Transcription:

David Feldman MD, MBA, FACS (Host): Patient safety and high reliability continue to be elusive goals in healthcare. Creating a culture of safety that will allow us to achieve these goals requires a number of important elements. In this series, we'll address what we believe are the essential ingredients in developing such a culture; mutual respect, teamwork and collaboration, human factors engineering and just culture.

I'm David Feldman, MD, Chief Medical Officer for The Doctors Company and Healthcare Risk Advisors, part of TDC Group.

On today's episode, we're delighted to welcome Michael Leitman, Professor of Surgery and Medical Education and Dean for Graduate Medical Education at the Icahn School of Medicine at Mount sinai. Today, Mike will discuss how important high-performance teams are to a culture of safety.

While team training and healthcare was galvanized by the development of TeamSTEPPS, organizations still struggle to get all team members to buy into this approach. Leaders have often pointed to success in other high-reliability industries like aviation, the military and nuclear power, but these models don't often resonate with clinicians. Checklists and other tools have also become useful adjuncts in this endeavor, but there are numerous challenges in adopting these.

This is the Leading Voices in Healthcare Podcast. So let's begin, Mike. As a practicing surgeon, you have always worked in teams. Tell us how you first got interested in formal teamwork training as an important patient safety tool.

Dr. Michael Leitman: Well, good afternoon, David, and thank you for inviting me to participate in this discussion. It's really important that physicians around the country understand how teamwork can be an important patient safety tool with formal training and practice. It really is very important. And I've been practicing surgery for more than 30 years and I've worked in high-performing and underperforming operating rooms. And it was really compelling to me to realize that high-performing OR teams really are necessary to enhance patient safety and to create an environment where all participants feel satisfied and happy with the care that patients received. And so, I was in a situation where I felt that in my particular operating room that this training and these behaviors would really enhance the culture in the operating room, as well as how participants in the operating room team felt about their jobs.

David Feldman MD, MBA, FACS (Host): And the people you worked with, how would they respond to this when you first started down this road?

Dr. Michael Leitman: I would say that in many operating rooms, including the one that I was working in, that most people understood that the surgeon really sets the tone for the conduct of the team and that they really were interchangeable and didn't feel valued. But when they began to understand that this was an opportunity for them to really become part of a surgical team and be appreciated for the work that they do, there was really pretty early buy-in.

David Feldman MD, MBA, FACS (Host): Interesting. Interesting. You know, it's funny when we think about who's in an OR, and this is probably true in a lot of parts of healthcare. The backgrounds are so different, right? The training, you just think doctors or nurses, their backgrounds and how they go through the system are so radically different. And yet, here they are all working together for the same goal, right? To get those patients through whatever experience they're working on with them with. And now, it's become even more important when training just continues to be different despite the fact that we all have the same goal in mind.

Mike, you know, when you think about this, why do you think clinicians, especially surgeons and both of us being surgeons, I think we have a particular knowledge of this, why do you think they've been so resistant to the concepts of team training and checklists and the like? Why do you think that is.

Dr. Michael Leitman: Well, David, I think, you know, the attitude toward an operating room and a group of individuals, which as you mentioned, do come from very different backgrounds. You have surgeons, anesthesiologists, residents, technicians, other people who go in and out of the OR. They really are from different backgrounds. And surgeons in particular, I don't necessarily think that in their training, that teamwork was universally embraced or even discussed, especially surgeons that trained many years ago. I think that many surgeons feel that they're the captain of the ship, my patient, my OR, my work, my rules. And I think that doesn't resonate well with other members of the team.

David Feldman MD, MBA, FACS (Host): Yeah, I think we've all seen it. I do think some of it, I think you're right, is kind of generational. You know, the people who went through training when you and I did, it was really, you know, "You're on your own and don't leave anything to anybody else." And when you take that as the gospel, if you will, through your training, it's easy to see why surgeons would be so resistant to this. But I think we all agree that surgery in particular, and medicine overall, is a team sport. It's too complicated to do this on your own. So, without everybody doing the same, you know, getting to that same goal, it just becomes very difficult.

Mike, you know, as healthcare risk advisors, we've done a lot of work helping our client hospitals to sort of spread the word about team training throughout many different departments. But your surgery group at Mount Sinai Beth Israel was really the first. How did you get buy-in from colleagues at the beginning of your journey?

