■ Physician-team:

Leveraging the power of collaboration to foster safe care

Team communication

A group of medical practitioners having a discussion in a hospital hallway.

Team communication is critical to safe care

Published: April 2021
15 minutes

Introduction

Most healthcare is delivered by teams of healthcare professionals. Each person’s actions contribute to patient safety and the overall effectiveness of the team.

Well-functioning teams offer the potential for delivering better care and reducing risks to patients by:

  • providing patients greater access to the most appropriate providers to manage specific clinical problems
  • enhancing analysis of clinical issues
  • providing continuity and coordination of care by different providers1

Well-functioning teams also result in less provider burnout and greater provider resilience.2 In CMPA data, communication breakdowns and teamwork failures are common reasons for patient safety incidents (accidents in Québec). Inter-professional communication issues are a key factor in delays in diagnosis, mishaps in surgery, medication incidents, and failures in the monitoring or follow-up of patients.

Good practice guidance

Successful teams have an effective organizational structure, value committed individuals’ contributions, and operate according to established team processes.3

Organizational structure:

  • clear purpose
  • safety and learning culture
  • defined roles and responsibilities
  • appropriate leadership
  • adequate resources

Individual contributions:

  • self-awareness
  • knowledge and skills
  • learning mindset
  • ability to lead
  • ability to follow
  • commitment to the patient and the team

Team processes:

  • coordination of member tasks
  • clear and relevant communication
  • decision-making strategies
  • conflict management
  • social relationships
  • continuous improvement

Good teams communicate:

  • often and in many contexts (e.g., briefings, debriefings, huddles, and handovers)
  • with purpose, using structured communication tools (e.g., SBAR)
  • to create a shared mental model
  • with psychological safety

Psychological safety is a shared belief that anyone on the care team can speak up and share their opinion respectfully without fear of retribution.4

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Many factors increase the risk of miscommunication.

Personal factors:

  • multitasking
  • not knowing who is on the team
  • not actively listening to colleagues, patients, or family members
  • fatigue, hunger, or stress

Organizational factors:

  • frequent interruptions
  • noise and visual distractions
  • multiple providers
  • frequent handovers
  • hierarchies that inhibit speaking up

Team factors:

  • ambiguity about roles and responsibilities
  • lack of effective leadership
  • changes in team personnel
  • differences in expectations
  • different languages and backgrounds

Failures in team communication have been categorized as:5

  • audience failure – a key person is missing from a critical conversation
  • occasion failure – poor timing of communication, or a failure to communicate a key piece of information at the appropriate time
  • content failure – insufficient or inaccurate information regarding critical details
  • purpose failure – failing to resolve a critical issue
  • system failure – a lapse in communication resulting from central processes such as technological issues

Content and purpose failures may be mitigated through the use of strategies such as:

  • holding huddles, briefings and debriefings
  • using structured communication tools
  • promoting team use of critical language
  • using closed loop communication
  • fostering speaking up

Team training can assist with the acquisition of strategies to mitigate communication failures. In most medical environments, teamwork training is best applied to the entire unit or ward management and not directed at specific procedures.6, 7

Safe care depends on sharing information appropriately and effectively. Good teams foster the sharing of information by building opportunities to communicate into their workflows. Formalized processes that foster clear and efficient communication ensure that everyone is on the same page and help create a shared model for what should happen.

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Briefings bring key team members together before a procedure or event. Their purpose is to ensure that all team members have the information they need to effectively and successfully do their job. Briefings can be used to:

  • introduce each member of the team
  • review the procedure to be undertaken
  • empower learners to discuss their learning goals
  • identify roles and tasks
  • identify potential safety risks
  • surface specific concerns
  • review potential medication and equipment issues
  • discuss contingency plans
  • invite questions and ensure a shared mental model

Structured team processes such as briefings force the team to “slow down when it should” at the preparation phase of clinical decision-making. They also let healthcare providers confirm information or ask questions about the specific patient, the environment, the tasks, or the timing or urgency. These proactive efforts promote team situational awareness and highlight potential critical situations ahead.

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Debriefings are used to foster in-the-moment learning and team self-correction immediately after procedures or significant events. Debriefings are opportunities for exploring and learning from what happened during an event or experience. Regardless of whether a procedure or event went well, debriefings offer an opportunity to continuously improve processes and team function.

Conduct debriefs in a setting that allows privacy. Debriefings do need not take long, and can be guided by questions like:

  • What did we do well?
  • What did we learn so we can do better the next time?
  • What got in the way that we can fix?

