Safer Surgery 144 coordination. Verbal communication and feedback has been shown to improve team performance in image guided surgical teams (Shiliang Chang et al. 2008). Bearing the recent evolution in medical simulation in mind, it is now prime time to take one step further, looking at the whole perioperative team, the OR team and not only the patient’s pathophysiology and the surgeon. The A-TEAM scale which rates all team members enables this step towards increased team coordination. As shown in Table 9.1 it assesses behaviours. It is important to keep in mind the impact of patient outcome variables, clinical performance and team members’ subjective experiences of the process of teamworking. Consequently, such additional assessments also have to be addressed by other scales in order to yield a more ne- grained analysis. True mastery of intra-operative skills transcends from teamwork in harmony with manual dexterity. It stems from mastery of oneself, being fully aware and in tune with the rest of the team, despite leadership or followership and irrespective of the current context. The traditional focus being mainly on the leader deserves challenge and a new hypothesis needs to be outlined; the equal importance of followership for successful surgery. This evolution can be considered as sluggish within the eld of perioperative care. According to empirical evidence, one reason could be the inherent promotion of vertical climbing of the pyramid of hierarchy within surgery, rather than a horizontal process-oriented approach. Intimidation and harassment have been described as functional educational tools in surgical education (Musselman et al. 2005). The authors found that intimidation was sustained in the surgical education by encapsulation and rationalizing the behaviour to ‘good’ or ‘benecial’ intimidation. These fundamental values in the surgical community towards education have no doubt served as conservers of the old system. This mastery of teamwork can be developed and trained by a systematic approach and requires the attempt to assess all team members’ performance, since it is the combined effort of the team that yields the net result for the ones we are set to treat and help – the patients. In summary, the A-TEAM scale could be a suitable tool for elucidating the complex interaction between leaders and followers. Further, it could be used in the study of the relationship between the teamwork process and teamwork outcome, as well as for feedback during training. We propose further validation of the A-TEAM scale with the ultimate goal to enhance teamwork output for optimal perioperative care. References Agency for Healthcare Research and Quality (2006) TeamSTEPPS ™ : Strategies and Tools to Enhance Performance and Patient Safety. 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Yule, S. Flin. R., Maran. N., Rowley. D., Youngson. G., Paterson-Brown. S. (2008) Surgeon’s non-technical skills in the operating room: Reliability testing of the NOTSS behaviour rating system. World Journal of Surgery, 32 (4), 548–56. Ziegert, J.C. (2004) A unied theory of team leadership: Towards a comprehensive understanding of leading teams. Paper presented at the 19th Annual Conference of the Society for Industrial and Organizational Psychology, Chicago, IL. Chapter 10 Introducing TOPplus in the Operating Theatre Connie Dekker-van Doorn, Linda Wauben, Benno Bonke, Geert Kazemier, Jan Klein, Bianca Balvert, Bart Vrouenraets, Robbert Huijsman and Johan Lange Introduction The focus in healthcare is changing from cost-effective ways of delivering care to delivering care that is safe, has a high standard of quality and improves patient outcomes like a shorter hospital stay and less complications. In this respect, concerns about patient safety are rising worldwide. Different studies suggest that 30–40 per cent of patients do not receive care in compliance with current scientic evidence and, possibly even worse, 20–25 per cent of the care provided is not needed or potentially harmful (Grol 2001, Schuster et al. 1998). Although surgical safety knowledge has improved substantially, it is estimated that 3–16 per cent of all hospitalized patients are affected by adverse events and almost 50 per cent of these events occur during surgical care, involving all surgical disciplines (Cuschieri 2006, World Health Organization 2008). The replication of the Harvard Medical Study in the Netherlands showed that 5.7 per cent of all patients hospitalized suffered from adverse events causing temporary or permanent disabilities, and 4.1 per cent of all patients who die during hospitalization die because of these probably preventable incidents (de Bruijne 2007, Wagner and de Bruijne 2007). Inadequate anaesthetic safety practices, avoidable surgical infection and poor communication among team members are issues that are common, deadly and preventable problems in all countries and all settings (World Health Organization 2008). It is suggested that half of adverse events can be prevented, provided professionals in healthcare accept that human error is inevitable, teams are willing to learn from mistakes and organizations are looked at from a systems perspective. In this context the team is a small separate unit of a larger organizational system in which management decisions and organizational processes are important factors in relation to patient safety. The lack of support (managerial as well as nancial), inadequate training and staff or the absence of reliable management information systems can all be causes for latent failures that eventually lead to adverse events (see Figure 10.1). Safer Surgery 152 Figure 10.1 Causes for latent failures leading to adverse events (adapted from Reason 2005) Introducing TOPplus into the Operating Theatre 153 If a team works together effectively in the right working environment, it can avert a considerable proportion of life-threatening complications. ‘Cooperation among team members’ and ‘Promote effective team functioning’ are two recommendations of the Institute of Medicine (IOM) to achieve a healthcare system that is: safe, effective, patient centred, timely, efcient and equitable (Institute of Medicine 2001). These recommendations support the creation of a system where it is easier ‘to do things right than to do things wrong’ and underscore the importance of teamwork and communication in relation to patient safety. This is especially true within a complex and critical environment like the operating theatre (OT). Errors in OT can have serious consequences for patients and families but also for healthcare professionals themselves and the entire healthcare organization. Poor communication and collaboration between OT members, being one of the major causes for incidents, renders the team itself to be the most critical resource to improve surgical safety (Sexton et al. 2006). In addition to technical knowledge and skill, good communication and teamwork are critical for teams to be effective in complex and critical environments like the OT (Yule et al. 2006). Good teamwork depends on each individual team member having a better understanding of what others do, to anticipate the needs of other team members, adjust to each others actions, and have a shared understanding of the procedure (Baker et al. 2006). Establishing a high level of situational awareness is one of the conditions for teams to work effectively. Yet most teams in OT have had little team training and cannot rely on adequate work structures to improve effective teamwork and improve patient safety. The aim of the project TOPplus is to improve situational awareness, decision- making, transparency and cooperation among team members; characteristics that are key in the requirements of the World Health Organization (WHO) Guidelines for Safe Surgery (World Health Organization 2008). Improvement of these characteristics helps individual team members to make the transition from autonomous professional to team player and overcome one of the barriers to achieve safe care. Healthcare professionals must be open to others with respect to problems and anticipate accordingly. This also requires looking at care process as a system including other departments like the clinical ward (Amalberti et al. 2005). This in turn leads to reliable processes where a team of healthcare professionals work together for the benet of the patient and structurally decrease the number of incidents and preventable deaths. It is at this specic team level where the proposed intervention TOPplus is situated, the level that is also the least well understood level of the structure of healthcare (Batalden and Splaine 2002). TOPplus and Underlying Principles TOPplus is based on the principles of crew resource management (CRM). CRM training encompasses a wide range of knowledge, skills and attitudes including communication, situational awareness, problem solving, decision-making, and teamwork (also referred to as non-technical skills). . Vincent, C.A. (2007) Observational teamwork assessment for surgery (OTAS): Renement and application in urological surgery. World Journal of Surgery 31 (7), 1373–81. Van Vugt, M. (2006) Evolutionary. mainly on the leader deserves challenge and a new hypothesis needs to be outlined; the equal importance of followership for successful surgery. This evolution can be considered as sluggish. cardiac centres (2003) Behavioural markers of surgical excellence. Safety Science 41 (5), 409–25. Safer Surgery 146 Catchpole, K.R., Giddings, A.E., Wilkinson, M., Hirst, G., Dale, T. and de Leval,