Effective Teamwork in Healthcare, Exams of Public Health

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Which statement best describes a team? a) A group of people who work together b) A group of people who try to accomplish the same goal c) A group of people who work together in a coordinated way, which maximizes each team member's strengths, to achieve a common goal - correct answer c) A group of people who work together in a coordinated way, which maximizes each team member's strengths, to achieve a common goal A team is more than just a group of people who work side by side. A team is a group of people who work together in a coordinated way, which maximizes each team member's strengths, to achieve a common goal. Such a group can anticipate mistakes, overcome obstacles, and navigate difficult situations. When teams communicate poorly in health care, consequences can sometimes include: a) Providing care with incomplete or missing information b) Confusion during transitions in care c) Team members not speaking up about their concerns d) All of the above - correct answer d) All of the above

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A critical element in effective teamwork is communication. Teams that do not communicate well are not truly teams, but merely groups of individuals working side by side. According to The Joint Commission, communication failures between care providers or between care providers and patients and families is consistently the main underlying cause of serious adverse events. All of the above choices are some of the potential consequences of poor communication. When health care teams do not communicate effectively, bad things can happen. It's a Tuesday morning, and you and your colleagues are waiting in the OR for the arrival of the surgeon. She is running 30 minutes late. As you prepare for the surgery, you chat with your colleagues about their weekend. The surgeon enters the room and all talking stops. She smiles briefly and walks toward the patient. She turns to the team and says, "I am late, and we have a patient waiting here, people. Let's get moving and get this done." The team is mostly silent during the procedure. The surgeon has loud music playing and indicates she would rather listen to the music than talk with the team. At the close of the surgery, the surgeon says a brief thank you to the team and leaves the OR.

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This example describes a team that: a) Demonstrates effective collaboration and teamwork b) Has limited communication and does not work as a cohesive group - correct answer b) Has limited communication and does not work as a cohesive group This team does not interact well in a professional capacity. Although the surgeon is professional, she does not engage team members, invite participation, and encourage collaboration. The surgeon has clearly told the team that getting the case done so she can get on with her day is the priority, not safe care. It's a Tuesday morning, and you and your colleagues are waiting in the OR for the arrival of the surgeon. She is running 30 minutes late. As you prepare for the surgery, you chat with your colleagues about their weekends. The surgeon arrives and says, "Hi, I'm Mary Birru. I apologize for being late; one of my other cases ran long. Before we get started, let's go around the room and introduce ourselves. I want to make sure we're all on the same page." Everyone on the team does brief introductions. The surgeon encourages everyone to participate in the process and says, "If you see something troubling or have a question, please speak up." The team conducts a time-out to confirm the correct patient and surgical site and discusses a few of the issues that may come up during the case. At the end of

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surgery, the surgeon thanks every team member by name and asks for input on what went well and what could be improved. This - correct answer a) Demonstrates effective communication and teamwork This team works as a cohesive group. Every member's input is valued, and they frequently communicate to ensure the safest possible care. The team does not assume safe care, but takes the time to communicate and assure it. Mohammed is a respiratory therapist who is going off shift. Sofia is the therapist coming on shift. Two patients are transitioning care from one provider to the other. During the transition, Mohammed and Sofia have a quick conversation in the hall while several people are walking by and patient monitor alarms are going off. They are interrupted two or three times. Neither one of them looks at notes or jots anything down. They just talk: Mohammed: Okay, Mrs. Jones in 406, acute asthma attack, came in last night... Sofia: Got it.

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Mohammed: Mr. Niemeyer in 411, lung cancer with postobstructive pneumonia, oxygen dependent... Sofia: Right. Do you believe the scenario described above is an effective patient hand-over? a) Yes b) No - correct answer b) No The best answer is no. Transitions in care are inherently risky, and ineffective hand-overs can increase the likelihood of error and patient harm. To be effective, a hand-over communication should take place in a quiet area where participants cannot be interrupted. It should involve structured communication techniques. Communication should be two- way and involve active participation from both parties. Effective health care teams have several important characteristics, including: a) The ability to rehearse procedures together, like a choir or a sports team.