In encouraging physicians and healthcare providers to speak openly and honestly, participants should also be reminded that debrief objectives do not include criticizing the care of any team member or assigning blame.8Debriefings may be more difficult to hold or may not occur at all after a failure of team communication,9 making their routine implementation after any procedure or significant event even more crucial to team learning. It is wise to develop terms of reference and protocols for debriefing that clearly state that the debrief process is for quality improvement purposes and that participants must keep all information discussed confidential. This encourages participants to feel comfortable speaking openly and respectfully in order to learn from each other.

Routine debriefs after each care episode are not usually documented. In cases where information is collected—typically following a patient safety incident (accident in Québec)—the information should be gathered and compiled under confidential cover for purposes of quality improvement. Access to the information should be limited to those listed in the terms of reference and protocols under protection of quality assurance legislation.

Debriefs are ideally positioned to link daily operations to formal quality assurance reviews, especially if they identify issues requiring significant changes to systems or processes. A quality assurance committee can examine the issues to identify areas for improvement and then share its recommendations with leadership so that appropriate changes can be made.

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The purpose of a huddle is to create collective awareness of the issues and circumstances that may have an impact on care. Ideally, huddles are interdisciplinary in order to foster team situational awareness.

Scheduled huddles are typically held at the beginning of a shift and help create a predictable routine that allows team members to discuss issues such as:

  • patient load
  • problems anticipated during the shift
  • bed availability
  • staff availability

Unscheduled huddles can be called at any time in response to an evolving situation that requires the team to rethink its care plan in order to ensure the ongoing safety of care. 

Huddles can be supported by white boards (analog or digital) that can be viewed at a glance by all team members. However, it is important that these boards comply with privacy and confidentiality requirements. In patient rooms, white boards can help facilitate patient and family communication with the team and can serve as an anchor to bedside rounds.

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Briefings, debriefings, and huddles provide opportunities for teams to communicate and foster collective situational awareness. Establishing a norm of communication can help ensure that team members communicate the right information efficiently in a way that will make sense to other team members.

  • Structured communication tools like SBAR, IPASS and SIGNOUT can promote completeness and efficiency of handovers.
  • Critical language tools like CUS and 5-step advocacy can promote speaking up and clarity of messaging.
  • Repeat back/read-back and closed loop communication can minimize misunderstandings and can be especially useful for verifying verbal instructions and orders.

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Checklists may:

  • improve communication across the patient care team
  • foster a patient safety mindset
  • promote situational awareness
  • confirm that required tasks are completed

A checklist consists of a series of tasks or items relevant to a shared goal. In 2010, Accreditation Canada recognized the use of the surgical safety checklist as essential to patient safety and established it as a required organizational practice.10, 11

Three distinct procedural stages are identified in the CPSI Surgical Safety Checklist :11

  1. Briefing – before induction of anaesthesia
  2. Time out – before skin incision
  3. Debriefing – before patient leaves OR

Patient safety experts encourage customization of the surgical safety checklist to address the unique needs of a surgical discipline and practice environment.

The roles and responsibilities of each team member as they pertain to the checklist should be clear. The success of the implementation of a surgical safety checklist lies not in the checklist itself but rather in the culture of learning and continuous improvement upon which it is founded. In such a context, the checklist is seen not only as a process required by hospital policy but also as a reminder of everyone’s commitment to surgical safety and as an acknowledgment of the fact that we are all fallible.

Much of the checklist’s success in achieving the desired outcome depends on the implementation and integration of the checklist into the operative room team processes.11, 12 One of the main concerns articulated by providers is lack of time; however, studies have shown that checklist completion takes less than two minutes.13 Furthermore 74% of patients report feeling safer with checklist use.14

Strategies to support appropriate use of the surgical safety checklist (SSCL)

For care providers

  • Promote a culture of safety with open and respectful communication that encourages patients, families, and providers to speak up when they have concerns.
  • Work to customize the SSCL and make it relevant to your facility and specialty.
  • Engage with the purpose of the SSCL.
  • Follow the hospital policy and procedure for surgical counts.
  • Use a structured communication tool during the transfer of care.
  • Report concerns about the use of the SSCL to help facilitate improvements in patient safety.

For healthcare leaders

  • Develop and make clear values and expectations around the safety of surgical care.
  • Develop and implement clear surgical safety policies and procedures.
  • Manage drift away from safe practices using a just culture approach.
  • Allocate appropriate resources for effective implementation and periodic evaluation of the SSCL to enable continuous quality improvement.
  • Provide feedback about improvements to the healthcare providers.
  • Foster a learning mindset by supporting multidisciplinary education programs to support policies related to teamwork, communication, and situational awareness.

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Communicating with team members electronically can facilitate remote consultations, help coordinate care, and even provide a sharing forum for medical education. However, electronic communication, while efficient, has pitfalls. Brief messages can make it difficult to provide enough detail. In addition, many applications may not meet provincial/territorial privacy standards and requirements.

