Teamwork is an essential component of perioperative care and affects almost every process of care by anesthesiologists. This article examines why teamwork is critical to patient safety, how teamwork may be successfully taught to perioperative personnel, and how it may be successfully measured and implemented in the clinical setting.

There are times when an anesthesiologist may not see a single colleague all day long. After preoperative consultation with the patient, you may be setting up your room when the patient rolls in, anesthesia is quickly induced, and the surgeon works while you remain behind the drapes for hours on end. After a long procedure, you bring your patient to the recovery room, speak briefly to a nurse, and head home for the evening, having interacted with only a handful of people during your entire shift. On days like this, you can be forgiven for overlooking the fact that work in anesthesiology is truly a team sport.

Nearly every aspect of perioperative medicine is enhanced and directly affected by teamwork. However, what defines teamwork? The common expression, “I know it when I see it,” may be applied here. However, nearly every definition of team or teamwork includes some combination of the words “group,” “collaboration,” “common goal,” “complete task,” “effective,” and “efficient.” While the anesthesiologist in the example above may have personally encountered few people during the day, nearly every aspect of the successful patient care that was provided was impacted by teamwork.

Consider, for example, preparing a patient in the preoperative holding area. For that patient to be in the gurney with an I.V. in their arm and ready for consent, the collaboration of the surgeon, administrative staff, OR scheduler, preoperative nursing staff, and OR nurses was required. If that patient required preoperative workup for a chronic condition, even more team members, such as a consulting physician, administrative and nursing staff, and the preoperative clinic anesthesiologist, may have been involved.

Teamwork is essential for most perioperative processes (Figure 1). When we consider more complex processes, teamwork becomes even more important. Building a successful enhanced recovery after cesarean delivery (ERAC) pathway, for example, requires coordination among the obstetric service, anesthesia service, pharmacy, labor and delivery nursing, the regional anesthesia team, ante- and post-partum clinicians, the patient’s family members, administrators, and administrative staff. Even information technology personnel are needed to ensure adequate alerts and documentation in an institution’s electronic health record.

Figure 1: Teamwork is the foundation for every aspect of patient care.

Figure 1: Teamwork is the foundation for every aspect of patient care.

Teamwork is essential to patient safety. With the increasing complexity of cases in ambulatory centers and non-OR anesthesia locations, identifying a team and ensuring efficient communication and teamwork are critical for preserving patient safety. In a systematic review of 297 studies assessing the improvement of teamwork in a health care setting, implementation of teamwork training was associated with improvements in communications, increased awareness of patient safety, enhanced employee/patient satisfaction, and overall perception and attitudes among staff. Subsequent studies have demonstrated a reduction in the incidence of wrong-site surgery and retained foreign bodies after implementing teamwork interventions, and improved teamwork has been associated with more rapid interventions for changing patient conditions such as abnormal lab values.

Varying frameworks exist for training clinicians in effective teamwork. Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) is a systematic approach to teamwork developed by the Department of Defense (DoD) and the Agency for Healthcare Research and Quality (AHRQ) and has been deployed extensively across the country to improve patient safety via enhanced team performance. Thomas et al. used the AHRQ’s Hospital Survey on Patient Safety Culture before and after the implementation of TeamSTEPPS and were able to demonstrate significant improvement using this framework for team-based care.  Crew resource management (CRM), a framework adapted into health care from aviation, has been shown to generally produce positive reactions, enhance learning, and promote desired changes, all of which have positive impacts on safety.

Given the importance of teamwork to patient safety, it is imperative to examine how to develop effective teams in health care. Can teamwork be taught successfully, or is it an innate ability? If taught, by what methodology is education most successful? Chakraborti et al. uncovered several themes when conducting a meta-analysis of teamwork training methods of medical students and residents. Most curricula involved multidisciplinary learning environments, which is optimal for trainees in anesthesiology, given the multidisciplinary teams they work in. Well-established models, including CRM and TeamSTEPPS, are best learned in these environments. These methods educate residents to serve as either leaders or team members in critical events. CRM teaches skills such as closed-loop communication, information briefings, activity monitoring, and the importance of speaking up. TeamSTEPPS is a comprehensive multidisciplinary curriculum that centers on teaching leadership skills, situation monitoring, mutual support behaviors, and effective communication as the pillars upon which teamwork is based.

