The Doctor’s Advocate | Fourth Quarter 2022
Perspectives from the CMO

Building a Culture of Safety in Healthcare, Part Two: Teamwork

David L. Feldman, MD, MBA, FACS, Chief Medical Officer, The Doctors Company and TDC Group; Senior Vice President, Healthcare Risk Advisors

While some medical schools are now taking a more teamwork-oriented approach, many of us were trained to remain ever the captains of our ships, taking a “my patient, my work, my rules” approach.1 We were trained to fly on our own.

I said “fly” on purpose. I know many medical professionals are tired of the aviation comparison or never found it apt.2 Still, in medicine as in other professions that have an extra obligation to achieve high reliability, research into how people work together informs our choices. Adopting formalized systems for communication within our teams helps us implement evidence-based best practices for communication and teamwork, thus improving patient safety and mitigating our own risks for litigation.3

Which Communication System Is Best for Teamwork?

At this moment in our journey toward zero harm, we have an excellent problem. We have so many communication systems that it’s hard to choose. So I’ll synthesize what I’ve observed over many years of implementing large-scale patient safety programs: No matter where you work, if nothing else, I’d recommend implementing three key components of TeamSTEPPS®:4 (1) leadership as modeling of teamwork, (2) consistent use of handoff tools, and (3) the situation-monitoring tool STEP.


Leadership is one of the key principles of TeamSTEPPS.5 The Agency for Healthcare Research and Quality’s (AHRQ’s) description of effective team leaders is laden with communication responsibilities, including “articulate clear goals,” “communicate changes,” “provide feedback when needed,” “facilitate information sharing,” and “model effective teamwork.” Clearly, AHRQ envisions leadership as a communications role.5

Modeling effective teamwork requires understanding and mastery of three types of team leadership tools: “Briefs are held for planning purposes; huddles are used for problem solving; and debriefs are used for reflection and process improvement.”5

Debrief: Many who work in patient safety will tell you that of all the teamwork tools, the debrief is the most important. If your team debriefs at the end of a patient encounter, the patient is probably going elsewhere—whether it is to skilled nursing, rehab, or recuperate at home. Thus, debriefs connect to continuity of care, which we know impacts patient safety.6 This is the team’s chance to discuss what happened, what went well, what didn’t, and what to change next time. And it is no surprise that the very first item on AHRQ’s checklist for debrief discussion is “Was communication clear?”5

Handoff Tools

Gaps in handoff communication contribute to patient risks and adverse events,7 so committing to a handoff system is a high-priority teamwork item. One well-established handoff tool is I‑PASS.

I-PASS: I noted in a previous column that Maimonides Medical Center in Brooklyn is implementing I-PASS across its system for all residents and much of its attending staff. Implementing this standardized communication system for handoffs has decreased medical errors and preventable adverse events at many other healthcare systems.8

Recently, I-PASS reviewed 500 random lawsuits and found that communication failures were present in 49 percent of claims, and nearly half of these were provider-to-provider communication failures. In addition, “forty percent of communication failures involved a failed handoff; the majority could potentially have been averted by using a handoff tool (77%).”9

Using I-PASS, conversations for handoffs and transitions of care include:

Illness severity.

Patient summary.

Action list.

Situational awareness and contingency plans.

Synthesis by the receiver.


STEP is a tool for monitoring situations in the delivery of healthcare.5 Like the debrief, situation monitoring through STEP starts with modeling from leaders of the team, department, and institution.

Status of the patient: Includes remaining alert to the patient’s status, from vital signs to psychosocial issues.

Team members: Includes noticing if a team member seems unusually stressed or exhausted. Many of us probably have a story regarding a time when we were too sleep-deprived or stressed to function, and someone sent us out to procure a caffeinated beverage or take a nap. When we look out for each other, we look out for our patients, too.

Environment: Is it too hot to function? Is background noise presenting distraction or making it hard to communicate? Does a piece of equipment need repair?

Progress toward goal: During a long surgery, a nurse may say, “I don’t know if you realize, but you’ve been working on this step for two hours—maybe you want to call for some help?” Time under anesthesia has its downsides, and those fully focusing on the problem at hand may not be aware of time passing. That’s why we work as a team.

Complexity in Healthcare Requires Teamwork

Recently I spoke with Michael Leitman, MD, a surgeon and longtime patient safety leader at Mount Sinai. Speaking about early-career professionals, Dr. Leitman emphasized that residents need to understand how “essential to patient safety is teamwork and interprofessional performance. It’s just part of the way we practice caring in hospitals—with the complexity of healthcare being what it is, that is just essential.”

To align your team’s communication habits with the complexity that confronts us in healthcare, listen to my conversation with Dr. Leitman,1 or consult the TeamSTEPPS Pocket Guide.4


  1. TDC Group. High performance teams—crucial for a culture of safety. Leading Voices in Healthcare. 2022. Available at
  2. Dhand S. Aviation doesn’t hold all the answers to patient safety in health care. KevinMD. Published August 24, 2013.
  3. Use of structured communication tools to improve surgical patient safety. American Academy of Orthopaedic Surgeons. Published October 2015.
  4. Pocket guide: TeamSTEPPS. Team strategies and tools to enhance performance and patient safety. Agency for Healthcare Research and Quality. Published January 2020.
  5. TeamSTEPPS for office-based care: leading teams. Agency for Healthcare Research and Quality. Published September 2015.
  6. Kripalani S, LeFevre F, Phillips CO, et al. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;297(8):831-841. doi:10.1001/jama.297.8.831
  7. Brightwell J. Miscommunication and hurried handoffs threaten patient safety. The Doctors Company. Published August 2022.
  8. Shah C, Sanber K, Jacobson R, et al. I-PASS illness severity identifies patients at risk for overnight clinical deterioration. J Grad Med Educ. 2020;12(5):578-582. doi:10.4300/JGME-D-19-00755.1
  9. Humphrey KE, Sundberg M, Milliren CE, Graham DA, Landrigan CP. Frequency and nature of communication and handoff failures in medical malpractice claims. J Patient Saf. 2022;18(2):130-137. doi:10.1097/PTS.0000000000000937

The Doctor’s Advocate is published by The Doctors Company to advise and inform its members about loss prevention and insurance issues.

The guidelines suggested in this newsletter are not rules, do not constitute legal advice, and do not ensure a successful outcome. They attempt to define principles of practice for providing appropriate care. The principles are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results.

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