Interdisciplinary Collaboration, Team Functioning, and Patient Safety1
As concern over the number of health care errors has risen, so has interest in the development of care delivery processes that minimize the potential for error. Among the strategies proposed by experts is the creation, training, and support of highly developed interdisciplinary teams and collaborative work groups (Chassin et al., 1998; Disch et al., 2001; Palmersheim, 1999). The desire for effective team performance has been mentioned in the health care literature for years. What has been less evident is what constitutes effective team performance, how it is created and nurtured, and how it directly or indirectly influences care delivery outcomes. These unknown attributes and products of work teams should be explored thoroughly to enable sound recommendations concerning the promotion of interdisciplinary teams and collaborative work groups as a measure for assuring safe patient care.
This appendix is divided into three main sections. The first contains an extensive review of the literature concerning interdisciplinary teams and their impact on care delivery and safety outcomes. Included in the review are summaries of relevant research from health care, industry, and other work groups involved in error-prone and high-risk team behaviors. The second section provides evidence-based recommendations for strategies to develop, train, and assess the performance of interdisciplinary teams. The final section delineates needs for further research.
TEAMS AND PERFORMANCE OUTCOMES
The importance of understanding and maximizing team performance has been discussed by several authors, who note that 70 to 80 percent of health care errors are caused by human factors associated with interpersonal interactions (Schaefer et al., 1994). Others stress the increasing numbers of professionals directly involved in care delivery processes and the relationship between the resulting importance of cooperative working relationships and the complexity of patient needs (Headrick et al., 1998). Addressing this demand is hindered by a number of factors, including the wide variation in team makeup, which ranges from those composed of senior clinicians overseeing residents and fellows (Posner and Freund, 1999) to those involving representatives of multiple professions from multiple organizations (Green and Plesk, 2002; Kosseff and Niemeier, 2001; Stone et al., 2002). Clear differences exist in those situations in which team makeup is driven by hierarchical learning or reporting mechanisms and those in which the team members have equal influence on team performance and outcome. In addition, health professionals interact in a variety of ways, ranging from loosely coordinated collaborative relationships at one end of the continuum to more tightly organized work teams at the other, often within the same day (Headrick et al., 1998). Difficulties also arise when determining whether the failure of a team’s performance is the cause or the result of poor team member behavior. In a study of deteriorating team performance, a back-and-forth pattern developed between member performance and overall team performance as top management teams began to fail (Hambrick and D’Aveni, 1992).
Theories of Work Team Effectiveness
A number of theories exist concerning the ways in which teams work and how they produce favorable outcomes. Some of the more prominent theories relevant to the discussion of decision making for patient safety and for the creation of desirable care delivery outcomes are reviewed below.
Early Theories of Team Behavior
Early theoretical efforts to conceptualize the group processes operating in teams drew heavily upon sociological studies of hierarchical differentiation. In these investigations, the social structure of the group was examined for its impact on team communication and problem solving (Feiger and Schmitt, 1979). In summarizing the basic research in this field, Feiger and Schmitt note that status-driven hierarchical processes undermine analysis and problem-solving activities in teams. These same processes may facili-
tate coordination and synthesis activities, however. Feiger and Schmitt also examined the relationship between degree of hierarchy and patient outcomes in four teams in a long-term care setting. They found that better outcomes were perfectly rank-correlated with less hierarchy in the interaction patterns of team members.
In focusing on other group processes that can undermine the effectiveness of team performance, Heinemann and colleagues (1994a) summarize several sociological theories relevant to group decision making and apply them to geriatric interdisciplinary health care teams. Groupthink (Janis, 1972, 1982)—a process theorized to affect highly cohesive teams in which efforts are made to control the input of information that challenges the team’s thinking—is more likely to occur in situations of high stress where there is pressure to act. The theory was first used to examine the dynamics of what went wrong in political fiascoes, such as the Bay of Pigs invasion of Cuba under the leadership of President Kennedy and the Challenger disaster. In tests of the theory, directive leadership was found to increase the likelihood of groupthink processes.
Theories of framing and group polarization have been used to refine ideas developed in groupthink theory. Framing theory focuses on the interpersonal context of decision making, while group polarization theory emphasizes how group discussion exaggerates initial preferences of team members for risk taking or caution. Discussions also have focused on the linkages between the stage of development of group/team cohesiveness and the potential for groupthink behavior (Longley and Pruitt, 1980). In addition, Farrell and colleagues have examined how conditions in geriatric teams may approximate conditions required for groupthink processes and illustrate these processes in a case study description (Farrell et al., 1986, 1988, 2001). They offer the following guidelines for minimizing poor decision making related to these team processes: (1) emphasizing open, honest, and direct communication; (2) facilitating team development, which includes writing a mission statement, formulating goals and procedures for operating, clarifying roles, and orienting new team members; and (3) helping teams identify team processes that predispose to poor decision making, such as overreliance on directive leaders and team isolation. They emphasize the importance of retreats, administrative or process meetings, and acknowledgment of effective work.
Group development theory has provided the theoretical context for a number of studies of health care teams (Farrell et al., 1986, 1988, 2001). This theory posits that teams pass through a series of developmental stages prior to reaching their maximum work effectiveness. Few efforts have been made to measure team development and examine factors that influence team development. Consequently, the usefulness of this theory for understanding team safety behavior is uncertain. One study of researcher-designed and/or
-adapted measures of team development and team functioning has been conducted. This investigation explored a variety of factors affecting team development and team functioning and the impact of team functioning on team member burnout (Heinemann et al., 1994b).
Theories of Team Behavior and Error
Sasou and Reason (1999) have created a taxonomy of team errors, which they believe highlights the essential components of error detection in group processes. The dimensions of this taxonomy include (1) a determination of how the team made the error, (2) an appreciation for whether the team recognized the error and corrected it, and (3) an understanding of the human relations that contributed to the error. Sasou and Reason expanded the work of Reason (1990), who categorized human errors into three types—mistakes, lapses, and slips. According to the original conceptualization, mistakes and lapses arise in the planning and thinking process, whereas slips occur primarily in the execution phase. Mistakes and lapses are more likely to occur during team processes, whereas slips are caused primarily by individuals (Sasou and Reason, 1999).
Team errors consist of an error-making process and an error-recovery process. In the error-making process, errors occur as a result of individual or shared decision making. Individual errors are subdivided into independent and dependent errors according to the extent of information available during the decision-making process. Independent errors occur when the information available to the individual team member is correct; dependent errors occur when some part of the information is incomplete, absent, or incorrect. Shared errors are errors shared by some or all of the team members, regardless of whether they were in direct communication with the individual initiating the error. Shared errors are likewise subdivided into independent or dependent according to the amount and accuracy of the information available (Sasou and Reason, 1999).
The error-recovery process includes three stages—detection, indication, and correction (Sasou and Reason, 1999). The initial stage, detection, is followed by the indication phase, in which an identified error is brought to the attention of the group. If this fails to occur, the error is not fully recovered, and actions taken to correct the error are not likely to work. The final stage involves actual correction of the error.
Sasou and Reason (1999) have applied this taxonomy to 21 error events occurring in the nuclear industry, 21 events in the aviation industry, and 25 events in the shipping industry. Human factors reports were used to identify 28 team errors in nuclear industry events, 8 in aviation industry events, and 9 in shipping industry events. The findings suggest that individual er-
rors occur more frequently than shared errors and that failures to detect errors occur more often than failures to indicate or correct.
In this same study, the investigators identify internal and external factors that contribute to the errors made. They define these contributors as performance-shaping factors (PSFs), which include external factors such as darkness, temperature, and high work requirements that are shared by all team members working in the same environment. Internal PSFs include high stress, excessive fatigue, and deficiencies in knowledge and skill. According to Sasou and Reason (1999), internal PSFs are often influenced by external factors and may vary across individuals even under the same set of circumstances. Team PSFs are a third potential contributor to error. These include, for example, lack of communication, inappropriate task allocation, and excessive authority gradient (Sasou and Reason, 1999).
In their review of adverse events in the nuclear, aviation, and shipping industries, Sasou and Reason (1999) found the most common team PSF to be failure to communicate. Failure to communicate resulted in the inability to detect both individual and shared errors. Excessive professional courtesy, overtrusting, an air of confidence, and excessive belief were additional factors. Inadequate resources and deficient task management created errors and also led to detection failures. Excessive authority gradient was the most dominant factor in failures to indicate and correct errors, although excessive professional courtesy also led to team member reluctance to challenge error makers. Shared errors commonly occurred during the human–machine interface, where low task awareness, low situational awareness, and excessive adherence to overreliance on established practices contributed to mistakes. Failures to detect were influenced by deficiencies in communication and resource/task management, excessive authority gradient, and excessive belief. Failures to indicate/correct were influenced by excessive authority gradient, excessive professional courtesy, and deficiency in resource/task management. Based on these findings, the authors recommend that team error-reduction strategies focus on clarifying team member responsibility and accountability and on improving interpersonal skills performance. This includes efforts both to maximize communication success and to provide constructive feedback to established and well-respected team members.
A second theory of team behavior and safety processes proposes that four boundaries of safe or acceptable practice are evident in systems—physical, psychological, social, and economic (Bea, 1998). Individuals within systems function within a “safety space” created by these four boundaries and take action to withdraw when they perceive they are approaching one of the unsafe areas. In this model, the physical boundary reflects conditions in which the work or effort required is perceived to be
excessive. When approaching this boundary, employees develop work shortcuts to reduce the perceived threat. The psychological boundary represents conditions in which mental effort, stress, or anguish is unacceptable. Safety protection behaviors when approaching this boundary include withdrawal and aggressive action. The social boundary clarifies the limits of acceptable group norms and behavior and may include legal or corporate expectations for performance. The economic boundary indicates where economic viability or security is threatened and when approached often leads to cost-cutting measures.
