Niraj L. Sehgal, MD, MPH

I hear and I forget, I see and I remember, I do and I understand.

Confucius

Hospital medicine, first described in 1996,[1] is the fastest growing specialty in United States medical history, now with approximately 40,000 practitioners.[2] Although hospitalists undoubtedly learned many of their key clinical skills during residency training, there is no hospitalist‐specific residency training pathway and a limited number of largely research‐oriented fellowships.[3] Furthermore, hospitalists are often asked to care for surgical patients, those with acute neurologic disorders, and patients in intensive care units, while also contributing to quality improvement and patient safety initiatives.[4] This suggests that the vast majority of hospitalists have not had specific training in many key competencies for the field.[5]

Continuing medical education (CME) has traditionally been the mechanism to maintain, develop, or increase the knowledge, skills, and professional performance of physicians.[6] Most CME activities, including those for hospitalists, are staged as live events in hotel conference rooms or as local events in a similarly passive learning environment (eg, grand rounds and medical staff meetings). Online programs, audiotapes, and expanding electronic media provide increasing and alternate methods for hospitalists to obtain their required CME. All of these activities passively deliver content to a group of diverse and experienced learners. They fail to take advantage of adult learning principles and may have little direct impact on professional practice.[7, 8] Traditional CME is often derided as a barrier to innovative educational methods for these reasons, as adults learn best through active participation, when the information is relevant and practically applied.[9, 10]

To provide practicing hospitalists with necessary continuing education, we designed the University of California, San Francisco (UCSF) Hospitalist Mini‐College (UHMC). This 3‐day course brings adult learners to the bedside for small‐group and active learning focused on content areas relevant to today's hospitalists. We describe the development, content, outcomes, and lessons learned from UHMC's first 5 years.

METHODS

Program Description

Figure 1 is a representative calendar view of the 3‐day UHMC course. The curricular topics were selected based on the findings from our needs assessment, our ability to deliver that curriculum using our small‐group active learning framework, and to minimize overlap with content of the larger course. Course curriculum was refined annually based on participant feedback and course director observations.

Figure 1

The program was built on a structure of 4 clinical domains and 2 clinical skills labs. The clinical domains included: (1) Hospital‐Based Neurology, (2) Critical Care Medicine in the Intensive Care Unit, (3) Surgical Comanagement and Medical Consultation, and (4) Hospital‐Based Dermatology. Participants were divided into 3 groups of 10 participants each and rotated through each domain in the afternoons. The clinical skills labs included: (1) Interpretation of Radiographic Studies and (2) Use of Ultrasound and Enhancing Confidence in Performing Bedside Procedures. We also developed specific sessions to teach about patient safety and to allow course attendees to participate in traditional academic learning vehicles (eg, a Morning Report and Morbidity and Mortality case conference). Below, we describe each session's format and content.

RESULTS

DISCUSSION

We developed an innovative CME program that brought participants to an academic health center for a participatory, hands‐on, and small‐group experience. They learned about topics relevant to today's hospitalists, rated the experience very highly, and reported a nearly unanimous likelihood to change their practice. Reflecting on our program's first 5 years, there were several lessons learned that may guide others committed to providing a similar CME experience.

First, hospital medicine is a dynamic field. Conducting a needs assessment to match clinical topics to what attendees required in their own practice was critical. Iterative changes from year to year reflected formal participant feedback as well as informal conversations with the teaching faculty. For instance, attendees were not only interested in the clinical topics but often wanted to see examples of clinical pathways, order sets, and other systems in place to improve care for patients with common conditions. Our participant presurvey also helped identify and reinforce the curricular topics that teaching faculty focused on each year. Being responsive to the changing needs of hospitalists and the environment is a crucial part of providing a relevant CME experience.

We also used an innovative approach to teaching, founded in adult and effective CME learning principles. CME activities are geared toward adult physicians, and studies of their effectiveness recommend that sessions should be interactive and utilize multiple modalities of learning.[12] When attendees actively participate and are provided an opportunity to practice skills, it may have a positive effect on patient outcomes.[13] All UHMC faculty were required to couple presentations of the latest evidence for clinical topics with small‐group and hands‐on learning modalities. This also required that we utilize a teaching faculty known for both their clinical expertise and teaching recognition. Together, the learning modalities and the teaching faculty likely accounted for the highly rated course experience and likelihood to change practice.

Finally, our course brought participants to an academic medical center and into the mix of clinical care as opposed to the more traditional hotel venue. This was necessary to deliver the curriculum as described, but also had the unexpected benefit of energizing the participants. Many had not been in a teaching setting since their residency training, and bringing them back into this milieu motivated them to learn and share their inspiration. As there are no published studies of CME experiences in the clinical environment, this observation is noteworthy and deserves to be explored and evaluated further.

What are the limitations of our approach to bringing CME to the bedside? First, the economics of an intensive 3‐day course with a maximum of 33 attendees are far different than those of a large hotel‐based offering. There are no exhibitors or outside contributions. The cost of the course to participants is $2500 (discounted if attending the larger course as well), which is 2 to 3 times higher than most traditional CME courses of the same length. Although the cost is high, the course has sold out each year with a waiting list. Part of the cost is also faculty time. The time, preparation, and need to teach on the fly to meet the differing participant educational needs is fundamentally different than delivering a single lecture in a hotel conference room. Not surprisingly, our faculty enjoy this teaching opportunity and find it equally unique and valuable; no faculty have dropped out of teaching the course, and many describe it as 1 of the teaching highlights of the year. Scalability of the UHMC is challenging for these reasons, but our model could be replicated in other teaching institutions, even as a local offering for their own providers.

In summary, we developed a hospital‐based, highly interactive, small‐group CME course that emphasizes case‐based teaching. The course has sold out each year, and evaluations suggest that it is highly valued and is meeting curricular goals better than more traditional CME courses. We hope our course description and success may motivate others to consider moving beyond the traditional CME for hospitalists and explore further innovations. With the field growing and changing at a rapid pace, innovative CME experiences will be necessary to assure that hospitalists continue to provide exemplary and safe care to their patients.

