TeamSTEPPS Fundamentals Course: Module 2

Team Structure: Instructor's Materials

TeamSTEPPS^® Fundamentals Course: Module 2

Team Structure: Instructor's Materials

Contents

• Team Structure
• Objectives
• TeamSTEPPS Team Skills
• Partnering With the Patient
• Why Teamwork?
• High-Performing Teams
• Barriers to Team Performance
• Exercise: Teams and Teamwork
• Multi-Team System for Patient Care
• Core Teams
• Coordinating Teams
• Contingency Teams
• Ancillary and Support Services
• The Role of Administration
• Example: A Multi-Team System in the OR
• Exercise: Your Multi-Team System
• Team Member Characteristics
• Team Failure Video
• Teamwork Failure Video Analysis
• What Defines a Team?
• Paradigm Shift to a Team System Approach
• Effective Team Members
• Teamwork Actions
• References

Team Structure

Module Time: 50 Minutes

Say:

Teamwork cannot occur in the absence of a clearly defined team. Therefore, improving upon an existing— or designing a new— team structure is the first step in implementing a teamwork system in any environment.

Organizational researchers have long focused on the value of teams as a unit of task work, with leadership serving as a means for improving employee performance and attitudes. It is important to first understand the structure of teams to learn how to promote teamwork and create a climate conducive to effective team functioning. Such a climate is based on a commitment to collaboration, mutual accountability, acknowledgement, recognition, and professional respect.

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Objectives

Say:

Upon completion of this module, participants will be able to:

• Identify the characteristics of high-performing teams.
• Discuss the benefits of teamwork and team structure.
• Describe the components and the composition of a multi-team system (e.g., Core Team, Coordinating Team, Contingency Team, Ancillary Services, and Administration).
• Understand what defines a team.
• Define the roles and effectiveness of team members.

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TeamSTEPPS Team Skills

Say:

Team structure is an integral part of the teamwork process. A properly structured patient care team is an enabler and the result of effective leadership, communication, situation monitoring, and mutual support.

Team structure is the glue that holds together an effective strategy for ensuring patient safety and reducing medical error, taking into account the knowledge, performance, skills, and attitudes of medical team members.

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Partnering With the Patient

Key Point: Patients are part of the patient care team.

A key concept of team structure is partnering with the patient. Patients are part of the patient care team, and should be embraced and valued as contributing partners to patient care. Evidence shows that giving patients a greater role in their care can improve their health.

Patient-centered care is grounded in respect and action. Ways to effectively involve patients in their own care are to include the patient in rounds, involve the patient in key committees, involve family members (indirect care), and actively enlist the patient's participation.

Learning to work with patients and families as true partners is neither easy nor intuitive.

• Learn to listen.
• Ask patients how involved they prefer to be in their own care.
• Before launching into detailed status, ask patients about their concerns; otherwise, they might not listen to or understand what is being said to them.
• Speak in lay terms so that patients are not inadvertently embarrassed because they do not understand what is being said.
• Give patients and families access to relevant information.
• Ask patients and their families for feedback and to be proactive participants in patient care-they are also responsible for transforming relationships between healthcare providers and patients.

Example:

The Josie King Call Line — Condition Help ("Condition H")
The program enables parents and family members to call for immediate help if they feel the patient is not receiving adequate medical attention.

For more information:
http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Tools/ConditionHBrochureforPatientsandFamilies.htm

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Why Teamwork?

Say:

The goals of teamwork are to:

• Reduce clinical errors.
• Improve patient outcomes.
• Improve process outcomes.
• Improve patient satisfaction.
• Increase staff satisfaction.
• Reduce malpractice claims.

Teamwork may be determined by the physical layout of facilities —
Parts of units housed together may be considered teams.

 Discussion:

What are some other benefits of teamwork?

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High-Performing Teams

Say:

Over the course of this training, we will touch on the many interrelated aspects of high-performing teams. Generally speaking, high-performing teams have some common traits.

