Section 2: Explanation of Key Team Leadership Concepts and Tools

This section contains explanations and illustrations to help you better understand and appreciate the importance of team structure, leadership, and leadership tools. If you teach this content or want additional insights into how the material can be more fully learned, you may want to review the instructor suggestions in section 3.

Team Leadership

Team Leadership is one of the four essential skills central to safe, efficient, and patient-centered care.

Defining a Team

Team structure refers to the composition of an individual team or of a set of teams (a multi-team system, or MTS) working collaboratively to address the patient’s needs. Defining the team structure is an integral part of the teamwork process, and the leaders of all the interconnected teams should have a part in this definition. Properly structured patient care teams facilitate effective communication, leadership, situation monitoring, and mutual support. Conversely, effective communication and leadership are needed to establish a good team structure at the outset.

Proper team structure can promote teamwork by including a clear leader, involving the patient, and ensuring that all team members commit to their roles in effective teamwork.

It is important to identify and recognize the structure of teams, as teamwork cannot occur in the absence of clearly defined teams. Understanding a team's structure and how multiple teams interact to support the patient is critical for planning the implementation of TeamSTEPPS tools and strategies.

To ensure that trainings reach all affected team members, it is essential to know which teams are targeted for TeamSTEPPS; who on these teams may adopt the TeamSTEPPS intervention; and how the intervention may affect other teams in the care environment.

A team is different from a group. A group can achieve its goal through independent, individual contributions. Real-time coordination of tasks between individuals in a group is not required.

A team, however, consists of two or more people who interact dynamically, interdependently, and adaptively toward a common and valued goal; have specific roles or functions; and have a time-limited membership. While many teams interact with each other and the patient face to face, increasingly, teams include members participating virtually via web-based platforms, emails, and instant messages. Sometimes entire teams interact virtually and support patients remotely (via telehealth) as well.

During the temporal life of a team, the team’s mission is of greater value than the goals of the individual members. Some teams are formally defined and permanent. Other teams are created rapidly to respond to an emerging patient need. And sometimes team membership evolves rapidly as shifts and patient needs change. All these variations in team structure create challenges to the effective functioning of the team.

Team members:

• Include the team leaders and anyone involved in the process of patient care.
• Can be present physically or virtually.
• Have clearly defined roles and responsibilities.
• Are accountable to the team for their actions.
• Must stay continually informed for effective team functioning.

It is critical to acknowledge that a patient care team is not complete without the patient. Patients and family caregivers play vital roles in contributing to patient care. Sometimes the patient is fully engaged with the team. At other times they may defer to a family caregiver. Understanding how the patient wants to engage with the health professionals on the team is key to effective and patient-centered teamwork. It should also be noted that for patients with limited English proficiency, who are at higher risk of harm, including a medical interpreter as part of the care team is essential.

The responsibilities of patients and family caregivers as part of the team differ from those of other team members. Patient and family responsibilities include:

• Providing accurate patient information.
• Collaborating to create a care plan they will follow (e.g., taking medications, scheduling and attending appointments).
• Asking questions and voicing any concerns regarding the care plan.
• Monitoring the patient’s condition and reporting any changes in a timely manner.
• Coordinating and communicating with other family members.
• Encouraging and showing appreciation to other team members.

This TeamSTEPPS module includes several teamwork skills, tools, and strategies patients and their families can easily adapt and use. Thinking about how to equip patients or family caregivers to participate in teams is essential to maximize TeamSTEPPS’s value to your organization.

Examples of effective strategies for involving patients and family caregivers include:

• Engaging the patient in bedside rounds.
• Conducting handoffs at the patient’s bedside.
• Providing patients and family caregivers with tools for communicating with their care team (e.g., phone numbers, email addresses, patient portal).
• Involving patients in key committees.
• Actively encouraging patient and family caregiver participation.

Several organizations provide information, materials, and suggested strategies related to patient engagement, including the Agency for Healthcare Research and Quality (AHRQ), the U.S. Department of Defense (DoD) Patient Safety Program, The Joint Commission, the U.S. Department of Health and Human Services, the Institute for Healthcare Improvement, and Consumers Advancing Patient Safety.

Selected Resources

• The AHRQ-funded Guide to Patient and Family Engagement: Environmental Scan Report. 
• The DoD Patient Safety Program’s Team Up.
• The DoD Patient Safety Program’s Patient Activation Reference Guide.
• The Joint Commission’s Speak Up Campaigns. 
• The Institute for Healthcare Improvement’s Ask Me 3.
• The U.S. Department of Health and Human Services’ Partnering to Heal.
• The Institute for Heathcare Improvement’s Person- and Family-Centered Care Information.
• Information from Consumers Advancing Patient Safety.