I hear and I forget, I see and I remember, I do and I understand.

Confucius

Hospital medicine, first described in 1996,[1] is the fastest growing specialty in United States medical history, now with approximately 40,000 practitioners.[2] Although hospitalists undoubtedly learned many of their key clinical skills during residency training, there is no hospitalist‐specific residency training pathway and a limited number of largely research‐oriented fellowships.[3] Furthermore, hospitalists are often asked to care for surgical patients, those with acute neurologic disorders, and patients in intensive care units, while also contributing to quality improvement and patient safety initiatives.[4] This suggests that the vast majority of hospitalists have not had specific training in many key competencies for the field.[5]

Continuing medical education (CME) has traditionally been the mechanism to maintain, develop, or increase the knowledge, skills, and professional performance of physicians.[6] Most CME activities, including those for hospitalists, are staged as live events in hotel conference rooms or as local events in a similarly passive learning environment (eg, grand rounds and medical staff meetings). Online programs, audiotapes, and expanding electronic media provide increasing and alternate methods for hospitalists to obtain their required CME. All of these activities passively deliver content to a group of diverse and experienced learners. They fail to take advantage of adult learning principles and may have little direct impact on professional practice.[7, 8] Traditional CME is often derided as a barrier to innovative educational methods for these reasons, as adults learn best through active participation, when the information is relevant and practically applied.[9, 10]

To provide practicing hospitalists with necessary continuing education, we designed the University of California, San Francisco (UCSF) Hospitalist Mini‐College (UHMC). This 3‐day course brings adult learners to the bedside for small‐group and active learning focused on content areas relevant to today's hospitalists. We describe the development, content, outcomes, and lessons learned from UHMC's first 5 years.

METHODS

Program Description

Figure 1 is a representative calendar view of the 3‐day UHMC course. The curricular topics were selected based on the findings from our needs assessment, our ability to deliver that curriculum using our small‐group active learning framework, and to minimize overlap with content of the larger course. Course curriculum was refined annually based on participant feedback and course director observations.

Figure 1

The program was built on a structure of 4 clinical domains and 2 clinical skills labs. The clinical domains included: (1) Hospital‐Based Neurology, (2) Critical Care Medicine in the Intensive Care Unit, (3) Surgical Comanagement and Medical Consultation, and (4) Hospital‐Based Dermatology. Participants were divided into 3 groups of 10 participants each and rotated through each domain in the afternoons. The clinical skills labs included: (1) Interpretation of Radiographic Studies and (2) Use of Ultrasound and Enhancing Confidence in Performing Bedside Procedures. We also developed specific sessions to teach about patient safety and to allow course attendees to participate in traditional academic learning vehicles (eg, a Morning Report and Morbidity and Mortality case conference). Below, we describe each session's format and content.

RESULTS

DISCUSSION

We developed an innovative CME program that brought participants to an academic health center for a participatory, hands‐on, and small‐group experience. They learned about topics relevant to today's hospitalists, rated the experience very highly, and reported a nearly unanimous likelihood to change their practice. Reflecting on our program's first 5 years, there were several lessons learned that may guide others committed to providing a similar CME experience.

First, hospital medicine is a dynamic field. Conducting a needs assessment to match clinical topics to what attendees required in their own practice was critical. Iterative changes from year to year reflected formal participant feedback as well as informal conversations with the teaching faculty. For instance, attendees were not only interested in the clinical topics but often wanted to see examples of clinical pathways, order sets, and other systems in place to improve care for patients with common conditions. Our participant presurvey also helped identify and reinforce the curricular topics that teaching faculty focused on each year. Being responsive to the changing needs of hospitalists and the environment is a crucial part of providing a relevant CME experience.

We also used an innovative approach to teaching, founded in adult and effective CME learning principles. CME activities are geared toward adult physicians, and studies of their effectiveness recommend that sessions should be interactive and utilize multiple modalities of learning.[12] When attendees actively participate and are provided an opportunity to practice skills, it may have a positive effect on patient outcomes.[13] All UHMC faculty were required to couple presentations of the latest evidence for clinical topics with small‐group and hands‐on learning modalities. This also required that we utilize a teaching faculty known for both their clinical expertise and teaching recognition. Together, the learning modalities and the teaching faculty likely accounted for the highly rated course experience and likelihood to change practice.

Finally, our course brought participants to an academic medical center and into the mix of clinical care as opposed to the more traditional hotel venue. This was necessary to deliver the curriculum as described, but also had the unexpected benefit of energizing the participants. Many had not been in a teaching setting since their residency training, and bringing them back into this milieu motivated them to learn and share their inspiration. As there are no published studies of CME experiences in the clinical environment, this observation is noteworthy and deserves to be explored and evaluated further.

What are the limitations of our approach to bringing CME to the bedside? First, the economics of an intensive 3‐day course with a maximum of 33 attendees are far different than those of a large hotel‐based offering. There are no exhibitors or outside contributions. The cost of the course to participants is $2500 (discounted if attending the larger course as well), which is 2 to 3 times higher than most traditional CME courses of the same length. Although the cost is high, the course has sold out each year with a waiting list. Part of the cost is also faculty time. The time, preparation, and need to teach on the fly to meet the differing participant educational needs is fundamentally different than delivering a single lecture in a hotel conference room. Not surprisingly, our faculty enjoy this teaching opportunity and find it equally unique and valuable; no faculty have dropped out of teaching the course, and many describe it as 1 of the teaching highlights of the year. Scalability of the UHMC is challenging for these reasons, but our model could be replicated in other teaching institutions, even as a local offering for their own providers.

In summary, we developed a hospital‐based, highly interactive, small‐group CME course that emphasizes case‐based teaching. The course has sold out each year, and evaluations suggest that it is highly valued and is meeting curricular goals better than more traditional CME courses. We hope our course description and success may motivate others to consider moving beyond the traditional CME for hospitalists and explore further innovations. With the field growing and changing at a rapid pace, innovative CME experiences will be necessary to assure that hospitalists continue to provide exemplary and safe care to their patients.

