We've learned how athletic principles can encourage care givers to work in effective teams. And if you are a patient, you now have a pretty good idea of what teamwork looks like in healthcare. You should expect teamwork in healthcare because when everyone is on the same page, everyone has everyone else's back. What do I mean by that? Is if one caregiver makes a mistake, other team members understand the intended action and can quickly correct the mistake. Also teamwork reduces the fragmentation of care, greatly improving coordination. When there is teamwork, the right hand knows what the left hand is doing. In addition to creating sufficient structure, teams need an initial orientation to assure they immediately begin working effectively together. This is usually called a team launch. And a formal team launch has been shown to markedly improve team performance. There are eight steps to an effective launch. First, introductions. Everyone should introduce themselves. And in their introductions, each member should briefly describe her strengths and weaknesses. The sharing of weaknesses emphasizes that no one is perfect and begins to build trust among the team members. Secondly, agree on compelling and measurable goals. In healthcare, the goal is always to improve the health and well being of our patients. In addition, teams should aspire to achieve greater efficiency and one measure that captures efficiency is the duration of rounds. This is a measurable goal. Why not agree to a specific duration four rounds under two hours? Third, define everyone's role. This step is achieved by using the playbooks we discussed in the last session. Four, establish efficient communication. And this is cheap by using the SOAP and SBAR formats and forming huddles around the patient's bedside. Five, create performance milestones. For example, within one week we will consistently complete rounds within two hours. Six, agree on behavioral norms. This is probably one of the most important tasks. What will the team members always do and what will they never do? Most teams agree that all team members will communicate with each other in a respectful fashion. Another important expectation is that all patient are the team's patients, and all work is the team's work. What this means is that everyone leaves the hospital at the same time, after the team's work has been completed. What should team members never do? They should never be disrespectful or abusive to other caregivers. More about this issue in a minute. Seven, agree on how decisions will be made. In healthcare the senior physician usually has the final say when it comes to patient management decisions. Ideally, a team should try to come to a consensus and the senior physician, or coach moderate the discussion. If there is not a clear way to proceed, it is critical to obtain the patient's preferences. And eight, finally, the coach should end by motivating the team, by describing all the benefits of working within a true team, and focusing on the goals of a more efficient and higher quality care for patients. Everyone will begin to develop a sense of mission and a sense of team. When should a team launch be employed? Every time a team of caregivers comes together to accomplish a common goal. Examples, at the beginning of each new inpatient ward rotation. And I perform a team launch before every one of my rotations. Second, when members of a new operative team first enter the OR. The chief surgeon should perform a brief launch by having everyone introduce themselves, discuss the goals of the surgery, decide each person's expected role during surgery, discuss how they will communicate. Explain the expected duration of surgery, agree on the expected norms for behavior, and how decisions will be made. The head surgeon can then end with a brief pep talk. Another key place to launch is at the beginning of any emergency room rotation. The senior physician or head nurse can perform a brief launch. When a launch is performed everyone knows what to expect, and understands what each member of the team will be contributing to the effort. And these expectations, particularly in emergency situation, can mean the difference between life and death. Let me share a real life example of how effective teamwork can save lives. Ashley, a beautiful 20-year-old woman. Her name and age have been changed for the sake of confidentiality. Presented to the emergency room, frightened and ashen-faced. While sitting on the toilet, she had passed a huge amount of bright red blood. Her bleeding was not associated with any pain. Her systolic blood pressure was less than 80. In other words, she was in shock. And she required eight units of blood, over three quarters of her blood volume, to bring her blood pressure back to normal. On arrival to our floor, the bleeding had stopped, and the fiber optic scopes that examined her stomach and upper bowel as well as her rectal area and lower bowels revealed no source of bleeding. A week before I had launched our team, and everyone had settled into their expected roles. As our team circled around her bed, one of our nurses quickly took her blood pressure. It was normal. The intern and senior resident questioned her, and again learned she had no symptoms prior to her bleeding, and that she continued to deny any abdominal pain. The blood had clearly come from her rectal area, and the test for blood in her stool was positive. As the coach of the team, I suggested that the third-year medical student quickly review the medical literature on painless lower gastrointestinal bleeding. And a review revealed that a leaking intestinal wall vessel almost always caused this problem. The cure, surgical resection of the bowel segment containing the leaky vessel. Armed with this evidence, my senior resident, our quarterback, called the gastroenterology specialist and insisted that he come to our patient's bedside immediately. We also warned our two bedside nurses that Ashley could begin bleeding again at any time, and that we needed to have the blood for transfusion available on the floor. As we huddled around her bed we all realized we are sitting on a time bomb. Within 15 minutes, the gastroenterologist arrived, and a few minutes after his visit, Ashley's bed sheets became stained with bright red blood. The gastroenterologist quickly called the lower bowel surgeon who he knew was an expert in identifying bleeding vessels in the bowel. Our nurses quickly hung blood and with the help of the intern student, rushed Ashley to the OR. And they also attended her surgery. The bleeding vessel was identified and a three-inch segment of bowel containing the leaking vessel was resected. After total loss of 12 units of blood, our beautiful young patient was cured. We knew that our fast actions and effective teamwork had saved her life. As Ashley left the hospital we presented her with a card congratulating her for surviving her life-threatening illness. And gave her a small medal as a memento to wear around her neck. She will always be part of our training and we will never forget her bravery and miraculous recovery. As you can see, I'm very proud of my team's accomplishments. We worked beautifully together and I will never forget the relief and joy at seeing Ashley walk out of the hospital cured of her illness. But