Grace Terrell, MD, MMM

Teamwork is important in providing high‐quality hospital care. Despite tremendous efforts in the 10 years since publication of the Institute of Medicine's To Err is Human report,1 hospitalized patients remain at risk for adverse events (AEs).2 Although many AEs are not preventable, a large portion of those which are identified as preventable can be attributed to communication and teamwork failures.35 A Joint Commission study indicated that communication failures were the root cause for two‐thirds of the 3548 sentinel events reported from 1995 to 2005.6 Another study, involving interviews of resident physicians about recent medical mishaps, found that communication failures contributed to 91% of the AEs they reported.5

Teamwork also plays an important role in other aspects of hospital care delivery. Patients' ratings of nurse‐physician coordination correlate with their overall perception of the quality of care received.7, 8 A study of Veterans Health Administration (VHA) hospitals found that teamwork culture was significantly and positively associated with overall patient satisfaction.9 Another VHA study found that hospitals with higher teamwork culture ratings had lower nurse resignations rates.10 Furthermore, poor teamwork within hospitals may have an adverse effect on financial performance, as a result of inefficiencies in physician and nurse workflow.11

Some organizations are capable of operating in complex, hazardous environments while maintaining exceptional performance over long periods of time. These high reliability organizations (HRO) include aircraft carriers, air traffic control systems, and nuclear power plants, and are characterized by their preoccupation with failure, reluctance to simplify interpretations, sensitivity to operations, commitment to resilience, and deference to expertise.12, 13 Preoccupation with failure is manifested by an organization's efforts to avoid complacency and persist in the search for additional risks. Reluctance to simplify interpretations is exemplified by an interest in pursuing a deep understanding of the issues that arise. Sensitivity to operations is the close attention paid to input from front‐line personnel and processes. Commitment to resilience relates to an organization's ability to contain errors once they occur and mitigate harm. Deference to expertise describes the practice of having authority migrate to the people with the most expertise, regardless of rank. Collectively, these qualities produce a state of mindfulness, allowing teams to anticipate and become aware of unexpected events, yet also quickly contain and learn from them. Recent publications have highlighted the need for hospitals to learn from HROs and the teams within them.14, 15

Recognizing the importance of teamwork in hospitals, senior leadership from the American College of Physician Executives (ACPE), the American Hospital Association (AHA), the American Organization of Nurse Executives (AONE), and the Society of Hospital Medicine (SHM) established the High Performance Teams and the Hospital of the Future project. This collaborative learning effort aims to redesign care delivery to provide optimal value to hospitalized patients. As an initial step, the High Performance Teams and the Hospital of the Future project team completed a literature review related to teamwork in hospitals. The purpose of this report is to summarize the current understanding of teamwork, describe interventions designed to improve teamwork, and make practical recommendations for hospitals to assess and improve teamwork‐related performance. We approach teamwork from the hospitalized patient's perspective, and restrict our discussion to interactions occurring among healthcare professionals within the hospital. We recognize the importance of teamwork at all points in the continuum of patient care. Highly functional inpatient teams should be integrated into an overall system of coordinated and collaborative care.

TEAMWORK: DEFINITION AND CONSTRUCTS

Physicians, nurses, and other healthcare professionals spend a great deal of their time on communication and coordination of care activities.1618 In spite of this and the patient safety concerns previously noted, interpersonal communication skills and teamwork have been historically underemphasized in professional training.1922 A team is defined as 2 or more individuals with specified roles interacting adaptively, interdependently, and dynamically toward a shared and common goal.23 Elements of effective teamwork have been identified through research conducted in aviation, the military, and more recently, healthcare. Salas and colleagues have synthesized this research into 5 core components: team leadership, mutual performance monitoring, backup behavior, adaptability, and team orientation (see Table 1).23 Additionally, 3 supporting and coordinating mechanisms are essential for effective teamwork: shared mental model, closed‐loop communication, and mutual trust (see Table 1).23 High‐performing teams use these elements to develop a culture for speaking up, and situational awareness among team members. Situational awareness refers to a person's perception and understanding of their dynamic environment, and human errors often result from a lack of such awareness.24 These teamwork constructs provide the foundational basis for understanding how hospitals can identify teamwork challenges, assess team performance, and design effective interventions.