Dr. Michael Leitman: Well, David, it was really blazing new trails for our group at Mount Sinai Beth Israel. We knew we had to make a change and just from, you know, reviewing performance, reviewing cases and reviewing staff satisfaction, we knew that had we had to make some necessary adjustments. And I think having a burning platform does give you an opportunity to engage individuals to make changes.

So we're the first group of surgeons and surgical team that went to Roanoke, Virginia during probably the hottest month of the year to begin process of officially team training under TeamSTEPPS using the methodology that was created by AHRQ. And I brought nine people with me for this training, nurses, anesthesiologists, other surgeons, technical staff and others to really understand what formalized team training looked like. And, you know, in the beginning, they didn't have a curriculum that was really set out for operating room or procedural room staff. It was really just generalized TeamSTEPPS training, which, you know, I think it was helpful to us to understand the context of the broader need for team training in healthcare, but also I think helpful for them to be able to adapt some of the necessary behaviors and skills, particularly for procedure-based specialties.

David Feldman MD, MBA, FACS (Host): And do you remember any of those initial reactions that your team had when you were going through this in this crazy hot environment and the whole newness of it? I mean, I don't know if you recall any of those because it was a while ago, but it might be kind of interesting to share that.

Dr. Michael Leitman: Yeah. You know, a couple of things come to mind. First of all, we had to do a readiness assessment. You know, it's not as if you all decide one day you want to be TeamSTEPPS-trained, and you can do that. You really need to perform an institutional assessment, really from the top down to just make sure that with this training, you're going to be able to use it in the most productive way.

Secondly, I think people were rather skeptical to take a week out of other lives, because it was one day of travel each side of a three-day full work schedule to do the training and it's been abbreviated somewhat over the years, but back then it was a big commitment to travel and to spend time together, which we really hadn't done in a formalized way, and then do the work together of receiving the training and then practicing the work that we did over that period of time. And I think there was a little bit of skepticism as to whether or not this type of training would be embraced by the institution overall, even though we were willing to take on this learning, whether we would be able to bring this back to our institution and make necessary change.

David Feldman MD, MBA, FACS (Host): Yeah. Interesting. You know, you brought up a good point earlier as well. This idea of training through the lens of your work, right? Your actual work. So you, as you mentioned, when you first did this, program that AHRQ and DOD (Department of Defense) put together, TeamSTEPPS, it was somewhat generic. And I think you and I have both realized over years that, as you teach this to others, you really have to do it in a way that resonates with them. So, you know, giving examples of what happens on a medicine floor is hard for OR folks to understand, right? And the OB folks have a whole different thing, and the ED folks do. So one of the things we've realized over the last number of years, is you really have to direct your training to the people's workspace, right? And the examples you give and all the scenarios you use want to be specific, so it really resonates with them. So they can say to themselves, "Yeah, I can see how that could happen," you know? I don't know if that's been your experience, but certainly it has been ours.

Dr. Michael Leitman: Absolutely. In fact, when we taught this training and continue to teach it to particular specialties, we oftentimes modify the curriculum and modify the videos and the discussion to really make it relevant to that particular subspecialty. So specialties within surgery, such as urology and neurosurgery and general surgery and cardiac surgery. It's really important to make it really relevant to that particular field of practice.

David Feldman MD, MBA, FACS (Host): And then it also comes to mind this idea of one of these gurus in teamwork training, a former or may still be a pilot, Steve Harden talks about telling is not training, right? So you can't just tell people about this and expect it's just going to happen, especially in the surgical world, right? All of us are creatures of habit. We're used to doing things a certain way. It's when we deviate from that, that we get nervous. That's certainly the way that both of us trained.

And then this final piece of Steve Harden's telling is not training is feedback. And you and I both participated in some interesting ways of giving people feedback on how they do in a timeout, right? And I think you had some of that. I think you've been doing that both live and using video cameras, right, to observe teams as they're going through a timeout and giving them feedback. How has that worked for you?

Dr. Michael Leitman: Well, it's been an interesting journey. I think that teaching team behaviors and providing a space where people can practice those behaviors outside of the operating room is certainly necessary to be successful at this, but then providing methodology to observe team behaviors in situ, in the operating room when people are doing their work has become part of the process of maintaining these skills and these behaviors.

