Improving Health Care Is a Team Effort

NASHVILLE—There are many who would say that the American health care system is broken. Peter Holbrook, MD, would agree.

“We spend more money in this country on health care than any other country in the world and yet we have the 37th best mortality rate. We have poor outcomes and there is widespread patient dissatisfaction.” At the 38th Critical Care Congress, Dr. Holbrook discussed how critical care medicine has addressed some of the current challenges of health care delivery and outlined some of the hurdles that still lie ahead. Dr. Holbrook is Chief Medical Officer at Children’s National Medical Center in Washington, DC.

THE QUALITIES OF A HIGH-PERFORMANCE TEAM

“We are a service industry,” Dr. Holbrook said. “We have customers and those customers have choices.” Any service industry, he said, should be guided by principles and have well-defined attributes.

For example, in the health care service industry, “first do no harm” is a fundamental principle. In addition, health care should be effective, efficient, and affordable. But customers are ultimately the ones who decide whether or not their needs have been met. “Customer satisfaction is therefore on the spectrum of quality,” Dr. Holbrook said. One of the ways of addressing complex issues of customer satisfaction is through use of multidimensional teams. He contends that medicine is still too focused on individuals as opposed to teams.

But the development of high-performance teams does not just happen by accident—it takes work. “I do believe that, throughout medicine, we are starting to address a number of significant problems that will allow us to learn how to take care of these problems as teams. As a result, when we get to the big problems where true health care reform comes in, we will be better served.”

High-performance teams have certain characteristics, Dr. Holbrook continued. They require that individuals subjugate themselves to the team in order to move forward. Despite this, strong leadership is needed, and anytime you involve more than one person, you need good communication.

STRATEGIES TO ENSURE OPTIMAL, SAFE PERFORMANCE

Dr. Holbrook outlined four barriers to the provision of safe health care, including the hazard of not setting limits on production or performance.

“Whatever industry you’re in, if volume production is the sole determinant of success, or if maximal performance is highly incentivized, safety suffers,” Dr. Holbrook said. “People cut corners in order to deliver high volume results. Similarly, if there are no limits on the performance of a particular individual, then the safety record goes down.”

But what about pioneering efforts or attempts to make new medical breakthroughs?

“In these cases, you’re pushing the performance, either of the individual or of the team, and it’s not surprising that some of these efforts have early safety problems. However, you can usually work those through to the point where they become more safe.” Since there is an inherent balance between safety and productivity, the endgame in this barrier is to have limits on either production or performance.

Excessive autonomy of the actors is the second barrier to safe performance: Does the actor subjugate his or her autonomy to the needs of others? Examples in the medical world include sponge counts. “It’s a slight restriction on autonomy but it is now a widely accepted practice. Another example is morbidity and mortality conferences where people—at least allegedly—display their wounded sides in order to make a point.” The endgame here is to try to standardize protocols and have respectful interactions with good communication.

The third barrier to safe performance hinges on the answer to the question, Are the craftsmen or lead actors in a situation interchangeable with one another? If so, that is a sign of safety. It means that things have become standardized.

“While it is not possible for certain highly-skilled surgeons or for intensivists to follow that model, generally, autonomy is inversely correlated with safety,” Dr. Holbrook observed. The endgame to overcome this barrier is to standardize the professional actors when possible and then recognize when it is not possible.

Perceived risk is the fourth barrier to safe health care. “When you have an expectation by the public that certain things won’t occur, then clinicians have a tendency to protect themselves from the possibility that the event actually will occur,” said Dr. Holbrook.

He offered the hypothetical example of a chief medical officer who requires multiple levels of approval to use a common device because one time it was used incorrectly and now the fear of malpractice lingers. Another example is a surgeon who refuses to operate on a high-risk patient because of the possible impact to his or her mortality statistics.

“That is self-centered protectionism that doesn’t work in the patient’s best interest,” Dr. Holbrook noted. The endgame here is to accept that there will be residual risk and protect ourselves in ways other than overregulation. “Overregulation is the enemy of good thought and that’s where we need to switch over into a different kind of safety measure.”

TOOLS FOR TEAMWORK

Teams in high performance settings where the potential for disaster is overwhelming and the need for consistency is mandatory are known as high-reliability organizations. Reliability refers to the probability that the system, structure, component, process, or persons will provide the intended function. The five principles of high-reliability organizations are as follows:

• Preoccupation with possible failure: Every event, whether large or small, is examined as a potential precursor to a problem.
• Reluctance to oversimplify: Complex problems require input from experts with experience in dealing with such situations.
• Sensitivity to operation: Every member of the team must know what is going on at all times.
• Acknowledgement and analysis of problems: Despite the best preparation, problems may arise; therefore, it is best to plan for problems. How the team reacts is crucial.
• Deference to experts: Seeking expert advice is appropriate. Following that advice can mean the difference between success and failure.

“In my opinion,” Dr. Holbrook said, “this describes the well-functioning ICU that I certainly have seen in many places. I think we are already operating, to some extent, in a high-reliability organization framework. We just need to make that stronger.”

Dr. Holbrook pointed out several tools used at his institution for helping teams achieve safety goals. The first is the mnemonic SBAR, which helps to facilitate good communication. “The initials help us remember to describe the Situation, the Background of the situation, our Assessment, and our Recommendation. We insist that all people communicate problems in this way.” Similarly, they use the concept of a structured handoff, based on the premise that a person owns a problem until it is effectively passed on to the next person.

The five P questions are also helpful—who is the Patient, what is the Plan, what is the Purpose, what are the Problems, and what are the Precautions that the next person should be thinking about.

Finally, the STAR approach means Stop and pause for a second, Think about what needs to be done, Act, and then Review to ensure you are comfortable. These techniques, along with a questioning attitude, closed-loop communication, and good documentation can help teams achieve maximal safety.

POLITICAL SOLUTIONS

It is hard to say at this point what health care reform will look like, Dr. Holbrook admits. But under any system of universal health insurance, invariably more patients will need critical care. That will increase the pressure on resources and decrease the tolerance for low-value care.

“We will have to address the resource allocation issues ever more aggressively,” Dr. Holbrook said. “There will be inevitably less autonomy for individuals, and I think there will be a greater need for high-performance teams.”

—Glenn S. Williams

Suggested Reading
Amalberti R, Auroy Y, Berwick D, Barach P. Five system barriers to achieving ultrasafe health care. Ann Intern Med. 2005;142(9):756-764.
Daschle T. Critical: What We Can Do About the Health-Care Crisis. New York, NY: Thomas Dunne Books; 2008.
Sunstein CR.Infotopia: How Many Minds Produce Knowledge. New York, NY: Oxford University Press; 2006.
Weick KE, Sutcliffe KM. Managing the Unexpected: Resilient Performance in an Age of Uncertainty. San Francisco, CA: Jossey-Bass; 2007.

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