Handoffs include the transfer of knowledge and information about the degree of uncertainty (or certainty about diagnoses, etc.), response to treatment, recent changes in condition and circumstances, and the plan (including contingencies). In addition, both authority and responsibility are transferred. Lack of clarity about who is responsible for care and for decision-making has often been a major contributor to medical error (as identified in root cause analyses of sentinel events and poor outcomes).

A call-out is a tactic used to communicate critical information during an emergent event. Critical information called out in these situations helps the team anticipate and prepare for vital next steps in patient care. It also benefits a recorder when present during a code or emergent event. One important aspect of a  call-out is directing the information to a specific individual.

SBAR provides a standardized framework for members of the healthcare team to communicate about a patient’s condition. SBAR is an easy-to-remember, concrete mechanism that is useful for framing any conversation, often a critical one requiring a clinician’s immediate attention and action. SBAR originated in the U.S. Navy submarine community to quickly provide critical information to the Captain. It provides members of the team with an easy and focused way to set expectations for what will be communicated and how. Standards of communication are essential for developing teamwork and fostering a culture of patient safety. In phrasing a conversation with another member of the team, consider the following:

• Situation—What is happening with the patient?
• Background—What is the clinical background?
• Assessment—What do I think the problem is?
• Recommendation—What would I recommend?

SBAR provides a vehicle for individuals to speak up and express concern in a concise manner.

The best way to address conflict is to collaborate because collaboration has the highest potential for a win-win-win situation. The common mission is the safe and improved care of the patient.

• All team members, the team, and the patient win (“win-win-win”)
• Requires commitment to a common mission
• Is a process, not an event

Collaboration takes time and effort, and in critical situations may not always be feasible. In that case, make the issue a topic during staff meetings and address how to handle the situation in the future.

Goals and relationships come into play:

• Collaboration involves full and open communication—must be attentive and open to each other.
• Collaboration is used when it is important to preserve critical objectives without compromising and at the same time to maintain relationships, when it is important to get to the root of the problems that could linger, and when there is a complex issue at hand.

Approaches to conflict resolution should be chosen to best match the situation at hand.

What if a conflict has become personal in nature? The DESC script can be used to communicate effectively during all types of conflict, and is most effective in resolving personal conflict. The DESC script is used in the more conflicting scenarios in which behaviors aren’t practiced, hostile or harassing behaviors are ongoing, and safe patient care is suffering.
DESC is a mnemonic for—

• D = Describe the specific situation
• E = Express your concerns about the action
• S = Suggest other alternatives
• C = Consequences should be stated in terms of impact on established team goals; strive for consensus

There are some crucial things to consider when using the DESC script:

• Time the discussion.
• Work on win-win—Despite your interpersonal conflict with the
  other party, team unity and quality of care are dependent on
  coming to a solution that all parties can live with.
• Frame problems in terms of personal experience and lessons
  learned.
• Choose the location—A private location that is not in front of the patient or other team members will allow both parties to focus on resolving the conflict rather than on saving face.
• Use “I” statements rather than blaming statements.
• Critique is not criticism.
• Focus on what is right, not who is right.

Advocacy and assertion interventions are invoked when a team member’s viewpoint does not coincide with that of a decision maker. In advocating for the patient and asserting a corrective action, the team member has an opportunity to correct errors or the loss of situation awareness. Failure to employ advocacy and assertion has been frequently identified as a primary contributor to the clinical errors found in malpractice cases and sentinel events.

Another type of mutual support is feedback. Feedback is information provided for the purpose of improving team performance. The ability to communicate self-improvement information in a useful way is an important skill in the team improvement process. Feedback can be given by any team member at any time. It is not limited to management roles or formal evaluation mechanisms. Performance feedback benefits the team in several ways:

• Fosters improvement in work performance
• Meets the team’s and individual’s need for growth
• Promotes better working relationships
• Helps the team set goals for ongoing improvement

Cross monitoring is used by fellow team members to help maintain situation awareness and prevent errors. Commonly referred to as “watching each other’s back,” it is the action of monitoring the behavior of other team members by providing feedback and keeping track of fellow team members’ behaviors to ensure that procedures are being followed appropriately. It allows team members to self-correct their actions if necessary. Cross monitoring is not a way to “spy” on other team members, rather it is a way to provide a safety net or error-prevention mechanism for the team, ensuring that mistakes or oversights are caught early. When all members of the team trust the intentions of their fellow team members, a strong sense of team orientation and a high degree of psychological safety result.

Awareness of your own condition to ensure that you are fit and ready to fulfill your duties is essential to delivering safe, quality care. Team members should assess and report if there is a personal situation affecting their ability to perform.
“I’M SAFE” is a simple checklist that should be used daily (or more frequently) to determine both your co-workers’ and your own ability to perform safely. I’M SAFE stands for—

• Illness. Am I feeling so bad that I cannot perform my duties?
• Medication. Is the medication I am taking affecting my ability to maintain situation awareness and perform my duties?
• Stress. Is there something (such as a life event or situation at work) that is detracting from my ability to focus and perform my duties?
• Alcohol/Drugs. Is my use of alcohol or illicit drugs affecting me so that I cannot focus on the performance of my duties?
• Fatigue. The effects of fatigue should not be ignored. Team members should alert the team regarding their state of fatigue (e.g., watch me a little closer today, I only had three hours of sleep last night).
• Eating and Elimination. Has it been 6 hours since I have eaten or used the restroom? Many times we are so focused on ensuring our patient’s basic needs that we forget to take care of our own. Not taking care of our elimination needs affects our ability to concentrate and stresses us physiologically.

To conduct a debrief:

• Facilitate the discussion as a leader by asking questions related to team performance. What did we do well?
• Recap the situation, background, and key events that occurred
  As a team, assess how the following played a role in the performance of the team:
• Team Leadership
• Situation Awareness
• Mutual Support
• Communication

Then summarize lessons learned and set goals for improvement.

This checklist can be used by the team during a debriefing to ensure that all information is discussed.