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8 System Strategies to Improve Patient Safety and Error Prevention System changes are needed in addition to enhanced supervision, workload adjustment, and fatigue prevention methods to enhance conditions for resident performance and patient safety. The committee recommends ways to make more effective handovers and error reporting an integral part of resident learning experiences to help achieve these goals. Teamwork co- ordination and clinical information technology can also foster increased learning, productivity, and patient safety. A transformation in the medical environment is needed so that a system-wide culture of safety develops and a system of blame is replaced with one of shared responsibility. The committee’s examination of graduate medical education has re- vealed that duty hours represent only one among many factors in residents’ experiences that may affect patient safety and resident learning. Although the committee’s deliberations about recommendations to help mitigate and prevent resident fatigue were central to its charge, it became apparent that additional changes at the system level could also help improve patient safety, resident education, and the quality of care. The committee further recognized that redesigning hospital practices or system processes may be necessary to facilitate redesign of graduate medical education or implemen- tation of the proposed recommendations. The strategies discussed in this chapter and the recommendations of the committee are aimed at systems that not only improve resident work and learning, but also improve the delivery of care in teaching institutions by all staff. The need for these steps is apparent now, under the current duty hour limits, and will continue to be important after implementation of the committee’s recommended changes to duty hours. 

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4 RESIDENT DUTY HOURS In order to implement such changes, an organization-wide approach is necessary to create an environment that involves all hospital workers in achieving the desired results of maximum safety and the provision of quality care. Adjustments that would assist in transforming the resident work environment, and the environment for all health workers, include improving communications skills among hospital staff, implementing team strategies to complete work more efficiently, and developing a safety cul- ture that extends across hospital settings. Therefore, this chapter discusses organizational and systems strategies that can help to (1) establish a culture of safety, (2) improve handover processes, (3) use adverse event and error- reporting systems for resident learning, and (4) develop a team culture to improve communication and task performance among residents. These ele- ments can both enhance a physician’s education and contribute to patient safety. LEARNING IN A CULTURE OF SAFETY Creating a culture of safety and developing teamwork have been broadly addressed in previous Institute of Medicine (IOM) reports, namely the Quality Chasm series (IOM, 2000, 2003, 2004). The committee builds on those earlier reports, focusing attention on adopting strategies for team- work development and error reporting to better serve the educational needs of residents while fostering safe patient care. Culture of Safety and High Reliability Definitions of the concept of a culture of safety vary, but organizations that establish a safety culture generally demonstrate the following charac- teristics (Singer et al., 2003): • Safety is considered the highest priority of the organization. • There are strongly shared values and behavioral norms throughout the organization that are centered around safety. • Resources and incentives are available for the organization to pur- sue and implement a safety commitment. • There is non-hierarchical and open communication among workers— particularly in safety-related scenarios. • There are rare occurrences of errors, but open recognition and reporting of them is accomplished without blame for individuals. • Organizational learning is highly valued. High-reliability organizations (HROs) build on culture of safety ele- ments to go beyond the norm and approach their goals of zero errors

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 SYSTEM STRATEGIES and avoidance of potential disasters, such as multiple deaths (Weick and Sutcliffe, 2001). Businesses in particularly risky industries that could have a catastrophic impact on the public, such as military operations, commer- cial airlines, and nuclear power generation, were among the first to adopt the continual processes needed to achieve high-reliability operations while producing minimal errors. Although recognition of a safety culture and high-reliability compo- nents and practices (e.g., teamwork, blame-free error reporting) are becom- ing more common in health care, there has yet to be widespread adoption of these practices across the medical field (Patterson et al., 2004). Reasons for slow adoption by some institutions include resistance to organizational change (Carroll and Quijada, 2004) and insufficient resources to support safety culture practices (Patterson, 2007), although some experts note that a major investment of resources is not necessary (Hines et al., 2008). Ten- sion can exist between the goals of a safety culture and individual residents, program directors, or departments, which is why leadership—at both the clinician and the executive levels—is a critical component in overcoming any resistance and establishing the importance of high reliability through- out an organization (Roberts et al., 2005). Leaders in healthcare settings accomplish this by aligning incentives and encouraging the ideas that drive a culture of safety, promoting the continued progression of system redesign and eventually sustaining the developments made (Roberts and Perryman, 2007). Suggesting that they be more active in establishing patient safety standards for clinical performance and that such practices become part of medical training is in line with recommendations from the IOM report To Err Is Human (IOM, 2000). In an effort to take a lead in promoting a culture of safety for health- care settings, the Agency for Healthcare Research and Quality (AHRQ) now encourages hospitals to adapt the concepts of high reliability to their organizations, along with the previously mentioned elements of safety cul- ture (Hines et al., 2008). The introduction of high-reliability practices is still relatively new in the medical field, and the exact impact of the culture of safety on specific improvements in healthcare organizations has yet to be documented on a broad scale (Shojania, 2005). However, it is known that error rates in hospital care tend to be far greater than those associated with HROs in other industries (e.g., airlines). The 44,000-98,000 estimated deaths in the United States related to medical errors are just one component of risks to patients. Many more nonfatal pre- ventable events also harm patients, with impacts such as extended hospital stays, pain and suffering due to hospital acquired infections, or an adverse drug event. The frequency of such errors certainly indicates a need for improvement and is discussed in Chapter 6. In this chapter the focus is on organizational attitudes and culture: ensuring that safety is given the promi-

