Improving Teams in Healthcare Appendix

Improving teams in healthcare Appendix

List of contributors

Archie Keeling, Craig Dyer, Lindsay Taylor, Lynne Quinney, Patrick Lillie, Rachel Forbes-Pyman, Sue Crossland, Summet Hindocha, Tom Baker, Wendy Randall, Yee Yen Goh

Round-table attendees

Tom Baker Royal College of Physicians Adrian Boyle Royal College of Emergency Medicine Sue Crossland Calderdale and Huddersfield Foundation Trust Anna Crossley Royal College of Nursing Sam Cryer Faculty of Physician Associates Nina Dutta Royal College of Physicians Kevin Enright London’s Air Ambulance Tony Garelick DocHealth Andrew Goddard Royal College of Physicians Sumeet Hindocha NHS Improvement Lowri Jackson Royal College of Physicians Govind Menon Cardiff and Vale University Health Board Carol Postlethwaite East Surrey Hospital Lynne Quinney Royal College of Physicians Mridula Rajwani Oxford University Hospitals Jazz Sidhu Royal College of Physicians Jude Tweedie Royal College of Physicians Jacob de Wolff London North West Healthcare NHS Trust

Acknowledgements

Sabreen Akhtar, Deborah Allen, Emma-Louise Bray, Craig Dyer, Richard Gilpin, Leanne Griffin, Andrew Griffiths, Shireen Gupta, Mark Reynolds, Matt Spencer

References

Resource 1: Building effective teams

1 Royal College of Physicians. Being a junior doctor. London: RCP, 2016. https://www.rcplondon.ac.uk/guidelines- policy/being-junior-doctor [Accessed 4 October 2017] 2 Royal College of Physicians. The medical registrar: Empowering the unsung heroes of patient care. London: RCP, 2013. 3 Manser T. Teamwork and patient safety in dynamic domains of healthcare: a review of the literature. Acta Anaesthesiol Scand 2009;53.2:143–151.

11 St Andrews Place, Regent’s Park, London NW1 4LE © Royal College of Physicians 2017 Tel: +44 (0)20 3075 1649, Fax: +44 (0)20 7487 5218 www.rcplondon.ac.uk/improvingteams Registered charity no 210508

4 Firth-Cozens J. Cultures for improving patient safety through learning: the role of teamwork. Qual Saf Health Care 2001;10.suppl 2:ii26–ii31. 5 West, MA et al. The link between the management of employees and patient mortality in acute hospitals. International Journal of Human Resource Management 2002;13.8:1299–1310. 6 Carter, AJW, West, M. Sharing the burden - teamwork in health care settings. In J Firth-Cozens, J, Payne RL (eds), Stress in health professionals: psychological and organisational causes and interventions. Chichester: John Wiley and Sons, 1999: 191–202. 7 Buttigieg SC, West MA, Dawson JF. Well-structured teams and the buffering of hospital employees from stress. Health Serv Manage Res 2011;24.4:203–212. 8 Katzenbach JR, Smith DK. The discipline of teams. Harvard Business Review 2005;83.7:162. 9 Rutherford JS, Flin R, Mitchell L. Teamwork, communication, and anaesthetic assistance in Scotland. Brit J Anaesth 2012 https://doi.org/10.1093/bja/aes172 10 West MA, Lyubovnikova J. Real teams or pseudo teams? The changing landscape needs a better map. Industrial and Organizational Psychology 2012;5(1):25–28. https://doi.org/10.1111/j.1754-9434.2011.01397.x [Accessed 4 October 2017]. 11 West M, Dawson JF. Employee engagement and NHS performance. London: The King’s Fund, 2012:1–23. http://www.kingsfund.org.uk/sites/files/kf/employee-engagement-nhs-performance-west-dawson-leadership- review2012-paper.pdf [Accessed 4 October 2017]. 12 West M, Borrill C, The influence of team working. In Cox J King J, Hutchinson A McAvoy P. Understanding doctors’ performance. Oxford: Radcliffe Publishing, 2005. 13 Dickinson H, Ham C, Snelling I, Spurgeon P. Are we there yet? Models of medical leadership and their effectiveness: An exploratory study. Final report. NIHR Service Delivery and Organisation programme, 2013. http://www.netscc.ac.uk/hsdr/files/project/SDO_FR_08-1808-236_V07.pdf [Accessed 4 October 2017] 14 Salas E, Granados D, Klein C et al. Does team training improve performance? A meta-analysis. Human factors 2008;50:903–33 15 West M, Dawson, J. Employee engagement and NHS performance. London: The King’s Fund, 2012. 16 Walmsley J, Miller K. A review of the health foundations leadership programme 2003–07. London: The Health Foundation, 2008. 17 Maben J, Peccei R., Adams M, Robert G, Richardson A, Murrells T, Morrow E. Patients’ experiences of care and the influence of staff motivation, affect and wellbeing. NIHR Service Delivery and Organisation Programme, 2012. 18 Weaver SJ, Dy SM, Rosen MA. Team-training in healthcare: a narrative synthesis of the literature. BMJ Quality & Safety 2014;23(5):359–372. https://doi.org/10.1136/bmjqs-2013-001848 [Accessed 13 November 2017]. 19 Schmulz J, Manser T. Do team processes really have an effect on clinical performance? A systematic literature review. Brit J Anaesth 2013;110:539–44 20 Rowland P. Core principles and values of effective team-based health care. J Interprof Care 2014;28(1):79–80. https://doi.org/10.3109/13561820.2013.820906 [Accessed 13 November 2017]. 21 Rabol L, Andersen ML, Ostergaard D et al. Descriptions of verbal communication errors between staff. An analysis of 84 root cause analysis reports from Danish hospitals. BMJ Quality and Safety 2011;20:268–74. 22 Singh H, Thomas EJ, Petersen LA. Medical errors involving trainees: a study of closed malpractice claims from 5 insurers. Arch Intern Med 2007;167:2030–6. 23 Madden E, Sinclair M, Wright M. Teamwork in obstetric emergencies. Evidence Based Midwifery 2011 Sep 2;9(3):95-101. 24 Faculty of Leadership and Management. Leadership and management standards for medical professionals. 2nd edition. London: FMLM, 2016. https://www.fmlm.ac.uk/individual-standards [Accessed 4 October 2017]. 25 West M, Armit K, Loewenthal L et al. Leadership and leadership development in healthcare: The evidence base. London: Faculty of Medical Leadership and Management, 2015.

