PatientsChartingCourse

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a learning culture. Teams work by planning forward, reflecting back, communicating clearly, and resolving conflict. Data and information are con­ tinuously analyzed so that problems can be identified early on; actions can be taken; and feedback can be provided to clinicians, employees, and leaders.

Joyce Lammert of the Virginia Mason Medical Center (VMMC) explores team-based learning and care through the experiences of VMMC. She highlights changes in medicine brought about by the digital age and changes in the patient-physician compact that give more authority to the patient. Lammert offers several recommendations for accelerating teambased care and driving centers of excellence, including a shift in medical schools’ teaching strategies to more of an interactive, team-based model; rapid process improvement workshops; and incorporation of routine learning collaboration in real practice settings.

Alice Bonner, formerly of the Massachusetts Department of Health (now Centers for Medicare & Medicaid Services), Craig Schneider­ of the Massachusetts Health Data Consortium, and Joel S. ­Weissman of Harvard Medical School address the importance of team-based care in the context of care transitions. They underscore the importance of interdisciplinary teams that are able to deliver safe, effective, culturally appropriate, and timely care within and across settings. Standardized procedures can improve the quality of care and reduce suboptimal­ outcomes and patient experiences, leading to more appropriate use of services and lower costs.

PRACTICAL EXPERIENCE WITH COLLABORATIVE

MODELS IN THE HEALTH PROFESSIONS

Allan S. Frankel, M.D., and Michael Leonard, M.D.

Pascal Metrics, Inc.

Across a variety of settings and industries, groups that effectively coordinate teamwork and improve science tend to achieve their goals (Mathieu et al., 2008). Since the Institute of Medicine (IOM) report To Err Is Human (1999) was published, the healthcare industry has learned a great deal about teamwork and improvement, but few in health care methodically combine the two in order to reap their full potential. Instead, teamwork and improvement are taught and applied separately. As a result, goals take longer to attain. Healthcare leaders have little in depth knowledge of teamwork and improvement and therefore a limited ability to integrate the two concepts in order to improve practice. This paper explores the components of a continuous learning environment (Batalden and Splaine, 2002; Mohr and Batalden, 2002), positing that teamwork and improvement are essential—and inextricably linked—components of a successful learning environment.

must be able to manage and apply these components. Of note is that even if the three elements are excellent, that is insufficient unless they are also linked together.

A Recent History of Teamwork Practice in Health Care

Aviation in the late l980s looked to teamwork to address human error, building on a science called human factors that examined the limitations of human performance in complex environments (Porter, 1964). Scientists focused on how human beings interact cognitively and physically with their environment and cognitive frailty and physical limitations to understand the causes of error. They formed hypotheses based on concepts by psychologists such as Rasmussen (Rasmussen et al., 1991) and Reason (Dekker, 2002; Reason, 1997) that divided cognition into three discrete categories—automatic, rule-based, and knowledge-based thought—each generating specific types of errors (Table 8-1).

Initial efforts in aviation to decrease error focused on ergonomics and the physical environment, but the industry realized that most error occurred because of team dynamics (Dekker, 2002). Helmreich (1993) and others sought to understand the relationship between teamwork and error and to develop a training program to address the issues involved. The end result was a program entitled Cockpit Resource Management, so named because the goal was to have groups work effectively with the members of the team and whatever was available in the physical environment. This title quickly became Crew Resource Management (CRM), reflecting that the aviation

TABLE 8-1  Cognition: Automatic, Rule-based, and Knowledge-based

Thinking

SOURCE: Data derived from Reason, 1997.

learned about teamwork in aviation’s high-fidelity simulators, they assumed that CRM-based training would suffice. They were, and are, mistaken. This misperception has also stymied clinicians who teach teamwork in the healthcare setting. In fact, although high-fidelity operating room simulators have positively influenced and transformed anesthesiology practice in the United States over the past 25 years, they have been unable to penetrate further into the healthcare system because they did not garner interest from hospital leaders and, initially, lacked a strong evidence base showing the value of simulation training (Cooper and Gaba, 2002). Today, other disciplines are becoming engaged, but hospital leadership has been slow to do so.