Strategies to keep teams and organizations functioning within the safety zone created by these boundaries involve designing robust structures that include attention to (1) redundancy, in which alternate paths are available to carry demands; (2) ductility, in which components are able to deform without failing and to shift demands to other paths when necessary; and (3) excess capacity, in which components are designed to carry demands beyond those normally expected. Full integration of these fail-safe measures requires the development of cohesive work teams that emphasize integrity, trust, and cooperation (Bea, 1998). Necessary also are sufficient training of members who have direct influence over the system’s safety; the development of positive economic and psychological incentives that promote safety behaviors; the development of effective internal and external checking and verification procedures; and standards of performance, including procedures for disciplinary action when rules are breached and the introduction of methods to promote early identification of and response to emerging risks.
According to this model, three approaches can be used to maximize consistent practice within teams and return to safe systems. The first is a reactive approach, which results in analysis of the failure or failures of the system. This process focuses on understanding the reasons for failure and how to avoid it in the future. Most commonly, the process results in the development of safety guidelines, procedures, and rules for performance (Bea, 1998). The proactive approach works to analyze the system before it fails and to put into place measures that prevent the anticipated failure. One of the difficulties with this approach is its focus, which directs attention to what may go wrong rather than what is working right. For this reason, Bea adds a third approach, which he believes needs further development and exploration. This real-time approach stresses the responses that occur during a crisis when a buildup of danger signals requires immediate action to return the system to its normal state. The real-time approach recognizes those situations in which the sequence of events or the novelty of the situation is unpredictable and different from previous experiences. In this scenario, employees are provided with enhanced abilities to rescue themselves from the threatening event and to return the system to its usual safe state. Training, including the use of simulation techniques, is the most use-
ful approach for developing these skills. Ideally, the training should address the three cognitive processes that govern how well people respond during a crisis: (1) overall knowledge of background information and related conditions; (2) attention dynamics, or the control and management of mental workload, maintenance of situation awareness, and avoidance of fixations; and (3) strategy development, which includes considering trade-offs between conflicting goals, dealing with uncertainty and ambiguity, setting effective priorities, and making good decisions (Bea, 1998).
A third team- and safety-related theory focuses on team effectiveness, including the ability to avoid or minimize the potential for error. In this model, team effectiveness is measured by the team’s ability to solicit and value differences in team members’ assumptions and world views (Korsgaard et al., 1995). Even in the best of circumstances, however, team members may become disengaged from the team if they believe the action taken by the team differs from their personal view. For this reason, reviews of effective team decision making should consider both the quality of the decision and the impact of the decision-making process on team members’ commitment to the decision, their continued attachment to the team, and their trust in the team leader. These latter three dimensions serve as antecedents to cooperation among team members, which is essential to the ultimate support for and action on a decision made.
One approach to determining the potential level of team member support for a team decision is consideration of a team member’s perceived level of procedural justice during the decision-making process. The tenets of procedural justice suggest that fair treatment is central to all humans and is a major determinant of their reaction to how decisions are made and executed (Korsgaard et al., 1995). The concept is focused in particular on the meaning of involvement in the decision-making process and less so on the individual’s ultimate control over the decision outcome. Perceptions of fairness are influenced by the extent to which team members show consideration for the input of other team members and the extent to which individual members’ input affects or is reflected in the final decision. In the case of health care teams designed according to hierarchical reporting determiners, procedural justice is influenced considerably by the senior members of the team. If the senior members routinely seek and incorporate junior members’ opinions in decision making, junior members are more likely to perceive the team process as just and supportable. If, on the other hand, junior team members perceive the process as unjust, they are much less likely to cooperate with or support any decisions made. They also are far more likely to disengage from the group and to minimize the potential benefit of the group process for patient safety decisions.
This theory of team effectiveness and the impact of team leader consideration and responsiveness was tested in a study of intact teams of middle-
and upper-level managers of a Fortune 500 company (Korsgaard et al., 1995). In this study, decisions made in teams with high levels of consideration behavior by leaders were perceived by team members as much more fair than decisions in low-consideration groups. Members of high-consideration groups also were significantly more committed to the decisions made, especially when their level of influence was low. In addition, high-consideration group members increased their commitment to the team over time, while low-consideration group members disengaged. Member influence in decision making had the most dramatic effect, with the quality of decisions made in high-influence groups being significantly greater than that of decisions made in low-influence groups. A comparable effect on decision quality was not seen for level of leader consideration.
Organizational Behavior and Team Performance
More recent theories have been proposed concerning the ways in which organizations and work groups successfully reduce the potential for error. Some of these theories center on high-reliability organizations, defined as organizations that operate relatively free of error for long periods of time, frequently in hazardous environments (Bea, 1998; Gaba, 2000). High-reliability organizations view safety as the top functional objective for the organization (Gaba, 2000). They have extensive process auditing procedures to assist in the identification of safety problems and have well-established reward systems that reinforce error-reduction behaviors (Bea, 1998). High-reliability organizations focus their error-reduction activities at the systems level and incorporate rehearsals of familiar scenarios of failure. They also recognize the likelihood of human error and attempt to train their workforce to recognize and recover from such error (Reason, 2000).
According to Gaba (2000), health care institutions have viewed safety as a by-product of non-negligent care rather than a goal to be achieved. This world view differs from that of high-reliability organizations, in which safety is the focus of all actions. Altering this view has been difficult, especially in light of the problems associated with planning for and measuring the impact of accidents that do not occur (as a result of the focus on error-free outcomes). Gaba suggests that health care’s decentralized system contributes to the proliferation of error. Individual practices and the reluctance to consolidate care delivery processes have led to highly variable performance patterns and the likelihood of negative events. Even in those cases in which health care organizations have joined larger health services systems, the focus on these collaborations has been on business operations and cost savings, not safe practices. Shifting this focus to coincide with the expectations of high-reliability organizations will be difficult.
An application of high-reliability theory has been described for and tested in organizations requiring nearly error-free operations to prevent the occurrence of catastrophes (Weick and Roberts, 1993). In this model, high-reliability organizations engage in aggregate mental processes that are more fully developed than those evident in organizations concerned with process efficiency. Weick and Roberts have tested this model with flight team members whose interactions with others are coordinated in explicit and visible ways and whose socialization is continual. In addition, when working alone, these workers have less of a grasp of the system than when working together. In this situation, the system is constructed of interdependent worker abilities and of individuals who react quickly to novel and rapidly occurring situations. Furthermore, the consequences of any lapse of team member attention are rapid and disastrous.
In this model, the collective mind of group members is a reflection of overlapping knowledge and actions that are taken with care, rather than any within-group similarity of attitudes (Weick and Roberts, 1993). Weick and Roberts define the actions taken with care as heedful actions—actions that are critical, consistent, purposeful, attentive, and vigilant. Heedful performance denotes continuous learning that is modified by previous performance. The more heedful the interactions among team members, the more developed is the team’s collective mind and the greater is the team’s ability to comprehend and respond to unexpected events that evolve quickly in unanticipated ways. When heedful actions are spread across more activities and more connections, group understanding is increased, and the potential for errors is reduced.
Weick and Roberts (1993) suggest that when heedful behaviors are visible, rewarded, modeled, and discussed, new team members learn this style of responding. The new team members subsequently incorporate these behaviors into the definitions of who they are in the system and reaffirm this style in their actions. Collective mind is renewed and reaffirmed during the socialization of new team members and is maximized when senior team members describe and review representative failures as well as successes. The style of senior member interactions also contributes to the development of heedful behaviors by new team members. If those interactions are poor, heedful behavior may suffer, resulting in errors in communication or action by new members. In addition, attention may be focused on individual actions or needs rather than group actions. If this process continues over time, small, individual errors can grow to large-scale group error. Weick and Roberts suggest that this process has important implications for team development strategies in which training may be focused exclusively on content rather than heedful behaviors. They also recommend that training programs include attention to the social processes and dynamics of the work group.
An additional theory of organizational behavior relevant to team interactions and patient safety is the microsystem concept described by Nelson and colleagues (2002). According to this model, the health system is composed of a front-line clinical microsystem, an overarching macrosystem, and patient subpopulations needing care. Two assumptions of this framework are that the microsystems produce the quality, safety, and cost outcomes associated with delivery of services and that the outcomes of the macrosystem can be no better than the microsystems of which it is composed. To bring about the changes needed to reduce errors in health care, fundamental changes need to occur at all levels of the system. In addition, efforts need to be made to optimize each individual microsystem and to establish seamless, timely, reliable, and efficient linkages among clinical microsystems. According to Nelson and colleagues, one of the benefits of this conceptual approach is its attention to the front-line component of service delivery.
Health care microsystems evolve over time and conduct the primary work associated with the core aims of the organization. They are composed of a small group of people who work together on a regular basis to provide care to a discrete subpopulation of patients (Nelson et al., 2002). In this framework, clinical microsystems are the essential building blocks of the health system and as such contribute significantly to the outcomes seen. They are tightly or loosely connected with one another and perform better or worse under different operating conditions.
