Teams, Competence, and Safety in Surgery

Expert Teams

Every day, we see expert teams working, whether they are astronauts working together on the international space station using the CanadaArm to launch or retrieve satellites, construction workers building the next skyscraper, our favorite sports team, or emergency responders. In each situation, a group of individuals, each with specific skills, have come together to perform a task, a task that any one member would not be able to achieve on her or his own.

The concepts underpinning expertise in teams and team behavior have only recently been studied in medicine. The need for effective teamwork and effective communication has been recognized by many reports and reports describing the safety of health care around the world, such as the Canadian Adverse Event Study and the report on Adverse Events among Children in Canadian Hospitals. These reports and others, such as To Err Is Human and Crossing the Quality Chasm, have surfaced the concrete connection between teamwork and increased patient safety and quality of care. Moreover, they highlighted the many contributing factors that facilitate quality human and team performance in health care.

What Is a Team and What Does It Do?

A team can be defined as a group of two or more individuals who share a common goal, composed of members, each having specific skills and roles to perform in order to attain a known goal successfully. Team members rely upon each other. Teams as a whole and their members adapt to changes in the context or situation in which they find themselves. Baker and colleagues describe these characteristics as the “specific knowledge, skills, and attitudes” that team members must possess.

Effective teams embody a collective approach and action, composed of interdependent tasks to achieve the goal. The members of a team and the team possess specialized knowledge and skills, and make decisions and trade-offs while executing the collective action. They learn from experience so that performance can be improved. Often, teams work under conditions of high demand and stress, and in situations where the consequences of failure can be profound such as in health care.

To be most effective, a team must be directed by a common and understood goal. To achieve that goal, the members must share a common mental model of both the goal and the task(s) required to achieve it. “When teammates hold similar cognitive representations, they are better able to anticipate one another's needs and actions, to engage in more efficient searches for information, to jointly interpret cues in their environments, and to negotiate solutions to problems encountered.” Members share a “team orientation”; “we can only achieve our goal together, otherwise we fail.”

To build the team orientation, members must establish mutual trust. This is done by training and working together, supporting each other and learning from experience as they participate in the authentic situations that the team is intended to address. They know each other and the tasks. They monitor each other's performance and provide backup support when needed. They are effective verbal and nonverbal communicators, balancing voicing and listening.

What teams do, specifically the “activity of working together,” has been described by Edmonson as “teaming”. Teaming is “a dynamic state, not a bounded static entity.” “Teaming blends relating to people, listening to other points of view, coordinating actions and making shared decisions. Effective teaming requires everyone to remain vigilantly aware of others needs, roles and perspectives.” Teaming embodies cognitive and affective skills in the members and the team. It does not require a stable structure. Teaming is the “engine of organizational learning.” Through “repetitive cycles of communication, decision making, action and reflection, with each cycle informed by the result of the previous cycles until the outcomes are achieved.” During this process, the differences between the knowledge and skills of members become clear, effective communication leads to improved coordination, and effective interdependent actions develop.

Effective teams are competent; their members are competent at the individual level and the team is collectively competent. Commonly, individual competence is conceived of as a quality that the person develops, acquires, or possesses; a state achieved. Collective competence differs; it is a characteristic of a team. It is only achieved by participating in the authentic situations that the team is intended to address. Team competence is distributed across the network of individuals and is consistently evolving because of the interconnecting behaviors enacted in time and space between the members of the team.