I hear and I forget, I see and I remember, I do and I understand.

Confucius

Hospital medicine, first described in 1996,[1] is the fastest growing specialty in United States medical history, now with approximately 40,000 practitioners.[2] Although hospitalists undoubtedly learned many of their key clinical skills during residency training, there is no hospitalist‐specific residency training pathway and a limited number of largely research‐oriented fellowships.[3] Furthermore, hospitalists are often asked to care for surgical patients, those with acute neurologic disorders, and patients in intensive care units, while also contributing to quality improvement and patient safety initiatives.[4] This suggests that the vast majority of hospitalists have not had specific training in many key competencies for the field.[5]

Continuing medical education (CME) has traditionally been the mechanism to maintain, develop, or increase the knowledge, skills, and professional performance of physicians.[6] Most CME activities, including those for hospitalists, are staged as live events in hotel conference rooms or as local events in a similarly passive learning environment (eg, grand rounds and medical staff meetings). Online programs, audiotapes, and expanding electronic media provide increasing and alternate methods for hospitalists to obtain their required CME. All of these activities passively deliver content to a group of diverse and experienced learners. They fail to take advantage of adult learning principles and may have little direct impact on professional practice.[7, 8] Traditional CME is often derided as a barrier to innovative educational methods for these reasons, as adults learn best through active participation, when the information is relevant and practically applied.[9, 10]

To provide practicing hospitalists with necessary continuing education, we designed the University of California, San Francisco (UCSF) Hospitalist Mini‐College (UHMC). This 3‐day course brings adult learners to the bedside for small‐group and active learning focused on content areas relevant to today's hospitalists. We describe the development, content, outcomes, and lessons learned from UHMC's first 5 years.

METHODS

Program Description

Figure 1 is a representative calendar view of the 3‐day UHMC course. The curricular topics were selected based on the findings from our needs assessment, our ability to deliver that curriculum using our small‐group active learning framework, and to minimize overlap with content of the larger course. Course curriculum was refined annually based on participant feedback and course director observations.

Figure 1

The program was built on a structure of 4 clinical domains and 2 clinical skills labs. The clinical domains included: (1) Hospital‐Based Neurology, (2) Critical Care Medicine in the Intensive Care Unit, (3) Surgical Comanagement and Medical Consultation, and (4) Hospital‐Based Dermatology. Participants were divided into 3 groups of 10 participants each and rotated through each domain in the afternoons. The clinical skills labs included: (1) Interpretation of Radiographic Studies and (2) Use of Ultrasound and Enhancing Confidence in Performing Bedside Procedures. We also developed specific sessions to teach about patient safety and to allow course attendees to participate in traditional academic learning vehicles (eg, a Morning Report and Morbidity and Mortality case conference). Below, we describe each session's format and content.

RESULTS

DISCUSSION

We developed an innovative CME program that brought participants to an academic health center for a participatory, hands‐on, and small‐group experience. They learned about topics relevant to today's hospitalists, rated the experience very highly, and reported a nearly unanimous likelihood to change their practice. Reflecting on our program's first 5 years, there were several lessons learned that may guide others committed to providing a similar CME experience.

First, hospital medicine is a dynamic field. Conducting a needs assessment to match clinical topics to what attendees required in their own practice was critical. Iterative changes from year to year reflected formal participant feedback as well as informal conversations with the teaching faculty. For instance, attendees were not only interested in the clinical topics but often wanted to see examples of clinical pathways, order sets, and other systems in place to improve care for patients with common conditions. Our participant presurvey also helped identify and reinforce the curricular topics that teaching faculty focused on each year. Being responsive to the changing needs of hospitalists and the environment is a crucial part of providing a relevant CME experience.

We also used an innovative approach to teaching, founded in adult and effective CME learning principles. CME activities are geared toward adult physicians, and studies of their effectiveness recommend that sessions should be interactive and utilize multiple modalities of learning.[12] When attendees actively participate and are provided an opportunity to practice skills, it may have a positive effect on patient outcomes.[13] All UHMC faculty were required to couple presentations of the latest evidence for clinical topics with small‐group and hands‐on learning modalities. This also required that we utilize a teaching faculty known for both their clinical expertise and teaching recognition. Together, the learning modalities and the teaching faculty likely accounted for the highly rated course experience and likelihood to change practice.

Finally, our course brought participants to an academic medical center and into the mix of clinical care as opposed to the more traditional hotel venue. This was necessary to deliver the curriculum as described, but also had the unexpected benefit of energizing the participants. Many had not been in a teaching setting since their residency training, and bringing them back into this milieu motivated them to learn and share their inspiration. As there are no published studies of CME experiences in the clinical environment, this observation is noteworthy and deserves to be explored and evaluated further.

What are the limitations of our approach to bringing CME to the bedside? First, the economics of an intensive 3‐day course with a maximum of 33 attendees are far different than those of a large hotel‐based offering. There are no exhibitors or outside contributions. The cost of the course to participants is $2500 (discounted if attending the larger course as well), which is 2 to 3 times higher than most traditional CME courses of the same length. Although the cost is high, the course has sold out each year with a waiting list. Part of the cost is also faculty time. The time, preparation, and need to teach on the fly to meet the differing participant educational needs is fundamentally different than delivering a single lecture in a hotel conference room. Not surprisingly, our faculty enjoy this teaching opportunity and find it equally unique and valuable; no faculty have dropped out of teaching the course, and many describe it as 1 of the teaching highlights of the year. Scalability of the UHMC is challenging for these reasons, but our model could be replicated in other teaching institutions, even as a local offering for their own providers.

In summary, we developed a hospital‐based, highly interactive, small‐group CME course that emphasizes case‐based teaching. The course has sold out each year, and evaluations suggest that it is highly valued and is meeting curricular goals better than more traditional CME courses. We hope our course description and success may motivate others to consider moving beyond the traditional CME for hospitalists and explore further innovations. With the field growing and changing at a rapid pace, innovative CME experiences will be necessary to assure that hospitalists continue to provide exemplary and safe care to their patients.