This microsystem model was tested by Nelson and colleagues (2002) through the use of a qualitative design consisting of observation, interview, review of documents, and analysis of financial data. In this study, 20 high-performing clinical microsystems were identified through a review of lists of award winners, literature citations, previous research findings, expert opinion, and nominations from leaders of exemplary organizations. A structured screening interview and questionnaire were used to select 20 microsystems from an initial 75 sites. The investigators identified a set of nine success characteristics evident across all sites that led to highly favorable systemic outcomes: the leadership of the microsystem, the culture of the microsystem, the macro-organizational support of the microsystem, a focus on patients, a focus on staff, interdependence of care teams, the availability and use of information and information technology, a focus on process improvement, and an outstanding performance pattern (Nelson et al., 2002). An emphasis on patient safety, health professional education, and awareness of the impact of the external environment also were evident at these institutions.
Nelson and colleagues (2002) believe that the critical role of these naturally occurring microsystems has been ignored in previous efforts to reduce health system errors. They suggest that attention has been directed instead
at clinicians, consumers, and others, thereby ignoring the essential building blocks of the health care system. They recommend pushing the decision making, process ownership, and accountability expectations out to the microsystems where the greatest potential for impact lies.
This micro- and macrosystem model can be linked to earlier work on “teams” and their role in health care delivery conducted by Schmitt (1991). Schmitt sorts the interdisciplinary health team literature into three different levels according to the extent of linkage between the microsystem and the macrosystem of the health care institution: (1) the functioning team as a small work group, which usually is defined as three or more members representing different disciplines who share responsibility for an integrated plan of care for a specific cohort of patients over time; (2) the unit-level microsystem, in which the mix of staff involved with patients varies from patient to patient; and (3) institutional policies and procedures that support either the small work group or unit-based care delivery process. The impact of team approaches on patient outcomes, including safety outcomes, potentially can be studied from any of these perspectives.
This shift in conceptualization is further described by Schmitt (2001), who introduces the ideas behind “team” as the second and third levels of relationship falling between microsystem and macrosystem. The basic shift in thinking in this approach is its focus on the concept of collaboration in the delivery of care among diverse health professions. Collaboration, which has been defined as “cooperatively working together, sharing responsibility for solving problems and making decisions to formulate and carry out plans for patient care” (Baggs and Schmitt, 1988:145), incorporates efforts to coordinate care. Interdisciplinary teams can be viewed as one specific form of collaboration that is relevant to certain situational circumstances of health care delivery. Questions can then be raised about other forms of collaboration between disciplines and the effects of that collaboration on care delivery outcome.
Examples of studies that fit into this refined framework include a study of differences in mortality outcomes in intensive care units (ICUs) in 13 U.S. hospitals. After performing risk adjustment for differences in patient severity of illness and ruling out several other potential explanations, Knaus and colleagues (1986) argue that the greater presence of interdisciplinary interaction and coordination of care among staff contributed to the differences seen. Included in their discussion of potential contributors to favorable care provider relationships is the availability of policies and procedures (e.g., joint care rounds) that support coordination and collaboration in care, which they suggest accounts for the lower mortality rates seen in some units. The identification of these differences in the care delivery process was retrospective, however, making the assurance of cause–effect relationships uncertain. In a second, prospective study of 42 randomly chosen ICUs
(Shortell et al., 1992, 1994), an ICU nurse–physician questionnaire was used to evaluate perceptions of the multiple dimensions of care delivery process, such as leadership, communication, coordination, and conflict management. Although not associated with risk-adjusted mortality, these caregiver performance variables were associated with better technical care, efforts to meet family needs, and decreased ICU length of stay.
In a second national study of 25 ICUs, Mitchell and colleagues (1996) found the flow of information that is characteristic of interdisciplinary collaboration to be associated with more-favorable staff perceptions of unit conflict management, collaboration, staff quality, and quality of care. It was not associated with any clinical outcomes, however. Moreover, many aspects of the care delivery process were examined in these studies, making it difficult to assess the actual contribution of interdisciplinary caregiver interaction to the outcomes seen.
Additional support for the interdisciplinary collaboration concept is provided by Baggs et al. (1992, 1999), who examined the relationship between collaborative discharge decision making between nurses and physicians and patient outcomes. In both studies, nurses’ perceptions (but not physicians’) of greater collaboration was found to be linked to a small but significant reduction in risk-adjusted mortality and readmission in the medical ICU. Higgins (1999) could not reproduce these findings, but there were significant differences in her study design compared with that of Baggs and colleagues. More recently Gittell et al. (2000:810) studied “relational coordination,” defined as consisting of “four communication dimensions (frequent, timely, accurate, and problem-solving communication) as well as three relationship dimensions (shared goals, shared knowledge, and mutual respect)” among respondents representing five disciplines (physicians, nurses, social workers, physical therapists, and case managers) caring for hip and knee arthroscopy patients in nine hospitals. Greater perceived relational coordination was associated with patient perceptions of higher quality of care, less post-operative pain, greater post-operative functioning, and shorter length of stay.
Generally, the literature concerning collaboration in health care focuses primarily on nurse–physician interaction, whereas the literature on interdisciplinary teams focuses on a broader array of disciplines involved in care delivery. To develop a full appreciation of the impact of collaboration on safety outcomes, research must be expanded (as in Gittell et al.’s  study) to include additional disciplinary groups.
Health Care Work Groups and Performance Outcomes
Much of the literature pertaining to interdisciplinary health teams has focused on the clinical microsystems level, particularly as it relates to multi-
or interdisciplinary care delivery teams. Following is a review of this research to date.
Six integrative reviews of research concerning interdisciplinary teams and care delivery outcomes were found in a search of medical, nursing, psychology, sociology, education, and business electronic databases. In the following summary of these integrative reviews, additional reports relevant to the content of the reviews are incorporated.
Integrative Review # 1
The earliest integrative review is that of Halstead (1976), focused on the literature pertaining to team delivery of care in the areas of chronic illness and rehabilitation. Halstead (1976:507) identifies three broad categories of literature in his review of 25 years of team-related reports: opinion articles, descriptions of programs, and “serious efforts to investigate the effectiveness of team care.” The bulk of the literature falls into the first two categories.
Halstead (1976) identified only 10 studies published between 1951 and 1975 that met the criterion of requiring a comparison or control group as part of the design. Given the emphasis on chronic illness and rehabilitation, most of the outcomes focused on various types of patient functioning (e.g., social, intellectual, and activities of daily living). In about half of the studies, investigators focused on morbidity outcomes or measures of service utilization; few addressed employment, mortality, or costs of care. In judging the overall effectiveness of team interventions, six of the studies revealed an association between favorable outcomes and the team approach. In two studies, results were mixed, supporting greater effectiveness for only some of the outcomes seen. The results of the remaining two studies indicated that team approaches are as effective as usual care approaches (no difference). The results also were mixed in studies in which utilization of services and costs of care were assessed. In light of the meager evidence, Halstead (1976:507) concluded that team care is still “largely a matter of faith and the subject of many platitudes.”
Integrative Review # 2
The second systematic review targeted research examining the effectiveness of interdisciplinary geriatric teams (Schmitt et al., 1988) and focused mainly on studies published in the early 1980s. Eleven studies were identified that met the criterion of having a comparison or control group, or other design features used to address the absence of such a group. The geriatric teams examined were almost all hospital-based. In a later review, Schmitt (2001) organized and summarized the outcome data from Schmitt
et al. (1988) to allow for a clear comparison with Halstead’s (1976) earlier results. Outcomes examined in these studies covered the same broad range represented in Halstead’s review, with differences appropriate to the geriatric focus (i.e., the employment category is missing, but referrals to higher or lower levels of care are examined in about half the geriatric studies). Of the 11 studies included, the results from 7 demonstrated greater effectiveness with the team approach; results of 3 studies indicated that team care is similar to or more effective than (depending on the outcome studied) the care provided by the comparison group; and results for 1 study showed no differences in any of the outcomes compared.
In summarizing the similarities and differences between the reviews of Halstead (1976) and Schmitt et al. (1988), Schmitt (2001) notes that functional outcomes were the most frequently assessed in both cases. Functional status also demonstrated a positive change in response to the team approach. In the geriatric team studies, referral to reduced levels of care was a consistent finding with the team care approach. When mortality rates were examined, no difference is seen. Service utilization was investigated more often in recent studies, but with mixed results. Where investigators studied cost outcomes, no differences in costs or cost savings were found. In many of these studies, however, the financial impact of greater use of health services was not studied directly.
Integrative Review # 3
Schmitt (2001) provides a third summary of the outcomes of 24 studies of the effectiveness of geriatric (20 studies) and other team (4 studies) interventions, focusing on the mid-1980s to the mid-1990s. Of the 24 studies examined, 1 finds team intervention to be more effective, while 15 show the team approach to be similar to that of the comparison group for some outcomes and more effective for others. The more frequent pattern of mixed outcomes (i.e., some improved, others similar) may be related to the greater frequency with which multiple outcomes are examined in any given study, as compared with earlier studies in which the number of outcomes is limited to one or two. Results of 7 studies show no difference in outcomes. In 1 study results are mixed, with survivors in the experimental group having lower functioning than those in the comparison group, probably because team intervention reduces mortality by keeping sicker individuals alive. Results indicate that team consultation activities alone are not sufficient to produce improved outcomes. An impact was demonstrated, however, when expert teams provided both assessment and treatment interventions.
