TeamSTEPPS^® is an effective tool to level the hierarchy in healthcare communication by empowering all stakeholders

Healthcare organizations share a love-hate relationship with the mention and use of the term hierarchy. The Merriam-Webster dictionary [1] defines a hierarchy as a classification of a group of people according to ability or to economic, social, or professional standing. Interestingly, this definition applies to many different sectors of the healthcare community as well as the many levels of each profession that exist in each of them. Global health professionals are keenly aware of the health inequalities that exist through social stratification that is based on the role of power. In line with the first part of the definition, the World Health Organization suggests that some of the structural stratifiers in a global health hierarchy may include income, education, occupation, social class, gender, and race/ethnicity [2]. These so-called stratifiers and separation of power create a health system that is seen as a ‘social determinant of health’, whereby socioeconomic positions determine quality and levels of care [2, p. 46].

Shifting from the macro to the micro aspects of healthcare, and the second part of our definition, we find healthcare organizations that are staffed with professionals that include every classification of caretaker, manager, and provider from junior to senior levels. Each of these professions cooperate in a structure that grants and is often based on power from amongst other things, expertise and experience. The hierarchies that exist in healthcare organizations can be steep, vary in levels, or be relatively flat. Each is fully capable of reducing teamwork and communication to cultures of shame and blame if the culture within the structure discourages empowerment of the worker of any level to raise concerns. In unhealthy organizations, team members may abstain from speaking up and issues can go unresolved leading to clinical error and even wellness issues.

From a communication standpoint, hierarchies are beneficial for healthcare teams, especially when time and clarity is an issue. Team members prefer to have a clear leader on their team [3]. An effective leader operating in a suitable level of the hierarchy can quickly assign tasks and roles, especially during emergent cases to ensure task coverage and minimize delays. In healthcare systems, physicians regularly take on leadership roles and decision-making responsibilities. For the most part, this is an accepted state within the hierarchal structure, although there is research that suggests that this can create tension in interprofessional teams, with some marginalized team members feeling that their input is less valued [3].

A core healthcare team can have its standard hierarchal relationships, while new hierarchies may be formed by contingency and coordinating teams called by the core team to provide specialized care. For example, a group of healthcare providers in the emergency department, operating as a core team may call upon the expertise of a trauma surgeon who may assist or take responsibility for a clinical case. As with this example, a leader may possess expert power and possibly wisdom and seniority that come from experience and education in their profession or specialization.

The power that each person possesses affects the team in different ways. Hierarchies that allow fear and intimidation or discourage respectful, candid communication can affect teamwork and patient care. Healthcare workers may not speak up, even when it could make a difference for patient safety because they do not want to be wrong, are unsure, or do not want to hurt someone’s feelings [4]. We may think of relatively flat hierarchies as providing the best collaborative experiences, but this does not equate to providing the best outcomes. Research has shown that without proper assignment and carefully implemented plans some tasks can fall through the cracks leading to delays in treatment and clinical error [5]. Rabøl et al. [5] referred to these unfulfilled tasks as ‘no-ones-tasks’ as one team member may assume that a task is being done by another member, or that it is someone else’s job because it was not directly assigned to them. Effective teams require definitive leadership, clearly assigned roles, and shared decision-making. Team members need to feel that they can and are willing to speak up to question orders and be involved in shared decision-making.

When properly implemented, Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS^®) can be a powerful program for improving teamwork and communication. This powerful program can empower all stakeholders to have a voice and provide them methods for speaking up that can minimize the negative aspects of hierarchies in medical settings.

Among the effective advocacy tools that are included in the program, there are three that stand out that can be used to clarify information and stop the line when necessary to prevent or minimize patient harm. The first tool is a check-back. It is a form of closed-loop communication that can clarify information to ensure that the sender–receiver pair is on the same page or have a shared-mental model. Under pressure from task overload, it may not be uncommon for a healthcare provider to utter the wrong order or become fixated on a certain aspect of the situation as to miss something that may be equally or more important. The check-back can be used by team members to confirm orders such as ‘I heard you call for 5 mg of epinephrine to be drawn, do you mean 1mg?’ or ‘I heard you call for 1 mg of epinephrine, would you like me to administer it also or just draw it up?’ But what happens when a concern is not acknowledged by the leader or other team member? This is where two additional patient advocacy tools may be applied including the two-challenge rule and CUS (I’m concerned, I’m uncomfortable, this is a safety issue, stop the line).

The two-challenge rule is applied by one or more people voicing their concerns to ensure that they are heard. A team member raises a concern in a firm and supportive manner to help the provider see what they may not (‘I can get you a pair of gloves’) and this concern may be expressed a second time if needed because the receiver may not have received the message properly and may commit a safety violation (‘Since we are trying to stay as aseptic as possible in this procedure, stop, before you go any further and I’ll get you some gloves’).

The CUS tool is a bit more direct and uses a trigger word to escalate the team member’s concern. For example, the team member may notice that the provider does not have control of the guidewire and they are about to slide the central venous catheter over the wire into the vein. We know this can lead to clinical error including losing the guidewire in the vein. In addition to the visit to the vascular surgeon, this would require removing the wire, this could prevent a sick patient from receiving a working line. A team member can advocate for the patient while looking out for the provider. They can also escalate the matter if the concern is not recognized or addressed properly. An example of conversation using CUS may include:

Team member:

‘I am concerned because you are ready to advance the catheter, but you do not have hold of the guidewire’

Provider looking confused. Team member escalates the concern.