CHALLENGES TO EFFECTIVE TEAMWORK

Several important and unique barriers to teamwork exist in hospitals. Teams are large and formed in an ad hoc fashion. On a given day, a patient's hospital team might include a hospitalist, a nurse, a case manager, a pharmacist, and 1 or more consulting physicians and therapists. Team members in each respective discipline care for multiple patients at the same time, yet few hospitals align team membership (ie, patient assignment). Therefore, a nurse caring for 4 patients may interact with 4 different hospitalists. Similarly, a hospitalist caring for 14 patients may interact with multiple nurses in a given day. Team membership is ever changing because hospital professionals work in shifts and rotations. Finally, team members are seldom in the same place at the same time because physicians often care for patients on multiple units and floors, while nurses and other team members are often unit‐based. Salas and others have noted that team size, instability, and geographic dispersion of membership serve as important barriers to improving teamwork.25, 26 As a result of these barriers, nurses and physicians do not communicate consistently, and often disagree on the daily plan of care for their patients.27, 28 When communication does occur, clinicians may overestimate how well their messages are understood by other team members, reflecting a phenomenon well known in communication psychology related to egocentric thought processes.29, 30

The traditionally steep hierarchy within medicine may also serve as a barrier to teamwork. Studies in intensive care units (ICUs), operating rooms, and general medical units reveal widely discrepant views on the quality of collaboration and communication between healthcare professionals.3133 Although physicians generally give high ratings to the quality of collaboration with nurses, nurses consistently rate the quality of collaboration with physicians as poor. Similarly, specialist physicians rate collaboration with hospitalists higher than hospitalists rate collaboration with specialists.33 Effective teams in other high‐risk industries, like aviation, strive to flatten hierarchy so that team members feel comfortable raising concerns and engaging in open and respectful communications.34

The effect of technology on communication practices and teamwork is complex and incompletely understood. The implementation of electronic heath records and computerized provider order entry systems fundamentally changes work‐flow, and may result in less synchronization and feedback during nurse‐physician collaboration.35 Similarly, the expanded use of text messages delivered via alphanumeric paging or mobile phone results in a transition toward asynchronous modes of communication. These asynchronous modes allow healthcare professionals to review and respond to messages at their convenience, and may reduce unnecessary interruptions. Research shows that these systems are popular among clinicians.3638 However, receipt and understanding of the intended message may not be confirmed with the use of asynchronous modes of communication. Moreover, important face‐to‐face communication elements (tone of voice, expression, gesture, eye contract)39, 40 are lacking. One promising approach is a system which sends low‐priority messages to a Web‐based task list for periodic review, while allowing higher priority messages to pass through to an alphanumeric pager and interrupt the intended recipient.41 Another common frustration in hospitals, despite advancing technology, is difficulty identifying the correct physician(s) and nurse(s) caring for a particular patient at a given point in time.33 Wong and colleagues found that 14% of pages in their hospital were initially sent to the wrong physician.42

ASSESSMENT OF TEAMWORK

One of the challenges in improving teamwork is the difficulty in measuring it. Teamwork assessment entails measuring the performance of teams composed of multiple individuals. Methods of teamwork assessment can be broadly categorized as self assessment, peer assessment, direct observation, survey of team climate or culture, and measurement of the outcome of effective teamwork. While self‐report tools are easy to administer and can capture affective components influencing team performance, they may not reflect actual skills on the part of individuals or teams. Peer assessment includes the use of 360‐degree evaluations or multisource feedback, and provides an evaluation of individual performance.4347

