Teamworking and patient safety: Introduction

This commentary describes a clinical case that took place in Australia. The issues that led to the patient’s death did not occur because of a lack of clinical knowledge, unavailability of investigations or uncaring staff. Mrs M died because the teams providing her care failed to work well together. Poor teamwork causes more patient harm and poor healthcare than any of the above. As doctors, we must understand teamwork and how to create an environment that allows excellent clinical care to flourish.

Below is the clinical summary, and we hear from three other perspectives:

1. A psychologist with expertise in human behaviours and healthcare

2. The view of an RMO who is at the beginning of their career

3. Someone outside the medical profession - an experienced ward occupational therapist who regularly sees new medical teams come and go

If you prefer listening to reading, head to the bottom of this page for a link to a podcast that includes these articles.

Clinical summary

Mrs M, a fit 69-year-old woman, underwent an uncomplicated elective laparoscopic cholecystectomy. The next morning, upon review by the surgical team, it was decided that she should remain in the hospital for another night for observation due to shoulder tip pain and nausea. That afternoon, Mrs M was transferred without the consultation of the surgical team from the surgical ward to a low-dependency rehabilitation unit.

By the next morning, she was tachycardic, and diaphoretic and had a distended abdomen. Mrs M was reviewed by the rehabilitation ward medical officer who prescribed intravenous (IV) fluids and analgesia, ordered blood tests and requested an urgent surgical review.

The surgical team then saw Mrs M as part of their morning ward round. On review, Mrs M still had generalised abdominal tenderness, with abnormal vital signs, and an abdominal X-ray and CT scan were ordered.

Mrs M continued to deteriorate over the day. Another set of abnormal vital observations was taken following the ward round (which showed a fall in her oxygen saturation level, hypotension and tachypnoea, a pulse rate reading was not recorded), yet no doctor was informed. Mrs M was seen by two of the unit’s interns after they were called to review her in the CT room for an observed change in her condition. They found her looking pale and unwell and relayed their concerns to their registrar over the phone who told them to treat Mrs M with IV fluids and analgesia.

The registrar contacted the consultant surgeon to discuss the blood results, and again to discuss the CT findings. It was decided that Mrs M would return to the theatre later that day for explorative laparotomy, followed by transfer to ICU for post-operative observation.

The intensivist on duty reviewed her and diagnosed peritonitis and renal failure, and prescribed triple antibiotic and rapid IV fluid therapy, and strict monitoring of fluid balance. Mrs M was concurrently seen by the anaesthetic house officer on duty for a pre-anaesthetic assessment. As she had single IV access, only one antibiotic was administered when she was called to the operating room.

Once in the operating theatre, surgery was delayed by an hour and ten minutes. This was due to Mrs M becoming profoundly hypotensive upon anaesthetic induction. A bile leak was found intra-operatively and the abdomen was lavaged.

It was not discovered until her arrival in ICU later that evening that Mrs M had only received one of the three prescribed antibiotics. She was severely septic by then, requiring inotropes, dialysis, and mechanical ventilation. A second laparotomy two days later found widespread bowel and hepatic ischaemia, and Mrs M died the next day of multi-organ failure.

Questions for reflection

• How many clinical teams were involved in this case?

• What factors impacted the performance of individuals within their medical speciality teams?

• What factors impacted the performance between the different teams? How could this be improved?

Dysfunctions affecting teams and teamwork – by Dr Shelly Jeffcott. Psychologist and expert in human behaviours and patient safety in healthcare.

During the pandemic, some groups are working extraordinarily well while others have become fragmented. In the current circumstances, we must rely on our teams much more and here we need trust and psychological safety. Psychological safety is a shared feeling that it is okay to be open and honest in a group setting.

Things change rapidly. Communication comes at us from all over. We are overloaded.

When decisions leading to major changes are being made on an hourly or daily basis. We are going to make mistakes. In these circumstances, we must forgive and learn so we are focussing on how we get through this, how we innovate, how we share the ideas we have, and how we are able to challenge decisions we think may not be working. It is important to feel that you are part of a team because the burden is too great to carry on your shoulders alone. I think that it is hard to eliminate that feeling of being alone. To do that we need peer support groups. This is basically just about tapping into informal but helpful support that you get from peers and supervisors. It’s important to talk about challenges and opportunities at work.

This must be done in a way that makes you feel safe and makes you feel that you can tap into that camaraderie. The team usually has people that know what it is like to walk in your shoes and may be able to share their advice and opinions with you to help.

We all think of teams differently, depending on who we are and the work we are doing. Commonly, your team is your immediate peers who are doing similar work and have common goals and challenges. But, of course, teams exist all throughout organisations, across departmental boundaries and up and down the organisation too. Hierarchy is a very interesting concept that can impact on team and individual work. It affects the way we interact and relate to each other and to those who supervise our work.