sometimes caregivers can destroy teamwork by exhibiting disruptive behavior. What do I mean by disruptive? The crediting body, the US Joint Commission, defines it as quote, overt actions, such as outbursts, and physical threats, as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities. What does this look like? Let me give you an example. Doctor D, the initial has been changed for confidentiality, a consulting physician, began screaming at the ICU nurse just outside the door of a critically ill patient. She was furious that a procedure to drain fluid from the patient's lung had not been performed. A medical resident rushed over to calm the situation, but was loudly rebuked. Both the resident and the nurse looked on as Dr. D jumped up and down, and as described by another observer, acted like a two year-old throwing a tantrum. As noted in the official letter of complaint by the head nurse, Dr. D demeaned her profession, upset the nurse as well as the fellow physicians, disturbed several family members that were trying to cope with the imminent death of loved ones, and embarrassed everyone. What does a leading expert in patient care quality and safety, Dr. Lucian Leape, adjunct professor of Harvard School of Public Health, have to say about disruptive caregivers? >> The problem of disruptive behavior is really a serious one and I think we're finally coming to grips with it. But we've sort of pretended it wasn't there for a long time. Mostly because I think people really didn't know what they could do about it. I personally think it is very serious. And the whole issue of disrespectful behavior is one of the root causes of our problems in improving safety. There's the problem of the outlandish position of which you just read an example of, but beyond that there are other levels of disrespect that are equally harmful. That humiliating way we often treat nurses or medical students. Maybe not shouting and being overtly disruptive, but clearly disrespectful and It's very damaging to morale. It's very damaging to communication. It cuts us off from one another and it really is very harmful. So we need to do something about this. I think the causes are very complex. Some of these are just personality problems, but a lot of it is learned behavior. That is, it's things that physicians learn in medical school, and in residency, from their role models. It's also related a great deal, I think, to the stressful situation people are in. People who otherwise have good control of their emotions can lose it when they are under a lot of stress. And we have managed to create an environment where everybody's under stress, so there's a lot of different causes for it, but the fact of the matter is, it is poisonous to collaboration. It is detrimental to patient safety, and we have to do something about it. My own feeling is it starts at the top, that is, the organization has to have a policy that says we do not tolerate grossly disrespectful behavior, and that if you do this, there are consequences. And unless that's in place then it's very difficult for anybody in the front line to deal with it. The nurse in the situation can't do anything if the institution doesn't back her up and doesn't back up a policy. So, we have to have a policy. I think beyond that, we need to get at the root causes and that means we need to do a lot to, if you will, rehabilitate these people. Take people who have these problems and teach them to behave properly. And that of course should start in medical school. We should start with medical students being taught about the importance of respect, and most of all, they have to have proper role models. They have to have their teachers be people who model this. So it's a big issue, it's a big order. But it's something that's time has come to do something about it. >> Now Lucian, if a nurse, he or she encounters particularly disruptive behavior, do you have any recommendations for them? What they can do on the spot, and immediately afterwards? >> On the spot is very difficult because emotions are very high, and the person who has just been humiliated or treated badly is not in the position to do much to the person who's abusing them. So probably the best thing in that situation is to just be quiet and get the situation over with. The important thing, however, is not to let it stop there. That is, this kind of behavior will continue unless something is done about it. Now if you're in an institution that doesn't want to do anything about it, then that's a problem. But if your institution does indeed have policies and practices, then it's important this kind of behavior be reported and it go up to the appropriate level to be dealt with. But I think the individual is very hard pressed to do much about it if the leadership hasn't got effective policies. Of course, if they had effective policies, perhaps it wouldn't happen. So this is a chicken and egg kinda problem. But I think it's very difficult for people on the front line. An institution cannot survive if it tolerates this kind of behavior. >> Lucian, I totally agree and thank you very much. >> My pleasure. >> Why should institutions actively address this problem? Because this behavior distracts everyone, increases the risk of errors and leads to job dissatisfaction and destroys the possibility of meaningful teamwork. In short, it disrupts the systems of care. Ironically, often defective systems lead to frustration. And frustration can lead to disruptive behavior. Disruptive behavior, in turn, causes further system breakdown and worsens the systems further, creating a vicious downward cycle. Finally, how do teams get better? Just as all athletic teams require coaching, so too do healthcare teams. At the present time few medical teams receive outside coaching. But to really improve, teams require someone to provide a mirror of their behaviors. The outside coach should usually be a peer or an outside consultant. He or she should primarily describe what they see, as their focus should include effort. The coach can identify social loafers, i.e., someone who is not contributing as much effort as other members toward achieving the team's goals. Two, performance issues, often teams will avoid creating new operational strategies and are fearful of change. The coach can encourage new ways of functioning that may improve the efficiency and quality of care. Three, knowledge and skill. Too often, teams fail to utilize the skills of one or more of the members of the team. Stereotypes can result in women, minorities and younger caregivers being ignored. The coach can encourage all team members to participate. Inner personal conflicts and intermittent friction are to be expected within teams, and coaches should avoid mediating in these issues. The team needs to learn how to manage these issues without external intervention. Self coaching should also be encouraged, and team members should frequently ask what went well today, and what could be improved. As team members become more comfortable asking these questions, they will be able to improve on their own, and self improving teams are the ultimate goal. These super teams have the potential to lift our health delivery systems to new heights in quality, safety, and patient-centered care. We all can be patient champions. Thank you.
