Implications of Team Theory and Science for Nurse Credentialing Research

Sallie J. Weaver, PhD

March 3, 2014

© The Johns Hopkins University, The Johns Hopkins Hospital, and Johns Hopkins Health System

Disclosures

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• Portions of my work have been funded by:

• ARHQ

• The Johns Hopkins Institute for Clinical & Translational Research

• Veterans Administration

• VHA, Inc

• DaVita, Inc

“…It has become necessary to develop medicine as a cooperative science;…clinicians, specialists, laboratory workers uniting for the good of the patient, each assisting in elucidation of the problem at hand, and each dependent upon the other for support.”

–William J. Mayo, Commencement

speech at Rush Medical College

1910

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2013….

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Beware of illusory correlation: “…if relevant actors accept the need to adopt a particular practice, implementation should occur unproblematically” (Gondo, 2012)

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Diffusion of intensity-modulated radiation therapy (IMRT) among a sample of patients receiving radiation therapy for prostate cancer

Nguyen PL, Gu X, Lipsitz SR, Choueiri TK, Choi WW, Lei Y, Hoffman KE, Hu JC. Cost implications of the rapid adoption of newer technologies for treating prostate cancer. J Clin Oncol. 2011 Apr 20;29(12):1517-24. doi: 10.1200/JCO.2010.31.1217.

Undoubtedly healthcare has been recognized as a team endeavor...

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Teamwork & leadership impacts clinical outcomes, care quality, and patient safety

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• Lack of communication = most frequently occurring ‘behavioral

failure’ in a review of closed claims (Griffen et al., 2008)

• Teamwork failures show a strong correlation with technical clinical

errors (r = .57 - .67) (El Bardissi et al., 2008; Weigmann et al., 2007)

Sub-optimal teamwork 11% of missed nursing care (Kalisch & Lee, 2010)

• Systematic efforts to improve teamwork (e.g., team-training) linked

with significant improvement in acute and outpatient settings:

60% reduction in med-surg fall rates (Spiva et al., 2013)

93% reduction in missing orders in outpatient oncology (Brunnell et al.,

2013)

Reduction of 0.5deaths/1000procedures per each quarter

teamwork intervention in place (Neily et al., 2010; Young-Xu et al., 2011)

What do we know about high-performing teams from over 5 decades of research? (Salas et al. 2004; Weaver, Wildman, & Salas, 2008)

Teams that perform well:

• Hold shared mental models

• About the team, system, strategies, processes, goals

• Have clear roles and responsibilities

• Have clear, valued, and shared vision

• Optimize resources

• Have strong team leadership

• Engage in a regular discipline of feedback

• Develop a strong sense of collective trust and confidence

• Create mechanisms to cooperate and coordinate

• Manage and optimize performance outcomes

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Many of the competencies underlying effective teamwork have been articulated (& adopted) Teamwork

Coordination Cooperation Communication

Attitudinal/Motivational Components

Behavioral Strategies

Information Exchanges &

Protocols • Back-up Behavior

• Cross-monitoring & cue-association strategies

• Adaptation

• Task-related assertiveness

• Conflict management

• Boundary spanning

• Reflection & team-self correction

• Collective/Team Orientation

• Collective Efficacy

• Team Cohesion

• Psychological Safety

• Trust

• Briefings

• Debriefings

• Closed-loop Communication

• Brief, clear, timely

(Salas, Wilson et al. ,2008)

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How do we know this? (Weaver et al., 2013)

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• Theories & studies of team effectiveness

Subjective evaluative judgment regarding results of performance

• Theories & studies of team performance

What teams do

• Theories & studies of team composition & development

How teams form, ebb, and flow over time Team training

• Theories & studies of multi-team systems

Teams or networks of teams

These competencies can be developed through systematic team training

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Strongest evidence for bundled team-training interventions (Weaver, Dy, Rosen, 2013)

• Examples include: TeamSTEPPS VA Medical Team Training Many adaptations of

crew/crisis resource management (CRM)

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• Optimize transfer of training and generalization by coupling learning activities & practice opportunities with org. support and structured teamwork tools

Measuring teamwork processes is possible and psychometrically sound measures are available Salas, Rosen, & Weaver (2013)

• Behavioral marker systems & observational tools:

NOTECHS, OTAS, TENTS…many

• Surveys (Valentine et al. 2011)

36 distinct scales

12 --> relationships to non-self-reported outcomes

• Situational judgment tests (Lievens,

Buyse, & Sackett, 2005)

• However…

Quantifying individual team member contribution to team outcomes less clear

Measures of multi-team system performance evolving

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Meaningful movement toward care integration, however, is a team-of-teams endeavor

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Image: R&R in DC

Image: Healthcare IT News

Important conceptual questions remain Particularly within a multi-team system context…

Sequencing, timing, and synchronization (entrainment)

Staging and integration

Transdisciplinary decision making processes

Role (or goal) confusion or conflict

“Pro-acting”: Anticipation, self-correction, back-up behavior

Boundary spanning

Transactive memory systems

─ Who knows who knows what and how do they know?

What emergent conditions/states are most important for well coordinated, high quality care? Which have we not considered?