Lencioni¹ describes the five dysfunctions of teams, the first of which is the absence of trust. The second is the fear of conflict. The third is a lack of commitment. The fourth is avoidance of accountability. The fifth is inattention to detail. I think that if we run along hierarchical lines, we are more likely to fall into one of those dysfunctions.

1. Absence of trust

The first is about absence of trust, which really goes to the idea of psychological safety. Without trust, we are much less likely to be able to understand the work that happens. We are much less likely to hear from the voices we need to hear from, in order to understand the nature of the real challenges and opportunities. Have you ever seen the ‘iceberg of ignorance’? This is the idea that 100% of the problems are known at the bottom levels, while only 75% of the problems are known at the supervisory level. As you move higher and higher, knowledge of the problems decreases until you get to the top level, and there is only knowledge of between 7% and 10% of the problems. There is a muting or censorship of the reality of what is happening in the frontline as you go up. This is because people do not want to hear bad news, and people are frightened to share bad news.

2. Fear of conflict

The second dysfunction is around fear of conflict. This is something that I find fascinating, and related to psychological research done in the 1970’s. Although we are all individuals with our own views and worldviews, just like in high school, we still want to be popular. We still want to be in a harmonious group.

Even if it is dysfunctional, we do not want to stick out. It is a frightening thing to be other (that is, different from or alien or an outsider), so that fear of conflict can suppress our ability to be open and honest. To question things or to bring new but divergent information. I think that is hugely problematic in many ways.

3. Lack of commitment

The idea of a lack of commitment is an interesting one – it is the third dysfunction of a team. It is not the idea that people do or do not want to do their best. It is more the idea that there is no constancy of purpose or shared mental model of the plan of work: there is no sense that you are all trying to achieve a shared goal. So, people become disenfranchised because they do not really feel that they are included in the decisions being made, and they do not get a full picture of what is going on. They do not feel that they have been communicated with well. A lack of commitment is, from a psychological perspective, when you become less intrinsically motivated. Intrinsic motivation would be the feeling that you just want to do your best and are proud to be working in the team. On the other hand, extrinsic motivation is when you do something, for example, because otherwise you will get into trouble; for example, you are worried about getting your wages docked. Extrinsic motivation does not create a nice environment.

4. Avoidance of accountability

The fourth point is avoidance of accountability. This is the idea that, as I said earlier with respect to psychological safety, your leaders are able to admit when they have done wrong, or when they do not know all the answers, despite doing their best given the circumstances. That is really, really critical. If they do not do that, they avoid being accountable. That filters down and can result in a toxic team.

5. Inattention to results

The fifth dysfunction is inattention to results, which is where the focus of the team member is on their own personal success rather than the success of the team. This is the mindset where a person if thinking “I want to maintain my status and protect my ego” and is putting that before everything else that the team needs to succeed.

Characteristics of strong teams include:

• Psychological safety

• Supported communication flowing up, down and across groups, such that silos break down

• Situational awareness opportunities

• Shared mental models.

Remember the workplace and team culture is not just something that happens to you; it is something you are part of, and that you can create. Some of the best and smartest people I have ever worked with are the clinically untrained, support staff. I think everyone has value which comes through when you begin to create opportunities for people to come together, show their value, speak up safely and show their experiences. How can you help us to create more cross-fertilisation between different groups, up and down the hierarchy, to all come together and talk about how work really happens?

The junior doctor’s view on teamwork and patient safety - Dr Georgette Paatsch

Commencing a career as a medical professional during a global pandemic was always going to prove a challenge. Flexibility and adaptability are more important than ever as the clinical landscape continues to change and the role of a junior doctor evolves. Within this, there is an even greater emphasis on being a junior doctor who is an active member of a well-functioning team in providing patient-centred care. As interns entering the first year of clinical practice, we have been taught from early in medical school that communication, collaboration, and organisation are the keys to a successful career. Perfect these skills and you will be a well-respected junior within the treating team.

It feels obvious to say that working well in a team is an essential skill for an intern, but as highlighted in the case studies, when the treating teams do not work collaboratively amongst themselves, the outcomes for patient safety can be catastrophic. In retrospect, it was incredibly naïve to enter my internship assuming that the medical team I was allocated to would be the main, and most important, team to be a part of. While it certainly plays a big role, I would argue that the most important team that contributes to patient safety is made up of every person who is involved in patient care from the moment they enter the hospital to the day they leave.

A team is a group of people working towards a common goal, and in our case, that goal is assisting our patients to return to health and return home.

Sure, a patient may be deemed medically fit for discharge but without a pharmacist to dispense a Webster pack, an Occupational Therapist to provide rails and a shower chair, a physiotherapist to provide a mobility aid, nursing staff to give urinary catheter self-management education, or ward clerks to book transport home, how can we ensure patient safety on discharge?