https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/leadership-leadership-development- health-care-feb-2015.pdf [Accessed 4 October 2017]. 26 NHS Leadership Academy. Healthcare Leadership Model, version 1.0. Leeds: NHS Leadership Academy, 2013. https://www.leadershipacademy.nhs.uk/wp-content/uploads/2013/10/NHSLeadership-LeadershipModel-10- Print.pdf [Accessed 4 October 2017]. 27 Holbeche L, Mayo A. Motivating people in lean organizations. London: Taylor & Francis, 2009. 28 Borrill CS et al. Team working and effectiveness in health care. British Journal of Healthcare Management 2000;6.8:364–371. 29 NHS staff survey 2017. http://www.nhsstaffsurveys.com [Accessed 4 October 2017]. 30 NHS Thames Valley and Wessex Leadership Academy. The importance of working in an effective team – Creating the culture and climate to promote innovation and patient safety. NHS TVWLA. www.tvwleadershipacademy.nhs.uk/enews-02/importance-working-effective-team [Accessed 4 October 2017]. 31 Suff P, Reilly P. Pulling together: Getting the most out of teams. Brighton: Institute for Employment Studies, 2006. www.employment-studies.co.uk/system/files/resources/files/mp70.pdf [Accessed 4 October 2017]. 32 Holbeche L. The high performance organization. London: Routledge, 2015. 33 NHS Improvement. Engaging, supporting and valuing doctors in training: better engagement. NHSI, 2017. https://improvement.nhs.uk/resources/engaging-supporting-and-valuing-doctors-in-training/ [Accessed 4 October 2017]. 34 NHS Improvement. Building a culture of engagement with doctors in training. NHSI, 2017. https://improvement.nhs.uk/uploads/documents/Case_study.Imperial_3.pdf [Accessed 4 October 2017]. 35 Borrill C, West M. How good is your team? A guide for team members. Birmingham: Aston Centre for Health Service Organisation Research, 2002. https://scele.ui.ac.id/berkas_kolaborasi/konten/MKK_2014genap/borril_team.pdf [Accessed 4 October 2017].

