**3. Teamwork**

As we have moved from parallel practice to the concept of integrative multidisciplinary care, the intensive care team has evolved to include many physicians and healthcare professionals who share the common goal of delivering high quality, coordinated patient-centred care. Team members are highly skilled professionals who contribute from their diverse knowledge and experiences to improve patient care.

The structure of the team can vary depending on the needs of the patient and the availability of staff. During a typical admission to the intensive care unit (ICU) a patient can expect to receive care from the following team members; ICU doctor, ICU nurse, medical/surgical doctor, physiotherapist, dietician, occupational therapist, speech and language therapist, pharmacist, psychologist and social worker. The delivery of patient care is the result of a highly coordinated effort from each of these professionals. Many critical care units will be in teaching hospitals, so there will be students and trainees in each discipline present and participating in the team. With healthcare staff delivering care over 24-hour periods, there is a handover of patient information across shifts. This means relatively large numbers of trained staff are required to maintain safe care. To operate a large team in a cohesive fashion takes attention and a proactive approach to resolving differences in opinion. Excellent communication assists greatly in keeping a team together, with the common aim of giving good patient care.

## **3.1 High performance teams in the intensive care unit**

There is an emerging body of research, which suggests that high-performance teams lead to improved outcomes in healthcare. Initially coined in the 1950s and adopted as a concept within organisation development, a high-performance team consist of a group of skilled individuals with a shared goal. The analogy has been drawn from Formula 1 motor racing and nuclear energy production. All highperformance teams are under pressure to deliver consistently high-quality results in a climate of significant risk. Through open communication, role expectations and group operating procedures, the high-performance team collaborate to produce reliable superior results.

Considering the wide variety of expertise amongst professionals involved in delivering critical care, the concept of a high-performance team seems appropriate to adopt. In this section, we discuss the essential components of highperformance teamwork and the potential barriers faced in the busy intensive care environment.

## *3.1.1 Fundamental elements of high-performance teamwork in the intensive care unit*

## *3.1.1.1 Common goals*

The ICU team must agree upon short- and long-term goals of care for each patient. These goals are individualised and reflect the priorities of the patient and their family. All team members, including the family, should be involved in the initial setting of goals of care. Ideally, these goals should be written down and be easily accessible to all team members. There should be regular and routine evaluation of progress and all team members must agree on amendment of processes if goals are not sufficiently reached.

## *3.1.1.2 Clear roles and responsibilities*

Each member of the ICU team must have individual, discipline-specific roles, and responsibilities. It is important that team members are aware of each other's functions, so each has a clear understanding of both individual and team obligations. Labour should be divided according to the expertise available to enhance team efficiency in realising common goals. Holding information in separate silos across the ICU team may cause difficulties in communication, especially out of usual working hours. For this reason, it is preferable if clinical records are contributed to and maintained centrally. This is easy to achieve when an electronic record is used.

## *3.1.1.3 Accountability*

High-performance teams must demonstrate individual and shared accountability. Individual accountability is dependent upon the personal values of each team member. It may be encouraged by setting personal goals for team members and regular feedback to the individual. Shared accountability can be achieved by agreeing upon group-wide operating rules and standards. Regular review and reinforcement of standards will encourage mutual accountability amongst the team. Open discussion of risk, adverse events and error is a key element in producing accountability: if critical care staff feel that they work in a climate of compassionate understanding of adverse events, they are more likely to be comfortable managing their personal responsibility for patient care.

## *3.1.1.4 Leadership*

Effective teams require a team leader who is responsible for overseeing group performance. The team leader should ensure provision of a cohesive and supportive team environment. Although traditionally the physician would be the team lead in ICU, the lead in any given scenario may be determined by the needs and experience of the team at that time, rather than in a hierarchical manner. Shared decision making is fundamental to a high-performance team. The team leader should abolish the topdown leadership style and encourage every team member to have a voice, regardless of their position. The value of this approach becomes clear as the team develops and leads to richer interaction. When a critical incident occurs that requires flat lines of communication and prompt action, prior investment of time and effort in professionalism development across the team delivers excellent results in terms of patient care and how team members feel after the event. If there is a poor outcome, follow up

between the team leader and team members is important to support staff and extract learnings that can be shared with the aim of improving care.