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.

The disclosure statement for the following article, Investing in the Future: Building an Academic Hospitalist Faculty Development Program, by Niraj L. Sehgal, MD, MPH, Bradley A. Sharpe, MD, Andrew A. Auerbach, MD, MPH, Robert M. Wachter, MD, that published in Volume 6, Issue 3 pages 161166 of the Journal of Hospital Medicine, was incorrect. The correct disclosure statement is: All authors report no relevant conflicts of interest. The publisher regrets this error.

The disclosure statement for the following article, Investing in the Future: Building an Academic Hospitalist Faculty Development Program, by Niraj L. Sehgal, MD, MPH, Bradley A. Sharpe, MD, Andrew A. Auerbach, MD, MPH, Robert M. Wachter, MD, that published in Volume 6, Issue 3 pages 161166 of the Journal of Hospital Medicine, was incorrect. The correct disclosure statement is: All authors report no relevant conflicts of interest. The publisher regrets this error.

The disclosure statement for the following article, Investing in the Future: Building an Academic Hospitalist Faculty Development Program, by Niraj L. Sehgal, MD, MPH, Bradley A. Sharpe, MD, Andrew A. Auerbach, MD, MPH, Robert M. Wachter, MD, that published in Volume 6, Issue 3 pages 161166 of the Journal of Hospital Medicine, was incorrect. The correct disclosure statement is: All authors report no relevant conflicts of interest. The publisher regrets this error.

Communication and teamwork failures are the most frequently cited cause of adverse events.1, 2 Strategies to improve communication have focused on implementing formal teamwork training programs and/or teaching specific communication skills.36 For instance, many institutions have adopted SBAR (Situation‐Background‐Assessment‐Recommendation) as a method for providers to deliver critical clinical information in a structured format.7 SBAR focuses on the immediate and urgent event at hand and can occur between any 2 providers. The situation is a brief description of the event (eg, Hi Dr. Smith, this is Paul from 14‐Long, I'm calling about Mrs. Jones in 1427 who is in acute respiratory distress). The background describes details relevant to the situation (eg, She was admitted with a COPD exacerbation yesterday night, and, for the past couple hours, she appears in more distress. Her vital signs are). The assessment (eg, Her breath sounds are diminished and she's moving less air) and recommendation (eg, I'd like to call respiratory therapy and would like you to come assess her now) drive toward having an action defined at the end. Given the professional silos that exist in healthcare, the advent of a shared set of communication tools helps bridge existing gaps in training, experience, and teamwork between different providers.

Regulatory agencies have been heavily invested in attempts to standardize communication in healthcare settings. In 2003, the Joint Commission elevated the concerns for wrong‐site surgery by making its prevention a National Patient Safety Goal, and the following year required compliance with a Universal Protocol (UP).8 In addition to adequate preoperative identification of the patient and marking of their surgical site, the UP called for a time out (TO) just prior to the surgery or procedure. The UP states that a TO requires active communication among all members of the surgical/procedure team, consistently initiated by a designated member of the team, conducted in a fail‐safe mode, so that the planned procedure is not started if a member of the team has concerns.8 Simply, the TO provides an opportunity to clarify plans for care and discuss events anticipated during the procedure among all members of the team (eg, surgeons, anesthesiologists, nurses, technicians). This all‐important pause point ensures that each team member is on the same page.

Whereas a TO involves many high‐risk procedural settings, a significant proportion of hospital care occurs outside of procedures. Patients are often evaluated in an emergency department, admitted to a medical/surgical ward, treated without the need for a procedure, and ultimately discharged home or transferred to another healthcare facility (eg, skilled nursing or acute rehabilitation). In this paper, we introduce the concept of Critical Conversations, a form of nonprocedural time out, as a tool, intervention, and policy that promotes communication and teamwork at the most vulnerable junctures in a patient's hospitalization.

Rationale for Critical Conversations: a Case Scenario

An 82‐year‐old man with hypertension and chronic obstructive pulmonary disease (COPD) is admitted to the hospital with community‐acquired pneumonia and an exacerbation of his COPD. The admitting physician evaluates the patient in the emergency department and completes admission orders. The patient arrives on the medical/surgical unit and the unit clerk processes the orders, stimulating a cascade of downstream events for different providers.

Description of a Critical Conversation

In the hours that follow an admission, providers (and often the patients or their family as well) invariably exchange any number of inefficient calls or pages to clarify care plans, discuss a suspected diagnosis, anticipate concerns in the first night, and/or highlight which orders should be prioritized, such as medications or diagnostic studies. A Critical Conversation at time of admission does in this circumstance exactly what a TO attempts to provide before a procedure foster communication and teamwork as a patient is about to be placed at risk for adverse events. The exchange involves discussion of the following:

• Admitting diagnosis

• Immediate treatment plan

• Medications ordered (particularly those new to a patient to anticipate an adverse event)

• Priority for completing any admitting orders

• Guidelines for physician notification when a change in patient condition occurs.

At the other end of a hospitalization, with the known complications arising from a patient's discharge,11, 12 the same process is needed. Rather than having each discipline focus on an individual role or task in getting a patient safely discharged, Critical Conversations allow the entire team, including the patient,13 to ensure that concerns have been addressed. This might help clarify simple measures around follow‐up appointments, whom to call with questions after discharge, or symptoms to watch for that may warrant a repeat evaluation. Nurses anecdotally lament that they first learn about a planned discharge only when the discharge order is written in the chart or if a patient informs them. Both scenarios reflect poorly on the teamwork required to assure patients we're working together, and that key providers are on the same page with respect to discharge planning. The exchange at discharge involves discussion of these elements:

• Discharge diagnosis

• Follow‐up plans

• Need for education/training prior to discharge

• Necessary paperwork completed

• Anticipated time of discharge.