Resource 2: Team culture

1 Royal College of Physicians. Being a junior doctor. London: RCP, 2016. 2 Royal College of Physicians, The medical registrar: Empowering the unsung heroes of patient care. London: RCP, 2013. 3 Manser T. Teamwork and patient safety in dynamic domains of healthcare: a review of the literature. Acta Anaesth Scand 2009;53:143–51. 4 Firth-Cozens J. Cultures for improving patient safety through learning: the role of teamwork. Qual Health Care 2001;10(Suppl 2):ii26–ii31. 5 West MA et al. The link between the management of employees and patient mortality in acute hospitals. Int Jo Hum Resour Man 2002;13:1299–1310. 6 Carter, AJW, West M. Sharing the burden-teamwork in health care settings. In: Firth-Cozens J, Payne RL (eds), Stress in health professionals: psychological and organisational causes and interventions. Chichester: John Wiley and Sons, 1999:191–202. 7 Buttigieg SC, West MA, Dawson JF. Well-structured teams and the buffering of hospital employees from stress. Health Serv Manag Res 2011,24:203–12. 8 Pollack S, Frolkis J. Creating strong team culture. www.stepsforward.org/modules/create-healthy-team-culture [Accessed 13 November 2017] 9 Ofri D. My near miss. New York Times 28 May 2013. www.nytimes.com/2013/05/29/opinion/addressing-medical- errors.html [Accessed: 2 September 2017]. 10 Agency for Healthcare Research and Quality Advancing Excellence in Health Care. Annual Progress Report to Congress: National Strategy for Quality Improvement in Health Care. Rockville: AHRQ, 2014.

11 Sharmila D. Doctors in distress. Lancet 2011;377:454–455. 12 NHS Survey Coordination Centre. Staff Survey 2016 Detailed Spreadsheets. 2016. 13 Nancarrow SA, Booth A, Ariss S et al. Ten principles of good interdisciplinary team work. Hum Resour Health 2013;11. https://doi.org/10.1186/1478-4491-11-19 [Accessed 13 November 2017]. 14 Borrill, CS et al. The effectiveness of health care teams in the National Health Service. Report. Birmingham: University of Aston in Birmingham, 2000. 15 Francis R. The Mid Staffordshire NHS Foundation Trust Inquiry. London: Crown, 2010. 16 Berwick DM. A promise to learn – a commitment to act. Improving the safety of patients in England. London: DH, 2013. 17 Bosse HM, Mohr J, Buss B et al. The benefit of repetitive skills training and frequency of expert feedback in the early acquisition of procedural skills. BMC Medical Education 2015;15:22. https://doi.org/10.1186/s12909-015-0286-5 [Accessed 13 November 2017]. 18 Kluger AN, DeNisi A. The effects of feedback interventions on performance: A historical review, a meta-analysis, and a preliminary feedback intervention theory. Psychological Bulletin 1996, 119(2), 254–284. 19 Ivers NM, Grimshaw JM, Jamtvedt G et al. Growing Literature, Stagnant Science? Systematic Review, Meta- Regression and Cumulative Analysis of Audit and Feedback Interventions in Health Care. J Gen Intern Med 2014;29:1534–1541. https://doi.org/10.1007/s11606-014-2913-y [Accessed 17 November 2017]. 20 Walsh CM, Ling SC, Wang CS et al. Concurrent versus terminal feedback: it may be better to wait. Acad med 2009;84(10Suppl):S54–7. 21 Herb E, Leslie K, Price C. Teamwork at the top. Teaching material. 2001. Available at: www.mckinsey.com/business-functions/organization/our-insights/teamwork-at-the-top [Accessed: 2 September 2017]. 22 World Health Organization. Topic 4: Being an effective team player. Teaching material. 2014. Available at: www.who.int/patientsafety/education/curriculum/who_mc_topic-4.pdf [Accessed: 2 September 2017]. 23 Jain AK, Fennell ML, Chagpar AB et al. Moving Toward Improved Teamwork in Cancer Care: The Role of Psychological Safety in Team Communication. J Oncol Pract 2016;12:1000–1011. 24 Anderson C, Brown CE. The functions and dysfunctions of hierarchy. Organ Behav 2010;8:124–132. https://doi.org/10.1016/j.riob.2010.08.002 [Accessed 17 November 2017]. 25 Okuyama A, Wagner C, Bijnen B. Speaking up for patient safety by hospital-based health care professionals: a literature review. BMC Health Serv Res 2014;14:61. https://doi.org/10.1186/1472-6963-14-61 [Accessed 17 November 2017]. 26 Weller J, Boyd M, Cumin D. Teams, tribes and patient safety: overcoming barriers to effective teamwork in healthcare. Postgrad Med J 2014;90:149–154. 27 McMaster E, Phillips C, Broughton N. Righting the wrongs of traditional medical hierarchy. Anaesthesia 2016;71(1): 110–1. 28 MSF Union. Workplace bullying definitions. https://bullyonline.org/old/workbully/defns.htm [Accessed 4 October 2017] 29 Institute for Safe Medication Practices. Disrespectful Behavior In Healthcare ... Have We Made Any Progress In The Last Decade? Newsletter, 2013. www.ismp.org/newsletters/acutecare/showarticle.aspx?id=52 [Accessed: 2 September 2017]. 30 Rosenstein AH, O’Daniel M. A Survey of the Impact of Disruptive Behaviors and Communication Defects on Patient Safety. Jt Comm J Qual Patient Safe 2008;34:464–47. 31 Hickson GB, Federspiel CF, Pichert JW et al. Patient Complaints and Malpractice Risk. JAMA 2002;287:2951–2957. https://doi.org/10.1001/jama.287.22.2951 [Accessed 17 November 2017]. 32 Hickson G, Entman SS. Physician practice behavior and litigation risk: evidence and opportunity. Clin Obstet Gynaecol 2008;51:689–99.

