Comments
For those familiar with American football, Bo Schembechler, the long-standing coach of University of Michigan, gave a well-known speech before a Big Ten Championship: “No man is more important than the team, no coach more important than the team. The team, the team, the team!” (1). Indeed, research on football teams is extensive. Although many believe that intensive care unit (ICU) teams save lives, the evidence is surprisingly weak. Clinicians are seeking guidance about how to develop effective ICU teams, but current research does not provide answers. Looking at football teams and considering applications to the ICU could outline a path for clinicians and researchers to advance the science of teams and improve patient care.
Download Figure |
The literature abounds with definitions of team and teamwork; however, merely colocating individuals does not create a team or teamwork. Colocation may create a group, but groups and teams are distinct (2). A group denotes a commonality among individuals (e.g., football players), whereas a team is individuals with high task interdependence and shared common goals (3) (e.g., the University of Michigan football team). Teamwork is “the interdependent components of performance required to effectively coordinate performance of multiple individuals” (3). In health care, it is defined as two or more professionals working together interdependently to deliver care toward a shared goal (4). Teamwork involves interdependency and has two components: 1) structure: who are the professionals; and 2) function: how they work together. Effective teamwork is arguably achieved by a particular team composition (who) in which team members share common goals and train together (how). Assessing team performance is a way to evaluate a team’s effectiveness. Using these domains—composition, goals, training, performance (Table 1)—I compare and contrast ICU and football teams to shed light on areas for future research.
| ICU Teams | Football Teams | |
|---|---|---|
| Goals | Vary widely—by patient, by day, by shift | Clear shared goals across team members; may vary but likely one unifying goal |
| Training | Siloed; rarely do ICU teams train or practice together outside of clinical work | Routine; practice as a unit on the field and off the field |
| Team composition | Fluid, dynamic, heterogeneous | Static, definitive membership boundaries; often homogenous |
| Assessing performance | Infrequent; focused on individual-level performance or group performance—rarely team performance | Routine; assesses individual, dynamic team, and team performance; used comparatively to benchmark and assess progress over time |
Unlike football teams with stable membership, ICU teams change each shift. Fluctuating team membership creates “dynamic teams” working together for varying patient needs. Similarly, football teams are composed of three dynamic teams: offense, defense, and special teams; understanding the composition of each is crucial for effective coordination.
Although team composition is important in theoretical studies on teamwork (5), few studies examine the optimal ICU team composition; what best supports the Awakening, Breathing Coordination, Delirium, and Early mobility bundle (6) delivery or sepsis care? By not identifying the role of the team members who influence an outcome (i.e., articulating team composition), the signal between teamwork and outcomes will remain diluted. Yet, virtually no studies, aside from ongoing work “The Role of Interprofessional Teamwork in Complex Care Delivery” (K08-HS024552), measure dynamic team composition and team performance. Future research must focus on ICU dynamic teams, designing studies that empirically measure and improve their performance. This is more complex and requires examination of teams at the patient-shift level, but it is consistent with how ICU care is actually delivered.
In football and other sports, teams and coaches use extensive video review to examine plays and composition (7). Building on this approach, using video or other methods (8) to conduct deep dives into patient cases with ideal outcomes could identify optimal team composition. For example, video reflexive ethnography (9), which uses video recordings of actual clinician interactions and accompanying facilitated discussion, could be a novel way to apply football’s use of video and examine ICU team composition and teamwork. As administrators work to optimize care with finite resources, understanding what ICU team composition is needed for complex evidence-based care becomes increasingly important.
Explicit goal setting is common in football and is associated with greater likelihood of success (10), but it may be less common in clinical practice. Discharging a patient alive may not be a specific-enough goal. Examples of ICU goal setting that have been beneficial include use of a daily rounding checklist to identify goals (11) or to improve mobility (12). However, these approaches are not common.
One reason for limited ICU goal setting may be that goalposts are continually moving as patient needs change. But goal setting in ICU teams needs to be responsive to these changes. Opportunities to develop a shared mental model (13) about the goals for each patient, each team, and each shift must be prioritized. Applying processes from football—like huddles and time-outs—may be useful. Huddles could serve as an opportunity for teams each shift to orient to patient care goals. Although the purpose and end result of huddles may differ between football and ICU teams, they are meant to ensure efficient communication. Furthermore, time-outs are used for procedures but they are not applied to team dynamics. Time-outs could allow dynamic teams to connect and confirm evolving patient care goals. With the push by the National Institutes of Health for precision health care, which emphasizes individualization, goal setting and frequent orientation to the goals are necessary.
Football teams train together, on and off the field. But training a football team and an ICU team is different. In health care, formal training occurs in silos, and ICU dynamic teams are not purposefully created as in football teams. As such, training occurs ad hoc, may be interprofessional, but often includes implicit learning of roles and responsibilities. This haphazard approach to ICU team training may have profound patient care implications.