Finally, where many patients are admitted to a hospital, improve, and then return home, others develop acute changes during their hospitalization. For example, the patient in our case scenario could develop respiratory failure and require transfer to the intensive care unit (ICU). Or a different patient might have an acute change in mental status, a new fever, a new abnormal vital sign (eg, tachycardia or hypoxia), or an acute change re existing abdominal painall of which may require a battery of diagnostic tests. These circumstances define the third time for a Critical Conversation: a change in clinical condition. Such situations often require a change in the care plan, a change in priorities for delivering care at that time (for the patient in need and for other patients being cared for by the same nurse and physician), a need for additional resources (eg, respiratory therapist, phlebotomist, pharmacist), and, ultimately, a well‐orchestrated team effort to make it all happen. The specific item prompting the Critical Conversation may impact the nature of the exchange, which involves discussion of these components:

• Suspected diagnosis

• Immediate treatment plan

• Medications ordered (particularly those new to a patient to anticipate an adverse event)

• Priority for completing any new orders

• Guidelines for physician notification when a change in patient condition occurs.

In addition to the above checklist for each Critical Conversation, each exchange should also address two open‐ended questions: 1) what do you anticipate happening in the next 24 hours, and 2) what questions might the patient/family have?

One may ask, and we did, why not have a direct communication daily between a physician and a bedside nurse on each patient? Most physicians and nurses know the importance of direct communication, but there are also times when each is prioritizing work in competing fashions. Adopting Critical Conversations isn't meant to deter from communications that are vital to patient care; rather, it is intended to codify distinct times when a direct communication is required for patient safety.

Lessons Learned

Table 1 provides an example of a Critical Conversation using the sample case scenario. Table 2 lists the most frequent outcomes that resulted from providers engaging in Critical Conversations. These were captured from discussions with bedside nurses and internal medicine residents on our primary medical unit. Both tables highlight how these deliberate and direct communications can create a shared understanding of the patient's medical problems, can help prioritize what tasks should take place (eg, radiology study, medication administration, calling another provider), can improve communication between providers and patients, and potentially accomplish all of these goals in a more efficient manner.

Making Critical Conversations Happen

Integrating Critical Conversations into practice requires both buy‐in among providers and a plan for monitoring the interactions. We recommend beginning with educational efforts (eg, at a physician or nurse staff meeting) and reinforcing them with visual cues, such as posters on the unit (Figure 1). These actions promote awareness and generate expectations that this new clinical policy is being supported by clinical and hospital leadership. Our experiences have demonstrated tremendous learning, including numerous anecdotes about the value of Critical Conversations (Table 3). Our implementation efforts also raised a number of questions that ultimately led to improved clarity in later iterations.

Figure 1

Table 3.Provider Experiences Using Critical Conversations

Nothing is worse than meeting a patient for the first time at admission and not being able to answer the basic question of why they were admitted or what the plan is. It gives the impression that we don't talk to each other in caring for patients. [Critical Conversations] can really minimize that interaction and reassure patients, rather than make them worried about the apparent mixed messages or lack of communication and teamwork.Bedside Nurse
[Critical Conversations] seemed like an additional timely responsibility, and not always a part of my workflow, when sitting in the emergency department admitting patients. But, I found that the often 60 second conversations decreased the number of pages I would get for the same patientactually saving me time.Physician
I don't need to have direct communications for every order written. In fact, it would be inefficient for me and the doctors. On the other hand, being engaged in a Critical Conversation provides an opportunity for me to prioritize not only my tasks for the patient in need, but also in context of the other patients I'm caring for.Bedside Nurse
Late in the afternoon, there will often be several admissions coming to our unit simultaneously. Prioritizing what orders need to be processed or faxed is a typically blind task based on the way charts get organizedrather than someone telling me this is a priority.Unit Clerk
There are so many times when I'm trying to determine what the care plans are for a new admission, and simply having a quick conversation allows me to feel part of the team, and, more importantly, allows me to reinforce education and support for the patients and their family members.Bedside Nurse
Discharge always seems chaotic with everyone racing to fill out forms and meet their own tasks and requirements. Invariably, you get called to fix, change, or add new information to the discharge process that would have been easily averted by actually having a brief conversation with the bedside nurse or case manager. Every time I have [a Critical Conversation], I realize its importance for patient care.Physician

Communication and teamwork failures are the most frequently cited cause of adverse events.1, 2 Strategies to improve communication have focused on implementing formal teamwork training programs and/or teaching specific communication skills.36 For instance, many institutions have adopted SBAR (Situation‐Background‐Assessment‐Recommendation) as a method for providers to deliver critical clinical information in a structured format.7 SBAR focuses on the immediate and urgent event at hand and can occur between any 2 providers. The situation is a brief description of the event (eg, Hi Dr. Smith, this is Paul from 14‐Long, I'm calling about Mrs. Jones in 1427 who is in acute respiratory distress). The background describes details relevant to the situation (eg, She was admitted with a COPD exacerbation yesterday night, and, for the past couple hours, she appears in more distress. Her vital signs are). The assessment (eg, Her breath sounds are diminished and she's moving less air) and recommendation (eg, I'd like to call respiratory therapy and would like you to come assess her now) drive toward having an action defined at the end. Given the professional silos that exist in healthcare, the advent of a shared set of communication tools helps bridge existing gaps in training, experience, and teamwork between different providers.

Regulatory agencies have been heavily invested in attempts to standardize communication in healthcare settings. In 2003, the Joint Commission elevated the concerns for wrong‐site surgery by making its prevention a National Patient Safety Goal, and the following year required compliance with a Universal Protocol (UP).8 In addition to adequate preoperative identification of the patient and marking of their surgical site, the UP called for a time out (TO) just prior to the surgery or procedure. The UP states that a TO requires active communication among all members of the surgical/procedure team, consistently initiated by a designated member of the team, conducted in a fail‐safe mode, so that the planned procedure is not started if a member of the team has concerns.8 Simply, the TO provides an opportunity to clarify plans for care and discuss events anticipated during the procedure among all members of the team (eg, surgeons, anesthesiologists, nurses, technicians). This all‐important pause point ensures that each team member is on the same page.

