A blog by Adrian Wong, CUSIC fellow in Oxford.
One of my highlights from the ICS State of the Art meeting 2014 was the talk by Prof Brindley on the final day of the conference. Entitled ‘Resuscitation – not as easy as A, B, C’, I was expecting an update of sorts on resuscitation of critically ill patients. Instead, what followed was an engaging and captivating talk about teamwork, communication and human factors within the intensive care unit. One quote in particular, resonated very strongly with me – “A team of experts isn’t an expert team”. Teamwork is more than just subordinates doing what the leader says. It is about maximising the mental and physical problem-solving capabilities, such that the sum exceeds its parts.
Personally, one of the main challenges of working in critical care is the fact that we are truly a multi-disciplinary team. From doctors to nurses, to allied health professionals such as dieticians and physiotherapists, we all play our part in trying to deliver the best possible care for our patients.
A genuine no-blame environment where organisations learn from their mistakes is often iterated in medical management and is something we should aspire to. The events of MidStaffs and its subsequent reports have made all healthcare professionals take a long hard look at themselves. People were too afraid to come forward, to raise concerns about the care patients were getting or rather not getting. The new statutory duty of candour was introduced for NHS bodies in England (trusts, foundation trusts and special health authorities) from 27 November 2014, and will apply to all other care providers registered with CQC from 1 April 2015.
Duty of Candour – The volunteering of all relevant information to persons who have or may have been harmed by the provision of services, whether or not the information has been requested and whether or not a complaint or a report about that provision has been made. (Francis)
Every healthcare professional must be open and honest with patients when something goes wrong with their treatment or care which causes, or has the potential to cause, harm or distress. Organisations should continuously be vigilant against potential systems failure.
Intensive Care Medicine is a dangerous specialty
Working in such a high pressure, time-critical environment with high functioning individuals, it is easy to see how mistakes can happen. Medicine has begun to embrace the concept of human factors when dealing with medical errors. Human factors encompass all those factors that can influence people and their behaviour. In a work context, human factors are the environmental, organisational and job factors, and individual characteristics which influence behaviour at work.
It is very seldom that medical errors occur due to a single mistake. They usually occur due to a systems failure – the oft-quoted Swiss cheese model. Hence it is important that errors are analysed and lessons learnt to prevent recurrence.
The landmark case of Elaine Bromiley, who died following surgery, has highlighted the importance of human factors in ensuring optimal performance of the team. I believe that it has made the medical profession look at itself and accept it is human. Elaine was cared for by a team of experts comprising no fewer than 2 consultant anaesthetists. Doctors and especially consultants are expected/assumed to be good leaders to the rest of the medical team. Yet, as Professor Michael Harmer stated in his independent review: “This was a tragic case from which many lessons can and need to be learnt.”
Becoming an expert team
Teamwork in the intensive care unit refers to the leadership, decision-making, communication and coordination behaviours used by multidisciplinary team members to provide patient care. Patient safety research has demonstrated the importance of effective teamwork in ensuring positive patient outcomes in the ICU. Borrowing from the aviation industry’s Crew Resource Management, medical teams now use a combination of simulation as well as classroom-based teaching.
Healthcare teams are usually trained in technical aspects of their job but typically receive no human factors training. Hence, the lack of attention to training in non-technical skills and raising awareness of common error traps explains why the research literature and major incident reports are replete with examples of leadership, situational awareness, communication, coordination and teamwork failures. Indeed a common feature for such human factor courses, is that the focus should not be on the individual technical skills but rather how the team functions. The feedback and debriefing process are key elements to such training.
Underpinning all of this is engagement between the individual team members. Engagement is crucial and yet members of the team will not do so unless they feel “safe” to do so. A key effect in the introduction of the WHO Checklist is emphasis on the team. Every member of the team introduces him/herself. Such a simple action empowers individuals to be brave and speak up when they have concerns, thereby levelling the traditional hierarchical arrangement of medicine. The patient’s wellbeing is the overwhelming priority. As mentioned above, the Duty of Candour means that every healthcare professional has a responsibility to raise concerns about a failing team.
What do you do about a failing/flailing team? What do you do about the individual who is compromising team performance? The team is only as strong as its weakest link. There are national documents when it comes to dealing with failing doctor including consultants.
The bottom line is this, ask yourself, are you prepared to stand up for the team and hence the patient? How will you deal with the non-team player who refuses to be trained? Prof Brindley has the answer – sack them.
Adrian wrote this blog for the Intensive Care Society in his role as the chair of the Trainee Committee.