Adaptive team coordination in anaesthesia teams: Measures for diagnosis and improvement

1. Adaptive team coordination in anaesthesia teams: Measures for diagnosis and improvement Gudela Grote, Enikö Zala-Mezö & Barbara Künzle ETH Zürich Johannes Wacker University Hospital Zürich Acknowledgement: We thank the Daimler-Benz-Foundation for their financial support.

2. Basic principles of organization design: Two approaches to uncertainty management* * Uncertainties may stem from the system environment and/or from the transformation processes within the system.

3. Team coordination • “tuning of interdependent work processes to promote concerted action towards a superordinate goal” • Coordination can be explicit or implicit • Coordination can be achieved through (e.g. Van de Ven et al., 1976) • Central programs and plans, e.g. standard operating procedures • Personal leadership • Reciprocal team interaction

4. Adaptive coordination • Based on demands of situations different types of coordination have to be chosen (e.g. Entin & Serfaty, 1999; Grote et al., 2004; Orasanu, 1993): • e.g. implicit coordination through standards and reciprocal team interaction during high task load • e.g. personal leadership in novel situations

5. Hypotheses (1) In work situations with high standardization more implicit coordination and less leadership behaviour and heedful interrelating is found compared to work situations with low standardization. (2) In work situations with high task load more heedful interrelating and implicit coordination, and less leadership behaviour is found compared to work situations with low task load. (3) The assumed coordination patterns under (1) and (2) are linked to better team performance.

6. Methods • Video recordings of 23 anaesthesia teams (anaesthesia induction for planned real operations) • Rating of coordination behavior: • Implicit coordination versus explicit coordination (Entin and Serfaty, 1999) • Personal coordination through leadership (Yukl, 1999) • Personal coordination through heedful interrelating (Weick and Roberts, 1993). • Performance rating: • Global performance rating by an anaesthesia expert

7. Changing patient's position - explicit coordination

8. Results Support for hypothesis 1, no support for hypotheses 2 and 3

9. Rule types (Hale & Swuste, 1998) • Rules concerning goals to be achieved (goal rules): "It must be clearly understood that not all combinations of cumulative opera-tional problems (engine failure plus e.g. terrain, weather, availability of aerodroms etc.) can be covered by this policy. In such situations the solution offering the highest degree of safety should be sought." • Rules defining the way in which decisions about a course of action must be arrived at (process rules): "In order to complete a replan-ning, any documented cruise systems and all means available may be used, such as flight management systems and data contained in the respective AOMs." • Rules defining concrete actions (action rules): "Every evacuation must be carried out as quickly as possible. The passengers must be assisted to leave the aeroplane without their belongings and direc-ted to a point at a safe distance from the aeroplane."

10. Results of rules analysis: Cockpit vs. anesthesia

11. Discussion • Implicit coordination as desired form of coordination in anaesthesia (e.g. Heath et al., 2002; Zala et al., 2004) • Ambivalence regarding danger of relying too much on a presumed shared understanding of the situation (Zala et al., 2004) • Need for systematic “rules management” (Grote, 2004; Hale & Swuste, 1998): • Keeping flexibility of non-prescribed action and providing enough orientation for swift switches between coordination forms • Limitations of study: • small numbers of teams • low variance in performance measures • routine situations • mix of formal and informal rules inadequately covered

12. Extension of study underway • better performance measure • mix of more and less critical events in simulated setting • interviews with critical decision method based on video feedback

14. Video recording installation in the operating room

15. Performance measure Clinical performance: incorporates reaction times to non-routine events and expert ratings concerning the appropriateness of decisions and task execution. Definition of time periods: The measured time periods are defined as follows: • Perception time: Time elapsed from an “event” until the team recognizes the event - reflecting the ability of the team to react to potentially threatening events. • Decision time: Time elapsed from the event until the team has gained a plan to treat the problem or to react otherwise (indicated by a verbal declaration). • Execution time: Time elapsed from an “event” until the problem is solved (visible result on monitor, or declaration to neglect the problem). • Resumption time: Time elapsed from the moment when the “problem” is solved (execution time) until the team faces the next routine task according to underlying standardization. This time period is largely independent from both event and patient.

16. Critical Decision Method (Klein et al. 1989; Hoffman et al. 1998) • the interview method is designed to elicit tacit knowledge (written and unwritten rules, experience, etc.) behind activities and decisions • alteration of the method: instead of recalling a case from memory interviewer and interviewee watch the video tape together following the course of the anesthesia induction • Interview themes: • preparation for the operation • task distribution; • collaboration with unknown teammates; • dosage; • monitoring; • alarm signal; • non-routine events; critical events; etc. • Systematic reflection of own behavior as important element for training

17. Loose coupling through adequate rules management • Importance of process rules • Rules should clarify system boundaries and suggest ways of handling system states close to those boundaries(Rasmussen, 1997) • Rules should support adaptive coordination (Grote, Zala-Mezö & Grommes, 2004) • Level of the organization at which rules should be defined(Hale & Swuste, 1998) • the more predictable work processes are, the more rules can be decided upon at higher levels • the more innovative work processes are, the more rules need to be decided upon on operative levels • the more different organizational units have to interact, the more rules need to be decided upon at higher levels • Enabling higher order autonomy through participation in rule making(Grote, 1997) • Choosing appropriate technical support for rule use