Direct observation provides a more accurate assessment of team‐related behaviors using trained observers. Observers use checklists and/or behaviorally anchored rating scales (BARS) to evaluate individual and team performance. A number of BARS have been developed and validated for the evaluation of team performance.4852 Of note, direct observation may be difficult in settings in which team members are not in the same place at the same time. An alternative method, which may be better suited for general medical units, is the use of survey instruments designed to assess attitudes and teamwork climate.5355 Importantly, higher survey ratings of collaboration and teamwork have been associated with better patient outcomes in observational studies.5658

The ultimate goal of teamwork efforts is to improve patient outcomes. Because patient outcomes are affected by a number of factors and because hospitals frequently engage in multiple, simultaneous efforts to improve care, it is often difficult to clearly link improved outcomes with teamwork interventions. Continued efforts to rigorously evaluate teamwork interventions should remain a priority, particularly as the cost of these interventions must be weighed against other interventions and investments.

EXAMPLES OF SUCCESSFUL INTERVENTIONS

A number of interventions have been used to improve teamwork in hospitals (see Table 2).

CONCLUSIONS

In summary, teamwork is critically important to provide safe and effective care. Important and unique barriers to teamwork exist in hospitals. We recommend the use of survey instruments, such as those mentioned earlier, as the most feasible method to assess teamwork in the general medical setting. Because each intervention addresses only a portion of the barriers to optimal teamwork, we encourage leaders to use a multifaceted approach. We recommend the implementation of a combination of interventions with adaptations to fit unique clinical settings and local culture.

Teamwork is important in providing high‐quality hospital care. Despite tremendous efforts in the 10 years since publication of the Institute of Medicine's To Err is Human report,1 hospitalized patients remain at risk for adverse events (AEs).2 Although many AEs are not preventable, a large portion of those which are identified as preventable can be attributed to communication and teamwork failures.35 A Joint Commission study indicated that communication failures were the root cause for two‐thirds of the 3548 sentinel events reported from 1995 to 2005.6 Another study, involving interviews of resident physicians about recent medical mishaps, found that communication failures contributed to 91% of the AEs they reported.5

Teamwork also plays an important role in other aspects of hospital care delivery. Patients' ratings of nurse‐physician coordination correlate with their overall perception of the quality of care received.7, 8 A study of Veterans Health Administration (VHA) hospitals found that teamwork culture was significantly and positively associated with overall patient satisfaction.9 Another VHA study found that hospitals with higher teamwork culture ratings had lower nurse resignations rates.10 Furthermore, poor teamwork within hospitals may have an adverse effect on financial performance, as a result of inefficiencies in physician and nurse workflow.11

Some organizations are capable of operating in complex, hazardous environments while maintaining exceptional performance over long periods of time. These high reliability organizations (HRO) include aircraft carriers, air traffic control systems, and nuclear power plants, and are characterized by their preoccupation with failure, reluctance to simplify interpretations, sensitivity to operations, commitment to resilience, and deference to expertise.12, 13 Preoccupation with failure is manifested by an organization's efforts to avoid complacency and persist in the search for additional risks. Reluctance to simplify interpretations is exemplified by an interest in pursuing a deep understanding of the issues that arise. Sensitivity to operations is the close attention paid to input from front‐line personnel and processes. Commitment to resilience relates to an organization's ability to contain errors once they occur and mitigate harm. Deference to expertise describes the practice of having authority migrate to the people with the most expertise, regardless of rank. Collectively, these qualities produce a state of mindfulness, allowing teams to anticipate and become aware of unexpected events, yet also quickly contain and learn from them. Recent publications have highlighted the need for hospitals to learn from HROs and the teams within them.14, 15

Recognizing the importance of teamwork in hospitals, senior leadership from the American College of Physician Executives (ACPE), the American Hospital Association (AHA), the American Organization of Nurse Executives (AONE), and the Society of Hospital Medicine (SHM) established the High Performance Teams and the Hospital of the Future project. This collaborative learning effort aims to redesign care delivery to provide optimal value to hospitalized patients. As an initial step, the High Performance Teams and the Hospital of the Future project team completed a literature review related to teamwork in hospitals. The purpose of this report is to summarize the current understanding of teamwork, describe interventions designed to improve teamwork, and make practical recommendations for hospitals to assess and improve teamwork‐related performance. We approach teamwork from the hospitalized patient's perspective, and restrict our discussion to interactions occurring among healthcare professionals within the hospital. We recognize the importance of teamwork at all points in the continuum of patient care. Highly functional inpatient teams should be integrated into an overall system of coordinated and collaborative care.