“In a systematic review of 297 studies assessing the improvement of teamwork in a health care setting, implementation of teamwork training was associated with improvements in communications, increased awareness of patient safety, enhanced employee/patient satisfaction, and overall perception and attitudes among staff.”

All curricula evaluated by Chakraborti et al. also involved a form of active learning, such as simulation, case-based discussions, or role play. Feedback and/or debriefing sessions are critical components of such programs. These approaches allow learners to apply skills taught through lecture in real time. Ideally, debriefing sessions are then held immediately afterward by personnel trained in tools such as “debriefing with good judgement.” This provides opportunities for learners to uncover perspectives from which their actions are derived and reframe them to take new actions to achieve better outcomes in the future.

In addition to formal education, tools may be employed to create and facilitate teamwork, including checklists, rounds, or formalized feedback or reporting. These tools are often very successful at achieving specified tasks, such as completion of a preoperative time-out or decreasing infection risk for central venous line placement. Organizational redesign can also improve team functionality and effectiveness. For example, certain tasks may be reassigned during preoperative admission to facilitate timely surgical starts, such as confirmation of home medications or administration of prophylactic medication.

When considering how to assess the efficacy of teamwork, it is essential to clearly define which team is being measured. Teams can be synchronous (for example, the intraoperative team of physicians, nurses, and surgical technicians) or asynchronous (such as the longitudinal preoperative coordination by multiple individuals and subgroups). Importantly, in addition to working synchronously or asynchronously, team constructs can be considered as “bounded,” where membership is consistent with clearly defined roles, or “unbounded,” such as in workgroups in clinical units and departments where team behaviors are important but membership and roles vary over time or context. Unbounded workgroups are more characteristic of daily work in the perioperative setting.

Surveys can be used to measure team effectiveness. Survey-based approaches differ depending on which type of team construct is being evaluated and typically ask about behavioral processes (e.g., communication, coordination, workload sharing, use of all members’ expertise) and affective/cognitive states (e.g., respect, social support, role clarity, psychological safety, shared objectives).

Implementation research related to team effectiveness measures team performance, viability, and member outcomes. Performance can be assessed in terms of productivity, efficiency, and work quality. Team viability can be assessed based on the continuing existence of a team and members’ willingness to work together again. Member outcomes of both an individual sense of satisfaction and learning from the team’s shared activity can also be measured via self-reported surveys.

Success across all domains of team function are vital drivers of clinical outcomes, although clinical outcomes alone are an insufficient measure of teamwork, as they are driven by many factors beyond team function. Clinical outcomes following teamwork-based interventions are easier to measure objectively by choosing very narrow parameters such as wrong-site surgery, a task-based endpoint. In fact, task-based educational training for the purposes of fielding a successful team has the advantage of being easier to implement than generalizable training. In addition, the measured endpoint is easy to address – namely the success or failure of the stated goal. If, for example, one is performing team-based training for executing a new “time-out” process prior to induction of anesthesia in a remote location, the measured endpoints include such items as completion of time-out, accuracy of the involved steps, and avoiding associated perioperative errors. The main drawback to this type of training is that the skills learned herein, even for the best-performing teams, tend to be limited to completion of the specific intended task.

It is also critical to consider the composition of one’s team when tackling a task or set of tasks, as well as when teaching effective teamwork. Often, the simple act of identifying the relevant teammates needed for tasks jumpstarts the conversation regarding effective team functionality. When considering the effective functionality of an anesthesiology department, for example, the anesthesiologist may depend on numerous other personnel, including administrators, anesthesia technicians, and clinical researchers, and is in fact part of a much larger team working to improve safety and outcomes (Figure 2).

Figure 2: The teams within the teams that contribute to quality care.

Figure 2: The teams within the teams that contribute to quality care.

Team building via education, simulation, checklists, or protocols provides participants with skills that may translate to numerous potential situations that could arise. These skills may be deployed in such situations as crisis management during a cardiac arrest, implementation of a new postoperative acute pain management service, or coordination of a multidisciplinary team that deploys a new electronic health record. As anesthesiologists, it is critical to remember that we are part of a team that must function properly to ensure perioperative efficiency, timely interventions, and patient safety.