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Clinical Spotlight
Assessing Teamwork and Communication
in the Health Professions
Failures in teamwork and communication lead to treatment errors, inefficiency and workplace tension. To begin
to address this, we need to know what good teamwork
and communication look like and have some measure of
progress toward that goal (i.e., a method of assessment).
The evidence on teamwork and communication draws
from many industries1,2 and comprises knowledge, skills or
behaviors, and attitudes that lend themselves to different
approaches to assessment.
Knowledge: Assessing knowledge could begin by incorporating the literature on effective team communication
strategies in undergraduate, postgraduate and continuing education curricula and measuring it within existing
assessment programs. The oft-quoted adage “assessment
drives learning” is probably true, at least at the undergraduate level; if the material isn’t formally assessed, it
may not be considered important by learners.
Skills/behaviors: The skills and behaviors required for
effective teamwork are well described1-4 and measurable.
Key behaviors include managing the team (e.g., coordination, monitoring and supporting others); managing the
task (e.g., role allocation, planning, prioritizing, identifying, and utilizing resources); and developing a shared
team mental model (information sharing on task and
role). The communication skills underpinning effective
teamwork include closed-loop communication, structured
handover,5 callout6 (e.g., Stop, Notify, Assessment, Plan,
Priorities, Invite ideas [SNAPPI]), and graded assertiveness7 (Table 1), which lend themselves to use as assessment criteria of teamwork and communication skills.
Teamwork behaviors can be measured by survey or
observation. Survey instruments rely on self-report and
are open to bias.8 However, they are easier to administer
than observational instruments and, by making explicit
the components of teamwork, can potentially promote
learning.
Dietz et al9 recently undertook a review of behaviorally anchored rating scales for observer measurement of
teamwork and reported that while the marker systems
cover similar content, inconsistent terminology and different levels of granularity make comparisons difficult.
These systems have often been developed around acute
care events, and often in a simulated setting, probably for
logistic reasons. In acute care events, good teamwork is
required to avoid immediate, negative consequences for
the patient, reducing the time required to observe and
score teams. Simulation allows for scheduling, standardizing and repeating events, allowing for comparisons
between teams and change over time. Surveys of teamwork may be more feasible in routine or chronic care
settings.
Considerable effort has gone into establishing the validity and reliability of the teamwork measurement tools,
with varying levels of evidence. However, the need for
lengthy rater training (up to several days9) to produce reliable scores affects their feasibility for high stakes assessment or research. These instruments may be more valuable in helping teams to know what they are aiming for
in teamwork and communication. Linking the learning
objectives with the assessment tool through explicit criteria for performance and descriptions of good and poor
performance enables team members to consider each
item against their own team performance. Reflection and
feedback against these criteria identify gaps and strategies
to address those gaps. For example, an item on leadership could be, “A leader was clearly established”; a descriptor
of good performance could be, “One person was centralizing
information and decision making and coordinating the actions of the
team.” The descriptor for poor performance could be, “It
was unclear who was taking the lead, information was not centralized, and no one was taking on the role of coordinating the team
members.”
While self-assessment is prone to bias, there is some evidence that intensive care teams can reliably use teamwork
rating scales to discriminate different levels of teamwork
performance and thus recognize improvement.10
A partial list of potentially useful instruments for the
critical care context is provided in Table 2.3,10-16
Table 1.
Some Useful Communication Behaviors
Closed-Loop Communication
ISBAR (Structured Handover)
SNAPPI
(Callout in a Crisis)
Graded Assertiveness
Sender – clear, concise,
directed instruction
Identify – who you are
Situation – the main issue
Stop – leader steps back and
gets the attention of the team
Observation – The Sao2 is
drifting down.
Receiver – instruction
read back to ensure correct
understanding
Background – the background
history
Notify – inform the team of
patient status
Suggestion – Shall I call for
assistance?
Assessment – what you think
is going on
Assessment – your interpretation of the situation
Recommendation – what you
think needs to be done next
Plan – what you think needs
to be done
Challenge – I’m concerned
that the patient is hypoxic,
and we need to do something
to improve oxygenation.
Sender – confirmation of
instruction
Receiver – acceptance of
the task
Priorities – state the order for
the plan
Invite ideas – seek input from
the team
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Emergency – The patient is
hypoxic; this is an emergency,
and I’m calling for assistance.
February/March 2015+1 847 827-6869
Table 2.