TEAMWORK: DEFINITION AND CONSTRUCTS

Physicians, nurses, and other healthcare professionals spend a great deal of their time on communication and coordination of care activities.1618 In spite of this and the patient safety concerns previously noted, interpersonal communication skills and teamwork have been historically underemphasized in professional training.1922 A team is defined as 2 or more individuals with specified roles interacting adaptively, interdependently, and dynamically toward a shared and common goal.23 Elements of effective teamwork have been identified through research conducted in aviation, the military, and more recently, healthcare. Salas and colleagues have synthesized this research into 5 core components: team leadership, mutual performance monitoring, backup behavior, adaptability, and team orientation (see Table 1).23 Additionally, 3 supporting and coordinating mechanisms are essential for effective teamwork: shared mental model, closed‐loop communication, and mutual trust (see Table 1).23 High‐performing teams use these elements to develop a culture for speaking up, and situational awareness among team members. Situational awareness refers to a person's perception and understanding of their dynamic environment, and human errors often result from a lack of such awareness.24 These teamwork constructs provide the foundational basis for understanding how hospitals can identify teamwork challenges, assess team performance, and design effective interventions.

CHALLENGES TO EFFECTIVE TEAMWORK

Several important and unique barriers to teamwork exist in hospitals. Teams are large and formed in an ad hoc fashion. On a given day, a patient's hospital team might include a hospitalist, a nurse, a case manager, a pharmacist, and 1 or more consulting physicians and therapists. Team members in each respective discipline care for multiple patients at the same time, yet few hospitals align team membership (ie, patient assignment). Therefore, a nurse caring for 4 patients may interact with 4 different hospitalists. Similarly, a hospitalist caring for 14 patients may interact with multiple nurses in a given day. Team membership is ever changing because hospital professionals work in shifts and rotations. Finally, team members are seldom in the same place at the same time because physicians often care for patients on multiple units and floors, while nurses and other team members are often unit‐based. Salas and others have noted that team size, instability, and geographic dispersion of membership serve as important barriers to improving teamwork.25, 26 As a result of these barriers, nurses and physicians do not communicate consistently, and often disagree on the daily plan of care for their patients.27, 28 When communication does occur, clinicians may overestimate how well their messages are understood by other team members, reflecting a phenomenon well known in communication psychology related to egocentric thought processes.29, 30

The traditionally steep hierarchy within medicine may also serve as a barrier to teamwork. Studies in intensive care units (ICUs), operating rooms, and general medical units reveal widely discrepant views on the quality of collaboration and communication between healthcare professionals.3133 Although physicians generally give high ratings to the quality of collaboration with nurses, nurses consistently rate the quality of collaboration with physicians as poor. Similarly, specialist physicians rate collaboration with hospitalists higher than hospitalists rate collaboration with specialists.33 Effective teams in other high‐risk industries, like aviation, strive to flatten hierarchy so that team members feel comfortable raising concerns and engaging in open and respectful communications.34

The effect of technology on communication practices and teamwork is complex and incompletely understood. The implementation of electronic heath records and computerized provider order entry systems fundamentally changes work‐flow, and may result in less synchronization and feedback during nurse‐physician collaboration.35 Similarly, the expanded use of text messages delivered via alphanumeric paging or mobile phone results in a transition toward asynchronous modes of communication. These asynchronous modes allow healthcare professionals to review and respond to messages at their convenience, and may reduce unnecessary interruptions. Research shows that these systems are popular among clinicians.3638 However, receipt and understanding of the intended message may not be confirmed with the use of asynchronous modes of communication. Moreover, important face‐to‐face communication elements (tone of voice, expression, gesture, eye contract)39, 40 are lacking. One promising approach is a system which sends low‐priority messages to a Web‐based task list for periodic review, while allowing higher priority messages to pass through to an alphanumeric pager and interrupt the intended recipient.41 Another common frustration in hospitals, despite advancing technology, is difficulty identifying the correct physician(s) and nurse(s) caring for a particular patient at a given point in time.33 Wong and colleagues found that 14% of pages in their hospital were initially sent to the wrong physician.42