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 RESIDENT DUTY HOURS nence it requires for the provision of high-quality care, that residents and all other workers in the hospital are comfortable discussing errors, and that efforts are made to correct or prevent situations in which errors occur. To prevent such occurrences, hospital environments that promote com- munications by all levels and professions of workers should be supported. Encouraging questions about safety and blame-free reporting of errors would likely enhance the educational value of residents’ training and their ability to learn from all of their colleagues and continuously improve qual- ity of care through cooperative teamwork (IOM, 2001). This does not ap- ply only to medical residents, but focusing attention on them may be a good place to introduce the culture change required for this shift to team mental- ity or shared responsibility and accountability in healthcare settings. REDUCING ERRORS BY IMPROVING HANDOVERS Handovers, or transitions in patient care are an area of medical practice that is considered a substantial source of errors and risks to patients, but one that can benefit from immediate attention through processes improvement. More commonly referred to as “handoffs,” “transfers,” or “sign-out” in the United States, the committee chose the term “handover” for this report because it better encompasses the goal of these pivotal moments, suggesting that they are intended as a handing over of responsibility for a patient from one healthcare provider to another and not simply a quick transcription of patient information at the end of one’s time on duty. Continuity of care as described in Chapter 4 refers primarily to relationship building between physician and patient, and gaining thorough knowledge of a patient’s con- dition in order to provide the best treatment. A resident’s familiarity with a patient and his/her care is important, and discontinuity of care due to handing cases over to other residents has been shown to result in increased levels of preventable adverse events (Laine, 1993; Petersen, 1994). However, to achieve stronger patient-physician relationships and serve its educational purpose, continuity of care relies heavily on the continuity of information itself. Information transferred during handovers may include a patient’s name, bed location, blood pressure, diagnosis, and other critical data on patient status or treatment plan. A service that must be available 24 hours daily, such as health care, requires transferring this information and responsibility of tasks from one team member to another at some point or points during the day. In a hospital setting, for example, where teams of physicians, nurses, and residents are all responsible for a single patient, continuity of care involves a comprehensive handover of patient information from one provider or team to another so that clinical care can be maintained successfully among a healthcare team. Handovers take place among teams of nurses, teams of physicians, and teams of residents, as well as between those teams and between integrated care teams consisting of various types of clini-