Teamwork Measurement Tools
ToolDescription
OTAS – observational
teamwork assessment for
surgery11,12
Operating room teams: Covers
five behavior categories of
three subteams (surgical,
nursing and anesthesia) over
three phases of surgery
Teamwork Behavior Rater10,13,14
Intensive care teams: Covers
23 individual behavioral items
grouped into three main
categories, rated over entire
encounter
*Non-Technical Skills –
Anesthesia Non-Technical
Skills (ANTS)3,15 rater
Anesthesiologists: Covers four
behavior categories of anesthesiologists’ performance,
rated over entire encounter
*An instrument for non-technical skills for the ICU is under development by Reader et al.16
Attitudes: Attitudes are generally assessed through surveys
or interviews and, because they must rely on self-report,
results can be open to bias. Relevant instruments
include the Safety Attitudes Questionnaire,17 Assessment
of Interprofessional Team Collaboration Scale,8 the
TeamSTEPPS attitudes to teamwork,18 Collaboration
and Satisfaction about Care Decisions in intensive care
teams,19 and Heinemann’s Attitudes Toward Health Care
Teams Scale.20 Some studies using these instruments
have found that positive attitudes toward teamwork are
linked to improved patient outcomes. Attitudes are more
resistant to change than behaviors, and negative attitudes
toward teamwork can undermine initiatives to improve
it. Mutual trust and respect and a team orientation are
fundamental requirements for effective teamwork.
Clinicians need to be convinced of the relevance of
learning about teamwork and communication in order
to change, but important barriers exist. Training professional silos limit opportunities to learn about the roles
and capabilities of others and how they contribute to
decision making and patient management. Patient care
can be fragmented and responsibility delineated within
professional boundaries, creating barriers to working as a
whole team and monitoring and supporting each other.21
Hierarchical attitudes persist, and where power differentials exist between team members, open communication
is discouraged: the less powerful fear negative consequences, and the powerful fail to value the input of all
team members.22
While an individual may be competent, what matters
to the patient is the collective competence23 of the team
and their ability to perform, which depends on: individual competence; appropriate skill mix; prior experience working together; the environment and available
resources; and the organizational support for teamwork.
Furthermore, team membership is constantly changing.
With multiple factors influencing the performance of
teams, there seems little point in “failing” a particular
Critical Connections
Figure 1.
individual or team. The focus should be on continuous
improvement, which may require interventions at multiple levels.
So far we have considered the assessment knowledge,
skills and attitudes of teams and individual members. The
relevant outcome measures for overall team performance can
be considered using the input-process-output framework2
(Figure 1).
Measurable inputs influencing team performance
include: attributes of team members, including their
knowledge, skills and attitudes relevant to teamwork
and communication; the task at hand; environmental resources (e.g., availability of checklists, scheduled
team briefings); and the organizational culture in which
the team functions (e.g., valuing democracy in teams).
Observable behaviors, as measured by teamwork measurement tools, and compliance with established protocols
are process measures. Output measures include: patient
outcomes (complications, length of hospital stay, 30-day
mortality); use of time and resources; and impact on staff
(staff morale, staff retention). Mazzocco et al24 developed
the Behavioral Marker Risk Index, a simple instrument
to measure teamwork in operating room teams, and
found an association between index scores and the rate
of adverse patient events, suggesting a clear link between
teamwork process measures and patient outcomes.
Input-Process-Output Framework for Measuring Team Performance2
Input
Process
Output
Individual attributes
Teamwork behaviors
Patient outcomes
Team composition
Compliance with
protocols
Resource utilization
The task
Staff satisfaction
Environmental resources
Organizational culture
Conclusion
The purpose of assessing teamwork and communication
is to improve team performance. Effective teamwork and
communication depend on the knowledge, skills and attitudes of individual team members, their ability to form
teams, and an enabling environment and organizational
culture. Instruments to measure teamwork can:
1) help individuals and workgroups acquire the skills and
behaviors of effective teams, and 2) demonstrate improvement following interventions. The aim of improving team
performance is to produce better outcomes for patients,
and assessment of the quality and safety of patient care is
the ultimate yardstick against which to measure and drive
improvement in teamwork and communication.
References and disclosures are available at
www.sccm.org/criticalconnections.
Jennifer Weller, MD, MBBS, MClinEd, FANZCA, is an
associate professor of medical education at the University of
Auckland, New Zealand, and a consultant anesthesiologist at
Auckland City Hospital.