ASSESSMENT OF TEAMWORK

One of the challenges in improving teamwork is the difficulty in measuring it. Teamwork assessment entails measuring the performance of teams composed of multiple individuals. Methods of teamwork assessment can be broadly categorized as self assessment, peer assessment, direct observation, survey of team climate or culture, and measurement of the outcome of effective teamwork. While self‐report tools are easy to administer and can capture affective components influencing team performance, they may not reflect actual skills on the part of individuals or teams. Peer assessment includes the use of 360‐degree evaluations or multisource feedback, and provides an evaluation of individual performance.4347

Direct observation provides a more accurate assessment of team‐related behaviors using trained observers. Observers use checklists and/or behaviorally anchored rating scales (BARS) to evaluate individual and team performance. A number of BARS have been developed and validated for the evaluation of team performance.4852 Of note, direct observation may be difficult in settings in which team members are not in the same place at the same time. An alternative method, which may be better suited for general medical units, is the use of survey instruments designed to assess attitudes and teamwork climate.5355 Importantly, higher survey ratings of collaboration and teamwork have been associated with better patient outcomes in observational studies.5658

The ultimate goal of teamwork efforts is to improve patient outcomes. Because patient outcomes are affected by a number of factors and because hospitals frequently engage in multiple, simultaneous efforts to improve care, it is often difficult to clearly link improved outcomes with teamwork interventions. Continued efforts to rigorously evaluate teamwork interventions should remain a priority, particularly as the cost of these interventions must be weighed against other interventions and investments.

EXAMPLES OF SUCCESSFUL INTERVENTIONS

A number of interventions have been used to improve teamwork in hospitals (see Table 2).

CONCLUSIONS

In summary, teamwork is critically important to provide safe and effective care. Important and unique barriers to teamwork exist in hospitals. We recommend the use of survey instruments, such as those mentioned earlier, as the most feasible method to assess teamwork in the general medical setting. Because each intervention addresses only a portion of the barriers to optimal teamwork, we encourage leaders to use a multifaceted approach. We recommend the implementation of a combination of interventions with adaptations to fit unique clinical settings and local culture.

Teamwork is important in providing high‐quality hospital care. Despite tremendous efforts in the 10 years since publication of the Institute of Medicine's To Err is Human report,1 hospitalized patients remain at risk for adverse events (AEs).2 Although many AEs are not preventable, a large portion of those which are identified as preventable can be attributed to communication and teamwork failures.35 A Joint Commission study indicated that communication failures were the root cause for two‐thirds of the 3548 sentinel events reported from 1995 to 2005.6 Another study, involving interviews of resident physicians about recent medical mishaps, found that communication failures contributed to 91% of the AEs they reported.5

Teamwork also plays an important role in other aspects of hospital care delivery. Patients' ratings of nurse‐physician coordination correlate with their overall perception of the quality of care received.7, 8 A study of Veterans Health Administration (VHA) hospitals found that teamwork culture was significantly and positively associated with overall patient satisfaction.9 Another VHA study found that hospitals with higher teamwork culture ratings had lower nurse resignations rates.10 Furthermore, poor teamwork within hospitals may have an adverse effect on financial performance, as a result of inefficiencies in physician and nurse workflow.11