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 SYSTEM STRATEGIES cians. Handovers occur between emergency departments, different inpatient settings from surgical to postoperative care, and different hospitals, not to mention transitions out of hospitals to nursing homes or home care settings (Patterson et al., 2004). The act of transferring responsibility for patient care is not inherently a negative practice. However with each additional handover per patient, there is more opportunity for dilution or omission of information, which can lead to inaccuracies that affect patient care and outcomes (Arora et al., 2005, 2007; Horwitz et al., 2008; Petersen, 1994). Such communication breakdowns result in information gaps that intensify discontinuity of patient care and the potential for errors. These factors make them pivotal moments in the care continuum and an important aspect of preventing medical errors and ensuring patient safety (Saultz, 2003). For residents, these exchanges are also opportunities for professional interaction, learning how to assess patient care situations, and problem solving. The next several sections discuss the role handovers play in the continuity of patient care, the impact they have on patient safety and resident education, how they are affected by the regulation of duty hours, and suggestions for rede- signing handover processes to optimize patient safety and resident education. Consequences of Transfers and Communication Failure for Patient Safety Several studies, not specific to residents, highlight observed patient cases that point out the errors—at times fatal—caused by poor commu- nication during handovers (Beach et al., 2003; Gandhi, 2005; Vidyarthi, 2004; Wachter, 2008; Wachter et al., 2006). An evaluation by the Joint Commission in 2005 of more than 3,000 root-cause analyses of reported error data revealed that nearly 70 percent of sentinel events in accredited healthcare entities result from communication failures (Joint Commission International Center for Patient Safety, 2006). The Joint Commission fur- ther stated that there is evidence that at least half of such communication failures occur during handovers. In a study by Gandhi and colleagues, poorly executed handovers contributed to 20 percent (36 of 181) of mal- practice claims that resulted in serious harm or death to patients (Gandhi et al., 2006). Additionally, poor handover and follow-up practices at dis- charge are particularly likely to increase safety risks for patients (Forster et al., 2003; Moore et al., 2003). Poor discharge practices have been associ- ated with higher readmittance rates or avoidable readmission of discharged patients (Halasyamani et al., 2006). Because this evidence is not specific to residents, it demonstrates the extent to which poor communication perme- ates the health system, posing safety risks to patients. Among residents, however, communication failures are among the most common factors contributing to adverse patient events (Sutcliffe et al., 2004), and handovers are just one form of communication between resi- dents and their medical team. In a study by Singh (2007), 19 percent (46)

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 RESIDENT DUTY HOURS of cases with errors made by residents (including interns and fellows) that resulted in malpractice claims and led to medical injury of patients were attributed to poor handoffs. Another study by Arora et al. (2007) in which 27 percent (1,876) of medication entries in sign-out forms from handover procedures by interns contained either omissions of or commissions from notations in the original patient chart, 54 percent of them had the potential to cause moderate or severe harm to patients. Reducing possible mistakes during these moments can be crucial, and residents can achieve this largely by improving their handover processes, especially with guidance from their attending physician on the critical clinical information that best prepares the next shift of residents to anticipate and respond to changes in patients’ conditions. Variability of Handovers A likely contribution to errors during handovers is the variability of the handover process across settings without specification of the information that needs to be provided. Handover procedures and type of information transferred can vary from hospital to hospital and program to program within hospitals, and often are not structured or uniform between or among provider teams. Some use fax systems, others written tools, and others electronic tools, allowing handovers to take place either face-to-face, in written form only, in verbal form only, or in multiple forms—amplifying the variability of the process and information that gets transmitted across teams and care units. Solet and colleagues (2005) illustrate such variations in a single in- ternal medicine residency program that provides medical training across four different hospitals that each used different methods to transfer patient information. Three different computerized systems were utilized among the four institutions, and only two of the four used a computerized system for handovers. The other two hospitals conducted written handovers, one of which had a free-style form, using no templates or standard format, with residents’ writing up or communicating their notes as they wished. Other studies describe additional variations in handover processes and their differ- ing degrees of effectiveness in communicating necessary patient information (Borowitz et al., 2008; Horwitz et al., 2006). Impact of Duty Hour Regulations on Handovers and Continuity of Care Although fewer duty hours or appropriately placed rest periods may help to reduce fatigue in residents, they raise serious concerns for continu- ity of care. Practice has shown that the number of hours worked and the number of handovers among patients are inversely related, meaning that the

