Medicine. Crossing The Quality Chasm: A New Health System for the 21st Century; National Academies Press: Washington, DC, USA, 2001.
[6]
Institute of Medicine. Patient Safety: Achieving A New Standard for Care; National Academies Press: Washington, DC, USA, 2004.
[7]
Salas, E.; Dickinson, T.L.; Converse, S.A.; Tannenbaum, S.I. Toward an understanding of team performance and training. In Teams: Their Training and Performance; Swezey, R.W., Salas, E., Eds.; Ablex: Norwood, NJ, USA, 1992; Volume 12, pp. 3–29.
[8]
Tuckman, B.W. Developmental sequence in small groups. Psychol. Bul. 1965, 63, 384–399.
[9]
Kozlowski, S.W.J.; Gully, S.M.; Salas, E.; Cannon-Bowers, J.A. Team Leadership and Development: Theory, Principles, and Guidelines for Training Leaders and Teams. In Advances in Interdisciplinary Studies of Work Teams: Team Leadership; Beyerlein, M.M., Johnson, D.A., Beyerlein, S.T., Eds.; JAI Press: Greenwich, CT, USA, 1996; Volume 3, pp. 253–291.
[10]
Salas, E.; Canon-Bowers, J.A.; Johnston, J.H. How Can You Turn a Team of Experts into an Expert Team? Emerging Training Strategies. In Naturalistic Decision Making; Erbaum Associates: Mahwah, NJ, USA, 1997.
[11]
Beaubien, J.M.; Baker, D.P. The use of simulation for training teamwork skills in health care: How low can you go? Qual. Saf. Health Care 2004, 13, i51–i56.
[12]
Riley, W.; Hanson, H.; Gurses, A.; Davis, S.; Miller, K.; Priester, R. The Nature, Characteristics, and Patterns of Perinatal Critical Events Teams. In Advances in Patient Safety: New Directions and Alternative Approaches; Agency for Healthcare Research and Quality Publication (AHRQ): Rockville MD, USA, 2008; Volume 3, pp. 131–144.
[13]
Miller, K.; Riley, W.; Davis, S.; Hansen, H. In situ simulation: A method of experiential learning to promote safety and team behavior. J. Perinat. Neonat. Nurs. 2008, 22, 105–113.
[14]
Berwick, D.; Leape, L. Forward. In Achieving Safe and Reliable Healthcare; Leonard, M., Frankel, A., Simmonds, T., Vega, K., Eds.; Health Administration Press: Chicago, IL, USA, 2004; pp. vii–x.
[15]
Nelson, E.C.; Godfrey, M.M.; Batalden, P.B.; Berry, S.A.; Bothe, A.E., Jr; McKinley, K.E.; Melin, C.N.; Muething, S.E.; Moore, L.G.; Wasson, J.H.; et al. Clinical microsystems Part 1: The building blocks of health systems. Jt. Comm. J. Qual. Patient Saf. 2008, 34, 367–378.
[16]
Godfrey, M.M.; Nelson, E.C.; Wasson, J.H.; Mohr, J.J.; Batalden, P.B. Microsystems in healthcare: Part 3 planning patient centered services. Jt. Comm. J. Qual. Patient Saf. 2003, 29, 159–170.
Nielsen, P.E.; Goldman, M.B.; Mann, S.; Shapiro, D.E.; Marcus, R.G.; Pratt, S.D.; Greenberg, P.; McNamee, P.; Salisbury, M.; Birnbach, D.J.; et al. Effects of teamwork training on adverse outcomes and process of care in labor and delivery: A randomized controlled trial. Obste. Gynecol. 2007, 109, 48–55.
[19]
Flin, R.; Maran, N. Identifying and training non-technical skills for teams in acute medicine. Qual. Saf. Health Care 2004, 13, i80–i84.
[20]
Sundstrom, E.; Meuse, K.P.D.; Futrell, D. Work teams. Am. Psychol. 1990, 45, 120–133.
[21]
Riley, W.; Miller, K.; Davis, S.; Sweet, R. Describing high reliability: Distinguishing errors and breaches. Proc. Improv. Patient Saf. 2008, 9–13.
[22]
Riley, W. High Reliability and Implications for Nursing Leaders. J. Nurs. Manage. 2009, 17, 238–246.
[23]
Roberts, J.; Norman, G. Reliability and learning from the objective structured clinical examination. Med. Educ. 1990, 24, 219–223.
[24]
Reinersten, J.L.; Clancy, C. Keeping our promises: Research, practice, and policy issues in health care reliability. Health Serv. Res. 2006, 41, 1535–1538.
[25]
Gauthier, A.K.; Davis, K.; Schoenbaum, S.C. Achieving a high-performance health system: High reliability organizations within a broader agenda. Health Serv. Res. 2006, 41, 1710–1720.
[26]
Baker, D.P.; Day, R.; Salas, E. Teamwork as an essential component of high-reliability organizations. Health Serv. Res. 2006, 41, 1576–1598.
[27]
Riley, W.; Davis, S.; Miller, K.; McCullough, M. A model for developing high-reliability teams. J. Nurs. Manag. 2010, 18, 556–563.
[28]
Nolan, T.; Resar, R.; Haraden, C.; Griffin, F.A. Improving the Reliability of Health Care. IHI Innovation Series White Paper; Institute for Healthcare Improvement: Boston MA, USA, 2004.
[29]
Reason, J. Human error: Models and management. Br. Med. J. 2000, 768, 768–770.