Whereas a TO involves many high‐risk procedural settings, a significant proportion of hospital care occurs outside of procedures. Patients are often evaluated in an emergency department, admitted to a medical/surgical ward, treated without the need for a procedure, and ultimately discharged home or transferred to another healthcare facility (eg, skilled nursing or acute rehabilitation). In this paper, we introduce the concept of Critical Conversations, a form of nonprocedural time out, as a tool, intervention, and policy that promotes communication and teamwork at the most vulnerable junctures in a patient's hospitalization.

Rationale for Critical Conversations: a Case Scenario

An 82‐year‐old man with hypertension and chronic obstructive pulmonary disease (COPD) is admitted to the hospital with community‐acquired pneumonia and an exacerbation of his COPD. The admitting physician evaluates the patient in the emergency department and completes admission orders. The patient arrives on the medical/surgical unit and the unit clerk processes the orders, stimulating a cascade of downstream events for different providers.

Description of a Critical Conversation

In the hours that follow an admission, providers (and often the patients or their family as well) invariably exchange any number of inefficient calls or pages to clarify care plans, discuss a suspected diagnosis, anticipate concerns in the first night, and/or highlight which orders should be prioritized, such as medications or diagnostic studies. A Critical Conversation at time of admission does in this circumstance exactly what a TO attempts to provide before a procedure foster communication and teamwork as a patient is about to be placed at risk for adverse events. The exchange involves discussion of the following:

• Admitting diagnosis

• Immediate treatment plan

• Medications ordered (particularly those new to a patient to anticipate an adverse event)

• Priority for completing any admitting orders

• Guidelines for physician notification when a change in patient condition occurs.

At the other end of a hospitalization, with the known complications arising from a patient's discharge,11, 12 the same process is needed. Rather than having each discipline focus on an individual role or task in getting a patient safely discharged, Critical Conversations allow the entire team, including the patient,13 to ensure that concerns have been addressed. This might help clarify simple measures around follow‐up appointments, whom to call with questions after discharge, or symptoms to watch for that may warrant a repeat evaluation. Nurses anecdotally lament that they first learn about a planned discharge only when the discharge order is written in the chart or if a patient informs them. Both scenarios reflect poorly on the teamwork required to assure patients we're working together, and that key providers are on the same page with respect to discharge planning. The exchange at discharge involves discussion of these elements:

• Discharge diagnosis

• Follow‐up plans

• Need for education/training prior to discharge

• Necessary paperwork completed

• Anticipated time of discharge.

Finally, where many patients are admitted to a hospital, improve, and then return home, others develop acute changes during their hospitalization. For example, the patient in our case scenario could develop respiratory failure and require transfer to the intensive care unit (ICU). Or a different patient might have an acute change in mental status, a new fever, a new abnormal vital sign (eg, tachycardia or hypoxia), or an acute change re existing abdominal painall of which may require a battery of diagnostic tests. These circumstances define the third time for a Critical Conversation: a change in clinical condition. Such situations often require a change in the care plan, a change in priorities for delivering care at that time (for the patient in need and for other patients being cared for by the same nurse and physician), a need for additional resources (eg, respiratory therapist, phlebotomist, pharmacist), and, ultimately, a well‐orchestrated team effort to make it all happen. The specific item prompting the Critical Conversation may impact the nature of the exchange, which involves discussion of these components:

• Suspected diagnosis

• Immediate treatment plan

• Medications ordered (particularly those new to a patient to anticipate an adverse event)

• Priority for completing any new orders

• Guidelines for physician notification when a change in patient condition occurs.

In addition to the above checklist for each Critical Conversation, each exchange should also address two open‐ended questions: 1) what do you anticipate happening in the next 24 hours, and 2) what questions might the patient/family have?

One may ask, and we did, why not have a direct communication daily between a physician and a bedside nurse on each patient? Most physicians and nurses know the importance of direct communication, but there are also times when each is prioritizing work in competing fashions. Adopting Critical Conversations isn't meant to deter from communications that are vital to patient care; rather, it is intended to codify distinct times when a direct communication is required for patient safety.

Lessons Learned

Table 1 provides an example of a Critical Conversation using the sample case scenario. Table 2 lists the most frequent outcomes that resulted from providers engaging in Critical Conversations. These were captured from discussions with bedside nurses and internal medicine residents on our primary medical unit. Both tables highlight how these deliberate and direct communications can create a shared understanding of the patient's medical problems, can help prioritize what tasks should take place (eg, radiology study, medication administration, calling another provider), can improve communication between providers and patients, and potentially accomplish all of these goals in a more efficient manner.

Making Critical Conversations Happen

Integrating Critical Conversations into practice requires both buy‐in among providers and a plan for monitoring the interactions. We recommend beginning with educational efforts (eg, at a physician or nurse staff meeting) and reinforcing them with visual cues, such as posters on the unit (Figure 1). These actions promote awareness and generate expectations that this new clinical policy is being supported by clinical and hospital leadership. Our experiences have demonstrated tremendous learning, including numerous anecdotes about the value of Critical Conversations (Table 3). Our implementation efforts also raised a number of questions that ultimately led to improved clarity in later iterations.

Figure 1

Table 3.Provider Experiences Using Critical Conversations

Nothing is worse than meeting a patient for the first time at admission and not being able to answer the basic question of why they were admitted or what the plan is. It gives the impression that we don't talk to each other in caring for patients. [Critical Conversations] can really minimize that interaction and reassure patients, rather than make them worried about the apparent mixed messages or lack of communication and teamwork.Bedside Nurse
[Critical Conversations] seemed like an additional timely responsibility, and not always a part of my workflow, when sitting in the emergency department admitting patients. But, I found that the often 60 second conversations decreased the number of pages I would get for the same patientactually saving me time.Physician
I don't need to have direct communications for every order written. In fact, it would be inefficient for me and the doctors. On the other hand, being engaged in a Critical Conversation provides an opportunity for me to prioritize not only my tasks for the patient in need, but also in context of the other patients I'm caring for.Bedside Nurse
Late in the afternoon, there will often be several admissions coming to our unit simultaneously. Prioritizing what orders need to be processed or faxed is a typically blind task based on the way charts get organizedrather than someone telling me this is a priority.Unit Clerk
There are so many times when I'm trying to determine what the care plans are for a new admission, and simply having a quick conversation allows me to feel part of the team, and, more importantly, allows me to reinforce education and support for the patients and their family members.Bedside Nurse
Discharge always seems chaotic with everyone racing to fill out forms and meet their own tasks and requirements. Invariably, you get called to fix, change, or add new information to the discharge process that would have been easily averted by actually having a brief conversation with the bedside nurse or case manager. Every time I have [a Critical Conversation], I realize its importance for patient care.Physician