Looking across the above three reviews (Halstead, 1976; Schmitt, 2001; Schmitt et al., 1988), several things are apparent: (1) the study of team approaches to care delivery has focused primarily on the level of the func-
tioning team as a small work group in which the same identified team members share responsibility for a specific cohort of patients over time; (2) there has been considerable growth in efforts to examine the impact of team approaches using more rigorous research designs; (3) a greater variety of outcomes is being examined in any given study; and (4) there is a slowly accumulating body of evidence, primarily in hospital settings and mainly with older populations, that conscious team approaches to care delivery can result in improvements in a range of outcomes. As a group, however, the studies have a number of serious limitations, identified in two of the reviews. Among the concerns mentioned by Schmitt (2001) and Schmitt et al. (1988) are the inability to rule out confounders, such as a “demonstration” effect; differences in skill mix between team and usual-care personnel; differences in treatment intensity; and a long-standing focus on the effects of a single team compared with the usual-care situation. From study to study, structural aspects of the teams, such as size, mix of disciplines, and communication frequency and pattern, also vary. In addition, only recently has an effort been made to determine the magnitude of the effectiveness of team interventions. As a result, the impact of the overall quality of such efforts on outcomes cannot be assessed. Moreover, little attention has been paid to the multifaceted dimensions of team relationships, with no attempt being made to assess the active elements of the team intervention (e.g., communication processes, joint care planning, improved coordination of care).
Very recently, researchers have attempted to define the minimum requirements for team structure and process and to assess the effectiveness of comprehensive team delivery of care on care delivery outcomes. In a national, multisite controlled trial of the impact of the Veterans Administration’s (VA) inpatient unit and outpatient clinic geriatric evaluation and management (GEM) interdisciplinary teams on patient outcomes (Cohen et al., 2002), the core team members were clearly defined, and the elements of the intervention were well scripted. Process-of-care data assessing the perceptions of the effectiveness of team functioning were gathered at the initiation of the study and annually for three additional years. Team functioning and effectiveness data were compared with previously collected similar information from a representative sample of VA GEM teams (Schmitt et al., 2000).
No evidence was found that the GEM interventions reduced mortality as compared with usual care; however, the GEM inpatient unit treatment positively affected physical functioning and general health, pain, activities of daily living, and physical performance at discharge. Only the difference in pain levels was sustained at the 1-year follow-up point, regardless of type of follow-up care. Patients receiving outpatient GEM clinic treatment for a 1-year period posthospitalization improved only in mental health as compared with their hospital discharge score. No differences in costs of care
among the alternative treatments were evident at 1 year. Ineffective team functioning was ruled out as an explanation for the lack of greater differences among the alternative treatments because team “functioning met the criteria generally accepted to characterize the best-functioning units, with team functions and processes of care that were equivalent to those of other highly effective programs” (Cohen et al., 2002:911).
Integrative Review # 4
A fourth integrative review is that of Schofield and Amodeo (1999), who searched education, psychology, medical, and sociology databases to identify work on interdisciplinary teams. Their review was designed to address a series of questions, two of which pertain to the relationships between interdisciplinary teams and treatment and cost of care. The reviewers identified 138 articles containing significant substantive content pertaining to interdisciplinary teams. Of these, 55 were labeled as descriptive because they addressed some aspect of interdisciplinary teams but did not include a specific description of team process or any empirical data on process or outcome. Fifty-one articles were identified as process-focused because they contained descriptions of interdisciplinary team processes but no formal data. Twenty-one articles were research-based, using either qualitative or quantitative methods to assess the effect of a variety of variables on the team itself. An additional 11 articles were defined as outcome-based because they used research methods to assess the impact of an interdisciplinary team on some outcome that was distinct from team functioning. Schofield and Amodeo noted that only 1 of the 11 investigations adhered to four study design elements they considered necessary for assessing whether a team had an effect. Unfortunately, the reviewers did not explicitly identify these criteria in their review, nor did they provide a table highlighting the studies reviewed. Based on the investigations mentioned in the article, however, and the reference list provided, there appears to be little overlap with the studies critiqued in other reviews.
Schofield and Amodeo’s (1999) conclusions highlight the deficiencies associated with the existing research on interdisciplinary teams. They conclude that the available literature repeatedly endorses the team model, but contains little evidence of efforts to evaluate team effectiveness or assess team impact. The majority of the articles reviewed simply assume the value of interdisciplinary teams. Schofield and Amodeo also note the interchangeable use of the terms “interdisciplinary” and “multidisciplinary,” which are rarely defined by investigators. They express concern about the absence of well-conceived conceptual models of interdisciplinary teamwork and the failure to assess the actual components of the interdisciplinary process. According to the authors, investigators routinely treat the team as a fixed
entity rather than a multidimensional group consisting of diverse players, processes, and expectations for performance. Schofield and Amodeo suggest that the quality of the conceptualization of the teams is so poor that reliable conclusions cannot be drawn.
Integrative Review # 5
In a fifth review, Zwarenstein and Bryant (2002) include studies containing an explicit statement that the evaluated intervention was designed to improve collaboration between the nursing and medical professions. All randomized controlled trials, controlled pre- and postintervention studies, and interrupted time-series studies were eligible for inclusion. The authors searched the Cochrane Library and MEDLINE databases for evidence of research reports. Most of the articles identified in their search were descriptive reports of the problem, studies of professional substitution, and evaluations of undergraduate training programs and their impact on graduates’ attitudes toward collaboration.
Two studies meet Zwarenstein and Bryant’s (2002) inclusion criteria. The first study (Curley et al., 1998) was designed by an interdisciplinary continuous quality improvement team for the purposes of improving patient care on the inpatient medicine units of one hospital. This investigation was a randomized controlled firm trial of daily interdisciplinary rounds that included all disciplines involved in patient care, with order writing occurring during rounds. A “firm” was defined as a health care delivery “unit” that was part of the Firm System created in the study hospital. Three firm medical inpatient “units,” consisting of two ward services in each firm unit, comprised similar groups of patients and physicians. Three medical inpatient wards implemented the new rounds, while three wards continued with traditional physician work rounds.
Because of the hospital’s usual procedure of randomly assigning patients and physicians to firms, there were very few demographic or clinical differences among the 1,102 patients in the experimental and usual care groups. No differences between the experimental and usual care wards were seen for hospital mortality, type of hospital disposition, or readmission rates; after controlling for baseline differences in case mix, however, length of hospital stay for patients admitted to the experimental wards declined significantly following the intervention, as did total charges for care. A greater percentage of orders written for aerosol use were evaluated as appropriate on the experimental wards as compared with the control wards. In addition, a chart audit by nutritionists found dietary recommendations were implemented more frequently on the experimental wards. Staff on the experimental wards also reported more favorable perceptions of teamwork and communication patterns and a better understanding of patient care.
Control ward findings were unchanged during the same period. Subsequent to the study, interdisciplinary rounds were implemented on all six medical wards.
The second study reviewed by Zwarenstein and Bryant (2002) was conducted in Thailand (Jitapunkel et al., 1995) and involved the randomization of patients to a study or control ward, both of which were female wards, each in a separate hospital building. The new rounding process involving physicians and nurses occurred four times per week and consisted of joint decision making concerning treatment plans. A weekly team case conference of all disciplines involved in the care of these patients also was introduced. A historical comparison of current and past patient experience on the two wards was conducted as well. There were no differences in mean length of stay or mortality rate between the two study wards, during the trial or historically. However, reduced lengths of stay occurred on the experimental ward among those aged 60–74 who were discharged home. The benefits of collaboration were rated as “high” by team members.
Recent examples of reports evaluating the use of team-based, collaborative rounds that do not meet the rigorous design guidelines for a Cochrane systematic review include one focused on the care of cardiac surgery patients (Uhlig et al., 2002). This study was designed as a continuous quality improvement effort and nested conceptually in human factors science, the aviation safety literature, and high-reliability organization theory. A before–after single-case design was used to evaluate the introduction of daily interdisciplinary rounds that included the patient and family. In this process, a communication protocol was followed to maximize the consistency and completeness of the information exchanged and to facilitate effective decision making. During the rounding process, team members, patients, and families were encouraged to discuss anything they believed might have gone wrong in the care delivery process. The bedside round process was evaluated biweekly to ensure that the intended outcomes of the team process were achieved. According to the report’s authors, mortality rates have declined significantly since the introduction of the team-based approach, and the levels of satisfaction with the care delivery process among both patients/families and team members have increased.
In a third randomized controlled trial identified by Zwarenstein and Bryant (2002), nonrecommended drug use was reduced in an experimental set of nursing homes that introduced pharmacist visits to an interdisciplinary team (Schmidt et al., 1998). This trial was excluded from the review because of the impossibility of separating the effects of the interdisciplinary team intervention from those of the additional pharmacist visits. Despite its exclusion, this study is only one of a few attempts to assess team interventions in long-term care settings. One other clinical trial of an interdisciplinary team intervention in a long-term care setting occurred much earlier
(Feiger and Schmitt 1979; Schmitt et al., 1982). In this study, team intervention was found to be associated with more positive changes in health and functioning and less decline at 1-year follow-up in a sample of ambulatory diabetics. Among the four experimental teams studied, degree of collegiality in the teams’ interactions was correlated positively with patient outcomes. Unlike most studies in which collaboration is measured through self-report questionnaires, the degree of collegiality was assessed directly by means of coding interaction in videotaped team meetings.
More recently, Stone et al. (2002) examined a multidimensional interdisciplinary health care model introduced in 11 freestanding, not-for-profit long-term care facilities in eastern Wisconsin, which included interdisciplinary teams within and across sites. The investigators used both qualitative and quantitative means to measure program impact. The evaluation examined both the processes used to implement the model successfully and the outcomes associated with the model’s adoption.
