It’s called a surgical team, but recent studies suggest that more focus needs to be on teamwork. Reports on surgical error rates show that between 40% and 70% of errors can be attributed to non-technical issues such as poor communication [2,8,11] and approximately half of closed malpractice claims cite ineffective teamwork [4]. A study on pediatric cardiac surgery found a correlation between the number of technical errors that occurred and the quality of the surgical team’s non-technical skills [5].

 

Healthcare is a team sport

Borrowing from the airline and other high-risk industries, healthcare has recently started to adopt crew resource management or team training initiatives to address error rates. Two decades of research in other high-risk industries have established that team training is successful [6] and in the last five years in particular, nearly 500 studies on teamwork topics in healthcare have been published [7].

 

Team training is based on the assertion that outstanding technical skills alone are not sufficient for high levels of surgical performance; non-technical skills such as teamwork, communication, leadership, task management, and situational awareness are also vital [3].

 

What is team training?

Team training has become an all-encompassing phrase that includes a wide range of teamwork skills and learning strategies. Weaver et al (2014) wrote, “The critical element defining team training is that the learning activity focuses on developing, refining and reinforcing knowledge, skills or attitudes that underlie effective teamwork behaviors such as communication, coordination and collaboration.” [7] In many team training programs, there is an attempt to reduce the hierarchy within a team so that all team members feel comfortable speaking up if there is a problem. The skills taught can be valuable for both intact (always working together) and ad hoc teams (the norm for surgical teams) [6].

 

Various team training curricula include TeamSTEPPS, Crew Resource Management (CRM), and Medical Team Training (MTT) [7].

 

Surgical team training may include these common tools:

• Checklists
• Feedback
• Simulations

 

Whether the team flies a plane or performs spine surgery, team training approaches have been shown to improve safety, turnaround times, and in the case of surgical team training, decrease infection rates and OR waste.

 

Make a list, check it twice

Checklists are proven tools that bring focus to teams, from aviation to the operating room.

 

The World Health Organization (WHO) initiated the Safer Surgery Saves Lives project in 2007 [8], in which standards for the safe delivery of surgical care and a 19-item Surgical Safety Checklist (SSC) were trialed in eight countries and then globally circulated.

 

Mirroring the three phases of take-off, cruise and landing in the aviation industry, the SCC directs surgical teams to systematically follow standard checklist questions during “sign in” (before anesthesia induction), “time out” (before skin incision) and “sign out” (before the patient leaves the OR).

 

This includes, amongst other points: confirming patient identity and surgical site, team introduction and critical events review, confirmation of post-operative handling of specimens and patient destination.

 

A 2009 paper [9] published in the New England Journal of Medicine reported the results of the SCC trials and found that the rate of death declined from 1.5% before the checklist was introduced to 0.8% afterward. Inpatient complications also declined from 11.0% of patients at baseline to 7.0% after introduction of the checklist.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Feedback loops

Feedback is an important part of the learning and growth process in team training. It is often an aspect of debriefings and serves as course correction. It is a critical facet of personal growth and cultural change.

 

Feedback can be both formal and informal. Formal feedback can occur during debriefing, morbidity-mortality committee meetings, or goal assessment strategy meetings. Informal feedback during team meetings provides education opportunities and the evaluation of teamwork behaviors.

 

No matter where feedback occurs in the process, “the ability to capitalize on improvements to produce more change over time is critically linked…through a systems feedback loop” [10].

 

Testing it out

Simulations are a way for a surgical team to “get the kinks out.” Many simulations are designed to enable trainees to learn from adverse clinical outcomes or test out newly learned interpersonal or cognitive skills.

 

The University of Basel in Switzerland developed a simulation program called Team-oriented Medical Simulations (TOMS) [11]. The TOMS program provides interdisciplinary team training for nurses, anesthesiologists, orderlies, and surgeons using mannequins and live abattoir organs. Video is also used for debriefing and feedback after the simulation.

 

While the benefits of simulations for learners is apparent, there is little evidence to show that this translates directly into safer outcomes for patients. Instead, simulations are just one of the essential ingredients for improved patient outcomes.

 

Determining if the training is effective

There are four levels at which team training can be assessed for effectiveness [12].

Level 1: learner reactions to the training

Level 2: learner knowledge, confidence, and attitudes

Level 3: teamwork behaviors and skills

Level 4: clinical process and patient outcomes.

It is necessary for changes on the first three levels to occur to have organizational changes at level four. Studies on team training have assessed outcomes at various levels, but few studies have examined all four.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Effects of team training on patient outcomes

The largest study on the effects of a team training program on surgical outcomes in the US was conducted by the Veterans Health Administration (VHA) from 2006 to 2008 [13,14]. The study included 108 VHA facilities and over 180,000 procedures. The VHA team training borrowed heavily from the aviation industry training theories (CRM) and utilized checklists for preoperative and postoperative briefings.

 

Approximately two thirds of the facilities underwent team training while the remaining 34 facilities had not yet done so at the time of article publication and acted as a control. Patient outcomes were measured for one year after training occurred and compared with control facilities.

 

The facilities that received training experienced an 18% reduction in annual mortality [13] and a 17% reduction in annual morbidity [14], a statistically significant amount greater than the control facilities. A dose-response relationship was also derived which showed that for every quarter the training program was in place there was a reduction of 0.5 deaths per 1000 procedures [13,14].

 

In several write-ups of the study, the authors noted their belief that preoperative checklist-driven briefings were key to avoiding adverse events and establishing a shared mental model between surgical team members [13,14].

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other studies have found significant decreases in technical and procedural (non-technical) errors following team training for surgical teams [15]. Rates of revision surgery and complications such as infection have also been shown to decrease [16]. The converse is also true; patients whose surgical teams demonstrate less teamwork behaviors are at higher risk for complications and death [16].

 

Outside the OR

Team training has benefits that extend beyond better patient outcomes. Several studies have shown that efficiency and timeliness increased in facilities that conducted team training [4]. Likewise, case length and turnaround time in the OR have been shown to decrease [4]. One study even found that average length of hospital stay decreased after team training, although these results were not significant [5]. Team training can also help increase efficiency and communication in outpatient offices and clinical practices. Some facilities report that job satisfaction also increases following team training, which is likely a side benefit of a more collegial, efficient, and safe workplace.

 

While the benefits of team training can be myriad, the importance of buy-in and follow-up are essential to success. Initial cultural resistance by medical staff to the adoption of team training practices and the time needed for education has been noted in a few studies [5].

 

In some cases, the OR was closed for a day to conduct training, and without the support of medical staff to these types of occurrences, team training can be less effective. Continued education (just technical, skills-based CME) or follow-up is also essential to reinforce skills, keep medical staff up-to-date, and realize the full value of team training.

Read an interview with Robert Postigo