Human Resources: A Team versus B Team
One of the most important strategies to optimize safety is hiring, training, and retaining the right team members. Competent and effective team members are essential partners when building a high-reliability ED. Hire A team members. As originally described by Mayer and Cates5
“A team members get things done efficiently and effectively. They come to work on time and with energy to spare. A team members are committed to working with the team and doing what is right for the patient.”
Avoid hiring B team members who exhibit A team behaviors in reverse (see Table 68-2). It may take months of working side by side before differences in team members become apparent. One substantial challenge occurs when a B team member lacks self-awareness. That is, a B team member looks into the mirror and sees an A team member.
Table 68-2 A Team and B Team Attributes |Favorite Table|Download (.pdf)
Table 68-2 A Team and B Team Attributes
A Team Members
B Team Members
Measuring outcomes is an effective strategy in modifying B team behavior. Measuring clinical metrics (by provider) and feeding them back to each individual allows B team members without self-awareness to compare themselves to peers. Mentoring and coaching, in selected cases, effectively improves performance. Continuing to measure performance outcomes, aligning incentives, and professional accountability are critical to maintain these performance gains.
Establish and candidly communicate desired levels of performance when citizenship performance is unacceptable. Alternatively, having fellow team members evaluate each provider during performance reviews (ie, a 360 degree evaluation) is a powerful method of improving B team citizenship issues. The B team member can realistically see how their work appears to other team members when using this type of performance review as a mirror. Ultimately, deciding that a B team member does not fit into the system is just as important as hiring correctly.
Increased ED volume and diminished hospital capacity lead to overcrowding. Increasingly, patients are older, more medically complex, and often chronically ill. Caring for a chronically ill elder with sepsis in a crowded ED is difficult. Caring for that same patient in an ED with broken systems consistently produces errors and maloccurrences.
HROs focus on systems to prevent risk. Strategies to improve processes include
- Using the lean approach to process improvement: Lean uses a variety of analytical tools to preserve value with less work. It identifies and removes steps in a process that are not value added. This set of tools is particularly effective in complex processes like triage and the admission process.
- Measuring outcomes: Measure clinical metrics and risk outcomes by individual provider. Having providers review their outcomes allows them to participate in the process of improving patient flow, which in turn helps reduce risk.
- Managing outliers: Identifying and analyzing outliers identifies opportunities for system and risk-related improvement. For example, outliers for length of stay frequently suffer from multiple sources of delay and process error (see Figure 68-1). This approach requires persistence and attention to detail.
It is necessary to understand the systems of care because no one in the healthcare team makes a mistake on purpose. The after action review is a method of understanding a suboptimal or bad outcome.6 Developed by the US Army and Marine Corps to better enable their war fighters to assess combat encounters, an after action review can be used to define how an average outcome could have been turned into an even better outcome. An after action review analyzes the factors listed in Box 68-2.
Box 68-2 Components of an after Action Review |Favorite Table|Download (.pdf)
Box 68-2 Components of an after Action Review
- Intended results and measures
- Challenges that could have been anticipated
- What has been learned from similar situations
- Steps to ensure future success
This approach can be applied at the bedside or used for deeper dives into performance improvement and error reduction. It is of interest to point out that in the organizational accident/industrial safety experience, 70% to 80% of errors are blamed on the last person involved in the situation. Following investigation, less than 20% of errors are attributed to the last person.7 Learning why errors occur involves an iterative set of discussions and investigations. When performing an after action review, it is important for leaders to take the time to talk to the people involved in the case and then after the review, return to those people with an explanation (armed with acquired knowledge about the events surrounding the case). Making simple, a priori assumptions about why an error occurred and settling for the first set of conclusions helps ensure that series of mistakes will return.
Failure Modes and Effects Analysis
Another approach is failure modes and effects analysis (FMEA). In the context of the ED, FMEA requires a review of proposed changes by staff, prior to incorporating rapid change into the system's processes. FMEA
- Decreases team member stress about change
- Prevents unnecessary interruptions in the flow of patients through the department resulting from change
Without an FMEA review, organizations sometimes inadvertently add new barriers to providing effective, safe service in the effort to remove old barriers and actually add waste rather than value to the system.