─ Trust, cohesion, efficacy, justice

Network characteristics of effective care, education, and scientific research multi-team systems

─ Patterns of communication, coordination

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Important design, methods, and measurement issues to consider

• Multi-level/random effects models

• Network & pattern analysis

• Quasi experimental & comparative effectiveness designs

• Assessment methods • Survey measures exist (e.g., TeamSTEPPS Teamwork Attitudes

Questionnaire)

• Simulation: In-situ, center based, & low fidelity

• Assessment centers are common in industry for teamwork competency assessment & leadership selection

• Situational judgment tests (SJTs)

• Measuring team performance in multi-team systems

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Reflection, discussion, questions

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sjweaver@jhu.edu

References

Slide 4

• Shekelle PG, Pronovost PJ, Wachter RM, et al. The top patient safety strategies that can be encouraged for adoption now. Ann Intern Med. 2013;158(5 Pt 2):365–8. doi:10.7326/0003-4819-158-5-201303051-00001.

Slide 5

• Gondo M, Amis J. Variations in practice adoption: The roles of conscious reflections and discourse. Academy of Management Review, 2013:38(2);229.

• Nguyen PL, Gu X, Lipsitz SR, Choueiri TK, Choi WW, Lei Y, Hoffman KE, Hu JC. Cost implications of the rapid adoption of newer technologies for treating prostate cancer. J Clin Oncol. 2011 Apr 20;29(12):1517-24. doi: 10.1200/JCO.2010.31.1217.

Slide 7

• Bunnell CA, Gross AH, Weingart SN, et al. High performance teamwork training and systems redesign in outpatient oncology. BMJ Qual Saf. 2013;22(5):405–13. doi:10.1136/bmjqs-2012-000948.

• ElBardissi AW, Wiegmann DA, Henrickson S, Wadhera R, Sundt TM. Identifying methods to improve heart surgery: an operative approach and strategy for implementation on an organizational level. Eur J Cardiothorac Surg. 2008;34(5):1027–33. doi:10.1016/j.ejcts.2008.07.007.

• Griffen FD, Stephens LS, Alexander JB, et al. Violations of behavioral practices revealed in closed claims reviews. Ann Surg. 2008;248(3):468–74. doi:10.1097/SLA.0b013e318185e196.

• Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical team training program and surgical mortality. JAMA. 2010;304(15):1693–700. doi:10.1001/jama.2010.1506.

• Spiva L, Robertson B, Delk ML, et al. Effectiveness of team training on fall prevention. J Nurs Care Qual. 29(2):164–73. doi:10.1097/NCQ.0b013e3182a98247.

• Wiegmann DA, ElBardissi AW, Dearani JA, Daly RC, Sundt TM. Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation. Surgery. 2007;142(5):658–65. doi:10.1016/j.surg.2007.07.034.

• Young-Xu Y, Neily J, Mills PD, et al. Association between implementation of a medical team training program and surgical morbidity. Arch Surg. 2011;146(12):1368–73. doi:10.1001/archsurg.2011.762.

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References

Slide 8

• Salas E, Cooke NJ, Rosen MA. On teams, teamwork, and team performance: discoveries and developments. Hum Factors. 2008;50(3):540–7.

• Weaver, S. J., & Wildman, J. L., & Salas, E. (2008). How to build expert teams (pp.129-156). In C. L. Cooper & R. J. Burke (Eds.), The Peak Performing Organization. Oxford, UK. Taylor & Francis Ltd.

Slide 9

• Salas E, Wilson KA, Murphy CE, King H, Salisbury M. Communicating, coordinating, and cooperating when lives depend on it: tips for teamwork. Jt Comm J Qual Patient Saf. 2008;34(6):333–41.

Slide 10

• Weaver, S. J., Feitosa, J., Salas, E., Seddon, R., & Vozenilek, J. A. (2013). The science of teams: The theoretical drivers, models, & competencies of team performance for patient safety. In E. Salas & K. Frush (Eds.), Improving Patient Safety through Teamwork and Team Training (pp.3-26). New York, NY: Oxford University Press.

Slide 12

• 1Buljac-Samardzic M, Dekker-van Doorn CM, van Wijngaarden JDH, van Wijk KP. Interventions to improve team effectiveness: a systematic review. Health Policy. 2010;94(3):183–95. doi:10.1016/j.healthpol.2009.09.015.

• Weaver SJ, Dy SM, Rosen MA. Team-training in healthcare: a narrative synthesis of the literature. BMJ Qual Saf. 2014;E pub ahead of print. doi:10.1136/bmjqs-2013-001848.

References

Slide 13

• Lievens F, Buyse T, Sackett PR. The operational validity of a video-based situational judgment test for medical college admissions: illustrating the importance of matching predictor and criterion construct domains. J Appl Psychol. 2005;90(3):442–52. doi:10.1037/0021-9010.90.3.442.

• Salas, E., Rosen, M.A., & Weaver, S. J. (2013). Best practices for measuring team performance in healthcare. In W. C. McGahie (Ed.), International best practices for evaluation in the health professions . Radcliffe, London, UK.

• Valentine M, Nembhard IM, Edmondson AC. Measuring Teamwork in Health Care Settings: A Review of Survey Instruments. Med Care. 2013;Epub ahead. doi:10.1097/MLR.0b013e31827feef6.

Additional slides as needed

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QSEN Teamwork KSAs

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Non-technical skills scale Center for Patient Safety & Service Quality Imperial College, London http://www1.imperial.ac.uk/cpssq/cpssq_publications/resources_tools/revisednotechs/

Sevdalis N, Davis RE, Koutantji M, Undre S, Darzi A, Vincent CA. Reliability of a revised NOTECHS scale for use in surgical teams. American Journal of Surgery 2008;196:184-90.

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