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Since the 20th century, health care institutions have used morbidity and mortality conferences (MMCs) as a forum to discuss complicated cases and fatalities to capitalize on lessons learned. Medical technology, health care processes, and the teams who provide care have evolved over time, but the format of the MMC has remained relatively unchanged. The present article outlines 5 key areas for improvement within the MMC along with prescriptive and actionable recommendations for mitigating these challenges. This work incorporates the contributions of numerous researchers and practitioners from the educational, training, debrief, and health care fields. With the best practices and lessons learned from various domains in mind, we recommend optimizing the MMC by (1) encouraging a culture that leverages expertise from multiple sources, (2) allocating ample time for innovative thinking, (3) using a global approach that considers individual, team, and system-level factors, (4) leveraging learnings from errors as well as near misses, and (5) promoting communication, innovative thinking, and actionable planning. The 5 evidence-based recommendations herein serve to ensure that MMCs are structured learning events that promote, encourage, and support safe, reliable care. Furthermore, the outlined recommendations seek to capitalize upon the MMC's opportunity to engage early discovery as well as proactive risk assessment and action-oriented solutions.

Background Oncology care is delivered largely in ambulatory settings by interdisciplinary teams. Treatments are often complex, extended in time, dispersed geographically and vulnerable to teamwork failures. To address this risk, we developed and piloted a team training initiative in the breast cancer programme at a comprehensive cancer centre. Methods Based on clinic observations, interviews with key staff and analyses of incident reports, we developed interventions to address four high-risk areas: (1) miscommunication of chemotherapy order changes on the day of treatment; (2) missing orders on treatment days without concurrent physician appointments; (3) poor follow-up with team members about active patient issues; and (4) conflict between providers and staff. The project team developed protocols and agreements to address team members’ roles, responsibilities and behaviours. Results Using a train-the-trainer model, 92% of breast cancer staff completed training. The incidence of missing orders for unlinked visits decreased from 30% to 2% (p

Article-at-a-Glance Background In health care, others' lives depend on the team operating at a level beyond the sum of its individual parts. A framework (a heuristic) represents a three-pronged approach to teamwork in health care that entails communication, coordination, and cooperation. These fundamental requirements of teamwork represent the constant interaction that team members undertake to become an effective team. Guidelines, tips, and examples show how the framework can be applied to establishing and enabling teams to provide safe, reliable care. Guidelines The guidelines are as follows: (1) Support precise and accurate communication through a closed-loop communication protocol; (2) diagnose communication errors as you would any illness—Examine the team and look for symptoms, then treat the symptoms through team learning and self-correction; (3) recognize functional expertise by identifying and publicizing topical experts to evenly distribute work load and increase accuracy; (4) institute frequent practice opportunities to keep team skills in good shape because poorly honed skills will limit performance; (5) refine the team's shared mental models (SMMs) by pre-planning to build its implicit coordination skills, adaptability, and flexibility; (6) shape adaptive expertise by fostering a deep understanding of the task to increase team effectiveness; (7) build team orientation by taking steps to increase trust and cohesion to lower stress levels and increase satisfaction, commitment, and collective efficacy; and (8) prepare the team by providing learning opportunities for new competencies that will expose members to feedback and increase the team's overall efficacy. Conclusion Although not a comprehensive list, the guidelines and tips represent the most essential requirements for effective teamwork.

Objective: To determine if high fidelity simulation based team training can improve clinical team performance when added to an existing didactic teamwork curriculum. Setting: Level 1 trauma center and academic emergency medicine training program. Participants: Emergency department (ED) staff including nurses, technicians, emergency medicine residents, and attending physicians. Intervention: : ED staff who had recently received didactic training in the Emergency Team Coordination Course (ETCC®) also received an 8 hour intensive experience in an ED simulator in which three scenarios of graduated difficulty were encountered. A comparison group, also ETCC trained, was assigned to work together in the ED for one 8 hour shift. Experimental and comparison teams were observed in the ED before and after the intervention. Design: Single, crossover, prospective, blinded and controlled observational study. Teamwork ratings using previously validated behaviorally anchored rating scales (BARS) were completed by outside trained observers in the ED. Observers were blinded to the identification of the teams. Results: There were no significant differences between experimental and comparison groups at baseline. The experimental team showed a trend towards improvement in the quality of team behavior (p = 0.07); the comparison group showed no change in team behavior during the two observation periods (p = 0.55). Members of the experimental team rated simulation based training as a useful educational method. Conclusion: High fidelity medical simulation appears to be a promising method for enhancing didactic teamwork training. This approach, using a number of patients, is more representative of clinical care and is therefore the proper paradigm in which to perform teamwork training. It is, however, unclear how much simulator based training must augment didactic teamwork training for clinically meaningful differences to become apparent.

