Safer Surgery 214 In an ongoing research project, we investigate the relationship between adaptive coordination processes, non-technical skills ratings (Fletcher et al. 2003) and clinical performance of anaesthesia teams in both simulated and live settings during routine situations, as well as when confronted with non-routine events. Within this project we tested the taxonomy of explicit and implicit team coordination and heedful interrelating behaviour presented in Figure 13.1 for inter- rater reliability. This required that two coders independently coded two out of 15 simulated inductions of general anaesthesia. Analyses of Cohen’s Kappa values showed fair to substantial reliability (for Explicit coordination of information exchange κ = .67; for Explicit coordination of actions κ = .63; for Implicit coordination of information exchange κ = .32; for Implicit coordination of actions κ = .76; heedful interrelating (κ = .60) (Landis and Koch 1977).Indeed, these results indicate that the taxonomy we developed for various modes of anaesthesia team Category Definition Example Considering external conditions Includes considerations of conditions outside the team and their consequences. ‘They’re already waiting for us.’ Others Authoritarian behaviour I ncludes behaviours which are aimed at underlining power and status. Grabbing an instrument out of the hand of a team member without explanation. Silence and action Includes situations where team members work silently and independently. Silence and no action Coded if a person is obviously doing nothing at all – not even observing. A team member stands around without paying attention to the process. Chatting Includes non-task-relevant talk. T eam member talks about the weather. Technical alarm Includes technical (acoustic) warning signals from one of the machines. A n alarm goes off. T alking to patient Includes communicating with the patient beyond garnering or imparting clinical information. ‘You will start to feel very sleepy.’ Incompr ehensible communication Serves as a category for anything that is acoustically incomprehensible. Table 13.1 Concluded Measuring Coordination Behaviour in Anaesthesia Teams 215 behaviour allowed reliable measurement of explicit and implicit coordination and heedful interrelating behaviour. In particular, implicit action coordination which is by denition difcult to observe was able to be measured reliably. Only the fair Kappa value for implicit information coordination points out the need for further rening of the respective categories. The specic strengths of the taxonomy are (a) the precise assessment of explicit as well as implicit team coordination behaviour in the anaesthetic work environment in routine as well as non-routine situations and (b) the measurement of heedful behaviour which might serve as a mechanism facilitating the transition between explicit and implicit coordination. With regard to manageability, the hierarchical organization of the taxonomy simplies the coding procedure. Furthermore, the categories are detailed enough to allow for determination of successful coordination behaviour, which in turn helps to design team training interventions. Outlook Within our current research project, we compare the above coordination taxonomy with the observation system developed by Manser and colleagues (2008) and test their sensitivity in detecting teams’ behavioural differences between phases with varying workload in simulated as well as in live clinical settings in anaesthesia. In comparing these two observation methods for coordination behaviour, it is our intention to investigate the main differences between the two systems and how they can complement each other (see also Chapter 14 in this volume by Manser et al.). For instance, the observation system of Manser and colleagues (2008) records not only coordination behaviour but also clinical activities performed by the anaesthesia team and records actions carried out simultaneously. On the other hand, the taxonomy presented in Figure 13.1 focuses particularly on coordination of information exchange and of joint actions and provides a more detailed account of explicit and implicit coordination mechanisms and heedful interrelating. The comparison of the two observation systems will provide the data necessary for us to develop an integrated behaviour and communication observation system and improve methods for analysing team coordination behaviour in the operating room. By exploring the relationships between routine and non-routine event coordination behaviour, non-technical skills and clinical performance with the sketched methodology, the research project is expected to contribute to both our knowledge of adaptive team coordination behaviour and the development of appropriate and reliable methods for studying human factors inuencing levels of effectiveness in anaesthesia. This will allow for improvements in training anaesthesia teams and for enhancing organizational support for adaptive coordination. Safer Surgery 216 Acknowledgement We gratefully acknowledge the nancial support for this project by Swiss National Science Foundation. Also, we thank Raphael Agosti and Silja Barbara Sollberger for their assistance in behaviour coding. The rst author thanks Margarita Neff- Heinrich for her helpful comments on an earlier version of this chapter. 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This page has been left blank intentionally Chapter 14 Identifying Characteristics of Effective Teamwork in Complex Medical Work Environments: Adaptive Crew Coordination in Anaesthesi a Tanja Manser, Steven K. Howard and David M. Gaba Introduction The aim of psychological research on the relationship between human performance and patient safety is to support healthcare professionals and their organizations to provide patient care more safely, in a wider variety of clinical situations, with greater efciency and with increased satisfaction to both patients and practitioners. Such recommendations require an improved understanding of the performance of clinicians in terms of the strengths and vulnerabilities pertaining to their work environment. Although ‘performance’ is an intuitively meaningful concept, research on human performance in complex work environments usually has to integrate the complementary pieces of information provided by different research approaches, none of which by itself captures the entire picture (Gaba et al. 1998, Rall and Gaba 2004, Salvendy 2006). Sources of information include retrospective analyses of incident reports (i.e., reconstructive approach to human performance), prospective observation of routine patient care (i.e., naturalistic approach to human performance), prospective observation of the response to simulated events (i.e., quasi-experimental approach to human performance) and objective data from articial laboratory tasks (i.e., experimental approach to human performance). Both work/organizational psychology and applied cognitive psychology have successfully developed methodological approaches to address human performance issues in complex work environments. The methodological spectrum ranges from ethnographic eld studies to experimental studies in laboratory settings and from qualitative interviews to survey instruments (Bungard and Herrmann 1993, Salvendy 2006). However, methods need to be adapted to the specics of the complex medical work environment. For example, systems to evaluate the performance of two-person cockpit crews will not capture the dynamics of a multidisciplinary medical team with uid team membership. In recent years, signicant progress has been made in this area. Prominent examples are instruments for non-technical skills rating (Fletcher et al. 2004, Healey et al 2004, . 333–43. Reason, J. (2005) Safety in the operating theatre – Part 2: Human errors and organisational failure. Quality and Safety in Health Care 14, 56–61. Safer Surgery 220 Rhee, S.Y. (2006) Shared emotions. training anaesthesia teams and for enhancing organizational support for adaptive coordination. Safer Surgery 216 Acknowledgement We gratefully acknowledge the nancial support for this project by. and communication in high workload situations. Linguistische Berichte, Sonderheft 12, 127–55. Safer Surgery 218 Grote, G., Zala-Mezö, E. and Grommes, P. (2004) The effects of different forms of