The model introduced into the nursing homes is called Wellspring Innovative Solutions. It consists of clinical consultation and education by a geriatric nurse practitioner, a shared program of staff training using modules developed by the nurse practitioner, the sharing of comparative data on resident outcomes, and interdisciplinary care resource teams that develop and implement interventions designed to improve resident care (Stone et al., 2002). The Wellspring model focuses on quality improvement activities and the creation of an environmental culture that supports decentralized decision making and the recognition and rewarding of staff directly involved in resident care. The cultural shift undertaken through Wellspring also has targeted interagency collaboration, with each of the nursing homes sharing outcome data and providing consultation and advice to member facilities.
Member facilities have formed a loosely coupled alliance that provides overall administrative support for the model. In addition, a program coordinator and interdisciplinary quality improvement teams assist the geriatric nurse practitioner with delivery of the model. The Wellspring coordinator serves as an educator and a facilitator of communication throughout the alliance. Membership on the care resource teams is voluntary and open to both nursing and non-nursing staff. Clinical training modules are used to ensure that facility staff are up to date on clinical practices that pertain to their patient populations (Stone et al., 2002).
The impact of the Wellspring program was assessed by comparing Wellspring and non-Wellspring facilities in Wisconsin. Outcomes were measured as “deficiencies,” defined as being in noncompliance with various federal regulatory requirements. According to the investigators, Wellspring facilities had significantly fewer deficiencies postimplementation than did non-Wellspring facilities. A dramatic decline also was seen for the magnitude of
deficiencies, with Wellspring facilities going from reporting three times as many severe deficiencies to having no severe deficiencies after implementation of the model. Findings also suggest that Wellspring staff became much more vigilant as a result of the model and took a more proactive approach to delivering resident care. This vigilance was perceived as having prevented several serious events, although these observational findings could not be substantiated by outcome data. Nurse retention rates also improved significantly following implementation of the model, as compared with reductions in nurse retention rates in non-Wellspring sites (Stone et al., 2002).
Integrative Review # 6
A sixth integrative review focused on innovative models of health care delivery, including the use of interdisciplinary teams (Wadhwa and Lavizzo-Mourey, 1999). The emphasis of this review was on the impact of innovative models on outcomes among two vulnerable populations—the terminally ill and the mentally ill. Reviewers searched medical literature databases, reviewed reference lists of published reports, and contacted known experts and authors to identify additional work. Twenty-four articles met the reviewers’ criteria for inclusion, which required the presence of a control group.
Three studies included in the review evaluated the impact of interdisciplinary teams on outcomes among terminally ill patients, while seven examine their effect on the mentally ill (Wadhwa and Lavizzo-Mourey, 1999). Findings for the terminally ill population suggested the interdisciplinary team approach produced reductions in hospitalization rates and improvements in patient and family satisfaction. Few other differences were seen between control and experimental groups. The authors of the original studies and the integrative review suggest the absence of differences may be the result of the contamination of control groups, which frequently received interventions comparable to those of the experimental plan. Hospitalization rates and levels of patient and family satisfaction were found to be significantly improved for mentally ill patients overseen by interdisciplinary groups. Other outcome findings were comparable. In reviewing the evidence pertaining to the management of mentally ill populations, Wadhwa and Lavizzo-Mourey stressed the importance of including long-term support and outreach services with the use of interdisciplinary teams.
Teams and Patient Safety Outcomes
Reports of investigations of the impact of work teams on patient safety are limited. Most descriptions of work team success either are anecdotal or include only brief reviews of methods used to measure team effects. In many
cases, the reports focus on the development and use of safety review committees and the structures used to support the work of these teams (Piotrowski et al., 2002; Sim and Joyner, 2002; Wong et al., 2002). Many describe continuous quality improvement efforts, including some that bring together representatives from multiple organizations within health care systems (Green and Plesk, 2002; Kosseff and Niemeier, 2001).
In the studies of interdisciplinary team outcomes described in previous sections, medical error reduction is not examined directly. It appears reasonable to assume, however, that some overlap exists in the outcomes studied and patient safety outcomes. Interdisciplinary assessment and treatment create multiple opportunities to improve diagnosis, reduce omissions in care, and reduce avoidable error. Conversely, a breakdown in interdisciplinary communication, the fundamental element in building effective collaboration, can result in serious medical error. In an exploratory study, Schmitt (1990) provides a content analysis of 13 appellate court malpractice cases from a variety of states, in which the interactions of medicine and nursing were relevant to the case. In these cases, multiple disciplines were sued, and the negligence was distributed across disciplines based on the nature of the communication that had or had not occurred between disciplines. Key problems in communication patterns included those in which nurses communicated information important to the diagnosis and management of the case that was ignored by the physician, as well as those in which nurses failed to communicate relevant information; both communication patterns resulted in errors in diagnosis and management. A set of related issues underpins these sorts of interdisciplinary error-producing communication problems. These issues include counterproductive hierarchical communication patterns that derive from status differences; disjunctions in the distribution of authority, responsibility, and accountability across disciplines; issues of respect (or its lack); and lack of clarity with regard to legal and ethical obligations across disciplines.
In the limited literature concerning the contribution of health teams to patient safety outcomes, some reports describe a beneficial effect (Leape et al., 1999; Sovie and Jawad, 2001), whereas others report none (Bates et al., 1998). These differences are likely the result of the variety of methods used to assess team impact, the size and makeup of the teams, the variable dimensions of the team intervention, and the frequency and magnitude of the outcomes assessed.
A recently completed 3-year national study of medical and surgical units in 29 university teaching hospitals provides some additional information pertaining to the effect of teams on positive and negative care delivery outcomes. In this study, the consequences of hospital restructuring were examined for their impact on nurse staffing and patient care (Sovie and Jawad,
2001). The study’s investigators identified structure and process predictors of patient satisfaction and adverse patient outcomes, including falls, nosocomial pressure ulcers, and urinary tract infections. The Management Practices and Processes Questionnaire used to assess nurses’ perceptions of process indicators was based on an instrument developed by Shortell and colleagues (1991) for use in ICUs. The structure variables of registered nurse (RN) hours and all nursing personnel hours worked per patient day were found to be significant predictors of patient satisfaction and adverse outcomes. On medical units, one of the predictors of urinary tract infections was found to be reported collaboration of nurses with physicians. Similarly, in combination with the structure variables, reduced falls were associated with increased communication, collaboration, and conflict resolution between nurses and physicians.
In an earlier study of potentially harmful drug-related errors, care delivery team characteristics and nurse manager behaviors were assessed for their impact on detected error rates (Edmondson, 1996). In this non-experimental research design, eight hospital unit teams were randomly selected from two urban teaching hospitals affiliated with the same medical school. Potentially harmful drug-related errors were identified through daily chart reviews, informal visits to units to ask about unusual drug events, and incident reporting. Drug-related error data were collected for 6 months; team and nurse manager behaviors were assessed through nonparticipant observation and surveys distributed during the second month of the study.
Detected error rates were found to be strongly associated with high scores on nurse manager direction setting and coaching, perceived unit performance outcomes, and quality of unit relationships. Edmondson (1996) suggested that the unexpected association between more-favorable work environment and incidence of errors is actually a desirable outcome. She believed the increased numbers of detected errors were an indication of the influence of a safe reporting environment on error reporting. This perception is supported by comparable associations among nurse manager direction setting, quality of unit relations, and frequency of interceptions to prevent adverse drug events. Error interceptions also were found to be moderately correlated with unit tolerance for mistakes, suggesting that tolerant error-reporting environments facilitate both the detection of errors and the delivery of successful interventions to prevent harmful outcomes.
Team intervention in some studies is defined according to the products created by the team. For instance, Bates et al. (1998) measured team impact on the prevention of serious medication errors through the implementation of a recommended dilutions chart; a computerized drip-rate calculation program; the standardized labeling of intravenous bags, tubes, and pumps; and a pharmacy communication log for nursing and pharmacy staff. How the team devised these elements and how it influenced or oversaw each prod-
uct’s implementation is not clear. Whether all components were implemented equally also is unknown.
Methodological shortcomings have contributed to the difficulties inherent in determining the characteristics of effective teams and the processes used to reduce error. For example, in some cases team impact is assessed through the quality improvement performance of the attending physician (Posner and Freund, 1999). This approach is necessary when an institution assigns adverse events to the senior clinician overseeing the care delivery activities of the team. Although some justification can be made for using this reporting process, little useful information can be gleaned about what actually occurred within the team to produce the outcomes seen. In addition, the assignment of responsibility to the senior physician reinforces the hierarchical nature of the team, suggesting that regardless of what team members do, the overall product of the team is the result of the team director’s actions.
Although findings concerning the relationship between the existence and performance of health care teams and patient outcomes are mixed, evidence suggests the relationship is present when measured carefully and with a clear indication of team process and interaction components. The concept of collaboration within and apart from prescribed teams appears to be an important dimension of what makes teams (and individuals, dyads, or small groups) successful. Clearly, interpersonal communication, regard for others, a strong focus on patient safety goals, and constant reassessment of the environment are important aspects of the relationship between team performance and care delivery outcomes.
Non–Health-Related Work Groups and Performance Outcomes
Studies of non–health-related work groups have focused primarily on productivity and workplace injury outcomes. Nonetheless, performance and outcomes among non–health worker teams have some similarities with those of health care work groups; in both, sphere of influence is expected to widen, and goal-focused actions are expected to result in safer production processes.
Findings concerning team formation and safe environment are informative, with some studies demonstrating significant reductions in on-site injury (Kaminski, 2001) and others identifying differences according to span of control and perceived level of empowerment among team members (Hechanova-Alampay and Beehr, 2001). Hechanova-Alampay and Beehr suggest that simply empowering employees with decision-making authority is insufficient to prevent product error. Attention to the team members’ span of control also is necessary. If the span of control is too great, safety outcomes may suffer.