Some organizations are capable of operating in complex, hazardous environments while maintaining exceptional performance over long periods of time. These high reliability organizations (HRO) include aircraft carriers, air traffic control systems, and nuclear power plants, and are characterized by their preoccupation with failure, reluctance to simplify interpretations, sensitivity to operations, commitment to resilience, and deference to expertise.12, 13 Preoccupation with failure is manifested by an organization's efforts to avoid complacency and persist in the search for additional risks. Reluctance to simplify interpretations is exemplified by an interest in pursuing a deep understanding of the issues that arise. Sensitivity to operations is the close attention paid to input from front‐line personnel and processes. Commitment to resilience relates to an organization's ability to contain errors once they occur and mitigate harm. Deference to expertise describes the practice of having authority migrate to the people with the most expertise, regardless of rank. Collectively, these qualities produce a state of mindfulness, allowing teams to anticipate and become aware of unexpected events, yet also quickly contain and learn from them. Recent publications have highlighted the need for hospitals to learn from HROs and the teams within them.14, 15

Recognizing the importance of teamwork in hospitals, senior leadership from the American College of Physician Executives (ACPE), the American Hospital Association (AHA), the American Organization of Nurse Executives (AONE), and the Society of Hospital Medicine (SHM) established the High Performance Teams and the Hospital of the Future project. This collaborative learning effort aims to redesign care delivery to provide optimal value to hospitalized patients. As an initial step, the High Performance Teams and the Hospital of the Future project team completed a literature review related to teamwork in hospitals. The purpose of this report is to summarize the current understanding of teamwork, describe interventions designed to improve teamwork, and make practical recommendations for hospitals to assess and improve teamwork‐related performance. We approach teamwork from the hospitalized patient's perspective, and restrict our discussion to interactions occurring among healthcare professionals within the hospital. We recognize the importance of teamwork at all points in the continuum of patient care. Highly functional inpatient teams should be integrated into an overall system of coordinated and collaborative care.

TEAMWORK: DEFINITION AND CONSTRUCTS

Physicians, nurses, and other healthcare professionals spend a great deal of their time on communication and coordination of care activities.1618 In spite of this and the patient safety concerns previously noted, interpersonal communication skills and teamwork have been historically underemphasized in professional training.1922 A team is defined as 2 or more individuals with specified roles interacting adaptively, interdependently, and dynamically toward a shared and common goal.23 Elements of effective teamwork have been identified through research conducted in aviation, the military, and more recently, healthcare. Salas and colleagues have synthesized this research into 5 core components: team leadership, mutual performance monitoring, backup behavior, adaptability, and team orientation (see Table 1).23 Additionally, 3 supporting and coordinating mechanisms are essential for effective teamwork: shared mental model, closed‐loop communication, and mutual trust (see Table 1).23 High‐performing teams use these elements to develop a culture for speaking up, and situational awareness among team members. Situational awareness refers to a person's perception and understanding of their dynamic environment, and human errors often result from a lack of such awareness.24 These teamwork constructs provide the foundational basis for understanding how hospitals can identify teamwork challenges, assess team performance, and design effective interventions.

CHALLENGES TO EFFECTIVE TEAMWORK

Several important and unique barriers to teamwork exist in hospitals. Teams are large and formed in an ad hoc fashion. On a given day, a patient's hospital team might include a hospitalist, a nurse, a case manager, a pharmacist, and 1 or more consulting physicians and therapists. Team members in each respective discipline care for multiple patients at the same time, yet few hospitals align team membership (ie, patient assignment). Therefore, a nurse caring for 4 patients may interact with 4 different hospitalists. Similarly, a hospitalist caring for 14 patients may interact with multiple nurses in a given day. Team membership is ever changing because hospital professionals work in shifts and rotations. Finally, team members are seldom in the same place at the same time because physicians often care for patients on multiple units and floors, while nurses and other team members are often unit‐based. Salas and others have noted that team size, instability, and geographic dispersion of membership serve as important barriers to improving teamwork.25, 26 As a result of these barriers, nurses and physicians do not communicate consistently, and often disagree on the daily plan of care for their patients.27, 28 When communication does occur, clinicians may overestimate how well their messages are understood by other team members, reflecting a phenomenon well known in communication psychology related to egocentric thought processes.29, 30