This practitioner paper describes a variety of training development, assessment, and implementation issues and solutions that emerged from our research to develop behavior-based teamwork training for healthcare providers. These lessons-learned are based on our experiences in adapting aviation crew resource management (CRM) training for healthcare providers in the specialty areas of emergency care and labor and delivery. The discussion covers (a) issues surrounding training content and delivery, (b) methodological issues in conducting training evaluations, and (c) institutional characteristics, cultural change, and sustaining the behavioral intervention.

This article describes emergency department care work teams designed to improve team communication and coordination and reduce error. The core of this teamwork system is the teaching of teamwork behaviors and skills, development of teamwork habits, and creation of small work teams, all of which are key teamwork concepts largely drawn from successful aviation programs. Arguments for enculturating teamwork into ED practice are drawn from a retrospective study of ED malpractice incidents. Fifty-four incidents (1985-1996), a sample of convenience drawn from 8 hospitals, were identified and judged mitigable or preventable by better teamwork. An average of 8.8 teamwork failures occurred per case. More than half of the deaths and permanent disabilities that occurred were judged avoidable. Better teamwork could save nearly $3.50 per ED patient visit. Caregivers must improve teamwork skills to reduce errors, improve care quality, and reduce litigation risks.

Article-at-a-Glance Background Ineffective communication among medical teams is a leading cause of preventable patient harm throughout the health care system. A growing body of literature indicates that medical teamwork improves the quality, safety, and cost-effectiveness of health care delivery, and expectations for teamwork in health care have increased. Yet few health care professions' curricula include teamwork training, and few medical practices integrate teamwork principles. Because of this knowledge gap, growing numbers of health care systems are requiring staff to participate in formal teamwork training programs. Seven evidence-based, practical, systematic success factors for preparing, implementing, and sustaining a team training and performance improvement initiative were identified. Each success factor is accompanied by tips for deployment and a real-world example of application. Success Factors (1) Align team training objectives and safety aims with organizational goals, (2) provide organizational support for the team training initiative, (3) get frontline care leaders on board, (4) prepare the environment and trainees for team training, (5) determine required resources and time commitment and ensure their availability, (6) facilitate application of trained teamwork skills on the job; and (7) measure the effectiveness of the team training program. Discussion Although decades of research in other high-risk organizations have clearly demonstrated that properly designed team training programs can improve team performance, success is highly dependent on organizational factors such as leadership support, learning climate, and commitment to data-driven change. Before engaging in a teamwork training initiative, health care organizations should have a clear understanding of these factors and the strategies for their establishment.

Team performance measurement is a critical and frequently overlooked component of an effective simulation-based training system designed to build teamwork competencies. Quality team performance measurement is essential for systematically diagnosing team performance and subsequently making decisions concerning feedback and remediation. However, the complexities of team performance pose a challenge to effectively measuring team performance. This article synthesizes the scientific literature on this topic and provides a set of best practices for designing and implementing team performance measurement systems in simulation-based training.

Across health care, teamwork is a critical element for effective patient care. Yet, numerous well-intentioned training programs may fail to achieve the desired outcomes in team performance. Hope for the improvement of teamwork in health care is provided by the success of the aviation and military communities in utilizing simulation-based training (SBT) for training and evaluating teams. This consensus paper 1) proposes a scientifically based methodology for SBT design and evaluation, 2) reviews existing team performance metrics in health care along with recommendations, and 3) focuses on leadership as a target for SBT because it has a high likelihood to improve many team processes and ultimately performance. It is hoped that this discussion will assist those in emergency medicine (EM) and the larger health care field in the design and delivery of SBT for training and evaluating teamwork.

Mary Salisbury is President, The Cedar Institute, Inc., N. Kingstown, RI. Susan M. Hohenhaus is President, Hohenhaus & Associates, Inc, Wellsboro, Pa. For correspondence, write: Susan M. Hohenhaus, MA, RN, FAEN, 6 Willard Terrace, Wellsboro, PA 16901; E-mail: shohenha@ptd.net. J Emerg Nurs 2008;34:46-8. 0099-1767/$34.00 Copyright n 2008 by the Emergency Nurses Association. doi: 10.1016/j.jen.2007.11.008

To evaluate the effect of teamwork training on the occurrence of adverse outcomes and process of care in labor and delivery.A cluster-randomized controlled trial was conducted at seven intervention and eight control hospitals. The intervention was a standardized teamwork training curriculum based on crew resource management that emphasized communication and team structure. The primary outcome was the proportion of deliveries at 20 weeks or more of gestation in which one or more adverse maternal or neonatal outcomes or both occurred (Adverse Outcome Index). Additional outcomes included 11 clinical process measures.A total of 1,307 personnel were trained and 28,536 deliveries analyzed. At baseline, there were no differences in demographic or delivery characteristics between the groups. The mean Adverse Outcome Index prevalence was similar in the control and intervention groups, both at baseline and after implementation of teamwork training (9.4% versus 9.0% and 7.2% versus 8.3%, respectively). The intracluster correlation coefficient was 0.015, with a resultant wide confidence interval for the difference in mean Adverse Outcome Index between groups (-5.6% to 3.2%). One process measure, the time from the decision to perform an immediate cesarean delivery to the incision, differed significantly after team training (33.3 minutes versus 21.2 minutes, P=.03).Training, as was conducted and implemented, did not transfer to a detectable impact in this study. The Adverse Outcome Index could be an important tool for comparing obstetric outcomes within and between institutions to help guide quality improvement.(www.ClinicalTrials.gov), NCT00381056I.