 Discussion:

• In what way do "Shared Mental Models" contribute to the success of high-performing teams?
• Answers include: members can anticipate each other; coordinate without the need to communicate overtly; know when explicit communication is best; and know where to look for expertise.

Say:

Other traits of high-performing teams, which we will explore in more detail later in this course, include:

• Have clear roles and responsibilities.
• Have a clear, valued, and shared vision
  — a common purpose
  — an engaging purpose
  — a leader who promotes the vision with the appropriate level of detail
• Optimize resources.
• Have strong team leadership.

• Engage in a regular discipline of feedback
  — regularly provide feedback to each other and as a team
  — establish and revise team goals and plans
  — differentiate between higher and lower priorities
  — have mechanisms for anticipating and reviewing issues of team members
  — periodically diagnose team effectiveness, including its results, processes, and vitality (including morale, energy, and retention)

• Develop a strong sense of collective trust, team identity, and confidence
  — manage conflict by effectively confronting one another
  — have a strong sense of team orientation
  — trust other team members' intentions
  — believe strongly in the team's collective ability to succeed
  — develop collective efficacy
  — have a high degree of psychological safety

• Create mechanisms to cooperate, coordinate, and generate ongoing collaboration
  — identify teamwork and task requirements
  — ensure that the team possesses the right mix of competencies through staffing and development
  — distribute and assign work thoughtfully
  — consciously integrate new team members
  — involve the right people in decisions in a flexible manner
  — examine and adjust the team's physical workplace to optimize communication and coordination

• Manage and optimize performance outcomes
  — communicate often and at the right time to ensure that fellow team members have the information they need to contribute
  — use closed-loop communication
  — learn from each performance outcome
  — continually strive to learn

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Barriers to Team Performance

Say:

There are many barriers to effective team performance:

• Inconsistency in team membership.
• Lack of time.
• Lack of information sharing.
• Hierarchy.
• Defensiveness.
• Conventional thinking.
• Varying communication styles.
• Conflict.
• Lack of coordination and follow-up.
• Distractions.
• Fatigue.
• Workload.
• Misinterpretation of cues.
• Lack of role clarity.

 Discussion:

Can you provide examples of how some of these barriers might play out in your clinical environment?

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Exercise: Teams and Teamwork

Time: 5-10 minutes

Materials: Teams and Teamwork Exercise Sheet

Say:

Now let's look at the team in your own work area. Please take a few minutes to complete the Teams and Teamwork Exercise Sheet.

Do:

Give the participants several minutes to complete their sheets.

 Discussion:

• Who are the team members in your area or unit?
• What is the goal of your area or unit?
• What properties or characteristics make a group a team?

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Multi-Team System for Patient Care

Say:

This slide shows the model of a multi-team system (MTS). Each team within an MTS is responsible for various parts of patient care, but all must act in concert to ensure quality patient care.

The multi-team system is composed of several different teams.

Example 1 (Outpatient):
MTS Structure within a Family Practice Clinic

• The Core Team may be composed of the physician, nurse, and administrative staff member responsible for treating a patient. They come in direct contact with the patient.
• The Contingency Team may consist of a pharmacist or PharmD who can be called upon to participate in the event the medication regimen is complicated and requires special pharmacological expertise.
• The Coordinating Team in this example might include the clerk checking-in patients for each Core Team and the physician, nurse, and enlisted person responsible for that day's triage, resource management, and promotion of teamwork for the clinic.

Example 2 (Inpatient):
MTS Structure within a Tertiary Care Facility

• The Core Team may be composed of the physician, nurse, and cardiac catherization laboratory staff member responsible for performing a coronary angiography and dilation on a patient. They come in direct contact with the patient.
• The Contingency Team may consist of the cardiac surgeon, anesthesia and operating room staff who can be called upon to participate in the event the patient requires emergency surgery.
• The Coordinating Team in this example might include the chief nurse or physician responsible for triage and resource management for the intensive care units.

