The sharing of responsibility for meeting group task and maintenance needs is known as:

Teams and Teamwork

Health care is a team activity; it can even be considered and evaluated as a team sport. Teams take care of patients in general and especially on the labor and delivery suite.26 Furthermore, health care teams operate in an environment characterized by acute stress, heavy workload, and high stakes for decision and action errors.27 Individuals have limited capabilities; when their limitations are combined with organizational and environmental complexity, human error is virtually inevitable.28 The labor and delivery unit is a dynamic and complex care setting.17 In fact, the labor and delivery unit requires intense, error-free vigilance with effective communication and teamwork among various clinical disciplines who, although working together, have probably never trained together. This group includes obstetricians, midwives, nurses, anesthesiologists and nurse anesthetists, and pediatricians. The addition of trainees at all levels and in all disciplines enhances the potential for communication error. Siassakos et al.29 suggested that one of the most important components of effective training in obstetrics includes multiprofessional training and integration of teamwork training with clinical teaching. Multidisciplinary safety rounds enhance situational awareness among team members and encourage contingency plans for emergency management10,30 Chau and colleagues at the Brigham and Women's Hospital recently reported that providers on labor and delivery suites perceived that structured interprofessional rounds are effective in promoting teamwork.31

Ateam consists of two or more individuals who have specific roles, perform independent tasks, are adaptable, and share common goals. Salas et al.32 definedteamwork as a complex yet elegant phenomenon. It can be defined as a “set of interrelated behaviors, actions, cognitions, and attitudes that facilitate the required task work that must be completed.” Lack of teamwork has been identified as a leading cause of adverse events in medicine. Team behavior and coordination, particularly communication or team information sharing, are critical for optimizing team performance. Baker et al.33 stated that to work together effectively, team members must possess specific knowledge, skills, and attitudes (KSAs), including skill in monitoring each other's performance, knowledge of their own and their teammates’ task responsibilities, and a positive disposition toward working in a team. These authors have described characteristics of effective teams, which include team leadership, mutual performance monitoring, backup behavior, adaptability, shared mental models, communication, team/collective orientation, and mutual trust. Moreover, effective team performance in complex environments requires that team members hold a shared understanding of the task, their equipment, and their teammates (Table 11.1).27

Multidisciplinary Teams Provide the Foundation for Health Care Services

Multidisciplinary teams with strong and integrated communication skills are the foundational element of functional health care services for women. Providing comprehensive care is by definition a team sport. This team might include physicians, advanced practice nurses, physician assistants, nurses, pharmacists, nutritionists, social workers, educators, and care coordinators. New models for delivering health care services may bring together large and diverse teams of care providers to meet the needs of the patient. Many others, including smaller practices, will build virtual teams linking themselves and their patients to remote providers and services via telemedicine and online services. Evidence demonstrates that good communication and teamwork can reduce medical errors and improve care.22

While teamwork is often recognized as important, most health care professionals have had little or no training in working as part of a high-performing team. AHRQ and the Department of Defense’s Patient Safety Program have developed a tool to help organizations improve teamwork to improve care called TeamSTEPPS.23 TeamSTEPPS is an evidence-based teamwork system designed to improve communication and teamwork skills among health care professionals. It is a source of ready-to-use materials and a training curriculum to successfully integrate teamwork principles into all areas of a health care system. TeamSTEPPS provides higher quality, safer patient care by:

Producing highly effective medical teams that optimize the use of information, people, and resources to achieve the best clinical outcomes for patients.

Increasing team awareness and clarifying team roles and responsibilities.

Resolving conflicts and improving information sharing.

Eliminating barriers to quality and safety.

One critical team-based activity is care coordination designed to assess, meet, and anticipate the needs of patients, while helping them navigate effectively and efficiently through the health care system. Clinical coordination involves determining where to send the patient next (e.g., sequencing and communicating among specialists), what information about the patient is necessary to transfer among health care entities, and how accountability and responsibility is managed among all health care professionals (e.g., doctors, nurses, social workers, care managers, supporting staff, etc.). Care coordination addresses potential gaps in meeting patients’ interrelated medical, social, developmental, behavioral, educational, informal support system, and financial needs in order to achieve optimal health, wellness, or end-of-life outcomes, according to patient preferences.24

Health care professionals notice failures in coordination, particularly when the patient is directed to the ‘wrong’ place in the health care system or has a poor health outcome as a result of poor handoffs, for example, from the hospital to home or from one specialist to another, or due to inadequate information exchanges.

The health care community is struggling to determine how to measure the extent to which care coordination activities are being implemented. AHRQ’s new Care Coordination Measures Atlas24 lists existing measures of care coordination, with a focus on ambulatory care, and presents a framework for understanding care coordination measurement. The Atlas is useful for evaluators of projects aimed at improving care coordination, and for quality improvement practitioners and researchers studying care coordination.