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b) Stable membership; that is, they have the same people on the team from day-to-day. c) Effective communication techniques. d) The ability to achieve good results without strong communication. - correct answer c) Effective communication techniques. Effective health care teams have a shared goal and effective two-way communication. The membership of the team may change frequently (Answer B), and it's quite possible for a health care team to consist of people who have never worked together before (Answer A). That makes strong, two-way communication a critical part of delivering safe care. Which of the following is likely to be the most immediate result of building an effective health care team? a) Less costly health care b) Safer care c) Fewer delays in care d) Elimination of waste in the system - correct answer b) Safer care The best answer is that care will be safer. For example, according to The Joint Commission, an estimated 80 percent of serious medical errors

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can be linked to miscommunication between caregivers when patients are transferred or "handed-over." One of the hallmarks of effective health care teams is frequent, two-way communication — a characteristic that would likely have an immediate and positive effect on care transitions and safety. While better teamwork can lead to fewer delays, elimination of waste, and even less costly care, these results would likely be secondary to an increase in safety. As a nurse practitioner in a small, rural urgent care clinic, you believe that your clinic team works well together. Which of the following facts would best support your belief? a) Not a single complaint about unprofessional behavior has been filed by clinic members over the past year. b) The providers work in rotating shifts and rarely need to transmit information from one shift to the next. c) The team routinely takes a moment to discuss the plan and voice concerns before doing a procedure. d) All of the above. - correct answer c) The team routinely takes a moment to discuss the plan and voice concerns before doing a procedure. One of the main characteristics of strong health care teams is effective and frequent communication. The absence of unprofessional behavior (Answer A) does not necessarily mean the team is effective. And the

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failure to share information during shift changes is risky for patients (Answer B). One reason it's critical for caregivers to improve their teams' effectiveness is: a) Effective teams reduce the risk of errors by providing a "safety net" for individual caregivers. b) Effective teams limit the number of caregivers patients have to speak with, reducing confusion among patients and families. c) Teams rely less on technology and more on human capabilities, thus leading to better care. d) All of the above - correct answer a) Effective teams reduce the risk of errors by providing a "safety net" for individual caregivers. Effective teams — teams whose members communicate often and reciprocally — act as a kind of "safety net" that can help prevent errors resulting from one member's fatigue or distraction, for instance. Effective teams may still use technology often, and it's likely that patients and families will encounter many members of the team. When considering your role within a health care team, it is important to keep in mind that:

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a) No matter what profession you belong to, you will be a member of the team and must work intentionally toward making that team effective. b) You may be part of a team, but will likely be able to work autonomously without much input or help from others. c) Teamwork skills will come naturally to you, because we all learn them in other settings. d) You will need to be a good team member until you become an expert in your field, at which point you probably won't need teamwork skills - correct answer a) No matter what profession you belong to, you will be a member of the team and must work intentionally toward making that team effective. If you're entering any field in which you'll be caring for patients, it's a certainty that you will be a member of a team; in fact, you may be a member of multiple teams. As such, you'll have the responsibility to communicate effectively, value the contributions of other members, and keep building your team's ability to provide excellent care. Teamwork skills don't come naturally to everyone (Answer C), but anyone can learn and practice them. A vascular surgeon was doing a new, complicated procedure on a very high-risk patient in an unfamiliar setting. The procedure involved the coordinated efforts of several individuals, many of whom didn't know one another. The surgeon walked into the room and announced, "I have no pride invested in this procedure; I just want us to get it right. If you

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see anything that is helpful or see me getting off in the weeds, please speak up." He then went around the room and introduced himself to everyone by his first name. Is the surgeon showing good leadership? a) Yes b) No - correct answer a) Yes By introducing himself, encouraging participation, and valuing everyone's role, the surgeon creates a collaborative, open environment where people can participate and speak up easily. This allows the group to navigate problems, anticipate issues, and respond effectively to the ever-changing dynamics of surgery. A circulating nurse had performed many tasks flawlessly during a very complicated, seven-hour operation, when a surgeon observed a small piece of lint in the patient's belly button as they were closing the incision. Without stopping to think, he wheeled around, pointed at the nurse, and said, "If this patient gets infected, it will be your fault!" The nurse was devastated. Is the surgeon showing good leadership? a) Yes

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b) No - correct answer b) No By criticizing her publicly and blaming her for the piece of lint, the surgeon eradicated any possibility of teamwork with the nurse. Not only will the relationship between the surgeon and the nurse be different in the future, but this nurse will be far less likely to go out of her way to help the surgeon and much less likely to speak up if she sees him getting into trouble. Any other team members witnessing this episode will also be negatively affected by the surgeon's tone and reaction. They, too, will be hesitant to speak up in the future. You are a pharmacy student, and this month you are doing a clinical rotation in a pharmacy located just outside of town. This is a very different experience from working in a hospital pharmacy, and you are enjoying the time immensely. However, you notice that your preceptor (instructor), whom you respect and who has been practicing and teaching for many years, has been losing his train of thought unusually often when talking with patients. And while filling a prescription recently, he grabbed the wrong strength of pills — and then he barked at the pharmacy technician who corrected him. As he begins to fill another order this morning, you see that once again, he seems to be using the wrong pills. Which of the following is a factor that might make it difficult for you to say something to this pharmacist?