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Core Teams

Say:

Core Teams consist of team leaders and team members who are involved in the direct care of the patient. Core Team members include direct care providers (from the home base of operation for each unit), and continuity providers (those who manage the patient from assessment to disposition, for example, case managers). The Core Team is based where the patient receives care.

Core Teams should be small enough to ensure situation monitoring, development of situation awareness, and direct, unfiltered communication between members. To establish a shared mental model, Core Teams should be large enough to include skill overlap between members to allow for workload sharing and redistribution when necessary. Every Core Team has a primary leader who is readily identified by all members of the team. When multiple Core Teams exist in a unit, a method for denoting team affiliation is established to expedite information flow and resource coordination within the teams. A team distribution scheme denotes the assigned work area of each Core Team and facilitates the allocation of resources across the unit based on fluctuations in team workload.

Core Team leadership is dynamic; Core Team leaders are required to take on different roles at various points in the plan of care. Often these may be non-leadership roles, such as supporting a nurse starting an IV.

To establish a Core Team:

• Select the leader.
• Designate roles and responsibilities.
• Communicate essential team information.

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Coordinating Teams

Say:

The Coordinating Team is the group responsible for:

• Day-to-day operational management.
• Coordination functions.
• Resource management for Core Teams.

Direct patient care may be a secondary function with the exception of small facilities.

Coordinating Team leaders generally are designated. Multiple-role groups are usually required for each unit.

It is the role of the Coordinating Team to provide policy-level guidance, triage all emerging events, and prioritize decisionmaking to ensure maximal support to the Core Team.

Coordinating Team members facilitate Core Team actions and outcomes by collaborating with the Administrative Team and the Ancillary Services Teams to assign priorities and ensure throughput. It is also the Coordinating Team's responsibility to make certain that potential contingency situations are recognized and that the Contingency Team is notified of potential activities.

Coordinating Teams frequently comprise experienced personnel with a strong clinical background. This combination enhances the ability of the Coordinating Team members to rapidly assess the overall picture, anticipate the needs or potential needs between and across teams, and make priority-based decisions.

 Discussion:

• Who might be the members of the Coordinating Team for an outpatient clinic?
• Who might be the members of the Coordinating Team for a hospital?

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Contingency Teams

Say:

Contingency Teams are:

• Formed for emergent or specific events.
• Time-limited (e.g., Code Team, Disaster Response Team, Rapid Response Team*).
• Composed of team members drawn from a variety of Core Teams.

* Rapid Response Teams are a group of caregivers available to respond to a patient's bedside whenever a nurse or other caregiver feels a patient's condition is deteriorating.

Contingency Teams are responsible for immediate, direct patient care during emergency situations requiring more resources than are available to the Core Team. They generally consist of pre-identified members derived from varying units or Core Teams and have limited time to prepare for emergencies.

Contingency Team roles can be very specific and limited to a certain situation (e.g., Code Team) or have general responsibility for a broad category of situations (e.g., disaster response). The more general the responsibility, the greater the need for clear and unambiguous policy guidance from the Administrative Team to facilitate rapid decision-making and clear assignment of responsibilities.

In most cases, these teams do not spend much time together and the situations that they deal with are ever-changing, their roles are clearly defined, and leadership is designated based upon the needs of the patient and member expertise in dealing with the particular situation.

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Ancillary and Support Services

Say:

Ancillary Services consist of individuals who:

• Provide direct, task-specific, time-limited care to patients.
• Support services that facilitate care of the patients.
• Are often not located where the patients receive their routine care.

Ancillary Services are primarily a service delivery team whose mission is to support the Core Team. In general, an Ancillary Services Team functions independently.

Support Services consist of individuals who:

• Provide indirect, task-specific services in a healthcare facility.
• Integral members of the team who are service-focused, helping to facilitate the optimal healthcare experience for patients and their families.
• Roles are integrated in that they manage the environment, assets and logistics within a facility.