“Using Teamwork to Improve Patient Outcomes” continued from p1
Teamwork can be described in many ways, but researchers have utilized an input, process/mediator and output
framework to describe ICU team performance. In this
framework, team and task characteristics are components
of the inputs, transition and action processes are components of the process/mediator, and patient or team outcomes are components of the outputs.2 Examples of transition processes include multidisciplinary patient care rounds
and use of daily goals checklists. Patient care rounds are
an important team activity where the patient’s plan of
care is discussed formally and tasks prioritized. Initiation
of patient care rounds has been associated with positive
patient outcomes. For example, implementation of daily
multidisciplinary rounds by the nursing staff, a physician,
and a respiratory therapist to review a checklist of ventilator bundle goals for each patient decreased the incidence
of ventilator-associated pneumonia (VAP) from 1.5 per
month to 0.5 per month in a study of surgical trauma ICU
patients.3 Similar findings of a reduced VAP incidence
with the institution of multidisciplinary patient care rounds
were also observed in an open trauma ICU.4 Daily patient
care rounds led by an intensivist have been associated with
decreases in hospital length of stay (LOS), hospital costs
and postoperative complications.5 Additionally, nurses’
reports of collaboration with physicians on the decision to
transfer patients out of the ICU were positively associated
with patient mortality.6
Completion of a daily patient-centered goals form
during multiprofessional rounds was associated with an
increase in the understanding of daily goals (>85% of
nurses and medical residents) and decreased the average
patient ICU LOS by about one day.7 Although the study
could not establish a causal relationship between the use
of the goals form and a decrease in ICU LOS, the authors
attributed the benefit to clarifying tasks, care plans and
communication plans among caregivers.
In the Keystone ICU project, clinicians in 108 adult
ICUs in Michigan adopted evidence-based procedures to
Critical Connections
decrease catheter-related bloodstream infections, including use of a checklist to ensure protocol adherence. The
observed 66% reduction in the incidence of catheterrelated bloodstream infection is well-known to ICU clinicians. It is easily overlooked, though, that in addition to the
study procedures, the ICUs also implemented the use of
daily goals sheets to improve clinician communication, and
implemented a unit-based safety program to improve safety
culture, which may also have positively impacted the study
results.8
The benefit of checklists has also been demonstrated in
pediatric ICUs. In one study, implementation of a rounding checklist in a pediatric ICU was associated with fewer
accidental extubations.9 Many institutions have adopted
checklists for patient care with positive results, but ensuring
compliance with checklist completion may be challenging
and overuse of checklists should be avoided.10
Interestingly, although interventions to improve teamwork and perceptions of caregiver teamwork have been
associated with reductions in intermediate endpoints (i.e.,
patient LOS), an association with patient mortality has not
been consistently demonstrated. Additionally, ICUs with
higher levels of teamwork do not reliably perform better
when compared with ICUs with lower levels of teamwork.11 These inconsistent findings regarding the influence of teamwork on patient mortality are likely due to
confounding or lack of adequate study power and should
be addressed in future studies. Improvements in the quality
of teamwork have been associated with a broad variety of
positive patient outcomes, and efforts to improve teamwork
within an ICU should be investigated and implemented as
much as possible.
While improved team interactions have been associated
with positive patient outcomes, poor team interactions have
been associated with ICU adverse events. In an observational single-center study, communication events between
nurses and physicians comprised only 2% of observed
activities in the ICU, but were associated with 37% of
www.sccm.org
errors.12 A similar finding was observed in a multicenter
study where poor teamwork contributed to 32% of patient
safety incidents.13 About half of all ICU adverse events
are adverse drug events (ADEs).14 Patients experiencing
two or more ADEs have a threefold increase in the risk of
ICU death15 and half of all ADEs occur at the prescription stage.16 Medication errors may be prevented by the
inclusion of a pharmacist as an ICU team member. In
one study from the United States where pharmacists were
present at the time of medication prescription (either during patient care rounds or for consultation in the ICU),
a 66% reduction in the number of preventable ADEs
was observed.17 Similarly, in a Dutch study, ICU hospital
pharmacist review of admission orders was associated with
a 75% reduction in preventable ADEs.18 Furthermore, the
presence of clinical pharmacists in ICUs has been associated with a shorter time to liberation from mechanical
ventilation,19 lower mortality rates, and shorter ICU LOS
in patients with infections.20
In conclusion, the complexity of the care of critically ill
patients requires a coordinated team effort. Practitioners in
the ICU should seek opportunities to improve teamwork
in their own institutions. Team efforts such as multidisciplinary patient care rounds and a checklist with patient
care goals may improve patient outcomes and avoid
adverse events.
References and disclosures are available at
www.sccm.org/criticalconnections.
Seth Bauer, PharmD, FCCM, is a medical ICU clinical
specialist and member of the Medical ICU Quality Committee
at the Cleveland Clinic.
February/March 2015
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