Making teams more effective

In the first two articles of this four part series (published in the February and April issues of CSJ) I attempted to show that outstanding technical excellence alone is no guarantee that we will remain safe in our practice. I then tried to show how our delicate and complex cognitive processes made us susceptible to making errors or violating rules and regulations. I also argued that our susceptibility increased during times of stress, high workload and as a result of personal wellbeing. In this article I will discuss how a well-trained team can help to save the day in spite of our personal vulnerabilities. Perhaps it would be appropriate, once again, to look back into the world of aviation. In response to an unacceptable number of accidents airline regulators demanded that airlines invested in scientific research to identify why well trained and technically competent airline crews continue to crash aircraft and thereby lose their own lives in addition to those of the passengers. The fledgling Cockpit Resource Management (CRM) courses began. Within a few years researchers realised that looking at individual flight crew (pilots) behaviour was simplistic and the programme broadened out to include other professions who interacted with the flight crew, namely cabin crew, engineers and air traffic controllers and CRM became Crew Resource Management. A major step in the education progress of airline crews was the development of a properly researched, appropriately validated and objective framework of the skills required to be an effective team. The European system was known as Non Technical Skills (NOTECHS).1 Atrainability has been involved in various research projects developing a surgical NOTECHS system for use in healthcare.2 In broad terms the NOTECHS system splits human interaction into four categories: The first two categories are the social or behavioural skills of Leadership and Teamworking, while the remaining two categories are the cognitive skills of Situation Awareness and Decision Making. The system then further sub divides into four or five elements that make up each category and from there each element is populated with indicative observable behavioural markers that demonstrate the presence or absence of the skill. Many of you will have either observed, or been part of, a team where every problem that is encountered is seamlessly sorted out before the problem becomes a concern. I might also suggest that you will have worked in the vicinity of teams where the very opposite is the case. The NOTECHS system allows a trainer or facilitator to determine what makes teams effective, or indeed, ineffective! A skilled instructor can then focus the debriefing and any re-training so the team becomes more efficient and safer. One of the great challenges of the NOTECHS system is to have the ability to judge where, within the four categories, the ineffective performance is initiated. Let us look at an everyday example from a theatre list: The first patient arrives in the anaesthetic preparation room and is anaesthetised. When the patient is transferred to theatre and the surgical team arrive to commence the operation it is apparent that certain required instruments are missing and there is a long delay while the correct equipment is found. The situation could be considered as typical of the NHS. However, intelligent use of the NOTECHS system might easily throw light on the real reason. Let us consider some of the possible causes for the delay.

• The theatre list was altered because the first patient due was assessed as unfit for surgery on arrival at 8am.
• The theatre team may have prepared the incorrect kit for a variety of reasons such as not being clearly informed of the surgeon’s preferences.
• The surgeon may have altered the theatre list for a variety of reasons.
• The required kit may not have been available and the theatre staff decided on an alternative, which was not acceptable to the surgical team.
• The list was altered because of radiographer availability.
• No-one really checked the items.

The list of possible reasons is endless but ascertaining the actual reason is important if teams are to learn from such situations. What are the possible reasons in the above example for the delay happening? It could be poor Decision Making. It could be incorrect Situation Awareness. It might be ineffective Teamwork and Communication. It also could be down to poor Leadership. Only by engaging in an adult conversation with the team on the day can the actual reason for the situation be agreed.