Support Services are primarily a service-focused team whose mission is to create efficient, safe, comfortable and clean healthcare environments, which impact the patient care team, market perception, operational efficiency and patient safety.

 Discussion:

What are some examples of Ancillary and Support Services Teams?

Possible Answers:

• Clinical services
  — Laboratory
  — X-ray
  — Pharmacy

• Support services
  — Housekeeping
  — Sterile Processing
  — Bioengineering
  — Human Resource Management

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The Role of Administration

Say:

Administration includes the executive leadership of a unit or facility, and has 24-hour accountability for the overall function and management of the organization. Administration creates the climate and culture for a teamwork system to flourish by:

• Establishing and communicating vision.
• Developing and enforcing policies.
• Setting expectations for staff.
• Providing necessary resources for successful implementation.
• Holding teams accountable for team performance.
• Defining the culture of the organization.

The Administrative Team has no responsibility in the direct delivery of care, but provides the framework and guidance that ensure each team understands its role and responsibility and has access to the necessary resources to be successful. The Administrative Team also holds everyone accountable for exhibiting teamwork behaviors. For all teams to function effectively and provide the necessary mutual support, it is critical for the Administrative Team to develop and institutionalize proper policies and procedures that clearly articulate the roles and responsibilities of the other teams and team members.

Administration should strive to create a learning culture where there is trust and transparency to create a 'safe harbor' to report, analyze, and share information openly. This philosophy serves to define a culture of safety; however, just as in aviation and other high-risk industries, the change will not happen overnight.

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Example: A Multi-Team System in the OR

Say:

Here we see an example of a multi-team system in the Operating Room. In this example, the core team consists of: the surgeon, anesthesia, the circulating nurse, and the scrub technician. The coordinating team consists of: the charge nurse; an anesthesiologist; and a unit clerk. The ancillary services team consists of: radiology; pathology; and housekeeping. The contingency team consists of anesthesia. Administration consists of: Director of Surgical Services; the nursing director; and perioperative services.

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Exercise: Your Multi-Team System

Time: 5 Minutes

Materials: Paper of Multi-Team System Exercise Sheet

Say:

Individually, map out a multi-team system for your clinical environment, unit, department, work area, or ward.

Do:

Allow 4 minutes for individuals to map out their multi-team system on paper or on the Multi-Team System Exercise Sheet.

Say:

Think about:

• What types of team members make up each team?
• How do the teams in your unit or ward interact with one another?

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Team Member Characteristics

Say:

Now that we have examined the structure of teams within a given unit, we are going to look at team leaders and team members.

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Team Failure Video

Video Time: 3:12 Minutes

Materials: Video Vignette 4A (L & D Opportunity)

 Customizable Content:

Say:

Please consider how the lack of team structure plays a role in the situation shown in this video.

Do:

 Play the video by selecting the director icon on the slide.

 Discussion: Go to next slide >

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Teamwork Failure Video Analysis

Say:

 Discussion:

• Did the team members communicate essential information to each other?
  — No. Vital details were forgotten or not included, and no mechanisms were in place to support collaboration and information-sharing. Competing task and distractions were another factor.

• Did the team demonstrate mutual respect toward one another?
  — No. For example, Dr. Upton did not demonstrate respect to Dr. Dean upon expressing his disappointment in the way he handled the situation instead he attempted to lay blame.

• Did the team address issues and concerns?
  — No. When concerns were raised, they were ignored with conflict replacing collaboration.

• How could the team have partnered with the patient better?
  — The team could have asked how the patient preferred to be involved in her own care by asking questions, listening to her concerns, and giving her access to relevant information.

• What were the barriers to team performance in this vignette?
  — Lack of coordination and collaboration, delayed decisionmaking, lack of role clarity, conflict, lack of information-sharing, and misinterpretation of cues were the barriers to team performance.

• Which traits of high performing teams were lacking most in this vignette?
  — Regular discipline of feedback and communication, clear roles and responsibilities, strong team leadership, mechanisms for coordination and collaboration, and team trust were lacking most.

