On July 4, 1988, the warship USS Vincennes mistook an Iranian civilian jetliner for an F14 fighter plane and fired upon it, killing all 290 people on board. The military reviewed the tragic incident and determined the problem in part was a lack of coordination among command and control teams and a communication breakdown across teams.

 

In the wake of this tragedy, the Navy began a multiyear, multimillion dollar research program to formally study teamwork and team training. While the military had always been interested in teamwork, the emphasis had been on the team leader and not the coordination of the efforts of the team. The Navy’s research, followed by the other armed forces, has led to extensive research and development of the art and science of teamwork over the last 20 years.

 

Teamwork has been a buzzword around the business culture for some time. Leading businesses know that well-performing teams are the key to profits in a business. However, teamwork takes on a whole new level of importance in life or death situations, such as military combat, airline travel, and healthcare. In 1999, the Institute of Medicine (IOM) published To Err Is Human: Building a Safer Health System, a revealing review of the U.S. medical care system and the inadequacy of safety practices used in the treatment of patients. The IOM report estimated that medical errors result in 44,000 to 98,000 deaths annually—more than automobile accidents (43,458), breast cancer (42,297), or AIDS (16,516). Since then, there have been a number of initiatives and task forces to address this problem, including the development and research of team based training to improve patient safety.

 

While the focus on teamwork in healthcare has brought improvement, there is still work to be done. The study, "Medical Errors Involving Trainees: A Study of Closed Malpractice Claims from 5 Insurers," appeared in the October 22, 2007, issue of the Archives of Internal Medicine. The lead author, Hardeep Singh, MD, MPH, noted, “Our study confirms the relationship of poor teamwork to preventable errors and quality of care.” The Agency for Health Research and Quality (AHRQ) Director Carolyn M. Clancy, MD, stated this study “reminds us that we have a lot to do to ensure that hospitals are providing appropriate supervision to trainees and implementing team-training programs, both in the inpatient and outpatient setting.”

 

In addition to the obvious importance of teamwork for patient safety, there is also a critical need for effective teamwork to create the efficiencies needed to deal with increased patient volumes and decreasing reimbursements. Physicians today need to make sure they have expert teams, not just teams of experts. Expert teams aren’t created overnight. It’s a process and takes purposefulness and commitment. Teams typically begin in the formation stage, when people are learning, leaders are directing, and people are getting to know one another. Unfortunately, this is usually followed by the storming stage, during which cliques can development, a great deal of supervision is required, and disagreements can ensue. While many teams get permanently bogged down in the storming stage, better performing teams will enter a norming stage. In this stage, the team starts to actually work together as a team, goals and directions become clear, and the overall performance improves. Truly high-performing teams will enter a performing stage, where team members all exhibit leadership, self-motivation is high, and the team members all have strong skills and knowledge. The reality is that most teams will move up and down this spectrum as they progress and decline in their teamwork.

 

For some, discussion about teamwork and team-building conjures up images of warm and fuzzy games and retreats. Working on teamwork skills can be seen as a waste of time and money—and not “real work.” The reality is quite different. From 1955 to 2008, more than 300 empirical articles on teamwork, based on studying more than 10,000 teams, were published. For example, a study by Eduardo Salas, Diana R. Nichols and James E. Driskell (Small Group Research 2007; 38; 471) entitled “Testing Three Team Training Strategies in Intact Teams: A Meta-Analysis,” found unequivocally that team training improved performance.

 

A number of training methods can be used to deliver results, including cross-training, event-based approach to training, scenario-based training, self-correction training, stress exposure training, team adaptation training, and team leader training. The reality is that physician team settings vary dramatically from emergency room, to general surgery, to primary care physicians. The key is adapting your training to your specific environment. For those considering team training, it can be a waste of time and money unless the design and delivery of the training is based on scientific principles, the physicians take ownership, teamwork is rewarded and encouraged, and there is a feedback loop to debrief and measure success. True team development should focus on building the knowledge, skills, and attitudes of your team members and should be an ongoing process.

 

The handwriting’s on the wall. There is no doubt that quality of care will continue to be scrutinized with greater intensity, particularly with the shift to electronic medical records. The link between pay and quality of care is only going to get stronger. Physicians will have to continue to do more with less. There will be increased pressure to see more patients and be highly efficient. While more studies need to be done, we have enough data from the commercial airline industry and the military to show us that we need to strive for better teamwork in healthcare to improve safety. Since many physicians are also entrepreneurs, they must keep an eye on the bottom line, and the work of business has shown us undoubtedly that it’s hard to be profitable with a poorly performing team. In the near future, developing your healthcare team won’t be a luxury, but a necessity.