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a) You're just a student, and health care is hierarchical by design. b) The pharmacist got annoyed when someon - correct answer d) A and B The best answer is A and B. While challenging authority figures requires courage in any field, the hierarchical nature of health care can make speaking up particularly difficult. This is especially true when senior practitioners get upset with junior staff who voice concerns about safety. Other reasons it may be hard to say something in this case include your respect for the pharmacist, concern that you are mistaken, and fear of being yelled at or mistreated. For learners, there's the additional worry that your evaluations and grades may be affected. However, it is always your place to speak up where safety is concerned, even if you're not certain you're right. You are a pharmacy student, and this month you are doing a clinical rotation in a pharmacy located just outside of town. This is a very different experience from working in a hospital pharmacy, and you are enjoying the time immensely. However, you notice that your preceptor (instructor), whom you respect and who has been practicing and teaching for many years, has been losing his train of thought unusually often when talking with patients. And while filling a prescription recently, he grabbed the wrong strength of pills — and then he barked at the pharmacy technician who corrected him. As he begins to fill

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another order this morning, you see that once again, he seems to be using the wrong pills. Why should you tell the pharmacist about your concern? a) So that the pharmacist will think well of you when completing your evaluation at the end of the rotation b) So that you can make your knowledge and eye for detai - correct answer c) So that the patient does not experience an adverse event Speaking up about safety concerns should be a patient-centered act. Your goal in voicing your concern is simply to ensure the patient receives safe and effective care — in this case, the correct medication. Voicing your concern should not be about displaying your knowledge, currying favor, or getting someone in trouble. You are a pharmacy student, and this month you are doing a clinical rotation in a pharmacy located just outside of town. This is a very different experience from working in a hospital pharmacy, and you are enjoying the time immensely. However, you notice that your preceptor (instructor), whom you respect and who has been practicing and teaching for many years, has been losing his train of thought unusually often when talking with patients. And while filling a prescription recently, he grabbed the wrong strength of pills — and then he barked at the pharmacy technician who corrected him. As he begins to fill

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another order this morning, you see that once again, he seems to be using the wrong pills. You decide to speak with the pharmacist while he is filling the order. What would be the most appropriate thing to say? a) "Did you check the bottle from which you're dispensing that medication?" b) "I am concerned ther - correct answer b) "I am concerned there is a safety issue here." When speaking up, it is important to use clear, direct language. Words like "safety" or "concerned" can get people's attention. Hinting at a problem, such as in Answer A, is not sufficient. Likewise, using threats, as in Answer D, is not professional behavior. Answer C is the vaguest option, and it's least likely to result in a solution to the problem. You are a pharmacy student, and this month you are doing a clinical rotation in a pharmacy located just outside of town. This is a very different experience from working in a hospital pharmacy, and you are enjoying the time immensely. However, you notice that your preceptor (instructor), whom you respect and who has been practicing and teaching for many years, has been losing his train of thought unusually often when talking with patients. And while filling a prescription recently, he grabbed the wrong strength of pills — and then he barked

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at the pharmacy technician who corrected him. As he begins to fill another order this morning, you see that once again, he seems to be using the wrong pills. After you speak up, which of the following responses by the pharmacist would best indicate that this pharmacy has a culture of safety? a) "Thanks! I'll tell your supervisor that you helped me today." b) "If you know wha - correct answer a) "Thanks! I'll tell your supervisor that you helped me today." In a culture of safety, all individuals value safety. Those who help prevent errors should be rewarded, not punished or told not to repeat their behavior. If this were an especially strong culture of safety, the pharmacist would also suggest sharing his error with the rest of the staff and changing the system to make medication mix-ups less likely. Answer B is threatening and Answer C is likely to be confusing to the learner. Answer D shows that although this pharmacist may value safety, the rest of the group does not. What is a culture of safety? a) A place where errors never happen b) A place where errors are always caught