Since the publication of To Err Is Human (IOM, 1999), teamwork trainers have also struggled to compress multiple-day aviationand ­simulation-based teamwork programs into a shorter curriculum for health care. Hospitals and clinical units have balked at the idea of releasing physicians and nurses from duty, often with pay, for multiple-day sessions. Consultants and trainers, competing with each other for contracts and eager to satisfy, have shortened their sessions to accommodate demand. Even today, as an indication of just how far some organizations still have to go, some department chairs wonder whether their physicians can learn teamwork in the hour or two available for departmental meetings or grand rounds.

In health care, evidence that teamwork influences reliability is slowly appearing in the literature (Pronovost et al., 2006). However, the paucity of statistically proven links between clinical outcomes and team models is frustrating for those who believe in the value of teamwork. In aviation, by contrast, the training became an integral part of the industry as a response to the identification of human error as the major factor in accidents. Aviation did not wait for double-blind controlled trials to prove the training’s efficacy. Today CRM has been a part of civil aviation for 30 years and is perceived as instrumental in producing aviation’s enviable safety record. No one is suggesting that aviation CRM training be withdrawn because of a lack of evidence showing its value.

Comparing the roots of teamwork against those of improvement reveals why health care has not effectively linked the two. Teamwork training is based on a marriage of psychology, sociology, and engineering. Robert Helmreich, a psychologist, wrote the first comprehensive text on CRM. In contrast, improvement models such as LEAN and the Institute for Healthcare Improvement’s (IHI) Model for Improvement are focused primarily on using statistics to manage variation in stable industrial processes, and derive from the teachings of skilled statisticians and managers such as Shewhart, Juran, and Deming (Juran, 1995). Teamwork is a social science in which measurement is difficult, and linking process to outcome is an elusive challenge. Improvement, by contrast, centers on numbers collected from definable steps that lead to clearly measurable outcomes.

Improvement Science

William Edwards Deming proposed that the science of improvement comprises four domains: psychology, appreciation of a system, understanding variation, and theory of knowledge. Although Deming described effective leadership and management behavior, he did not go into detail about team behaviors and norms of conduct. He states in The New Economics, “Psychology helps us to understand people, interaction between people and circumstance, interaction between customer and supplier, interaction between teacher and pupil, interaction between a manager and his people and any system of management” (Deming, 2000). By contrast, the other three domains are extraordinary in their elegance and application. They are why Japanese car manufacturers gained such an advantage over U.S. companies. In health care, Deming’s work is the underpinning for IHI’s Model for Improvement.

Shewhart and Deming’s improvement science looks at stable industrial processes, evaluates the variation in output of the end product, and applies improvement techniques when appropriate to minimize unnecessary variation. Applied to health care, the industrial process is the care path of patients, and the output is the outcome of care for those patients. Standardization of care processes is necessary, facilitated by measurement of the processes and the outcomes. In diabetes, a standardized method of optimizing blood sugar levels culminates in good HgBA1Cs. In hip and knee surgeries, optimizing time, cost, and patient rehabilitation culminates in patients’ achieving good postoperative functional outcomes. The improvement model is applicable in every aspect of health care, from ambulatory to intensive care, from billing to central sterilization.

The backgrounds of these experts differ from providers of team training. Improvement science requires the setting of measurable aims that identify how a group is going to accomplish “what by when” (Langley et al., 2009). The aims require careful and reproducible measurement, subject to the full range of statistical manipulation. Means, medians, variance, standard deviation, and the like are all part of the nomenclature, a process very different from discussing team behaviors such as briefings and debriefings and the psychology of team relationships.

The improvement advisors at IHI are a good example. IHI trains these advisors, who then support clinicians engaged in activities by helping them perform small tests of change and measure the outcome. Those who do the teaching are mainly statisticians and their primary areas of interest are variation and its management in stable environments. Some have backgrounds in sociology and psychology, and spend some time teaching about the qualities of leadership and teamwork. However, their focus is on teaching how to apply the improvement model, not how to influence groups of clinicians to function in teams.