Team member:

‘I’m uncomfortable with you advancing the catheter any further because you do not have the guidewire and you will not be able to get ahold of it once you start pushing the catheter through the skin’

Provider looking confused and gets ready to continue the procedure. Team member escalates the concern

Team member:

‘Okay, let’s stop the line because we have a safety issue. Sarah, can you get Dr. Robinson and ask her to come in here.

The intent of the team member stopping the line and escalating the concern is both admirable and necessary. As a sender of the message, the team member tried to convey the concern they had that was not received or acknowledged by the receiver. As a responsible healthcare provider, the team member has an obligation to look after the well-being of the patient. Simultaneously, they also must look out for the leaders and other team members because we want to work in environments where people are supportive of one another. When the team member stops the line and asks for another provider to come in to assist, they are not asking for punitive action to be administered. Instead, they are recognizing that this caring provider just doesn’t hear their intended message or may not see the seriousness of an issue because their attention is directed elsewhere. We only need to look at the adverse events reported to the Joint Commission to realize that many errors, especially medication errors may be occurring under the watch of other team members.

In our department we trained over 560 people in TeamSTEPPS^® and our research showed improvements in both knowledge and team performance [6]. Aside from the research results, there were also plenty of opportunities for healthcare workers to apply their new communication skills in the hierarchies adherent to our organizational structure. The first case involves a senior specialist who was called to the bedside to perform a procedure. Recall an earlier point that there are existing hierarchies and that new ones may be formed when specialized providers are brought into the core team. In this case, the specialist asked for 1500 ml of a medication to be administered. The provider suspected or knew this was wrong and performed a check-back to confirm the order (‘Are you sure you want me to give 1500 ml?’). The specialist was extremely busy or distracted by the procedure and just responded, ‘Yes’. Rather than employing the two-challenge rule or CUS, the healthcare provider complied with the order. The healthcare provider knew or suspected that there was a problem and using a check-back was the right thing to do. However, for whatever reason, there was some reluctance on that person’s part to gain the undivided attention of the senior specialist who was busy with a clinical procedure and escalate their concern. In this case, the ball stopped rolling, the order was not challenged, and an error was allowed to occur until it was caught and corrected by another clinician.

In another case, a senior surgical resident was assisting an experienced surgeon with a clinical procedure. The resident noticed that a securement device was not tight enough and informed the attending physician (first challenge). The physician eyed the device and said that it looked fine to him. Before he could close up the patient, the senior resident issued his second challenge in a firm but supportive manner and asked the attending to double check the device. The attending checked the device and found that it was not fastened tightly. He thanked the resident and made it clear to him how it could have been a big problem if not for his respectful perseverance.

Why was one team member able to speak up and follow through with the advocacy tools while the other was more hesitant? We know that individual personalities and interpersonal dynamics play important factors. Initial teamwork and communication training is only part of an ongoing process of creating a supportive environment. A person can be trained in TeamSTEPPS^®, but fear and intimation caused by bullying, disruptive behaviors, or fear of retribution may prevent a worker from speaking up [7–8]. Following implementation, leaders need to reinforce the TeamSTEPPS^® behaviors at every opportunity [6], including addressing the reasons why people may not challenge an action or behavior that they know may be unsafe. Root cause analysis should not be limited to what could have been done but should also include asking why it was not. Intimidation by someone holding a specialization perceived to be more powerful (i.e. expert power), or by a more senior worker in a hierarchy can create an environment where workers do not feel safe to speak up.

Internal power hierarchies, including those attributed to some healthcare specialties, can diminish teamwork efforts and as noted by Hughes and Salas [9], students become aware of these sorts of hierarchies as early as medical school. We condone threatening examples of hierarchy when we tolerate clinical providers who play hardball with colleagues or subordinate team members. Leaders at all levels, including core and contingency team members, need to be trained to accept feedback without becoming defensive [10]. This means that everyone receives the training and understands the ramifications and intentions of the advocacy tools. We do not want juniors feeling that calling attention to a senior’s mistake can have negative repercussions [11]. This may cause them to remain silent when they should be speaking up.

Green et al. [12] described training and interventions that are used in the airline industry as remedial actions to address a team member’s unwillingness to challenge matters that can affect safety without fear of retribution. Airline captains are shown that they can admit their mistakes and can also be disciplined for not listening to their co-pilot. During TeamSTEPPS^® training, healthcare workers are taught to debrief regularly. This is an important tool that needs to be diligently reinforced following initial training. Debriefing provides a method for learning from our experiences [6] and noting where the TeamSTEPPS^® behaviors were applied or could’ve been applied to improve teamwork and communication. It also keeps all stakeholders, including the patient, the core team, administrators, and contingency team members on the same page concerning what has been done and what still needs to be accomplished. When performed regularly, debriefings provide all team members with timely, ongoing feedback regardless of their perceived or actual position in a hierarchy. Walton [11] described a technique used by a clinician whereby he intentionally makes an error in communication during clinical rounding. The team knows in advance that he will be doing so and it is their responsibility to speak up so that they avoid the error.

As with other industries, the hierarchy will continue to exist in healthcare and potentially impact quality and safety in a negative way. In our experience, TeamSTEPPS^® has been an effective tool to level hierarchy inherent within the organizational structures. Through the implementation of TeamSTEPPS^® tools and skillset, members from top to bottom can have a voice that will be heard.