A good intern is one who is an active contributor to the team. One way in which our role has adapted during this time of visitor restrictions is that we need to step up and be our patient’s advocate within the larger treating team. As an intern, you spend all day every day on the ward and will get to know your patients well. As such, you will know their history, progress, and discharge plan. You must actively contribute this knowledge to the team as these are integral to better patient outcomes.

During this year I have found that teamwork takes on many more forms. It is the comradery amongst peers of acknowledging that we are all in this together and we need to take time out to look after ourselves and each other.

It is important to remember that you will not be alone in feeling overwhelmed during your internship, particularly as the uncertainty continues, and that there are always people to talk to. Always ask for help, your teammates around you have years of clinical experience and provide a wealth of knowledge. And remember, to be an active contributor to a functional team, it is essential that you look after yourself first, to then be able to look after your patient.

Teamwork and patient safety are intricately intertwined within the healthcare system, and it is essential that any junior doctor entering this workforce acknowledges the importance of both. Interns are an important cog in the wheel of patient care and are valued members of the many teams they make up.

From the outside looking in – by Sally Eastwood, Occupational Therapist

It must be hard for junior doctors to fully immerse themselves into a new team with each new rotation. It is equally as hard for the pre-existing team members to learn to trust and rely on the new junior doctor every three months. After 15 years of working as an allied health professional within multidisciplinary teams on a range of inpatient wards, I have a sense of which teams are working well together and with the junior doctor allocated to the clinical service.

The better functioning teams are those where everyone communicates regularly, are working towards a common goal, and help each other during busy times. Over my career, I have worked closely with over 225 junior doctors and observed triple that number in other teams. It has become very easy to see which junior doctors will easily fit into the team, and which ones will find it challenging.

Starting out in clinical practice is exciting. After all those years studying at medical school, you now get to practice what you have learned. What’s important to remember is that you only just starting out and that there are nurses and allied health professionals that have been working in a team or on a ward for decades. Join the team actively by respecting their experience and soaking up their knowledge.

They have an abundance of real-world information to share if you would only ask. Don’t forget, those years of experience might just save you and your patient from harm.

If you don’t know the names of the staff, ask.

If you don’t know the roles of the team, ask. Every team and every hospital is different. Check your role in the team and how it fits in with the allied health team. Ask if the Occupational Therapist normally completes the cognitive assessments or if it is your role. Ask who coordinates the discharges, so you know who to liaise with about when a patient will be ready to go. All this information is valuable and if you don’t ask, you don’t know.

Be active and join the team

While it’s important to be realistic and accept that not every colleague or every team is going to hit it off. The key to success is being interested, inquisitive, and open to learning, these characteristics will always put a junior doctor in good stead to becoming an integral part of the team.

My advice for junior doctors starting out at a new hospital, department, or ward, is to actively ‘join’ the team. Introduce yourself to the team members around you, sometimes you may need to do this a few times—don’t be shy. Learn the names of the staff, if you forget, ask again. I would prefer someone to admit they have forgotten my name, and ask again, rather than have those repeated awkward moments where they do not address me for the next three months. Remember to ask about and learn about the whole team members – this includes clinical support staff such as ward clerks and domestic staff.

Teams want to embrace junior doctors

Junior doctors are a crucial part of the team, for one, they are often the most accessible part of the medical team. And the most in abundance. If you are hesitant to contact the senior medical specialist—imagine how we feel about having to approach them. We would far prefer to be talking to you.

Teams want to embrace junior doctors, so it is important to jump on board and meet us halfway. Mutual respect and a passion for patient care is essential. The other staff both clinical and clinical support find it is very easy to pick the junior doctors who are simply biding their time and just going through the bare minimum required from the enthusiastic and attentive junior doctor who is dotting their I’s and crossing the T’s.

For those junior doctors just biding their time, the team will only ask for help and answer your questions if absolutely necessary. That pattern of behavior leads to mistakes and important things get missed. You don’t have to love the area, to do a good job. Also, in those situations, the team will likely bypass you and instead seek out the registrar or consultant to get our questions answered – which makes the consultant wonder why.

We have a shared goal

Just remember we are all here working for the best possible outcome for our patients.

Considerations for further discussion

When you’re an intern on the ward, which teams are you a member of?

How can you optimise your contribution to team-working in healthcare? What skills and attitudes are important to providing excellent patient care?

Dr Jeffcott used the terms psychological safety and shared mental models. What do you understand by these?

This article is summarised from a series in the Future Leaders Communiqué, a patient safety publication produced by the Victorian Institute of Forensic Medicine. It is based upon learnings from Coroners’ cases in Victoria, Australia. You can listen to these conversations as a podcast episode here.