[30]
Cannon-Bowers, J.A.; Tannenbaum, S.I.; Salas, E. Defining competencies and establishing team training requirements. In Team Effectiveness and Decision Making in Organizations; Guzzo, R.A., Salas, E., Eds.; Jossey-Bass: San Francisco, CA, USA, 1995; pp. 333–380.
[31]
Sims, D.E.; Salas, E.; Burke, C.S. Is There a Big 5 in Teamwork? Presented at the 19th Annual Conference of the Society for Industrial and Organizational Psychology, Chicago, IL, USA, April 2004.
[32]
Flin, R.; O'Connor, P.; Crichton, M. Safety at the Sharp End; Ashgate Publishing Company: Burlington, VT, USA, 2008.
[33]
Shortell, S.M.; Schmittdiel, J.; Wang, M.C.; Li, R.; Gillies, R.R.; Casalino, L.P.; Bodenheimer, T.; Rundall, T.G. An empirical assessment of high-performing medical groups: Results from a national study. Med. Res. Rev. 2005, 62, 407–434.
[34]
Institute for Healthcare Improvement. Protecting 5 Million Lives Campaign Overview. Available online: http://www.ihi.org/IHI/Programs/Campaign/Campaign.htm?TabId=1 . (accessed on 29 April 2011).
[35]
Joint Commission. Preventing infant death and injury during delivery. Sentinel Event Alert 2004, 30, 1–3.
[36]
Riley, W.; Davis, S.; Miller, K.; Hansen, H.; Sweet, R. Detecting breaches in defensive barriers using in situ simulation for obstetric emergencies. Qual. Saf. Health Care 2010, 19, i53–i56.
[37]
Davis, S.; Riley, W.; Gürses, A.; Miller, K.; Hansen, H. Failure mode and effects analysis based on in situ simulations: A methodology to improve understanding of risks and failures. In Advances in Patient Safety: New Directions and Alternative Approaches; Agency for Healthcare Research and Quality Publication (AHRQ): Rockville, MD, USA, 2008; Volume 3, pp. 145–160.
[38]
Fanning, R.M.; Gaba, D.M. The role of debriefing in simulation-based learning. Simul. Health Care 2007, 2, 115–125.
[39]
Wilson, K.A.; Burke, C.S.; Priest, H.A.; Salas, E. Promoting health care safety through training high reliability teams. Qual. Saf. Health Care 2005, 14, 303–309.
[40]
Clancy, C.M.; Tornberg, D.N. TeamSTEPPS: Assuring optimal teamwork in clinical settings. Am. J. Med. Qual. 2007, 22, 214–217.
[41]
Aspden, P. Patient Safety: Achieving a New Standard for Care; National Academies Press: Washington, DC, USA, 2004.
[42]
Mann, S.; Pratt, S.; Gluck, P.; Nielsen, P.; Risser, D.; Greenberg, P.; Marcus, R.; Goldman, M.; Shapiro, D.; Pearlman, M.; et al. Assessing quality in obstetrical care: Development of standardized measures. Jt. Comm. J. Qual. Patient Saf. 2006, 32, 497–505.
[43]
Freeth, D.; Ayida, G.; Berridge, E.J.; Mackintosh, N.; Norris, B.; Sadler, C.; Strachan, A. Multidisciplinary obstetric simulated emergency scenarios (MOSES): Promoting patient safety in obstetrics with teamwork-focused interprofessional simulations. J. Cont. Edu. Health Prof. 2006, 29, 104.
[44]
Riley, W.; Davis, S.; Miller, K.; Hansen, H.; Saintfort, F.; Sweet, R. Non-technical skills team training to improve perinatal patient outcomes in a community hospital. Jt. Comm. J. Qual. Saf. 2011. (in press).
[45]
Davis, S.; Riley, W.; Miller, K. Reducing Patient Harm Through Interdisciplinary Team Training with In Situ Simulation. Proceedings of the Improving Patient Safety Conference, July 2008; Robinson College: Cambridge, UK.
[46]
Miller, K.; Riley, W.; Davis, S. Identifying key nursing team behaviors to achieve high reliability. J. Nurs. Manag. 2009, 17, 247–255.
[47]
Weinger, M.B.; Gonzales, D.C.; Slagle, J.; Syeed, M. Video capture of clinical care to enhance patient safety. Qual. Saf. Health Care 2004, 13, 136–144.
[48]
Reason, J. Managing the Risks of Organizational Accidents, 9th ed. ed.; Ashgate Publishing Ltd: Aldershot, UK, 2005.
[49]
Riley, W.; Davis, S.; Miller, K.; Sweet, R.; Hansen, H. Improved Patient Safety: Near Misses, Errors and Breaches. Proceedings of the Improving Patient Safety Conference, July 2008; Robinson College: Cambridge, UK.
[50]
Joint Commission. Failure Mode and Effects Analysis in Health Care: Proactive Risk Reduction; Joint Commission Resources: Chicago, IL, USA, 2005.
[51]
Saus, E.R.; Johnsen, B.H.; Eid, J.; Riisem, P.K.; Andersen, R.; Thayer, J.F. The effect of brief situational awareness in a police shooting simulator: An experimental study. Mil. Psychol. 2006, 18, S3–S21.
[52]
Waller, D.; Hunt, E.; Knapp, J. The transfer of spatial knowledge in virtual environment training. Mass. Inst. Technol. Presence 1998, 7, 129–143.
[53]
Morrison, A.M.; Catanzaro, A. High-fidelity simulation and emergency preparedness. Public Health Nurs. 2010, 27, 164–173.
[54]
Kneebone, R.L. Crossing the line: Simulation and boundary areas. Simul. Health Care 2006, 1, 160–163.