The traditionally steep hierarchy within medicine may also serve as a barrier to teamwork. Studies in intensive care units (ICUs), operating rooms, and general medical units reveal widely discrepant views on the quality of collaboration and communication between healthcare professionals.3133 Although physicians generally give high ratings to the quality of collaboration with nurses, nurses consistently rate the quality of collaboration with physicians as poor. Similarly, specialist physicians rate collaboration with hospitalists higher than hospitalists rate collaboration with specialists.33 Effective teams in other high‐risk industries, like aviation, strive to flatten hierarchy so that team members feel comfortable raising concerns and engaging in open and respectful communications.34

The effect of technology on communication practices and teamwork is complex and incompletely understood. The implementation of electronic heath records and computerized provider order entry systems fundamentally changes work‐flow, and may result in less synchronization and feedback during nurse‐physician collaboration.35 Similarly, the expanded use of text messages delivered via alphanumeric paging or mobile phone results in a transition toward asynchronous modes of communication. These asynchronous modes allow healthcare professionals to review and respond to messages at their convenience, and may reduce unnecessary interruptions. Research shows that these systems are popular among clinicians.3638 However, receipt and understanding of the intended message may not be confirmed with the use of asynchronous modes of communication. Moreover, important face‐to‐face communication elements (tone of voice, expression, gesture, eye contract)39, 40 are lacking. One promising approach is a system which sends low‐priority messages to a Web‐based task list for periodic review, while allowing higher priority messages to pass through to an alphanumeric pager and interrupt the intended recipient.41 Another common frustration in hospitals, despite advancing technology, is difficulty identifying the correct physician(s) and nurse(s) caring for a particular patient at a given point in time.33 Wong and colleagues found that 14% of pages in their hospital were initially sent to the wrong physician.42

ASSESSMENT OF TEAMWORK

One of the challenges in improving teamwork is the difficulty in measuring it. Teamwork assessment entails measuring the performance of teams composed of multiple individuals. Methods of teamwork assessment can be broadly categorized as self assessment, peer assessment, direct observation, survey of team climate or culture, and measurement of the outcome of effective teamwork. While self‐report tools are easy to administer and can capture affective components influencing team performance, they may not reflect actual skills on the part of individuals or teams. Peer assessment includes the use of 360‐degree evaluations or multisource feedback, and provides an evaluation of individual performance.4347

Direct observation provides a more accurate assessment of team‐related behaviors using trained observers. Observers use checklists and/or behaviorally anchored rating scales (BARS) to evaluate individual and team performance. A number of BARS have been developed and validated for the evaluation of team performance.4852 Of note, direct observation may be difficult in settings in which team members are not in the same place at the same time. An alternative method, which may be better suited for general medical units, is the use of survey instruments designed to assess attitudes and teamwork climate.5355 Importantly, higher survey ratings of collaboration and teamwork have been associated with better patient outcomes in observational studies.5658

The ultimate goal of teamwork efforts is to improve patient outcomes. Because patient outcomes are affected by a number of factors and because hospitals frequently engage in multiple, simultaneous efforts to improve care, it is often difficult to clearly link improved outcomes with teamwork interventions. Continued efforts to rigorously evaluate teamwork interventions should remain a priority, particularly as the cost of these interventions must be weighed against other interventions and investments.

EXAMPLES OF SUCCESSFUL INTERVENTIONS

A number of interventions have been used to improve teamwork in hospitals (see Table 2).

CONCLUSIONS

In summary, teamwork is critically important to provide safe and effective care. Important and unique barriers to teamwork exist in hospitals. We recommend the use of survey instruments, such as those mentioned earlier, as the most feasible method to assess teamwork in the general medical setting. Because each intervention addresses only a portion of the barriers to optimal teamwork, we encourage leaders to use a multifaceted approach. We recommend the implementation of a combination of interventions with adaptations to fit unique clinical settings and local culture.