Craniofacial surgery is teamwork

It is obvious from the congenital craniofacial malformations discussed in this chapter that the only possible approach to these patients is via a craniofacial team. Once the team members have examined the patient, and with the invaluable help of modern imaging, a plan of treatment is drawn up by the plastic surgeon and the neurosurgeon to incorporate all the morphological and functional aspects of the correction. These operations are too complex to be performed without significant previous experience with the problems involved. Such experience can only be obtained if these operations are performed in a limited number of specialized centers.

3 What is Teamwork?

Teamwork can be defined as the ability of team members to work together, communicate effectively, anticipate and meet each other's demands, and inspire confidence, resulting in a coordinated collective action. However, a clear and direct answer to the question ‘What is teamwork?’ has not been provided. According to McIntyre and Salas (1995), teamwork is a critical component of team performance and requires an explanation of how a team behaves. There are four key behavioral characteristics that compose teamwork: (a) performance monitoring, (b) feedback, (c) closed-loop communication, and (d) back-up behaviors.

The first requirement of teamwork is that team members monitor the performance of others while carrying out their own task. Monitoring ensures that members are following procedures correctly and in a timely manner, while also ensuring that operations are working as expected. Performance monitoring is accepted as a norm in order to improve the performance of the team in addition to establishing a trusting relationship between members.

Next as a follow-up activity to monitoring, feedback on the effectiveness or ineffectiveness of performance is passed along to members being monitored. Team members must feel at ease when providing feedback for teamwork to be effective. No obstacles (i.e., rank, tenure) should stand between members who are giving and receiving this vital information. Free-flowing feedback exists in the highest level of teamwork.

Teamwork involves the effective communication between a sender and receiver. Closed-loop communication describes the information exchange that occurs in successful communication. There is a sequence of behaviors that is involved in closed-loop communication: (i) the message is initiated by the sender; (ii) the message is accepted by the receiver and feedback is provided to indicate that it has been received; (iii) the sender double-checks with the receiver to ensure that the intended message was received. This type of communication is especially apparent in emergency situations.

Finally, back-up behaviors (i.e., the willingness, preparedness, and liking to back team members during operations) are required for effective teamwork. Team members must be willing to help when they are needed and must accept help when needed without feeling they are being perceived as weak. This requires that members know the expectations of their jobs while also knowing the expectations of others with whom they are interacting.

These four complex behavioral characteristics—performance monitoring, feedback, closed-loop communication, and backing-up behaviors—are necessary for effective teamwork. A failure of one of these aspects could result in ineffective team performance. Next, team training and four training strategies will be defined.

Teamwork

Teamwork can be defined as “skills for working in a group context, in any role, to ensure effective joint task completion and team member satisfaction […. and includes] coordinating activities with team members; exchanging information; using authority and assertiveness; assessing capabilities; supporting others.”170

Unlike teams in aviation, the military, and police and fire services, the OR team is unusual in that the command structure is ambiguous. Physicians (surgeon and anesthesiologist) are nominally superior to nursing and technical staff, but the two sets of physicians are coequally responsible for the patient during the immediate perioperative period.

Although surgeons were historically considered the “captain of the ship,” with even a legal doctrine giving them responsibility for the actions of all other OR team members, this has long since formally fallen by the wayside. Nonetheless remnants of this old history remain in aspects of the organizational structure and culture of OR environments. Clearly though when both anesthesiologists and surgeons are jointly caring for a patient, they are both responsible, and this situation can lead to complex issues of command authority, hierarchy, and control. Cooper recently published a paper investigating the critical role of the surgeon-anesthesiologist relationship for patient safety.324 Even though there is little research about this relationship, Cooper argues that the relationship for each surgeon-anesthesiologist dyad is perhaps the most critical element of overall team performance. His article explores functional and dysfunctional aspects of the relationship, identifies negative stereotypes each profession has of the other, and offers some suggestions on how to improve the working relationship.

Apart from the challenge of the coequal responsibility of the patient, the composition of teams in the OR holds some further challenges. Salas and colleagues defined a team as“a distinguishable set of two or more people who interact, dynamically, interdependently, and adaptively toward a common and valued goal/ objective/ mission, who have each been assigned specific roles or functions to perform, and who have a limited life-span of membership” (p. 4).325 A team is distinct from a group in that a group is an ad hoc collection of individuals without a specific mission and without specific roles. In the OR, all team members have the common goal of a good outcome for the patient. However, considerable disagreement can exist on how to achieve this goal and which elements of patient care have the highest priority. These differences are probably traceable to the fact that the OR team is itself made up of several crews (e.g., surgery, anesthesiology, nursing, as well as sometimes technical personnel from several domains) each of which has its own command hierarchy, its own global properties (professional standing, culture, traditions, and history), and its own set of local goals and objectives for management of the patient. A critical component of the success of this process comprises the establishment and maintenance of a shared mental model of the situation. The greater the overlap in mental models the more likely that team members will predict, coordinate, and adapt.13 To the degree that these objectives can be accomplished, the different individuals will be able to tailor their efforts toward a common goal.

