In the first part of a three-part series on teamwork in the New England Journal of Medicine, Dr. Lisa Rosenbaum discussed instances and theory of clinical teamwork (“Divided We Fall”, NEJM. 380;7 684-688, February 14, 2019, here.)
Reflecting on a recent clinical team-work experience, Dr Rosenbaum tells the story of the 1977 aircraft accident in Tenerife, Canary Islands that killed 583 people.
The after-accident analysis led to the development of Crew Resource Management (CRM), “a type of team training that aims to shift an individualistic culture toward shared responsibility.” (p. 686).
In 2000, the Institute of Medicine recommended CRM-based training to reduce medical errors.
Despite the face validity of CRM for medical care, Rosenbaum notes the lack of evidence that CRM-based training is effective. In discussing the limitations of the evidence, she mentions an insight by a colleague:
Neel Shah, a BIDMC obstetrician and Ariadne Laboratories researcher who is testing the potential impact of CRM more broadly, likens CRM to the surgical safety checklist in its capacity to foster better interpersonal dynamics. Referring to the checklist’s requirement that team members introduce themselves, for example, Shah notes, ‘It’s not only about knowing someone’s name. It’s primarily about giving someone permission to say something later.’ Similarly, Shah notes, by assembling everyone to discuss a patient in a structured debriefing, ‘you create both the permission and opportunity to activate them later if you need them.’ (pp. 686-687).
In other words, creating a social structure in which people interact regularly to consider their shared work helps build social bonds. Strong social bonds increase the odds that the members of the group will ask and receive help or point out problems outside the regular interactions.
Connection to Daily huddles
In my work with clinical teams using daily huddles, I have stressed the benefits of previewing the day’s work with attention to specific patient requirements and conditions like staff changes and equipment problems. Reduce surprises, reduce stress, reduce missing something important. I also encourage teams to structure their daily huddles as a Plan Do Study Act cycle, where the Study and Act steps related to Monday apply to Tuesday’s Plan and Do (here), integrating PDSA into the daily routine. PDSA is not just for special and infrequent projects.
Inspired by Dr Rosenbaum’s article, my conversations with teams should add that huddles allow teams to practice teamwork every day. Skills and habits developed in huddles should make it easier for people to work well in formal improvement teams.
Just as standardized daily work provides a systems foundation for process improvement, daily huddles provide a social foundation for effective process teamwork.