And while, you know, putting cameras in the operating room, not to record the actual surgical procedure, but it's just to observe individuals, listen to their conversations and see how they're doing their work and then providing them with those videos and being able to provide some constructive comments about those behaviors is really compelling to individuals. And I think it goes a long way to maintaining really good behaviors and appropriate teamwork.

David Feldman MD, MBA, FACS (Host): Yep. That's great. So, Mike, you now have a big role, right? Overseeing all of the training programs for the Mount Sinai Health System. What do you tell your program directors about the importance of high-performance teams that they should be discussing with their trainees? How does that work for you?

Dr. Michael Leitman: Well, I would say to the following that, you know, not every specific training program requires a formalized training in TeamSTEPPS. There may be other crew resource management systems or other teamwork development skills that can be taught. But in general, our program directors are aware that high-performing teams, you know, have certain specific behaviors and that they should provide that education to their residents and to engage faculty in that process so that people can communicate with each other, understand how to develop leadership skills in the process of their training as physicians and surgeons, and also maintain the work environment in the best possible way for all the people that support them in their work, technicians, nurses, and others, to really enhance the experience for everybdy.

David Feldman MD, MBA, FACS (Host): Yeah, I think it's true now that in a lot of medical schools, teamSTEPPS has become part of the medical school experience. How much medical students really get to that is unclear. But the idea, obviously, this has to start from the very beginning, right? It just becomes part of the culture that physicians, nurses, other healthcare people understand how important teamwork is in developing this culture of safety, you know, so...

Dr. Michael Leitman: I think that residents at a very early stage need to understand that in the center of everything that they do is a patient and that essential to patient safety is teamwork and interprofessional performance. It's just part of the way we practice caring in hospitals with the complexity of healthcare being what it is that is just essential.

And that, finally, nobody is talented enough to assemble a Ferrari and win a race on their own. That really requires tremendous teamwork to be high performing. And, again, to be able to provide a safe and effective environment for our patients, it's really necessary for them to work in interprofessional teams and to monitor their performance.

David Feldman MD, MBA, FACS (Host): Yeah. And the analogy you use of course is great, because think about all these other professional areas in society where teamwork is critical, right? Whether it's sports or music or, as you said, you know, racing the Ferrari. I mean, it's just part and parcel of what people do. And unfortunately, healthcare is late to the game in this, but we're making some strides.

So Mike, you know, for those beginning their team training efforts, what suggestions would you give to help engage clinicians and their institutions? How do people start down this road?

Dr. Michael Leitman: I would say the first step is really accepting the fact that we're human beings and we're not perfect. Every pencil that I ever picked up has an eraser and humans make error. And so much of what we do in teamwork is building a safety net under each patient, and a high reliability organization works to reduce variability in order that teams understand all the essential functions and can adapt, you know, in unpredictable circumstances.

So, how do we start? We identify opportunities to improve patient experience and safety, and we develop team training so that people can enjoy the work that they do and celebrate their successes and learn from each other and provide feedback to each other. Because, again, we want our patients to have the best possible outcome. And those organizations that realize that formalized team training would be helpful to them, there's lots of ways of seeking that out now. There are courses that are available online. There are individuals who are willing to come and share their knowledge to help them train others. The trainer methodology has certainly worked out for some of the formalized team training curriculum that you mentioned such as TeamSTEPPS and others. And so I think identifying what particular areas in their own organizations that really would benefit from this would help guide them because I think that there are certain team training programs that work better than others in particular specialty areas.

David Feldman MD, MBA, FACS (Host): And they don't want to have to spend five days in hot Roanoke, Virginia, right?

Dr. Michael Leitman: They don't have to do that, thankfully for them. And what has happened over the years is that I think, you know, for procedure-based areas, there's a body of information that has been developed over the years and for obstetrical units and for office practices and so on, that now specifically-oriented training programs can be modeled and taught and then individuals can teach each other how to train others in those particular practices.

David Feldman MD, MBA, FACS (Host): Yeah, it makes a lot of sense. There's a lot of resources out there. Well, Mike, thank you so much. And thank you to all for listening to our Leading Voices in Healthcare Podcast. Visit our website at thetdcgroup.com to learn more about the services we provide to healthcare professionals.