Football practice requires repetitive dynamic team training, in-person and via simulation. Healthcare training approaches that may be analogous include simulation and virtual reality. Simulation research is a burgeoning field, and although simulation is used in education, it is not common to conduct simulations within dynamic interprofessional teams (14). Enhancing use of simulation by focusing on dynamic team training could help teams practice how to work together effectively. More research is needed to identify how best to train dynamic teams in the ICU and to move forward and implement such training initiatives interprofessionally.
In football, detailed statistics and performance are assessed (15). These metrics drive individual and team training and performance. In health care, individual performance is assessed, either mandated through Centers for Medicare and Medicaid Services or via institutional physician monitoring. Rarely do we assess team performance, primarily because measuring team performance is difficult. But researchers and administrators need to partner to generate new ways and methods to measure ICU team performance, particularly dynamic team performance, and develop corresponding interprofessional incentives.
Relying on approaches used in football may be helpful. For example, teamwork is a process, but it is often not measured as a process. Time–motion methods, a tool from industrial engineering specifically designed to measure processes, have been used to study football and other sports team performance (16). Using time–motion methods to study the process of teamwork and outcomes could be a novel way of measuring ICU team performance.
In summary, critical care research can learn from the science of football teams. A focus on team composition, goal setting, training, and team performance assessment within dynamic teams is crucial. In football, time-outs, huddles, video analysis to study composition and performance, simulation, and time–motion methods are strategies that could be applied to ICU dynamic teams. In doing so, we may provide guidance to clinicians and researchers about how to build effective ICU teams and how to improve team performance for the well-being of patients, families, and ICU clinicians.
| 1 . | Kendra T. Bo Schembechler’s legendary “The Team” speech still rings true today in high school football. 2011 [Internet]. MLive; 2011 Aug 24 [accessed 2019 Oct 2]. Available from: www.mlive.com/sports/muskegon/2011/08/bo_schembechlers_legendary_the.html. |
| 2 . | Katzenbach JR, Smith DK. The discipline of teams. Harv Bus Rev 1993;71:111–120. |
| 3 . | Salas E, Cooke NJ, Rosen MA. On teams, teamwork, and team performance: discoveries and developments. Hum Factors 2008;50:540–547. |
| 4 . | Reeves S, Lewin S, Espin S, Zwarenstein M. Interprofessional teamwork for health and social care. Oxford, United Kingdom: John Wiley & Sons; 2010. |
| 5 . | Hackman J. Groups that work (and those that don’t): creating conditions for effective teamwork. San Francisco, CA: Jossey-Bass; 1990. |
| 6 . | Costa DK, Valley TS, Miller MA, Manojlovich M, Watson SR, McLellan P, et al. ICU team composition and its association with ABCDE implementation in a quality collaborative. J Crit Care 2018;44:1–6. |
| 7 . | Brümmer K. Subjectivation by video—ethnographic explorations on practices of video analysis in high-performance youth football. Ger J Exerc Sport Res 2018;48:358–365. |
| 8 . | Wang W, Zhang J, Yuan X, Liu S. MatchOrchestra: a generalized visual analytics for competitive team sports. J Vis 2016;19:515–528. |
| 9 . | Manojlovich M, Frankel RM, Harrod M, Heshmati A, Hofer T, Umberfield E, et al. Formative evaluation of the video reflexive ethnography method, as applied to the physician-nurse dyad. BMJ Qual Saf 2019;28:160–166. |
| 10 . | Hall HK, Byrne ATJ. Goal setting in sport: clarifying recent anomalies. J Sport Exerc Psychol 1988;10:184–198. |
| 11 . | Weiss CH, Moazed F, McEvoy CA, Singer BD, Szleifer I, Amaral LAN, et al. Prompting physicians to address a daily checklist and process of care and clinical outcomes: a single-site study. Am J Respir Crit Care Med 2011;184:680–686. |
| 12 . | Schaller SJ, Anstey M, Blobner M, Edrich T, Grabitz SD, Gradwohl-Matis I, et al.; International Early SOMS-guided Mobilization Research Initiative. Early, goal-directed mobilisation in the surgical intensive care unit: a randomised controlled trial. Lancet 2016;388:1377–1388. |
| 13 . | Boltey EM, Iwashyna TJ, Hyzy RC, Watson SR, Ross C, Costa DK. Ability to predict team members’ behaviors in ICU teams is associated with routine ABCDE implementation. J Crit Care 2019;51:192–197. |
| 14 . | Fung L, Boet S, Bould MD, Qosa H, Perrier L, Tricco A, et al. Impact of crisis resource management simulation-based training for interprofessional and interdisciplinary teams: a systematic review. J Interprof Care 2015;29:433–444. |
| 15 . | Day DV, Gordon S, Fink C. The sporting life: exploring organizations through the lens of sport. Acad Management Ann 2012;6:397–433. |
| 16 . | Roberts S, Trewartha G, Stokes K. A comparison of time-motion analysis methods for field based sports. Int J Sports Physiol Perform 2006;1:388–399. |
Supported by Agency for Healthcare Research and Quality grant K08HS024552 and in-kind research support from the Michigan Health and Hospital Association Keystone Center.
Author disclosures are available with the text of this article at www.atsjournals.org.