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c) A place where all staff can talk freely about safety problems without fear d) A place where all staff feel comfortable reporting errors only if they're guaranteed anonymity - correct answer c) A place where all staff can talk freely about safety problems without fear Humans, even humans using technology, are fallible. In health care, there will always be errors and near-misses. In a culture of safety, however, people feel comfortable discussing errors and are rewarded for their focus on patient safety. Although an anonymous reporting system may be useful, the fact that it needs to be anonymous may indicate that people don't feel comfortable discussing errors openly. A 62-year-old man with a two-week history of fatigue, shortness of breath, and easy bruising is seen at a primary care clinic on a Saturday morning. Lab work drawn the day before shows the patient to be anemic and having abnormalities with white blood cells. The patient is pleasant, but fatigued, and becomes short of breath walking to the exam room. A blood smear shows numerous abnormal white blood cells. The clinic physician tells the patient that something is wrong with his blood and recommends admission to the hospital. The patient agrees, and the physician calls his colleague in the hospital emergency room. The clinic physician makes the following statements. Which part of the statement is the background?

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a) I have Mr. Chan, a 62-year-old man whom I believe has acute myelogenous leukemia. b) Mr. Chan has a two-week history of fatigue, shortness of breath, and easy bruising. He was seen yesterday with lab reve - correct answer b) Mr. Chan has a two-week history of fatigue, shortness of breath, and easy bruising. He was seen yesterday with lab revealing a hematocrit The correct answer is B, in which the speaker shares history that is relevant to the current situation. A 62-year-old man with a two-week history of fatigue, shortness of breath, and easy bruising is seen at a primary care clinic on a Saturday morning. Lab work drawn the day before shows the patient to be anemic and having abnormalities with white blood cells. The patient is pleasant, but fatigued, and becomes short of breath walking to the exam room. A blood smear shows numerous abnormal white blood cells. The clinic physician tells the patient that something is wrong with his blood and recommends admission to the hospital. The patient agrees, and the physician calls his colleague in the hospital emergency room. Clinic Physician, " Mr. Chan has a two-week history of fatigue, shortness of breath, and easy bruising. He was seen yesterday with lab revealing a hematocrit"

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In the question above, does the physician give a complete SBAR through his statements? a) Yes b) No - correct answer a) Yes This is a complete SBAR. Within this communication, the two physicians are able to share information quickly and concisely and get the patient the treatment he needs. What is "SBAR"? a) A system for delivering information b) A system for identifying areas for improvement c) A system for confirming receipt of information d) A system for assessing patient values - correct answer a) A system for delivering information SBAR, which stands for "Situation-Background-Assessment- Recommendation," is a system for delivering information. It is an

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adaptation of a US Navy communication technique and can be an effective means to communicate urgent patient care issues. Linda, a pharmacist at an outpatient pharmacy for a medium-sized medical group, receives a call from John, a nurse practitioner in the cardiology clinic. John tells Linda he needs to call in a new prescription for hydrochlorothiazide at 50 mg once a day for Ms. Krane. At the end of the conversation Linda says to John, "Okay, so you want Ms. Joanne Krane to have a new prescription for hydrochlorothiazide at 50 mg by mouth once a day. Thirty pills and six refills." What has Linda just done? a) Increased the likelihood of error by repeating an order b) Provided a read back c) Used SBAR in communication d) B and C - correct answer b) Provided a read back This is a read back, which is used to confirm receipt of information (SBAR is a system for delivering information). The pharmacist went through the step of verbally verifying the order from the nurse practitioner by repeating it back to him, which can catch mistakes. The additional time that a read back requires is not a waste. In fact, it may make work more efficient by decreasing the need for later calls for clarification.

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You are a member of an intensive care unit team in a regional hospital. This morning, a patient had an unexpected severe allergic reaction (anaphylaxis) after being given a penicillin derivative. There was a significant delay in getting the physician involved and beginning treatment for this life-threatening condition. Fortunately, the patient is now stable and does not seem to be experiencing any lasting effects. At this point, what would an effective team leader do? a) Report this adverse event in the anonymous reporting system so that it can be investigated b) Ask administrators to launch an investigation immediately to find out who was responsible for this adverse event c) Add this medication to the patient's allergy list d) Conduct a debriefing - correct answer d) Conduct a debriefing Debriefings occur after events to find out what happened and what could be done better next time. The most effective debriefings happen soon after the event, while memories are fresh. However, the first priority is the patient's health - so debriefings should only occur after the patient is stabilized.