Prior to sharing any patient information, it is important to consider whether it is appropriate to engage in electronic communication with a colleague in the specific context. Could a phone call or in-person meeting be more appropriate? If an electronic message is chosen, it is important to ensure patient information will be safeguarded from theft, loss, and unauthorized use or disclosure. If the recipient of potentially identifiable patient information is outside the circle of care—be it for research, teaching, or learning—it is generally necessary to obtain express consent. Even within the circle of care, patient consent for sharing information electronically may be required by your medical regulatory authority (College). Failure to take any of these steps could result in a privacy complaint with potentially serious consequences.

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Checklist: Team communication

Good team communication promotes the delivery of safecare

Most healthcare is delivered by teams of health professionals.

As a team member, do you:

  • Actively listen?
  • Know the names of the members of your team?
  • Confirm roles and responsibilities of team members as required?
  • Communicate respectfully?
  • Promote a culture of psychological safety?
  • Provide sufficient information in a timely way?
  • Speak up early if you have patient safety concerns?
  • Listen up when spoken to about patient safety concerns?
  • Use structured communication tools to enhance and streamline team communication?
  • Participate in pre-procedure briefings, to promote a shared mindset?
  • Participate in team huddles to create situational awareness?
  • Participate in post-event debriefings, to promote learning in real time?
  • Use structured communication tools to transfer information?
  • Contribute to the surgical safety checklist mindfully in the operating room?
  • Convey the degree of urgency of an order?
  • Use only standard abbreviations?
  • Keep your writing legible?
  • Review clinical notes from other providers involved in the care of your patients?
  • Document your care carefully?

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References

  1. Arriaga AF, Sweeney RE, Clapp JT, et al. Failure to debrief after critical events in anesthesia is associated with failures in communication during the event. Anesthesiology. 2019 Jun;130(6):1039-1048. doi: 10.1097/ALN.0000000000002649
  2. Hartwick A, Clarke S, Johnson S, et al. Workplace team resilience. A systematic review and conceptual development. Organizational Psychology Review. 2020 Apr;10(3-4):169-200. doi: https://doi.org/10.1177/2041386620919476
  3. Mickan S, Rodger S. Characteristics of effective teams: a literature review. Aust Health Rev. 2000; 23(3):201-8
  4. Edmondson, A. Psychological Safety and Learning Behavior in Work Teams. Administrative Science Quarterly. 1999 Jun 1:44(2):350-83. doi: https://doi.org/10.2307/2666999
  5. Lingard L, Espin S, Whyte S, et al. Communication failures in the operating room: An observational classification of recurrent types and effects. Qual Saf Health Care. 2004 Oct;13(5):330-4. doi: 10.1136/qhc.13.5.330
  6. Lingard L, Espin S, Rubin B, et al. Getting teams to talk: development and pilot implementation of a checklist to promote interprofessional communication in the OR. Qual Saf Health Care. 2005;14(5):340-6. doi: 10.1136/qshc.2004.012377
  7. Pratt SD, Sachs BP. Team training: classroom training vs. high-fidelity simulation: Agency for Healthcare Research and Quality; 2006.
  8. Gardner R. Introduction to debriefing. Semin Perinatol. 2013 Jun;37(3):166-74. doi: 10.1053/j.semperi.2013.02.008
  9. Arriaga AF, Sweeney RE, Clapp JT, et al. Failure to debrief after critical events in anesthesia is associated with failures in communication during the event. Anesthesiology. 2019 Jun;130(6):1039-1048. doi: 10.1097/ALN.0000000000002649
  10. Mitchell J. How Accreditation Canada Supports Safe Surgery. Safe Surgery Saves Lives. 2010 Mar.
  11. Canadian Patient Safety Institute. Surgical Safety Checklist, 2009. Available from: https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/SurgicalSafety-Checklist-Resources.aspx
  12. Haugen AS, Sevdalis N, Søfteland E. Impact of the World Health Organization Surgical Safety Checklist on Patient Safety. Anesthesiology. 2019 Aug;131(2):420-425. doi: 10.1097/ALN.0000000000002674
  13. Barimania B, Ahangarb P, Nandra R, et al. The WHO Surgical Safety Checklist: A Review of Outcomes and Implementation Strategies. Perioperative Care and Operating Room Management: 2020 Dec;21(100117). doi: https://doi.org/10.1016/j.pcorm.2020.100117.
  14. Russ SJ, Rout S, Caris J, et al. The WHO surgical safety checklist: survey of patients' views. BMJ Qual Saf. 2014; 23(11):939–946. doi: https://doi.org/10.1136/bmjqs-2013-002772
CanMEDS: Collaborator, Communicator, Professional

DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.