Background
Providing safe health care depends on highly trained individuals with disparate roles and responsibilities acting together in the best interests of the patient. Communication barriers across hierarchies, failure to acknowledge human fallibility, and lack of situational awareness combine to cause poor teamwork, which can lead to clinical adverse events.
The aviation industry has long recognized that safety requires crew members to receive specific training in working as a team, in addition to technical training. Several studies have documented poor levels of teamwork in medicine. A classic study that compared perceptions of teamwork between operating room personnel and flight crews found that attending surgeons were significantly less likely to acknowledge fatigue or accept suggestions from junior staff than were pilots.
Growing recognition of the need for teamwork has led to the application of teamwork training principles, originally developed in aviation, to a variety of health care settings. While there is no single standardized teamwork training program for health care, all programs stress several key concepts. Teamwork training attempts to minimize the potential for error by training each team member to respond appropriately in acute situations. Teamwork training thus focuses on developing effective communication skills and a more cohesive environment among team members, and on creating an atmosphere in which all personnel feel comfortable speaking up when they suspect a problem. Team members are trained to cross-check each other's actions, offer assistance when needed, and address errors in a nonjudgmental fashion. Debriefing and providing feedback, especially after critical incidents, are essential components of teamwork training.
Teamwork training also emphasizes the role of human factors—for example, the effects of fatigue, expected or predictable perceptual errors (such as misreading monitors or mishearing instructions), and the impact of different management styles and organizational cultures. Teamwork training may be purely classroom-based or accompanied by simulations of specific scenarios such as cardiopulmonary resuscitation, "crash" Caesarean section, or multiorgan trauma.
Implementation and Effectiveness
Specific teamwork training programs in health care include TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety)—a program collaboratively developed by the US Department of Defense and the Agency for Healthcare Research and Quality—and MedTeams. These programs have been implemented in several environments, including the emergency department, operating rooms, obstetrics units, and outpatient primary care clinics.
While teamwork training is conceptually attractive, the evidence supporting the benefits of such programs in health care is inconsistent. A systematic review of teamwork training in health care and other industries highlighted the need to comprehensively evaluate teamwork interventions in order to accurately assess their effectiveness. Although studies have consistently demonstrated improvements in participants' knowledge of teamwork principles, attitudes toward the importance of teamwork, and overall safety climate, these have not necessarily translated into durable behavioral changes or improved skills. The only randomized trial of teamwork training in health care, performed in obstetrics wards, did not demonstrate any reduction in errors or improvement in clinical outcomes. However, a subsequent single-institution study using a similar intervention resulted in a decrease in the frequency and severity of errors. The effectiveness of teamwork training may depend on baseline perceptions of safety culture as well as the intensity and duration of the intervention.
Current Context
All military health facilities participate in the TeamSTEPPS program, but as yet, teamwork training is not required for other health care facilities. The Joint Commission's Universal Protocol for preventing wrong-site surgery mandates a preoperative "time out," based on teamwork training principles, in which all team members review the details of the surgery to take place. Many organizations are now coupling teamwork training programs with more specific efforts to structure communication, such as SBAR (situation, background, assessment, recommendation) training. The Agency for Healthcare Research and Quality is currently offering free TeamSTEPPS training sessions for eligible organizations until August 2009.
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What's New in Teamwork Training
Study: Predictors of successful implementation of preoperative briefings and postoperative debriefings after medical team training. Paull DE, Mazzia LM, Izu BS, Neily J, Mills PD, Bagian JP. Am J Surg. 2009;198:675-678.
Review: Interventions to improve team effectiveness: a systematic review. Buljac-Samardzic M, Dekker-van Doorn CM, van Wijngaarden JDH, van Wijk KP. Health Policy. 2009 Oct 24; [Epub ahead of print].
Study: Identifying organizational cultures that promote patient safety. Singer SJ, Falwell A, Gaba DM, et al. Health Care Manage Rev. 2009;34:300-311.
Commentary: Building team and technical competency for obstetric emergencies: the mobile obstetric emergencies simulator (MOES) system. Deering S, Rosen MA, Salas E, King HB. Simul Healthc. 2009;4:166-173.
Review: Approaching the evidence basis for aviation-derived teamwork training in medicine. Zeltser MV, Nash DB. Am J Med Qual. 2009 Oct 2; [Epub ahead of print].
Special or Theme Issue: Obstetric Quality and Safety. J Healthc Qual. 2009;31:3-52.
Commentary: What went right: lessons for the intensivist from the crew of US Airways Flight 1549. Eisen LA, Savel RH. Chest. 2009;136:910-917.
View all AHRQ PSNet resources on Teamwork Training
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Editor's Picks for Teamwork Training
The Inside of a Time Out. David L. Feldman, MD, MBA. AHRQ WebM&M [serial online]. May 2008
Team Training: Classroom Training vs. High-Fidelity Simulation. Stephen D. Pratt, MD and Benjamin P. Sachs, MB. AHRQ WebM&M [serial online]. March 2006
What Does Simulation Add to Teamwork Training?. David M. Gaba, MD. AHRQ WebM&M [serial online]. March 2006
Aviation Safety Methods: Quickly Adopted but Questions Remain. Eric J. Thomas, MD, MPH. AHRQ WebM&M [serial online]. January 2006
In Conversation with…Jack Barker, PhD. AHRQ WebM&M [serial online]. January 2006
 Effects of teamwork training on adverse outcomes and process of care in labor and delivery: a randomized controlled trial. Nielsen PE, Goldman MB, Mann S, et al. Obstet Gynecol. 2007;109:48-55.
Does crew resource management training work? An update, an extension, and some critical needs. Salas E, Wilson KA, Burke CS, Wightman DC. Hum Factors. 2006;48:392-412.
The collapse of sensemaking in organizations: the Mann Gulch disaster. Weick KE. Adm Sci Q. 1993;38:628-652.
Enhancing Patient Safety During Hand-Offs: Standardized communication and teamwork using the 'SBAR' method. Hohenhaus S, Powell S, Hohenhaus JT. Am J Nurs. 2006;106:72A-72B.
Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the MedTeams project. Morey JC, Simon R, Jay GD, et al. Health Serv Res. 2002;37:1553-1581.
Error, stress, and teamwork in medicine and aviation: cross sectional surveys. Sexton JB, Thomas EJ, Helmreich RL. BMJ. 2000;320:745-749.
Impact of CRM-based team training on obstetric outcomes and clinicians' patient safety attitudes. Pratt SD, Mann S, Salisbury M, et al. Jt Comm J Qual Patient Saf. 2007;33:720-725.
TeamSTEPPS: Strategies and Tools to Enhance Performance and Patient Safety. Department of Defense and the Agency for Healthcare Research and Quality. Rockville, MD: Agency for Healthcare Research and Quality; 2006.
Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. The Joint Commission.
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Related Patient Safety Primers:
Safety Culture
View all Patient Safety Primers
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