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You are a member of an intensive care unit team in a regional hospital. This morning, a patient had an unexpected severe allergic reaction (anaphylaxis) after being given a penicillin derivative. There was a significant delay in getting the physician involved and beginning treatment for this life-threatening condition. Fortunately, the patient is now stable and does not seem to be experiencing any lasting effects. The unit leaders are trying to figure out what changes they should make to prevent this treatment delay from happening again. Given what you know about the incident, what change would you recommend? a) Implement mandatory debriefings after the team works together on a patient. b) Fire the physician who failed to respond in a timely way. c) Stop using nursing assistants in the ICU. d) Implement the use of critical language in the ICU. - correct answer d) Implement the use of critical language in the ICU. Critical language (such as "I need some clarity") is an agreed-upon phrase or set of words that indicates to all members of a patient care team that there is a problem. It helps individuals who need to call attention to a problem but don't know what to say, especially if the patient is awake and listening; and it also serves as a red flag to team members that they need to stop and pay attention. Critical language might have helped the nursing assistant speak up more quickly when he

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observed problems with the patient's breathing. Debriefings, which occur after the event, would be a valuable source of learning, but they would not be sufficient to prevent an event like this one in the future. Effective team leaders: a) Have multiple degrees. b) Are usually physicians. c) Seek input from all members of the team. d) Know the correct answer in any given situation. - correct answer c) Seek input from all members of the team. Effective team leaders are not necessarily the ones with the most training, the most degrees, or the highest salary. And they don't always have all the answers. They do, however, seek feedback from all team members, recognizing that one person can't provide safe care alone. In Margaret's case, Peter, Amy, Jorge, and Teddy came to work planning to do a good job. They didn't intend for Margaret to die, and neither did anyone else in the hospital. Each of these individuals was known as a smart, well-trained person. But somehow, things went horribly wrong.

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Let's think about Margaret's case yet again, using what we've just learned about a systems approach to error. In the list of factors below, which do you think are the true underlying causes of Margaret's death? Select all that apply. a) Amy is a new employee on the unit. b) Margaret has dementia. c) Jorge switched Margaret to an oxygen mask. d) It was a busy day for Jorge. e) Jorge conveyed the change to Peter verbally and in passing. f) The hospital doesn't have an effective protocol to care for patients with dementia. g) Peter and Amy did not communicate about Margaret's oxygen. h) Teddy was late picking Margaret up for her - correct answer f) The hospital doesn't have an effective protocol to care for patients with dementia. The best answer is probably F -- the hospital doesn't have an effective protocol to care for patients with dementia. An office manager and her staff are opening a new pediatric clinic in a medical office park. She looks around the waiting room and sees uncovered electrical outlets, tables with sharp edges, and a beautiful porcelain vase on a thin wrought-iron pedestal. The office manager

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begins to worry that the waiting room may not be safe for rambunctious toddlers. Would an RCA be useful in this case? a) Yes b) No - correct answer b) No. By definition, RCAs are retrospective: they look back at an error that occurred, often from several perspectives - from the viewpoint of the patient, provider, nurse, supervisor, etc. In this situation, the office manager seeks to prevent error prospectively, before it happens. Other approaches can be used to prevent error prospectively. Failure modes and effects analysis (FMEA), for example, is a type of prospective investigation that's often used to analyze risky procedures and medications. If the office manager is aware of an accident that occurred at another clinic, and seeks to apply lessons learned from an RCA that clinic did, it would be an example of using RCAs to improve care in multiple locations. A resident in anesthesia slips partially used bottles of sedatives, narcotics, and anesthetics from the operating room and pain clinic into

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his pocket when his supervising attending isn't looking. He takes them home for his own use. Later, his roommate finds him passed out and not breathing on the couch in their apartment. Would an RCA be useful in this case? a) Yes b) No - correct answer b) No No. An RCA is not appropriate in cases of negligence or willful harm. These cases are better investigated by the police. This case is an example of criminal activity (stealing controlled substances) and gross professional misconduct (illegal drug use). While an RCA might be helpful to improve the way that medications are kept secure, the overall situation is one best left to the authorities. It is important to note that an error is rarely the result of criminal activity. Dr. Jones is having a very busy day in the internal medicine clinic. The printer that he uses to print computerized prescriptions for his patients is out of ink. He is already running 45 minutes behind but is trying to take good care of Mr. Diaz, who has hypertension and diabetes. Dr. Jones quickly hand-writes a prescription for an antihypertensive and gives it to Mr. Diaz. The pharmacy misreads the prescription and