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 SYSTEM STRATEGIES fewer hours residents spend in the hospital, the more often patient care has to be handed over to other residents (Horwitz et al., 2007b; Vidyarthi, 2004; Vidyarthi et al., 2006). Therefore, shorter shifts to comply with the 2003 duty hour regulations and periods of sleep within extended duty periods, as this committee recommends, can result in an increase of handovers. In light of the error rates associated with handovers (Arora and Farnan, 2008; Fletcher et al., 2005), increasing their frequency requires that hospi- tals improve the process in order to maintain or improve the quality of care. In the United Kingdom, this same trend of increased handovers (because of adherence to the European Working Time Directive) has led its Depart- ment of Health to emphasize the effectiveness of handovers as an area of improvement for patient safety (Sabir et al., 2006). Here in the United States, the Joint Commission has recently established a National Patient Safety Goal specific to improving handover practices (which apply to all healthcare professionals, not only to residents) as part of its accreditation process (Joint Commission, 2007). Experts in the field suggest that many errors stemming from poor handovers are preventable or can be made less severe if hospitals take steps to improve communication and coordination of care (Kripalani, 2008), create better opportunities for interaction, and provide better guidance for the process. Examinations of hospital systems and resident programs have shown that structured and supervised handover procedures can dramatically decrease the rates of errors associated with them (Catchpole et al., 2007; Horwitz et al., 2006). It has also been ob- served that implementing such processes is possible within current spending levels and without having to pass new legislation (Coleman and Berenson, 2004), thus building a case for improving quality of care through improved handovers. Instead of merely viewing more frequent handovers as an increased op- portunity for error, they can be viewed as another opportunity for resident learning. They represent a chance to develop macro cognitive skills such as recognizing and analyzing early warning signs or anticipating any problems that might arise for patients on the next shift, understanding warning signs in patients’ response to treatment, better planning for the care of patients, and improving communication and teamwork skills. Handovers are par- ticularly crucial for all clinical staff to learn to navigate, and it is important that residents be familiar with effective strategies in order to apply them successfully in any setting. Suggestions for possible interventions and train- ing follow in the next section. HANDOVER INTERVENTIONS The attention that handovers have received as a target area to improve patient safety is exemplified by the Joint Commission’s decision to issue

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0 RESIDENT DUTY HOURS a “Patient Safety Goal” (effective January 1, 2006) requiring hospitals to standardize their handover approaches and communications as components of improving continuity of care (see Box 8-1) (Joint Commission, 2007). It is generally believed that providing some structure for handover procedures is the appropriate solution for improving outcomes. Other industries in high-risk or high-reliability environments have already identified aspects of BOX 8-1 National Patient Safety Goal 2: Improve the Effectiveness of Communication Among Caregivers Requirement 2E   Implement a standardized approach to “hand off” communications, including an  opportunity to ask and respond to questions.  Rationale for Requirement 2E   The  primary  objective  of  a  handoff  is  to  provide  accurate  information  about  a  patient’s  care,  treatment,  and  services;  current  condition;  and  any  recent  or  anticipated  changes.  The  information  communicated  during  a  handoff  must  be  accurate in order to meet patient safety goals.    In health care there are numerous types of patient handoffs, including but not  limited to nursing shift changes; physicians’ transferring complete responsibility for  a  patient;  physicians’  transferring  on-call  responsibility;  temporary  responsibility  for staff leaving the unit for a short time; anesthesiologist’s report to post-anes- thesia recovery room nurse; nursing and physician handoffs from the emergency  department to inpatient units, different hospitals, nursing homes, and home health  care; and critical laboratory and radiology results sent to physicians’ offices. Implementation Expectations for Requirement 2E   The  organization’s  process  for  effective  handoff  communication  includes  the  following:  • Interactive  communications  allowing  for  the  opportunity  for  questioning  between the giver and receiver of patient information.  • Up-to-date information regarding the patient’s care, treatment and services,  condition, and any recent or anticipated changes.  • A process for verification of the received information, including repeat-back  or read-back, as appropriate.  • An opportunity for the receiver of the handoff information to review relevant  patient  historical  data,  which  may  include  previous  care,  treatment,  and  services.  • Interruptions  during  handoffs  are  limited  to  minimize  the  possibility  that  information would fail to be conveyed or would be forgotten. SOURCE:  Joint  Commission,  2007.  ©  The  Joint  Commission,  2008.  Reprinted  with  permission.