Industry-related safety studies have identified several organizational attributes that contribute to safe employee behaviors. Among these attributes are frequency of nonroutine work processes, level of work hazards, level of cooperativeness between employees and supervisors, level of work group cohesiveness, extent of supervisory management of safety actions, and supervisor experience (Simard and Marchand, 1995). Safety studies also suggest that the organization’s climate of safety is detectable at the work group level and that the importance team members place on safety is influenced significantly by supervisor behavior rather than policies and procedures (Simard and Marchand, 1995; Zohar, 2000). In addition, when climates are perceived as less safe, work groups generate a greater number of safety errors.
The effect of work team performance on product quality and labor productivity has been tested in a few manufacturing (Banker et al., 1996; Shrednick et al., 1992) and service (Cohen and Ledford, 1994) industries. The makeup of the teams in these investigations has varied across organizations, and decision-making authority has ranged from limited to semiautonomous. In addition, the team makeup has been specified in some cases, while in others, employees have volunteered to participate.
In the investigation by Banker et al. (1996), the initial months of work team development focused primarily on establishing trust between production workers and management. This focus was particularly important in an institution in which the presence of a bargaining unit had created a history of poor cooperation between workers and administrators. Despite the difficulties of creating high-performance work teams and developing trusting relationships between employees and administration at the site, the introduction of work teams resulted in significantly reduced product defect rates. Productivity also increased.
In the Cohen and Ledford (1994) study, no differences were found in actual safety performance outcomes between self-managed and traditional teams. Significant differences in team members’ perceptions of the quality of work and the desirability of work teams were seen, however, suggesting that the increased decision making and responsibility produced better work group relationships and assessment of group performance. These favorable perceptions did not extend to the organization as a whole.
Team members’ perceptions of team desirability, organizational support, and organizational outcomes also have been assessed in industry (Bishop et al., 2000). The expectation of the investigators was that favorable employee perceptions would produce improved levels of organizational commitment and better production outcomes. In these studies, favorable perception of the work group was consistently found to be related to level of employee performance and intention to remain employed at the study institution. Similar findings have been reported in the nursing literature,
where favorable perceptions of the work group result in intention to remain in the work setting and overall job satisfaction (Ingersoll, 1996; Ingersoll et al., 1996, 2000, 2002). These findings have the potential to influence patient safety performance through the retention of highly skilled and experienced employees.
Considerable interest has been expressed in the beneficial effects of a process defined as crew resource management (CRM), which is used primarily in the aerospace industry but increasingly is being applied to health services industries as well (Helmreich and Davies, 1997; Kosnik, 2002). CRM training in civilian aviation was developed in response to several investigations of airline accidents indicating that a considerable percentage of the accidents were crew-related (Aarons, 2002).
Discussions of CRM strategies for performance improvement and error reduction suggest it is particularly useful when newly trained individuals or persons unfamiliar with a complex process are placed in highly charged, specialized task performance conditions (George, 2002). In these cases, the new team member’s attention is focused almost exclusively on mastering the complex demands of the task. Any additional unforeseen event or unexpected condition may be missed or misinterpreted because of the limited available cognitive processing ability of the novice team member.
Critical to the success of CRM strategies is the development of a culture in which all members of the team feel comfortable in verbalizing alternative opinions or in questioning the senior team member’s view or planned action (George, 2002). Essential also is the availability of technology or task completion instruments that reduce the need for focused attention on the act of information gathering or the need for lengthy communications between team members. A third component of the CRM process is the routine use of standard operating procedures (SOPs), which define each team member’s roles and responsibilities and describes the specific actions required for each phase of the process. These SOPs are designed to make the best use of each team member’s time and to improve the situational awareness of the other team members (George, 2002). A concept alignment process is used to facilitate the expression of divergent opinions. In this case, an initial statement by a member of the team is either refuted or supported by another. If opinions differ, the team is responsible for seeking a third opinion. If one point of view can be validated with evidence and the other cannot, the validated view is accepted by the team. If both views can be validated, the senior member of the team chooses the action. If neither can be validated, the most conservative approach is taken (Kosnik, 2002).
CRM training generally includes several days of formal review of prior errors or accidents and in-depth self-assessments of communication style. These self-assessments are intended to facilitate team members’ appreciation of the ways in which strengths and weaknesses in personal communi-
cation affect crew coordination (Aarons, 2002). Health-related training sessions in CRM have included sessions related to team culture, problem solving, team communication, team-building skills, and workload management strategies (Kosnik, 2002).
Formal investigations of these processes are limited at this point. Work to this end is under way, however, particularly at the University of Texas, where the CRM approach is being tested for its usefulness in a number of industries, including health care. The concepts associated with CRM make intuitive sense and support health researchers’ and authors’ suggestions concerning the structure, training, and goal-focused approach needed for successful team outcomes in high-risk settings.
CREATING EFFECTIVE TEAMS AND COLLABORATIVE WORK RELATIONSHIPS IN THE WORKPLACE
Barriers to Effective Team Development and Performance
One of the most difficult barriers to effective team performance in health care is the differences in world view that exist across participating health professionals (Baggs and Schmitt, 1997; Prescott and Bowen, 1985). As Shine (2002) notes, physicians of the twentieth century have prided themselves on their individual autonomy and their perceived decision-making infallibility. Eliminating or reframing this perception will be difficult for many physician members of interdisciplinary teams. As a result, the formation of teams will best be served by the careful selection of individuals who already demonstrate an awareness of the need to change and are amenable to different ways of planning for and providing care.
A number of factors have been identified that contribute to poor interdisciplinary working relationships. Larson (1999) suggests these barriers lead to unethical care delivery practices because of the likelihood of deficient care delivery outcomes and the potential for patient harm when disciplines fail to work together. Principal in Larson’s summary of the literature is a divergence in perspective on the ability and authority of nurse members of interdisciplinary teams. In previous research concerning interprofessional relationships, physicians have routinely rated actual and ideal nurse authority significantly lower than have nurses (Larson, 1999). Physicians also have tended to focus on the need for nurses to provide more data when presenting information, whereas nurses have focused on the need to improve interpersonal relationships.
The creation of teams may increase the demands associated with the job and result in increased intraorganizational strain. In some cases, the benefits derived from using decision-making teams have not surpassed the costs associated with increased workforce stress (Landsbergis et al., 1999).
This problem may be a temporary one, however, with team members’ stress declining significantly as their role expectations and participation demands evolve over time (Parker et al., 1997).
Historical communication patterns also may interfere with effective team performance. Previous research suggests these patterns are highly complex, with novice team members demonstrating undesirable modeling or withdrawal behaviors when tension among team members is high (Lingard et al., 2002). In some cases, these interactions have been outright abusive (Barnsteiner et al., 2001; Manderino and Berkey, 1997), while in others, poor communication patterns have resulted in major loss of life and diminished public faith in health care (Schmitt, 1990), private industry, and service agencies. Two particularly notable cases are cited as instances in which poor team decision making resulted in a disastrous outcome and the loss of public faith. In each of these cases—the Ford Pinto recall and Challenger shuttle disaster—the failure of team members to question other members’ decision making and the fear of repercussions from senior management created an environment ripe for errors in decision making, as theorized within a groupthink framework.
In the Ford Pinto case, a reanalysis of internal and external documents, along with interviews of key informants, resulted in a reassessment of the factors contributing to the decision to market Pinto automobiles despite evidence of their poor crash test performance (Lee and Ermann, 1999). The investigators identified a number of such factors, including safety standards at the time; industry norms; the widespread assumption that smaller and cheaper cars were less crashworthy, resulting in a greater tolerance for poor performance; and the perception that the crash test procedures were inadequate and of limited usefulness.
The team errors that contributed to the undesirable outcome included the promotion of an inexperienced manager to a senior role in product safety recall and the manager’s use of SOP scripts to determine which automobiles warranted recall. Decisions regarding recall were based solely on the frequency of documented problems and the evidence of causal links to design defects (Lee and Ermann, 1999). Group members’ concerns over being ridiculed for recalling a car that did not meet recall specifications and fears of expressing their concerns to senior management also contributed in important ways. According to Lee and Ermann, team members stopped making requests for input because their recommendations were routinely rejected. Self-censorship also prevented senior administrators from hearing the growing concerns of employees working directly on cars. This combination of factors resulted in the continued production and sale of unsafe automobiles, which were recalled only after external pressure forced the action.
In the case of the Challenger launch decision, work group culture and restrictions on access to and dissemination of information silenced team
members whose input into decision making might have prevented the space shuttle’s takeoff (Roberts, 1997). Experts who might have provided alternative opinions about the safety of takeoff in adverse conditions were removed from the immediate decision-making process. In addition, the silence of key personnel was considered proof that the system was working rather than broken. Project team members also were pressured by political imperatives to adhere to cost estimates and liftoff schedule; bureaucratic expectations that stressed following procedural rules and relaying information according to hierarchical authority relations; and technical imperatives to use data, engineering analyses, and technical rationales to support opinion. Organizational rituals were common and their use widespread, contributing to the overall tendency for employees to behave in routine and nonspecific ways. The combination of these factors led to the shuttle disaster and the subsequent loss of public trust in the space program. According to Roberts, this case is particularly important to the study of team decision making and safe practice because poor decisions were made by a highly skilled team in an organization that would be described in today’s terms as highly reliable and decentralized.
Facilitators of Effective Team Development and Performance
Favorable attitudes toward team performance and collaborative patient management approaches maximize team outcomes. These attitudes are particularly important for interdisciplinary groups composed of individuals with differing values and expectations for outside-discipline performance and scope of practice (Schaefer et al., 1994).