33 GMC. Good medical practice. London: GMC, 2013. http://www.gmc-uk.org/guidance/good_medical_practice.asp [Accessed 4 October 2017] 34 British Medical Association. Workplace bullying and harassment of doctors. A review of recent research and policy recommendations. London: BMA, 2017. 35 Porath C, Pearson C. The price of incivility. Harvard Business Review, 2013. https://hbr.org/2013/01/the-price-of-incivility [Accessed: 2 September 2017].

Resource 3: Team communication

1 Royal College of Physicians. Being a junior doctor. London: RCP, 2016. 2 Royal College of Physicians. The medical registrar: Empowering the unsung heroes of patient care. London: RCP, 2013. 3 Manser T. Teamwork and patient safety in dynamic domains of healthcare: a review of the literature. Acta Anaesth Scand 2009;53:143–51. 4 Firth-Cozens J. Cultures for improving patient safety through learning: the role of teamwork. Qual Health Care 2001;10(Suppl 2):ii26–ii31. 5 West MA et al. The link between the management of employees and patient mortality in acute hospitals. Int Jo Hum Resour Man 2002;13:1299–1310. 6 Carter, AJW, West M. Sharing the burden-teamwork in health care settings. In: Firth-Cozens J, Payne RL (eds), Stress in health professionals: psychological and organisational causes and interventions. Chichester: John Wiley and Sons, 1999:191–202. 7 Buttigieg SC, West MA, Dawson JF. Well-structured teams and the buffering of hospital employees from stress. Health Serv Manag Res 2011,24:203–12. 8 Flin R et al. Human factors in patient safety: review of topics and tools. WHO: 2009. 9 Francis R. The Mid Staffordshire NHS Foundation Trust Inquiry. London: Crown, 2010. 10 Teamwork and Communication Working Group. Improving patient safety with effective teamwork and communication: Literature review needs assessment, evaluation of training tools and expert consultations. USA: Canadian Patient Safety Institute, 2011. 11 Gluyas H. Effective communication and teamwork promotes patient safety. Nursing Standard 2015;29:50–57. 12 Joint Commission on Accreditation of Healthcare Organizations. The Joint Commission guide to improving staff communication. Illinois, USA: Joint Commission Resources, 2005. 13 Wong MC, Yee KC, Turner P. Clinical Handover Literature Review. Hobart: eHealth Services Research Group. University of Tasmania, 2008. 14 Endacott R et al. Recognition and communication of patient deterioration in a regional hospital: a multi-methods study. Aust Crit Care 2007;20:100–105. 15 Harvey PA, Jennings R, Carter L et al. Audit of medication management after discharge from hospital to resident care. J Pharm Prac Res 2012;423:246–2. 16 Russell L et al. Patient safety-handover of care between primary and acute care: Policy review and analysis. Prepared for the National Lead Clinicians Group by the Australian Primary Health Care Research Institute, ANU. Canberra: National Lead Clinicians Group, Australian Government Department of Health and Ageing, 2013. 17 Rothwell M, Jukka C, Lum E et al. Retrospective Analysis of Emergency Readmissions to Rural and Regional Hospitals. Journal of Pharmacy Practice and Research 2011;41(4):290–294. 18 DiMeglio K et al. Group Cohesion and Nurse Satisfaction: Examination of a Team Building Approach. J Nurs Admin 2005;35:110–20. 19 Buring SM et al. Interprofessional education: definitions, student competencies, and guidelines for implementation. Am J Pharm Educ 2009;73:59.