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 SYSTEM STRATEGIES handover processes, and several of their lessons or techniques are applicable to hospital settings (Patterson et al., 2004). Examples from such industries were indeed drawn upon to help formulate the Joint Commission require- ments for these procedures. Improving handovers provides an opportunity to restructure the way residents learn, possibly leading them to greater collaboration with peers and supervisors and helping them to build new skills that promote qual- ity care. One-size-fits-all interventions or complete standardization of the process across all settings, however, is not feasible in a highly variable and complex system such as health care; therefore flexibility in adopting any suggested handover method would be crucial to its success (Patterson, 2008). Application of core components should be evaluated for each set- ting and care scenario to ensure that they are not used superfluously and do not hinder existing effective transfer methods (Patterson, 2008; Perry et al., 2008). It is expected that handover practices would be tailored somewhat to accommodate the differing needs of intensive care units compared to emer- gency rooms, surgical and internal medicine disciplines (Arora and Johnson, 2006), or outpatient and inpatient settings, but that core components would be instituted within a basic framework with consistent principles. Therefore, the basic elements that may help improve current medical han- dover processes presented in the following section are general suggestions. Limited data are available on the implementation of handover guidelines or their effectiveness, but the existing evidence suggests that following a some- what structured protocol does improve resident communication (Chung and Ahmed, 2007) and patient outcomes (Catchpole et al., 2007). General Guidance for Improving Handovers One of the factors most consistently found in the research to help en- sure successful handovers for residents is face-to-face interaction (Horwitz et al., 2007a; Parke and Mishkin, 2005; Solet et al., 2005). Solet et al. (2005) suggest that the combination of oral and written handoff is the most effective for transmitting patient information. Most residency programs do solely written sign-outs, and there are times when physicians can be avail- able only via phone or e-mail to exchange crucial information. However, direct face-to-face communication enhances the comprehension of written orders and allows for greater expression of what points need emphasizing and those that are less urgent (Solet et al., 2005). This approach also al- lows residents to ask questions and clarify instructions, interactions that are helpful for learning and avoiding errors. Face-to-face communication also creates clearer transitions of responsibility and authority on a case, which some believe is equally important to recognize during the handover process (Behara et al., 2005). Because of the benefits of face-to-face interactions,

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 RESIDENT DUTY HOURS finding locations in which they can occur with limited distractions or inter- ruptions may be helpful (Perry et al., 2008; Singer and Dean, 2006). For example, some advocate going to a patient’s bedside to perform transfers, which may have additional benefits associated with patient centeredness. Building in overlap time between shift schedules also helps set aside the time for this type of interaction, improving handover processes and increasing their educational value by providing the opportunity to ask questions and clarify treatment plans or other pertinent information (Afessa et al., 2005; Goldstein et al., 2004; Landrigan et al., 2004; Volpp and Landrigan, 2008). Each of these actions is very team oriented and often requires training be- cause they are not easily instituted by written standards alone. The literature further suggests that structuring the content of what is exchanged during handovers and using uniform language or terminology to communicate information assist in preventing omission of necessary information and help reduce confusion about what tasks are to be com- pleted (Arora et al., 2005). To aid in this process several studies recommend framing content by using written checklists such as “I pass the baton” or “Signout,” created by TeamSTEPPS™ (2007) and Horwitz et al. (2007a), respectively. These checklists outline specific information to exchange dur- ing handovers such as patient name, diagnosis, pending tests, allergies to medications, and so forth. Ideally, they would be as concise as possible without omitting relevant information. More advanced tools that achieve this same goal are electronic sign-out systems. Electronic systems can improve handover content by providing structured, easy-to-access databases of patient information and creating for- matted checklists of tasks that need to be considered for patient treatment. When residents record information electronically, they reduce paperwork and duplication. Electronic systems can also enhance the uniformity of ter- minology and procedures if multiple departments or an entire hospital uses the same electronic program, much like the Department of Veterans Affairs (VA) does with the system it recently adopted (Carpenter, 2008). The VA system combines sign-out strategies by importing patient data electronically but also includes a free-text entry segment that allows users to personally add treatment plans or anticipated tasks (Solet et al., 2005). Together, these factors can increase handover efficiency, reduce instances of content omis- sion, and help resident and integrated teams have consistent and up-to-date information about their patients and care schedules. Although electronic systems have demonstrated improved resident performance and patient outcomes by reducing rates of adverse events and allowing residents more time to spend on direct patient care (Petersen et al., 1998; Van Eaton et al., 2005), very few residency programs or hospitals actually employ electronic sign-out systems. There are reports that roughly 18 percent of large resi- dency programs have some form of electronic sign-out, as do 3 percent of