Accomplishing this blending of diverse opinions and world views requires a profound cultural shift within a health care organization or system (Shrednick et al., 1992). A 10-year experience at Corning International suggests this process is a constantly evolving one in which team members are vested with both the responsibility and the authority to deliver and manage customer service. The experience at Corning highlights eight key contributors to work team success: (1) a vision and clear goals that serve to communicate expectations at the outset and to guide the evolution of processes over time; (2) a clear commitment of senior management, including a willingness to take risks and to share power and authority for decision making; (3) a plan for focused attention on middle managers and others who may fear loss of control and power because of the shift to team-directed decision making; (4) the early and continuous inclusion of team members in all phases of project development; (5) the commitment to continuous, multi-format communication strategies; (6) a continuous focus on customer expectations and outcomes; (7) a program of education and training to support team member activities and those responsible for interacting with
teams; and (8) the development of a reward system that promotes team success.
Corning’s experiences are supported by reports of others in the literature. Overall findings concerning the effect of teams on error-free outcomes suggest the following factors contribute to team success or failure in error prevention, detection, and recovery:
Size and structure of team
Tenure of team members
Heterogeneity of team membership—cultural mix, functional expertise, professional groups represented
Level of autonomy and decision-making authority
Sphere of responsibility and authority
Nature of member participation—voluntary versus assigned
Relational properties (internal social structure)
Level of trust among team members
Knowledge of team members’ experiences and expertise
Team norms that support a focus on quality and safety
Patterns of communication/information exchange
Processes for exchange and dissemination of information within and across teams
Amount and complexity of information exchanged
Information processing methods
Knowledge and cognitive skills of team members
Expected outcome or product
Goal or charge of group
Clarity of team expectations
Complexity of team expectations
History of team members’ experiences with team performance and outcome
Mission and philosophy—zero tolerance of risk and harm
Level of specialization
Organizational culture and climate
Centralized versus decentralized
Independent versus system-supported/derived
History of organizational innovation, including the use of teams in decision-making and error reduction
Performance, staffing, workload, and other workforce standards
Error-reporting mechanisms and sanctioning processes
Amount and type of support provided to teams
Expert consultation for problem areas
Secretarial assistance for documentation of team activities and generation of reports
Support for process improvement activities
Level of senior management commitment
Level of midlevel management commitment and interpersonal style
Strategies for Developing and Maintaining Effective Work Teams and Partnerships
According to Schaefer and colleagues (1994), simple adherence to standards and protocols is insufficient for reducing health system errors. As these authors note, the creation of environments in which ideas and concepts are actively sought, discussed, and evaluated without regard for the status of the person or the group providing the information is essential to ensure optimum care delivery outcomes.
A combination of strategies will be required to achieve the effective working relationships needed to reduce care delivery errors and optimize care delivery outcomes. Among these strategies are the development of clear position descriptions and explication of role expectations for all members of the team (Disch et al., 2001). Particular attention should be paid to those areas of responsibility that overlap, because these are often the least well understood by competing disciplines and are frequently sources of tension during the delivery of care (Trey, 1996).
Disch et al. (2001) further recommend discussing in detail the shared vision for the team. In this process, individual team members’ expectations and concerns are explored to identify where misperceptions lie and what individuals expect from other members of the team. Essential also is the establishment of specific times and formats for evaluating the progress and performance of the team.
Attention also needs to be paid to team makeup, including the heterogeneity or homogeneity of team members in such areas as position within the organization or community, gender, socioeconomic status, ethnicity, age, and other characteristics that may increase the potential for restricted or open discussion and exchange of ideas. Ideal teams are those that represent the populations involved in both the delivery and the receipt of care. In
reality, teams often reflect the dominant population or culture and therefore miss the opportunity to maximize team outcomes and reduce the potential for error.
The makeup of the team may result in different levels of perceived success depending on the stage of team development. One study suggests that homogeneous team members tend to report more favorable outcomes and working processes early in the team’s development. Heterogeneous team members’ perceptions change over time, with members reporting improved work relationships as the group evolves. Heterogeneous teams also report a greater range of perspectives and alternatives generated (Watson et al., 1993). In this study, task performance remained higher for the homogeneous group throughout the study period, although the overall quality of decision making and team performance was comparable by the study’s end. In light of these findings, the investigators note the importance of allowing sufficient time for heterogeneous teams to develop the skills needed to work together effectively. The long-term impact, especially in the case of strategies for error identification and reduction, is worth the wait.
Team development strategies also need to include some attention to individual members’ assessment of personal strengths and weaknesses and how these contribute to team performance. Also important is self-assessment of perceptions about how error occurs, and how stress and team performance contribute to errors and error identification. Evidence from a survey of ICU and operating room physicians and nurses suggests these individuals seriously underestimate the effect of stress on performance and the likelihood of error (Sexton et al., 2000). In this study, 60 percent of health care professionals rated their ability to perform when fatigued as comparable to their performance when not fatigued during critical conditions. This same percentage believed in the ability of professionals to leave their personal problems behind when working. In addition, a majority of respondents (70 percent) rated their ability to make decisions in emergency situations as comparable to that during routine conditions. The investigators expressed their concern about the clear indication that health care workers failed to recognize the impact of stress and fatigue on decision making. They also noted that the percentages seen in this study were significantly higher than those reported for a sample of airline pilots, who demonstrated a considerably greater level of awareness of the impact of stress, personal problems, and critical events on decision-making errors.
In this same study, physicians rated the presence of collaborative relationships significantly higher than did nurses. Surgeons rated the quality of teamwork with others highly, while others did not reciprocate. On the contrary, nurses and anesthesia staff described the level of teamwork with physicians as poor. Respondents also reported difficulty in discussing mistakes, citing damage to their personal reputation, the threat of malpractice suits,
high expectations of family and society, possible disciplinary action, the threat to job security, and expectations of others as reasons for their reluctance to report. Recommendations for improving safety in the ICU focused on increasing staffing, while recommendations for the operating room centered on improved communication patterns (Sexton et al., 2000).
Mentioned frequently in discussions of strategies for error reduction and error recovery by teams is the use of simulations to create real-world conditions of uncertainty and decision-making response. A benefit of this approach is the ability to challenge team members concerning how to react in high-likelihood error situations without jeopardy to individual job security or risk to patients. According to experts, simulation training needs to be ongoing because of the potential for attitudes and skills to decay over time. Simulation procedures also need to be designed in accordance with conditions and experiences of the training organization (Helmreich, 2000).
Simulation methods help in assessing both technical skills and crisis management behaviors, including those associated with decision-making processes and team interaction (Gaba et al., 1998). Gaba and colleagues have successfully used simulations of perioperative crises to assess the technical and behavioral performance of team members and the overall team under high error situations. Included in their assessment of team performance is attention to orientation to case, inquiry/assertion, communication, feedback, leadership, group climate, anticipation/ planning, workload distribution, vigilance, and reevaluation behaviors. A limitation of their simulation process is the deliberate avoidance of combining nonphysicians and physicians on one team. Because most intraoperative crises are likely to include a variety of health care personnel, this restriction limits the application of the simulation procedure to actual practice.
At the University of Texas, an aviation model of threat and error has been adapted to the health care environment. According to the model developers, this approach fits with health care’s input–process–outcomes concept of team performance. Included in the simulation model are individual, team, organizational, environmental, and patient characteristics that contribute to latent and immediate threats to safe care delivery. Immediate threats are those associated with the patient’s condition or care provider’s ability, while latent threats pertain to aspects of the system that predispose to threat or error, such as staffing mix and number of staff (Helmreich, 2000).
Because health care teams are often dissimilar in makeup from other groups that have used simulations successfully, some additional refinement and study are needed to ascertain the most effective use of this training technology. In keeping with the high levels of stress and uncertainty associated with decision making in health care, computer applications and other
intelligent decision aids (IDAs) must be able to promote both high-level decision making under uncertainty and the ability to develop strategies for planning for and preventing stressful events (Kontogiannis and Kossiavelou, 1999). The most successful IDAs for team training purposes are those that mimic usual event escalation processes and contributors, including imagined action consequences, anticipation of rare events, and prioritization of tasks when time is limited. IDAs also can be used to provide information about an event or situation, to present multiple perspectives about potential contributors and possible outcomes, and to monitor task performance. In addition, they have potential relevance for facilitating contingency planning through the use of information displays concerning difficulties encountered in the past, critical errors associated with similar actions, and resources needed to activate the plan. Because the use of IDAs for assistance with decision making in highly stressful conditions is new, experiments and field evaluations of their effectiveness must be an integral part of their use (Kontogiannis and Kossiavelou, 1999).
Methods for Measuring the Safe Care Delivery Practices of Work Teams and Collaborative Groups
Reports on methods for monitoring team processes are few, with most evaluations of team performance focusing primarily on clinical outcomes rather than error or error avoidance. Although favorable outcomes are commonly interpreted as an indication of the absence of error, this assumption needs to be documented more clearly. Moreover, because the development and maintenance of effective teams are essential to safe care delivery processes and ideal outcomes, efforts need to be made to monitor and describe those collaborative groups and work teams that consistently produce safe care. Identifying teams and organizations as benchmarks for outcomes is insufficient; understanding and mimicking their processes also is required.