Communication and teamwork failures are the most frequently cited cause of adverse events.1, 2 Strategies to improve communication have focused on implementing formal teamwork training programs and/or teaching specific communication skills.36 For instance, many institutions have adopted SBAR (Situation‐Background‐Assessment‐Recommendation) as a method for providers to deliver critical clinical information in a structured format.7 SBAR focuses on the immediate and urgent event at hand and can occur between any 2 providers. The situation is a brief description of the event (eg, Hi Dr. Smith, this is Paul from 14‐Long, I'm calling about Mrs. Jones in 1427 who is in acute respiratory distress). The background describes details relevant to the situation (eg, She was admitted with a COPD exacerbation yesterday night, and, for the past couple hours, she appears in more distress. Her vital signs are). The assessment (eg, Her breath sounds are diminished and she's moving less air) and recommendation (eg, I'd like to call respiratory therapy and would like you to come assess her now) drive toward having an action defined at the end. Given the professional silos that exist in healthcare, the advent of a shared set of communication tools helps bridge existing gaps in training, experience, and teamwork between different providers.

Regulatory agencies have been heavily invested in attempts to standardize communication in healthcare settings. In 2003, the Joint Commission elevated the concerns for wrong‐site surgery by making its prevention a National Patient Safety Goal, and the following year required compliance with a Universal Protocol (UP).8 In addition to adequate preoperative identification of the patient and marking of their surgical site, the UP called for a time out (TO) just prior to the surgery or procedure. The UP states that a TO requires active communication among all members of the surgical/procedure team, consistently initiated by a designated member of the team, conducted in a fail‐safe mode, so that the planned procedure is not started if a member of the team has concerns.8 Simply, the TO provides an opportunity to clarify plans for care and discuss events anticipated during the procedure among all members of the team (eg, surgeons, anesthesiologists, nurses, technicians). This all‐important pause point ensures that each team member is on the same page.

Whereas a TO involves many high‐risk procedural settings, a significant proportion of hospital care occurs outside of procedures. Patients are often evaluated in an emergency department, admitted to a medical/surgical ward, treated without the need for a procedure, and ultimately discharged home or transferred to another healthcare facility (eg, skilled nursing or acute rehabilitation). In this paper, we introduce the concept of Critical Conversations, a form of nonprocedural time out, as a tool, intervention, and policy that promotes communication and teamwork at the most vulnerable junctures in a patient's hospitalization.

Rationale for Critical Conversations: a Case Scenario

An 82‐year‐old man with hypertension and chronic obstructive pulmonary disease (COPD) is admitted to the hospital with community‐acquired pneumonia and an exacerbation of his COPD. The admitting physician evaluates the patient in the emergency department and completes admission orders. The patient arrives on the medical/surgical unit and the unit clerk processes the orders, stimulating a cascade of downstream events for different providers.

Description of a Critical Conversation

In the hours that follow an admission, providers (and often the patients or their family as well) invariably exchange any number of inefficient calls or pages to clarify care plans, discuss a suspected diagnosis, anticipate concerns in the first night, and/or highlight which orders should be prioritized, such as medications or diagnostic studies. A Critical Conversation at time of admission does in this circumstance exactly what a TO attempts to provide before a procedure foster communication and teamwork as a patient is about to be placed at risk for adverse events. The exchange involves discussion of the following:

• Admitting diagnosis

• Immediate treatment plan

• Medications ordered (particularly those new to a patient to anticipate an adverse event)

• Priority for completing any admitting orders

• Guidelines for physician notification when a change in patient condition occurs.

At the other end of a hospitalization, with the known complications arising from a patient's discharge,11, 12 the same process is needed. Rather than having each discipline focus on an individual role or task in getting a patient safely discharged, Critical Conversations allow the entire team, including the patient,13 to ensure that concerns have been addressed. This might help clarify simple measures around follow‐up appointments, whom to call with questions after discharge, or symptoms to watch for that may warrant a repeat evaluation. Nurses anecdotally lament that they first learn about a planned discharge only when the discharge order is written in the chart or if a patient informs them. Both scenarios reflect poorly on the teamwork required to assure patients we're working together, and that key providers are on the same page with respect to discharge planning. The exchange at discharge involves discussion of these elements:

• Discharge diagnosis

• Follow‐up plans

• Need for education/training prior to discharge

• Necessary paperwork completed

• Anticipated time of discharge.

Finally, where many patients are admitted to a hospital, improve, and then return home, others develop acute changes during their hospitalization. For example, the patient in our case scenario could develop respiratory failure and require transfer to the intensive care unit (ICU). Or a different patient might have an acute change in mental status, a new fever, a new abnormal vital sign (eg, tachycardia or hypoxia), or an acute change re existing abdominal painall of which may require a battery of diagnostic tests. These circumstances define the third time for a Critical Conversation: a change in clinical condition. Such situations often require a change in the care plan, a change in priorities for delivering care at that time (for the patient in need and for other patients being cared for by the same nurse and physician), a need for additional resources (eg, respiratory therapist, phlebotomist, pharmacist), and, ultimately, a well‐orchestrated team effort to make it all happen. The specific item prompting the Critical Conversation may impact the nature of the exchange, which involves discussion of these components:

• Suspected diagnosis

• Immediate treatment plan

• Medications ordered (particularly those new to a patient to anticipate an adverse event)

• Priority for completing any new orders

• Guidelines for physician notification when a change in patient condition occurs.