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 SYSTEM STRATEGIES smaller residency programs (Horwitz et al., 2006), and that less than 5 per- cent of U.S. hospitals have adopted such procedures (Okie, 2007). At least one study has shown that if electronic sign-out systems are cumbersome, residents may find ways to work around them or discard them altogether (Landrigan et al., 2004). Furthermore, if implemented or used improperly, electronic systems can have unintended consequences that undermine cli- nician communication or patient care (Ash et al., 2007; Campbell et al., 2006; IOM, 2006), making the need for training in these systems an im- portant one. Further discussion of electronic system use among healthcare staff is addressed in more detail later in this chapter. In addition to the identified key components of tested handover meth- ods mentioned thus far, results from an observational study of residents dur- ing sign-out by Horwitz et al. (2007a) also illuminated the importance of residents’ having supervision available during the process and having time to formulate clear plans to carry out their assigned tasks. Opportunities for learning could be increased by the presence of appropriate supervisors during the handover process. Learning how to hand over responsibility and information is important, as is learning what patient signs to look for and what types of information are critical to forward to another caregiver. A supervisor can help new residents anticipate a patient’s future care needs. All together, the above results fall in line with a 2005 study that in- terviewed 26 interns from a university teaching hospital. These interns suggested improvements in handover practices to help them make more informed and accurate decisions about patient care and reduce duplicative or unnecessary work. The recommendations included a request for face-to- face interactions; reviewing anticipated areas for care or troubleshooting; and having an accurate, updated, legible, written worksheet that includes standard patient content and medical information (Arora et al., 2005). Since these were the suggestions of first-year residents, it may be that having the structured format is more beneficial to residents as they first learn these processes (rather than after several years of experience), which underlines the educational benefits of using these methods for handovers. Other components that can add structure to handover processes in- clude agreeing on an end-of-shift time that allows for an overlap of shifts, establishing pre-handover routines, determining a set location for transfers to take place, requiring that outgoing residents inform incoming residents of all patients in the department, and conducting joint bedside visits (Singer and Dean, 2006). Innovative Handover Strategies A number of handover strategies currently being developed and prac- ticed incorporate several of the components addressed above. A particular

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4 RESIDENT DUTY HOURS (Leonard et al., 2004). Targeting residents is a good way to introduce team- work and shared accountability across these interdependent teams, which can help develop structured communication among all healthcare workers and ultimately reduce gaps or errors in patient care. Teamwork and Task Performance The focus of teamwork for residents is individual performance in a team environment; helping each resident perform to his or her fullest capacity, most effectively and efficiently, while creating more learning op- portunities. Teamwork is defined as a set of interrelated behaviors, cogni- tions (thoughts), and attitudes (feelings) held by each team member that combine to facilitate adaptive, coordinated performance (Morgan et al., 1986; Salas et al., 2004). Learning and using the five core components of teamwork—specifically, leadership, mutual performance modeling, backup behavior, adaptability, and team orientation (Box 8-2)—can lead to more effective work processes. BOX 8-2 The Five Core Components of Teamwork 1. Team leadership: The  ability  to  direct  and  coordinate  the  activities  of  other  team members; assess team performance; assign tasks; develop team knowl- edge,  skills,  and  abilities;  motivate  team  members;  plan  and  organize;  and  establish a positive atmosphere. 2. Mutual performance monitoring:  The  ability  to  develop  common  under- standings  of  the  team  environment  and  apply  appropriate  task  strategies  to  accurately monitor teammate performance. 3. Backup behavior:  The  ability  to  anticipate  other  team  members’  needs  through accurate knowledge of their responsibilities. This includes the ability  to shift workload among members to achieve balance during periods of high  workload or pressure. 4. Adaptability: The  ability  to  adjust  strategies  based  on  information  gathered  from the environment through the use of backup behavior and reallocation of  intrateam resources. Altering a course of action or team repertoire in response  to changes in conditions (internal or external). 5. Team Orientation: The propensity to take others’ behavior into account dur- ing group interaction and the belief in the importance of the team’s goals over  individual members’ goals. SOURCE: Salas et al., 2005.