Strategies for evaluating team performance range from day-to-day quality assessment processes to formal investigations of team impact. Inherent in all discussions of the impact of interdisciplinary teams on patient safety and other care delivery outcomes, however, is the need for continuous assessment of team performance and impact. This continuous process is highlighted in a model of collaboration described by Sorine and colleagues (1996), who identify five essential components of the collaboration cycle, each requiring close monitoring of process and outcome. In Sorine et al.’s model, performance guidelines drive compliance agreements, which in turn influence preparedness training and implementation procedures. Once the procedures have been implemented, verification and improvement efforts are undertaken to ensure the quality and consistency of behaviors. These
actions subsequently spur the refinement or revision of performance guidelines. This process is continuous, resulting in improvements in team performance and care delivery outcomes over time.
Using this model, the evaluation of performance guidelines might focus on whether they are evidence-based or reflective of documented best practices. Their scope, reasonableness, and usefulness for guiding the formulation of compliance agreements also might be assessed. Compliance agreements and subsequent preparedness components would require evaluation of the achievement of compliance expectations and the effectiveness of training. The implementation process aspects of the evaluation would focus on whether the collaborative model had been introduced as intended and how it evolved over time, while the verification and improvement practices would constitute the ongoing quality improvement monitoring associated with ensuring compliance and achieving safe practices.
One method for assessment of safe and unsafe practices recommended by a non–health-related (aviation) industry entails observational audits of pilots and flight crews (Croft, 2001). In this process, termed a line operations safety audit (LOSA), specially trained observers ride in the airplane’s cockpit and observe the responses of the airplane’s pilots to such inflight threats as severe weather or congested airports. The observers also interview the pilots during and after the observational period. Reports of the observations made and summaries of the pilot interviews are entered into a database where trends are identified and reported back to participating airlines. No identifying information is included with the data to ensure that individual pilots are not penalized for identified deficiencies as a result of the observational monitoring (Croft, 2001). The focus of the experience is on monitoring and managing the industry’s overall training and safety program rather than on the individual pilot’s performance.
Observers are trained to monitor for five types of error—procedural, communications, proficiency, decision, and intentional. Errors are categorized as consequential when the pilot’s action puts the aircraft in an undesired state and inconsequential when safety is not adversely affected (Croft, 2001). In a review of observations conducted to date, observers have noted one threat to flight safety on 8 of every 10 flights and at least one error on every 6 of 10. These errors resulted in one undesired aircraft state in 3 of the 10 flights. Of importance in this observational process is the failure of pilots to detect over half of the errors made. In addition, when the pilots did catch an error, 1 of 20 (5 percent) was mismanaged. In the majority of cases, errors that compromised safety were caused by the pilot’s lack of knowledge concerning the airplane’s automation features.
The LOSA process is a lengthy and expensive one, incurring costs associated with observation of pilot performance, interview, and entry and analysis of data. Each audit requires approximately 3 months and is funded
by the participating airline and grants from the Federal Aviation Administration (Croft, 2001). At the time of the report on the LOSA process, data from 13 airlines had been obtained, and audit developers were anticipating a 2-year time frame for determining program effects. Application of this approach to health care would require careful consideration of the costs involved and the possibility of obtaining comparable information through other methods.
NEEDS FOR FURTHER RESEARCH
Health professionals interact with others in multiple ways and often under the most challenging of situations. As a result, opportunities exist for promoting beneficial impacts on the delivery of health care through the partnering of professionals involved in care delivery. These partnerships may occur between two persons (e.g., patient and practitioner, nurse and physician, pharmacist and care provider) or through the linking of representatives from multiple disciplines. In all cases, a clear pattern of performance and supportive practices emerges as essential to the success of these relationships.
Nonetheless, the need for increased attention to and understanding of effective team processes is evident. Although some investigators have begun to explore the mechanics and makeup of teams and how these factors contribute to care delivery outcomes, additional work is needed. Team processes, as defined by Marks and colleagues (2001:356), consist of “members’ interdependent acts that convert inputs into outputs through cognitive, verbal, and behavioral activities directed toward organizing taskwork to achieve collective goals.” According to Marks et al., taskwork involves what the team is doing, whereas teamwork describes how they do it. Taskwork is dependent primarily on skill and member competence; teamwork requires higher-level behaviors, including the ability to direct, align, communicate, negotiate, and monitor taskwork.
Marks and colleagues (2001) stress the need to focus research and team development strategies on the interaction processes evident in teams. They suggest that previous research devoted to team cohesion and situational awareness, for example, has tapped qualities that reflect member attitudes, values, and motivation rather than interaction processes per se. They also describe these variables as emergent products of team experience. Using this framework, Marks and colleagues suggest these variables are indicators of team input that influence teamwork processes and taskwork. As a result, their use in the assessment of how team behavior influences care delivery outcomes and safety behaviors is limited. According to Marks and colleagues attention needs to be shifted to team performance episodes, where inputs, actions, and outcomes occur in a continuous, dynamic process. Inherent in
this focus on performance episodes is attention to environmental and other influences that contribute to team processes at different points in time.
Team process dimensions include monitoring behaviors directed toward the assessment of goal achievement and feedback about that process. This monitoring activity identifies when goals have been achieved or abandoned and when new goals are needed for action. The monitoring activities undertaken by team members include the assessment of team resources and environmental conditions that contribute to goal achievement. Effective teams monitor internal and external factors that contribute to the team’s ability to perform its task. The internal monitoring process may be devoted to the assessment of team members’ performance errors and the development of strategies for eliminating or recovering from those errors. Team process behaviors also involve coordination activities, interpersonal processes, conflict management actions, motivating and confidence-building efforts, and regulation of team members’ emotions (Marks et al., 2001).
Marks and colleagues (2001) framework of team processes and outcomes stresses the multidimensional and constantly changing nature of teamwork behavior. This constant movement of teams from periods of transition between existing and new goals makes the measurement of team performance difficult, especially if single one-shot assessments are performed. In cases in which an organization’s safety outcomes are of interest, multiple measures and multiple assessment time frames are needed.
A variety of other explorations of team functioning and impacts on patient safety also are required. Among the areas of need identified in the literature are studies exploring the impact of stress (Sexton et al., 2000) and organizational culture on teamwork error and the role of the leader in facilitating or structuring team interaction. This aspect is particularly important in investigations of the relationships between team performance and error identification and reporting, where leader behavior may influence team members’ beliefs about the consequences of and ability to discuss mistakes (Edmondson, 1996). When previous experiences with the reporting of errors are seen as nonthreatening, team members not only detect and report more errors, but also intervene more effectively to recover from errors and prevent serious adverse events.
The application and conduct of focused investigations concerning the use of CRM principles and other non–health-related strategies for error reduction are needed. Early reports of the effectiveness of these strategies are encouraging, but additional work is required. The environments in which health care is delivered are often more diverse and variable than those of other fields, and the makeup of the teams involved is clearly different as well. Moreover, applications to the health care environment should focus on team processes that incorporate the full range of individuals likely to be involved in clinical decision making and action.
Funding is needed to support these research initiatives and the education and training that will be required to build and sustain the teams and organizational environments necessary to achieve high-quality care delivery outcomes. Legislation and regulations alone will not affect the high-level processes required to promote and create safety cultures in health care organizations. The cognitive, decision-making, and behavioral skills required for successful team membership will need to be addressed during early educational experiences and continue throughout the team member’s work life. Incentives also will be required to ensure that individuals and organizations move toward this new health care production framework. In general, the literature suggests the following areas are ripe for exploration and action in health care.
The literature to date suggests that the research concerning the relationships between work groups and safety outcomes would benefit from the testing of existing or evolving theories concerning work group relationships and work group safety. Several theories have been proposed, yet few have been tested in any sustained or evolutionary way. Although more recent studies demonstrate increased attention to theory-derived measures and hypothesized relationships, additional work is needed.
Collaboration, Communication, and Other Interpersonal Relationship Behaviors
Some evidence suggests and several authors recommend a broader focus on interpersonal interactions rather than team creation alone. These authors suggest that it is the interpersonal dynamics within team processes that contribute to favorable outcomes and reduced production error. They also stress the multiple ways in which health care workers interact in dyads, small groups, and unit-based teams. A focus on the characteristics of the interpersonal behaviors that facilitate effective interaction, decision making, and error-prevention performance may be more useful than a restricted focus on team behavior. Such a focus also may make the measurement aspects of assessing multidimensional team performance more manageable.
Patient Management and Oversight Responsibilities
Consistent with a focus on collaboration, communication, and interpersonal relationships is attention to the most effective patient management and care delivery approaches for reducing patient error. One of the difficulties apparent in the literature is the significant number of individuals in-
volved directly or indirectly in decision making concerning patients’ needs. Some limited evidence suggests that the use of case managers may be beneficial for facilitating desirable care delivery outcomes. Much of this beneficial impact is perceived to be related to the communication and collaboration skills of these individuals and the case manager’s ability to overcome systems barriers. Additional information is needed to clarify the impact of models of care delivery on patient safety outcomes.
Application of Non–Health Care Industry Training Standards
The literature concerning the effectiveness of safety-focused work group strategies in non–health care industries suggests this may be a useful vehicle for health care. At present, the research concerning these processes (both outside and within health care) is limited, necessitating cautious movement to this field of training, decision making, and error-prevention behavior. Some efforts have been made to introduce these team development and training strategies in health care, although such efforts have not been widespread. Additional information is needed concerning how these methods work with diverse work groups and less intense environments.
The evidence to date reinforces the need to identify what interpersonal and group interaction processes contribute to the delivery of safe care. A number of theories exist concerning how teams perform and how their behaviors contribute to safe or unsafe practices. Clearly evident is the need for additional information about which of these theories is most applicable to the delivery of quality health care and which approaches in health care and other industries demonstrate the most potential for favorable effect. In this paper, the current evidence concerning work groups and patient safety has been reviewed, with recommendations made for future action.
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