Working with patients and families as true partners entails:

• Listening to and eliciting feedback from patients and family caregivers.
• Assessing patients’ preference regarding involvement.
• Before launching into detailed status, asking patients about their concerns, needs, and questions.
• Speaking in lay terms to ensure that patients and family caregivers understand the information being shared.
• Allowing time for patients and family caregivers to ask questions.
• Providing patients and family caregivers access to relevant information on a portal or elsewhere.
• Treating patients and family caregivers as distinct, with different information, preferences, and concerns.

Resources available for patients and families include, for example, the Josie King Call Line—Condition Help ("Condition H"), which enables parents and family members to call for immediate help if they feel the patient is not receiving adequate medical attention.

MTS for Patient Care

Safe and efficient care involves the coordinated activities of an MTS.

Multiple teams are involved in patient care in all healthcare settings. However, the teams may differ substantially between hospitals and other settings. As shown in the Hospital Multi-Team Structure model, each team is responsible for various parts of patient care, but all must act in concert to ensure quality care. Coordination in other care settings is equally critical. While one team may focus on treating an underlying condition (e.g., cancer), other teams may address other health needs (e.g., catheter care and associated infections, unrelated heart problems). Still other teams may support the patient’s broader care needs related to mobility, nutrition, independent living, and, potentially, comfort or palliative care.

In non-hospital care settings, the teams that must coordinate with each other vary extensively from patient to patient. Ideally, each team involved in patient care engages in and supports care coordination across all involved teams. In a hospital setting, MTSs are composed of several different teams that are more consistently defined. These MTSs include the Core Team (which always includes the patient), the Contingency Team, the Coordinating Team, Ancillary and Support Services, and Administration. Some of these teams also exist in nonacute settings.

Core Teams

Core Teams consist of team leaders and team members who are involved in the direct care of the patient. Core Team members include the patient, sometimes a family caregiver, direct care providers, and continuity providers. Continuity providers manage the patient from assessment to disposition—for example, they include case managers. The Core Team is based where the patient receives care.

Core Teams should be small enough to ensure situation monitoring, development of situation awareness, and direct, unfiltered communication between members. To establish a shared mental model, Core Teams should be large enough to include skill overlap between members to allow workload sharing and redistribution when necessary. Every Core Team has a leader whom all members of the team can readily identify.

Core Team leadership is dynamic; Core Team leaders are required to take on different roles at various points in the plan of care. These may be non-leadership roles, such as supporting a nurse starting an IV.

Examples of Core Teams include:

• Outpatient (Family Practice Clinic): The Core Team may be composed of the physician, nurse, and administrative staff member responsible for treating a patient.
• Inpatient (Tertiary Care Facility): The Core Team may be composed of the interventional cardiologist, nurse, and cardiac catheterization laboratory staff members responsible for performing coronary angiography on a patient.
• Inpatient (Operating Room): The Core Team may be composed of the surgeon, the anesthesiologist, the circulating nurse, and the scrub technician.

Contingency Teams

Contingency Teams are:

• Formed for emergent or specific events.
• Time limited (e.g., Code Team, Disaster Response Team, Rapid Response Team).
• Composed of team members drawn from a variety of Core Teams.

Contingency Teams are responsible for immediate, direct patient care during emergency situations requiring more resources than are available to the Core Team. Their role may be very specific and time or situation limited, such as for a Code Team, or they may be responsible for a broad category of situations, such as disaster response. They generally consist of preidentified members derived from varying units or Core Teams and have limited time to prepare for emergencies.

Because Contingency Team members are called together for emergent or specific events, they do not typically spend much time working together as a team. However, their individual roles are clearly defined, and leadership is designated based on patient needs and member expertise in dealing with the particular situation. These teams may convene virtually. High-functioning virtual teams may make participation of team members more convenient, allow teams to convene and make decisions more rapidly, and include the patient and family caregivers more easily.

Examples of Contingency Teams include:

• Outpatient (Family Practice Clinic): The Contingency Team may include a pharmacist or Pharm.D. who can be called on if the medication regimen is complicated and requires special expertise.
• Inpatient (Tertiary Care Facility): The Contingency Team may be composed of the cardiac surgeon, anesthesia staff, and operating room staff who can be called on if the patient requires emergency surgery.
• Inpatient (Operating Room): The Contingency Team may be composed of anesthesia staff.

Coordinating Teams

The Coordinating Team is the group responsible for:

• Day-to-day operational management.
• Coordination functions, such as triaging emerging events and prioritizing decision making to ensure maximal support to the Core Team.
• Resource management for Core Teams, such as collaborating with the Administrative and Ancillary Teams to assign priorities and ensure task completion.

Coordinating Teams frequently include experienced personnel with a strong clinical background. This combination of expertise and skills enhances the ability of the Coordinating Team members to rapidly assess the overall picture, anticipate the needs or potential needs between and across teams, and make priority-based decisions.

Ancillary and Support Services

Ancillary Services are provided by individuals who:

• Provide direct, task-specific, time-limited care to patients.
• Support services that facilitate patient care.
• Are often not located where patients receive routine care. Ancillary Services are primarily a service delivery team whose mission is to support the Core Team. In general, an Ancillary Services Team functions independently.