8.7.2 The Nature of Effective Teamwork

Teamwork has traditionally been described in terms of classical systems theory, which posits that team inputs, team processes and team outputs are arrayed over time. In particular, team inputs include the characteristics of the task to be performed, the elements of the context in which work occurs and the attitudes team members bring to a team situation. Team process constitutes the interaction and coordination that is required among team members if the team is to achieve its specific goals. Team outputs consist of the products that result from team performance (Hackman, 1987; Ilgen, 1999; McGrath, 1984). Thus, teamwork per se occurs in the process phase, during which team members interact and work together to produce team outputs. Finally, teamwork does not require team members to work together permanently; it is sustained by a shared set of teamwork skills, not by permanent assignments that carry over from day-to-day (Morey et al., 2002). However, simply installing a team structure in an organization does not automatically result in effective teamwork. Effective team performance requires team members' willingness to cooperate for a shared goal. Moreover, effective teamwork depends on effective within-team communication and adequate organizational resources and support. In short, teamwork requires team members to develop a shared awareness of one another's roles and abilities. Without this awareness, serious but avoidable adverse outcomes may result from a series of seemingly trivial errors that effective teamwork would have prevented.

Extensive research has yielded numerous models of effective teamwork (Campion et al., 1993; Hambrick et al., 1996; Stevens & Campion, 1994; Fleishman & Zaccaro, 1992; West & Anderson, 1996). Historically, this literature has sought to identify generic teamwork skills that are associated with most teams. However, the focus has more recently shifted towards identifying the specific competency requirements that team members exhibit (Guzzo & Shea, 1992; Stevens & Campion, 1994; O'Neil et al., 1997). Although the term competency signifies a variety of meanings, it is generally used to denote the qualities needed by a jobholder (Parry, 1998). Specifically, Parry defined the term “competencies” as a cluster of related knowledge, skills and attitudes that (1) affects a major part of one's job (i.e. one or more key roles or Boyatzis (1982), in his seminal work on competencies, defines a job competency as “an underlying characteristic of a person, which results in effective or superior performance in a job”); (2) correlates with successful job performance; (3) can be measured against well-accepted standards; and (4) can be improved through training and development (O'Neil et al., 1997).

Generally speaking, team competencies are the attributes team members need to engage successfully in teamwork: As has been suggested, “…It is essential to understand the nature of competencies required to function in a team as a means to define selection criteria, design and conduct training, and assess team performance” (Guzzo & Shea, 1992). To explicate this understanding, Cannon-Bowers and colleagues identified three types of competencies that are critical for effective teamwork: (1) teamwork-related knowledge, (2) teamwork-related skills and (3) teamwork-related attitudes.

Teamwork

Teamwork is the bringing together of people who each contribute from complementary specialties. It is a collective competency which gives to the players what they need to get the job done right. The needs might be information, a service, or a product. A team or teams may be the security group or the security group in tandem with various product suppliers and consultants. Team composition will vary according to the mission, with each member contributing a different set of skills and abilities. Teamwork calls for sustained leadership and goal orientation.

In a single sentence, these three competencies operate to obtain access to the essential information, services, and products that fuel the security function, assuring quality through mutual cooperation.

2.3 Importance of Teamwork in Performing Forensic Analyses

Teamwork is an especially valuable approach in performing forensic analyses. As a rule, we have operated as a team with one of us doing the initial analysis and the other checking his/her results and conclusions. On occasion we have worked with one or two additional botanists. Teamwork helps to discover errors or bring out disagreements in interpretation that then can be discussed and resolved. Sometimes this results in more research or additional consultations. Teamwork is most effective when you and your other team member(s) can work on the evidence separately. If disagreements arise and cannot be reconciled through discussion, you may need to review and/or redo your work until agreement is reached.

Often you and your team member(s) work in isolation from investigators in other disciplines that may be involved in the same case. You simply prepare and submit your report. Sometimes your work is important only in the investigation prior to arrests or trials. Surprisingly, sometimes your forensic data may cause someone to confess their crime. Once caught in a lie, a suspect may recognize the futility of his/her claim of innocence. At other times, your data and conclusions may not be needed. Occasionally you will be asked to testify in court. We have found when serving on the defense team that having meetings where the various forensic disciplines present their findings can be very helpful when you are preparing your testimony for court. When working for the prosecution, you should receive a summary of the evidence against the defendant from the prosecutor. Teamwork may determine the verdict in court.