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 SYSTEM STRATEGIES Research by Jung and colleagues has demonstrated that as teams work together applying these components, they can increase their productivity and build shared ideas of how to accomplish a task (Jung et al., 2002). Teamwork depends on each team member’s ability and willingness to coop- erate toward achieving shared goals. For residents, these goals are providing effective patient care, maximizing learning, and minimizing errors. An example of using team efforts to achieve these goals is a general medicine residency program that recently developed a team-based teaching program to determine the effects of reducing workload and providing more supervision and teaching upon the quality of resident education and patient care. This was accomplished by creating integrated teams of two attendings (one a primary care physician and the other a hospitalist or subspecialist), two residents, three interns, and two medical students. The team remained together for 2 weeks or more at a time completing daily work and teaching schedules with a cap of 15 patients at any time, who were divided equitably among the interns. Compared to the traditional general medicine resident team, patients treated by the integrated team had a lower mortality rate (1.4 percent vs. 2.4 percent, p = .053) and significantly shorter length of stays (LOSs) (4.2 vs. 4.7 days, p < .01) (McMahon, 2008). The quality of discharge communications was also higher for the integrated team, and members managed to double their amount of time spent in educational sessions (McMahon, 2008), demonstrating that improved patient care and resident learning can both be facilitated by team structures. Other efforts incorporating interdisciplinary or multidisciplinary team rounds had very similar results of reduced LOS and improved core knowledge and team skills (Curley et al., 1998; O’Mahoney et al., 2007). Training Residents in Effective Teamwork Strategies Teamwork skills often need to be learned and numerous reports and publications highlight the importance of team training in realizing goals to enhance patient safety and clinical communication (Barach and Small, 2000; Barach and Weingart, 2004; Jeffcott and Mackenzie, 2008; Leonard et al., 2004). The skills acquired through resident team training can be taught using various techniques (Klein et al., 2009; Rosen et al., 2008; Salas and Cannon-Bowers, 2000a, 2001; Salas et al., 2008; Smith-Jentsch et al., 1998), including simulation strategies that can measure team competency (Zheng et al., 2008), and are valuable because they are applicable to many facets of resident work. Since there are multiple forms of team structures and methods in which teams can be trained, a straightforward way of introducing team-centered activity and skills into healthcare settings is by training residents as a team around completing specific tasks. Also referred to as “task-tailored train-

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 RESIDENT DUTY HOURS ing,” this type of training can be effective for several processes that take place in hospitals (e.g., surgical procedures, handovers, clinical rounds). For example, a study by Chung et al. (2007) applied a task-tailored team approach to the rounding process (a substantial part of some handover pro- cesses) performed by general surgical residents, specifically morning rounds. The strategy focused residents’ work during their rounds on three distinct tasks: detecting postoperative complications early or conducting orderly preoperative workup; informing patients of the agenda for the day; and answering patient questions and complaints. In addition to having them focus exclusively on these tasks, the members of the rounding team (nine members: one PGY-5 and eight PGY-1 to PGY-4s) were assigned specific roles. With this direction, residents’ work became more purposeful and efficient, and they completed rounds and associated work in 1 hour (Chung and Ahmed, 2007). After a year of implementation, attendings on duty ob- served substantial increases in resident professionalism and communication, demonstrating the positive effects of team structure and culture, not only on workload but on general attitude as well. Such structure also automated team continuity of care, increasing patient awareness of the resident team and satisfaction with care received (Chung and Ahmed, 2007). Whichever methods of handover intervention or error reporting are used, residents will have to be trained in the team components of coordi- nation, communication, and cooperation to conduct them most effectively and efficiently. In some facilities, faculty or supervisors may also have to be trained in these matters in order to ensure their organizational adoption and most effective implementation. CONCLUSION Redesigning any part of the resident learning process is a challenge. To eliminate preventable adverse events and intercept other errors before they harm the patient, it is important to have in place an environment that is both mindful of errors and nonpunitive, as well as leaders willing to consider redesign of the institutions’ systems and processes as necessary to reduce risks. The emphasis on handovers, blame-free error reporting, and teamwork does not mean that individual residents are not expected to develop a sense of loyalty or personal responsibility for individual patient care, but it helps ensure that the best information is available at all times for patient care given that a resident or any caregiver cannot be at the bedside 24 hours a day, 7 days week. It may not be possible to eliminate discontinuity altogether in healthcare settings, but the training system can strive to minimize its effects by enhancing the quality of handovers and error reporting, promoting patient-centered approaches, and improving physician relationships by facilitating communication through team struc-

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