The MedTeams project is a translational research effort to apply crew resource management (CRM) behavioral principles developed in aviation to emergency medical care. Hospital emergency departments share many of the same characteristics with workplaces where CRM is effective, such as time-stress, dispersed and complex information, multiple players, and high-stakes outcomes. Preliminary observations in emergency departments (ED) established that the same CRM behaviors employed by highly effective aviation teams could be useful in the ED (Weiner, Kanki, and Helmreich 1993; Simon, Morey, and Locke 1997). A retrospective review of ED closed claims revealed that failure to engage in one or more of these teamwork behaviors was associated with an adverse event and indemnity payments. In 43 percent of the cases reviewed, teamwork behaviors would have prevented or mitigated the adverse event had they been applied (Risser, Rice et al. 1999). Similar analyses attribute about 80 percent of anesthesia mishaps to human error and 70 percent of commercial aviation accidents to crew errors (Gardner-Bonneau 1993; Taggart 1994). Crew training has led to reductions in aviation mishaps beyond those produced by improvements in equipment and technology. The aviation community began introducing CRM training two decades ago and it is now required for all military and commercial U.S. aviation crews and air carriers operating internationally (Helmreich and Foushee 1993; Helmreich 1997). The basic principle of CRM is that crew communication and coordination behaviors are identifiable, teachable, and applicable to high-stakes environments. An additional principle is that those behaviors, although seen spontaneously, are not practiced reliably, regularly, or well unless specific training and reinforcement has established them. Specific CRM behaviors have been identified through experimentation and observation of high-reliability teams in demanding, time-stressed environments such as combat aviation and naval command and control centers (Leedom and Simon 1995; McIntyre and Salas 1995). Crew resource management training has been shown to be effective in these environments and is being extended into other domains (Helmreich and Foushee 1993; Salas et al. 1999). Finally, an essential principle of CRM is that a team needs to be formally established for teamwork behaviors to be effective. In contrast to the notion of a team as any loosely coordinated group of caregivers and support staff, the formal teamwork structure of this study stipulates that a team be made up of between 3 to 10 members. A team is composed of physicians, nurses, and technicians who are organized for a shift. The number of designated teams for a shift depends on factors such as staffing levels and patient volume. From these larger teams, ad hoc teams are formed to respond to emergent events such as resuscitations. In this model, teamwork is sustained by a shared set of teamwork skills rather than permanent assignments that carry over from day to day. Teamwork theory development has focused on input variables affecting team functioning such as task, work environment, and team member characteristics (Salas et al. 1992), what and how to train (Salas and Cannon-Bowers 2001), and outcome constructs of teamwork effectiveness (McIntyre, Salas 1995). Explanatory mechanisms of team processes exist in the form of constructs such as situational awareness and shared mental models, but relating team processes to work productivity outcomes has been limited by measurement difficulties with these constructs. Because this study examined the applicability of CRM to health care, a goal of this study was to generate a set of testable teamwork process–outcome propositions for future healthcare research. With respect to the training intervention, we sought to gain insight into the effectiveness of the training materials and methods, and features of the curriculum that needed revision. In addition, we sought to determine if the training intervention changed staff attitudes and behaviors and had an impact on patient care. These complementary perspectives are referred to as formative and summative evaluation in the education research literature (Bloom, Hastings, and Madaus 1971). The first objective of this study was to adapt an aviation-oriented teamwork curriculum to the particular circumstances of EDs by developing and then implementing a training curriculum (Emergency Team Coordination Course [ETCC]) organized around five team dimensions (maintain team structure and climate, apply problem-solving strategies, communicate with the team, execute plans and manage workload, and improve team skills) (Risser, Rice et al. 1999; Risser, Simon et al. 1999). The second objective was to evaluate the effectiveness of the intervention with measures developed to address three outcome constructs: Team Behaviors, Attitudes and Opinions, and ED Performance.

The effective reduction of medical errors depends on an environment of safety for patients in both clinically-based and systems-oriented arenas. Formal teamwork training is proposed as a systems approach that will achieve these ends. In a study conducted by Dynamics Research Corporation, weaknesses and error patterns in Emergency Department teamwork were assessed, and a prospective evaluation of a formal teamwork training intervention was conducted. Improvements were obtained in five key teamwork measures, and most importantly, clinical errors were significantly reduced.