Introduction

Teamwork is fundamental to successful clinical outcomes. Team working between the dental practitioner, the practice personnel and the dental technologist, who is typically in a remote location, is critical to success in the provision of indirect restorations and prostheses. Effectiveness, as with many, if not all, other measures of success, is greatly increased by individuals working as a team, not as a team of individuals working independently. Dentistry without teamwork is not in the best interests of the patient, carrying a high risk of failures and unnecessary comebacks and complaints.

Developing a team that is capable of effective teamwork can be challenging. Inclusion of dental technologists and the dental laboratory team in this process is best achieved by reciprocal visits between the practice and the laboratory, as well as ‘get-togethers’ to develop the necessary relationships, share a common understanding of goals and values, agree practical arrangements and, most importantly, facilitate communication. From time to time, team building must be followed with events to reinforce team spirit, refine practical arrangements and maintain the all-important relationship between the different members of the team. A strong team is an effective team; a weak team suffers limitations, including tensions between its members. For example, when things go wrong, members of a weak team tend to blame each other, often forgetting about the needs of the patient, instead of pulling together to resolve the problem quickly and effectively.

3 Teamwork Derailers

Teamwork does not “just happen.” Often, an organization will place a group of well-qualified individuals together to work on a project and is surprised when the team does not achieve greatness. Despite the many benefits of teamwork and cooperation at work, teamwork does not occur automatically. But why do teams derail, and how does teamwork erode? Team derailment is defined as the process whereby an effective team experiences a significant decline in performance. This section, from the vantage point of a team competency framework, identifies three primary culprits: high levels of stress; lack of knowledge of the team’s mission, objectives, norms, and resources; and dissolution of trust. Any of these may lead to a decrement in team performance and cooperation.

Stress can have a significant effect on an individual’s or a team’s ability to perform a job. For example, teams operating in the military often face a high-stress environment in which multiple tasks must be performed under time pressure and in ambiguous situations. However, stress can result from situations in which resources are stretched or exceeded, there is danger of physical or personal harm, or the capacity to perform is diminished. Outcomes of stress for individuals in teams can be physiological (e.g., increased heartbeat, sweating), emotional (e.g., fear or anxiety), social (e.g., difficulty in coordinating actions), cognitive (e.g., a narrowing of attention), or have a direct influence on performance (e.g., trade-offs in the speed and accuracy of task performance, impaired decision making). None of these outcomes is particularly pleasant, and all can potentially impair team performance. One solution for teams operating in high-stress environments may be to provide stress exposure training (SET), which is designed to reduce stress through the provision of information, skills training, and practice to trainees.

To avoid team derailment, team members also need to know their team’s strategic and tactical goals, what resources are available to help achieve those goals, and under what conditions the team members will be expected to perform. When this knowledge is lacking, coordination of team member actions and provision of backup behavior and support are also deficient. It has been suggested that when a team initially forms, team members should be given the opportunity to gauge each other’s abilities and skills and to cooperatively determine the purpose of their team. This is often referred to as creating a shared mental model of the team, the task, and the processes by which the team will complete the task. Having completed this, the team can then determine how it will accomplish its goals and establish norms of behavior and performance. When a team lacks a clear mental model, it fails to recognize and integrate task contingencies as they arise. Similarly, failure to maintain a shared perception of the situation, strategic and tactical goals, and the resources available to accomplish those goals can lead to decreased cooperation and teamwork.

Finally, trust has become a common construct in the teamwork literature due to its positive relationship to organizational citizenship behaviors, successful negotiation, and conflict management. Understandably, all of these behaviors are essential to cooperation as well. In 1998, Rousseau and colleagues defined trust as a willingness to accept vulnerability due to positive expectations of the intentions or behaviors of others. Mutual trust in a team is a deeply held confidence toward the team’s climate, internal environment, and members. It is an attitude held by team members regarding the climate or mood of the team’s internal environment. When team members work interdependently to achieve group goals, they must be willing to accept a certain amount of risk so as to rely on each other and openly share information. Lack of trust in this situation may result in a reduction of information sharing as well as extensive time spent in monitoring team members, not for the purpose of improving performance but rather for ensuring their trustworthiness. When organizations fail to create policies that foster trust among team members or do not allow sufficient team interaction, cooperation will deteriorate. Now that some ways in which teams and teamwork may erode have been presented, the next section describes ways in which teamwork may be enhanced in work organizations.