Support Services are primarily a service-focused team whose mission is to create efficient, safe, comfortable, and clean healthcare environments, which affect the patient care team, market perception, operational efficiency, and patient safety. Examples include radiology services, pharmacy, and food services.

Role of Administration

Administration includes the executive leadership of a unit or facility and has 24-hour accountability for the overall function and management of the organization. The Administrative Team has no responsibility in the direct delivery of care but provides the framework and guidance that ensure each team understands its role and responsibility and can access the resources it needs to succeed.

Administration creates the environment and culture for a teamwork system to flourish by:

• Establishing and communicating vision.
• Developing and enforcing policies and procedures that clearly articulate the roles and responsibilities of the other teams and team members.
• Setting expectations for staff.
• Providing necessary resources for successful implementation.
• Holding teams accountable for team performance.
• Defining the culture of the organization.

Administration should strive to create a learning culture of trust and transparency that creates a safe environment to report, analyze, and share information openly. This philosophy serves to define a culture of safety that can be achieved through sustained effort over time.

Team Leadership

Leadership is the linchpin that holds a teamwork system together. In the hospital, a clinician is generally identified as the designated team leader; in other care settings, the team lead may be a nurse or a case manager. However, within teams the formal leader may not always lead the team to address the situation at hand. This module is titled “Team Leadership” because any team member may take on the leadership role depending on the situation and the current team structure.

To create an environment of teamwork to flourish in support of patient safety and the delivery of high-quality care, leading teams involves:

• Establishing a care plan for each patient supported by the team, identifying roles and responsibilities of team members, developing norms within the team for operating, and communicating the plan to all team members.
• Monitoring the patient care plans and surrounding situation to better anticipate patients’ needs, effectively manage the resources to meet those needs, and adjust the plan as needed.
• Modeling appropriate behavior and reinforcing and rewarding appropriate behavior when team members exhibit it.

Types of Team Leaders

Team leaders are well-informed team members who make decisions and act. Team leaders engage other team members to establish team goals and maintain its focus. There are two types of leaders.

The first type is the designated team leader. For a team to function successfully, a leader must be designated. This leader has the knowledge, skills, and attitudes to achieve the established goals. In most clinical situations, the clinician in charge is the designated team leader.

The second type is the situational leader. The responsibility for leading the team may change depending on the case. Situational leaders emerge at designated times, such as during anesthesia induction, and spontaneously, such as being the first responder to a code.

In high-performing teams, any member of the team with the skills to manage the situation can assume the role of situational leader. Once the situation has been resolved or the designated leader is ready to assume control, the situational leader resumes the role of team member.

Effective Team Leaders

When leading teams, both designated and situational team leaders must have defined responsibilities and the skills needed to meet them. At its core, leading teams involves the following responsibilities:

• Identifying a goal and defining patient care plans to achieve the goal
• Assigning tasks and responsibilities
• Sharing the patient care plan
• Monitoring the care plan and progress toward the goal
• Modifying the patient care plan and communicating changes to all team members
• Reviewing the team’s performance

It is critical that when leading teams, designated and situational leaders also have the skills to:

• Establish “rules of engagement” under which team members will operate and perform their roles.
• Manage and allocate resources effectively to ensure that team members have what they need to succeed.
• Provide feedback to team members regarding their assigned responsibilities and progress toward the team’s goal.
• Facilitate information sharing among team members.
• Encourage team members to assist one another when needed.
• Facilitate conflict resolution.
• Model effective teamwork.

Defining the Patient Care Plan

Leading teams involves identifying a goal or goals for the team’s performance and developing and clearly articulating patient care plans to achieve the team’s goal. In an MTS, each team requires leadership, and the care across all the teams within the MTS also must be coordinated and led.

For each team and the entire MTS, the team leader (whether designated or situational) must develop a plan of care for the patient in order to achieve a specific health outcome—the identified goal. As part of gathering information needed to develop the plan, the team leader should seek input from staff to ensure the patient care plans use all known information.

Developing a care plan also involves considering the available resources with respect to time, people, equipment, and information relative to the patient’s needs. The goal is to formulate a patient care plan that effectively uses available resources while maintaining the highest standards with respect to patient care and safety.

Assigning Tasks and Responsibilities

It is typically the responsibility of the designated leader to assign roles and tasks to other team members. In some cases, a situational leader may also make such assignments. When leading the team, you should:

• Determine the tasks and roles to be assigned:
  • Consider priorities, work requirements, and availability of resources.
• Determine which roles must be filled and allocate tasks appropriately:
  • Consider the knowledge, experience, skill, availability, and scope of practice of each team member.
• Communicate clear expectations of what team members need to do:
  • Communicate the patient care plans, team member roles, and task responsibilities.
• Request feedback about the care plans and about progress toward achieving their goals.