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What Defines a Team?

Say:

A team is different from a group. A group can achieve its goal through independent individual contributions. Real-time coordination of tasks between individuals is not required.

A team consists of two or more people who interact dynamically, interdependently, and adaptively toward a common and valued goal, have specific roles or functions, and have a time-limited membership. During the temporal life of a team, the team's mission is of greater value than the goals of the individual members.

Team members:

• Include anyone involved in the process of patient care who can take action, including the leader.
• Have clearly defined roles.
• Are accountable to the team for their actions.
• Must stay continually informed for effective team functioning.

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Paradigm Shift to a Team System Approach

Say:

Moving to a team system approach will result in a number of shifts in traditional work patterns:

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Effective Team Members

Say:

Effective team members:

• Are better able to predict the needs of other team members and are proactive versus reactive.
• Provide quality information and feedback.
• Engage in higher level decision-making.
• Manage conflict skillfully.
• Understand their roles and responsibilities.
• Reduce stress on the team as a whole through better performance.

Effective team members "achieve a mutual goal through interdependent and adaptive actions."

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Teamwork Actions

Materials: Flipchart or Whiteboard (Optional) Markers (Optional)

Say:

Teamwork actions include:

• Assembling a team.
• Selecting a leader.
• Identifying the team's goals and vision.
• Assigning roles and responsibilities.
• Holding team members accountable.
• Actively sharing information among team members.
• Providing feedback.

 Discussion:

What actions will you take to improve your team's structure and effectiveness?

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References

DeChurch, L. A. and M. A. Marks. "Teams Leading Teams: Examining the Role of Leadership in Multi-Team Systems." Journal of Applied Psychology 89. 2003.

Fleishman, E. A., M. D. Mumford, S. J. Zaccaro, et al. "Taxonomic Efforts in the Description of Leader Behavior: A Synthesis and Functional Interpretation." Leadership Quarterly, 2: 245, 1991.

Harris, T. C. and J. L. Barnes-Farrell. "Components of Teamwork: Impact on Evaluations of Contributions to Work Team Effectiveness." Journal of Applied Social Psychology 27, 1694-1715. 1997.

Kozlowski, S. W. and B. S. Bell. "Work Groups and Teams in Organizations." Borman, W. C., D. R. Ilgen, D. R., and R. Klimoski. In Comprehensive Handbook of Psychology: Vol. 12 Industrial and Organizational Psychology. New York, Wiley.

McGrath, J. E. "The Influence of Quasi-Therapeutic Relations on Adjustment and Effectiveness in Rifle Teams." Journal of Abnormal and Social Psychology 65, 365-375. 1962.

Morgeson, F. P. "Leading as Event Management: Toward a New Conception of Team Leadership." Poster session presented at meeting of the Society of Industrial and Organizational Psychology, St. Louis, MO. 1997.

Salas, E., C. S. Burke, and K. C. Stagl. "Developing Teams and Team Leaders: Strategies and Principles." Leader Development for Transforming Organizations. Edited by Demaree, R. G., S. J. Zaccaro, and S. M. Halpin. Lawrence Erlbaum Associates, Inc., Mahwah, NJ, 2004.

Sims, D. E., E. Salas, and C. S. Burke. "Is There a 'Big Five' in Teamwork?" 19th Annual Meeting of the Society for Industrial and Organizational Psychology. 4. Chicago, IL, 2004.

Sundstrom, E. "Supporting Work Team Effectiveness: Best Management Practices for Fostering High Performance." Jossey-Bass, Inc., San Francisco, CA, 1-1-1999.

Tjosvold, D. "Flight Crew Collaboration to Manage Safety Risks." Group and Organization Studies 15, 177-191. 1990.

Zaccaro, S. J., A. L. Rittman, and M. A. Marks. "Team Leadership." Leadership Quarterly, 12: 451, 2001.

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