20 Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care 2004;13(Suppl 1):i85–i90. 21 Endsley MR. Toward a theory of situation awareness in dynamic systems. Hum Factors 1995;37:32–64. 22 Care Quality Commission. National Guardian’s Office. www.cqc.org.uk/national-guardians- office/content/national-guardians-office [Accessed 9 October 2017]. 23 World Health Organization. Topic 4: Being an effective team player. Teaching material. 2014. Available at: www.who.int/patientsafety/education/curriculum/who_mc_topic-4.pdf [Accessed: 2 September 2017]. 24 King, HB et al. TeamSTEPPSTM:team strategies and tools to enhance performance and patient safety. In Henriksen K, Battles JB, Keyes MA (eds), Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 3: Performance and Tools). Rockville MD: Agency for Healthcare Research and Quality (US), 2008. 25 Pocket guide: TeamSTEPPS. Available at www.ahrq.gov/teamstepps/instructor/essentials/pocketguide.html [Accessed 9 October 2017]. 26 SBAR Toolkit. Institute for Healthcare Improvement. Available at http://www.ihi.org/resources/Pages/Tools/sbartoolkit.aspx [Accessed 9 October 2017] 27 Hales B et al. Development of medical checklists for improved quality of patient care. Int J Qual Health Care 2007;20:22–30. 28 World Health Organization. Surgical safety checklist and implementation manual. Available online: www.who.int/patientsafety/safesurgery/ss_checklist/en/ [Accessed 9 October 2017]. 29 Toft B, Mascie-Taylor H. Involuntary automaticity: a work-system induced risk to safe health care. Health Ser Manag Resour 2005;18:211–16. 30 Goldenhar LM et al. Huddling for high reliability and situation awareness. BMJ Qual Safe 2013;22:899–906. 31 Royal College of Physicians. Acute care toolkit 1. London: RCP, 2015. 32 1000 Lives Plus. Improving Clinical Communication Using SBAR. NHS Wales: 2011

Resource 4: Team development

11 NHS staff survey 2017. http://www.nhsstaffsurveys.com [Accessed 4 October 2017] 12 Faculty of Leadership and Management. Leadership and management standards for healthcare teams. 1st edition. London: FMLM, 2017 [unpublished]. 13 GMC. Leadership and management standards for all doctors. London: GMC, 2012. 14 NHS Health Education England. Junior doctor morale: Understanding best practice working environments. https://hee.nhs.uk/sites/default/files/documents/Junior%20Doctors%27%20Morale%20- %20understanding%20best%20practice%20working%20environments.pdf [Accessed 4 October 2017] 15 CIPD. Teamworking, factsheet, June 2006. 16 West M, Slater J. The effectiveness of team working in primary health care. Oxford: Health Education Authority, 1996. 17 Schippers MC, West M,Dawson JF. Team reflexivity and innovation: The moderating role of team context. Journal of Management 2015;41.3:769–788. 18 West M. Reflexivity, revolution, and innovation in work teams. In Beyerlein MM, Johnson DA (eds), Product development teams. Stanford: JAI Press, 2000. 19 West MA. Effective teamwork: Practical lessons from organizational research. (3rd edition). Oxford: Blackwell Publishing, 2012. 20 Tan H. Debriefing after critical incidents for anaesthetic trainees. Anaesthesia and intensive care 2005;33.6:768. 21 Pocket guide: TeamSTEPPS. https://www.ahrq.gov/teamstepps/instructor/essentials/pocketguide.html#debrief [Accessed 17 November 2017]. 22 Chadwick RJ et al. Support for compassionate care: Quantitative and qualitative evaluation of Schwartz Center Rounds in an acute general hospital. JRSM open 7.7 2016: 2054270416648043. 23 The Point of Care Foundation. Schwartz Rounds information pack for smaller organisations. https://www.pointofcarefoundation.org.uk/wp-content/uploads/2017/01/Attach-1.-New-Information-pack- small.pdf [Accessed 4 October 2017] 24 Kjeldmand D, Holmström I. Balint groups as a means to increase job satisfaction and prevent burnout among general practitioners. The Annals of Family Medicine 2008;6.2:138–145.