In addition to the above checklist for each Critical Conversation, each exchange should also address two open‐ended questions: 1) what do you anticipate happening in the next 24 hours, and 2) what questions might the patient/family have?

One may ask, and we did, why not have a direct communication daily between a physician and a bedside nurse on each patient? Most physicians and nurses know the importance of direct communication, but there are also times when each is prioritizing work in competing fashions. Adopting Critical Conversations isn't meant to deter from communications that are vital to patient care; rather, it is intended to codify distinct times when a direct communication is required for patient safety.

Lessons Learned

Table 1 provides an example of a Critical Conversation using the sample case scenario. Table 2 lists the most frequent outcomes that resulted from providers engaging in Critical Conversations. These were captured from discussions with bedside nurses and internal medicine residents on our primary medical unit. Both tables highlight how these deliberate and direct communications can create a shared understanding of the patient's medical problems, can help prioritize what tasks should take place (eg, radiology study, medication administration, calling another provider), can improve communication between providers and patients, and potentially accomplish all of these goals in a more efficient manner.

Making Critical Conversations Happen

Integrating Critical Conversations into practice requires both buy‐in among providers and a plan for monitoring the interactions. We recommend beginning with educational efforts (eg, at a physician or nurse staff meeting) and reinforcing them with visual cues, such as posters on the unit (Figure 1). These actions promote awareness and generate expectations that this new clinical policy is being supported by clinical and hospital leadership. Our experiences have demonstrated tremendous learning, including numerous anecdotes about the value of Critical Conversations (Table 3). Our implementation efforts also raised a number of questions that ultimately led to improved clarity in later iterations.

Figure 1

Table 3.Provider Experiences Using Critical Conversations

Nothing is worse than meeting a patient for the first time at admission and not being able to answer the basic question of why they were admitted or what the plan is. It gives the impression that we don't talk to each other in caring for patients. [Critical Conversations] can really minimize that interaction and reassure patients, rather than make them worried about the apparent mixed messages or lack of communication and teamwork.Bedside Nurse
[Critical Conversations] seemed like an additional timely responsibility, and not always a part of my workflow, when sitting in the emergency department admitting patients. But, I found that the often 60 second conversations decreased the number of pages I would get for the same patientactually saving me time.Physician
I don't need to have direct communications for every order written. In fact, it would be inefficient for me and the doctors. On the other hand, being engaged in a Critical Conversation provides an opportunity for me to prioritize not only my tasks for the patient in need, but also in context of the other patients I'm caring for.Bedside Nurse
Late in the afternoon, there will often be several admissions coming to our unit simultaneously. Prioritizing what orders need to be processed or faxed is a typically blind task based on the way charts get organizedrather than someone telling me this is a priority.Unit Clerk
There are so many times when I'm trying to determine what the care plans are for a new admission, and simply having a quick conversation allows me to feel part of the team, and, more importantly, allows me to reinforce education and support for the patients and their family members.Bedside Nurse
Discharge always seems chaotic with everyone racing to fill out forms and meet their own tasks and requirements. Invariably, you get called to fix, change, or add new information to the discharge process that would have been easily averted by actually having a brief conversation with the bedside nurse or case manager. Every time I have [a Critical Conversation], I realize its importance for patient care.Physician

The growth of hospitalists nationally continues at an unprecedented pace.1 In academic medical centers, the development of hospital medicine groups either as independent divisions or as part of divisions of general internal medicine (DGIM) reflects this trend. Drivers for growth in the academic setting include housestaff work hour restrictions, increased need for oversight on teaching services, development of nonhousestaff services, surgical comanagement, and greater emphasis on efficiency, quality, and safety.26 These drivers have created tremendous opportunities for hospitalists, but the rapid growth has also created challenges to achieving traditional academic success.7, 8

While hospitalists feel the traditional academic pressures to produce new knowledge and teach, the extraordinary need to expand clinical services has resulted in a young hospitalist workforce, with most lacking fellowship training. At the same time, there are few senior mentors available. Taken together, many academic hospital medicine (AHM) programs find themselves populated by large cadres of junior faculty without the support, training, and mentoring they need to succeed in a faculty career.9 For hospital medicine groups, the risk to faculty recruitment, retention, productivity, and morale is high.

In this article, we describe the development and implementation of a multifaceted Faculty Development (FD) program whose goal was to provide our faculty with clinical, educational, leadership, and scholarly skills that would promote academic output and foster work satisfaction.

Methods

Results

Seven faculty participated in the inaugural program. We compared their scholarly output and experiences (6 faculty completed the survey; 87% response rate) with that of 11 more senior faculty who completed the comparison survey. Of note, the response rate of the comparison group was 69% (5 faculty who departed from our division during the previous 2 years were not surveyed). New faculty were surveyed at the start of the academic year with the follow‐up survey completed the following June. The more senior faculty completed the survey once at the same time as the baseline survey for the new faculty. All new faculty participated in each of the Core Seminars, the Teaching Course, the required number of Coaching sessions, and the observed teaching activity. We did not track their attendance at Divisional activities such as Grand Rounds or the Lunch Seminars.

Overall, the FD programmatic offerings were rated highly by new faculty (on a scale of 1 [lowest] to 5 [highest] for a global rating of each FD activity): Core Seminars 4.83 0.41, Coaching Program 4.5 0.84, Teaching Course 4.5 0.55, Grand Rounds 4.83 0.41, and Lunch Seminars 4.5 0.84. Table 2, which compares responses to a series of end of the year statements posed to new faculty, highlights notable differences in their level of comfort with specific skills and resource awareness. Given the small sample size, statistical significance was not calculated. Table 3 illustrates similar comparisons focused on academic output, which demonstrate that new faculty gave more talks to trainees, had greater involvement in hospital committees, more actively participated in quality and safety projects, and submitted more abstracts to regional or national meetings. New faculty also responded differently to which part of the FD program was most influential with 1 suggesting the Coaching Program, 2 the Core Seminars, 2 the entire program efforts, and 1 did not specify.