TEAMWORK: Learning from surgery and other industries

Whilst clients may talk about their legal team, the law has a reputation as a bastion of individualism, fostered through an education promoting that individualism through historic, hierarchical structures. Such a culture used to exist in surgery, and my generation can indeed remember real life Sir Lancelot Spratts strutting their stuff. We have learned to behave differently. Good teamwork is critical; an ‘A’ surgeon in a ‘B’ team is unlikely to succeed.

I spent my professional life operating on the hearts of babies, often seen as an archetype of individual technical proficiency. High-stakes surgery; a craft with minimal margin for error. Yet it is not a one-person sport. From diagnosis, through decision-making, surgery itself, after care and follow up, large numbers of often unseen people are involved, and each is critically important to the whole. Wide ranging skills are needed, and whilst we all understand each other’s role, we cannot actually do each other’s job.

In any large team, the individual can feel like a valueless little cog in a big machine, whereas any engineer will know that without that little cog, the big machine does not function well. In the law, as in medicine, these cogs are people and as the psychologist Kurt Lewin proposed in his 1943 heuristic equation B = f(P,E), behaviour is a function of the person and their environment. Where you work, and who you work with; human factors.

The complex inter-relationships of team-based work are shown in Fig.1. This model places you at the centre and describes you as having certain liveware; your physical and mental attributes, the knowledge you possess, the attitudes you hold, the cultures you represent and the stresses to which you are subject at any time. When you start interacting with others, they too have their own liveware and so it becomes necessary to interact via teamwork and communication. Norms of behaviour are formed and often leadership of some kind becomes necessary. You also must interact (especially in my world) with ever increasing and rapidly changing technology and equipment, theoretically supported by sets of procedures, policies and manuals (he terms these software) which back up any organisation but are often rarely read. And finally, the external environment in which you work may change radically in many ways, political, economic or physical… think Brexit, Trump’s tariffs or a move to Canary Wharf.

All these interactions influence you and your behaviour. Individual failure is less common than problems occurring at the interfaces, and the bigger the team the greater number of possible interactions. For a team of 4, there are 6 possible 1:1 interactions. A team of 8 has 28 possible 1:1 interactions, and 255 if interacting with greater than one member of the team. You can calculate the number of potential 1:1 interactions for a team with n members from this simple formula: n(n–1)/2</b

A seminal review of the leadership and management of surgical teams by Giddings and Williamson provides a strong evidence base for good practice, applicable in many professional and corporate settings. The authors draw attention to the problematic nature of teamworking in healthcare because of varying (and often large) size of teams, varying quality of interfaces with other teams, and the cultural history in which teams have evolved. Similar issues beset legal practice. In fact, in many organisations people think they are working in teams but actually are working in groups.

This table (adapted from Giddings and Williamson) highlights the differences between the two.

We have all endured workplace meetings where some individuals (usually male) dominate meetings and quieter voices are not heard. Body language can be aggressive and inhibiting to free discussion. People leave the meeting feeling their views have not been heard or valued. Keeping this table in mind is very useful, and a shift to the left is recommended! It can be immensely helpful to video such meetings and play the recordings back to the participants. Most of us are unaware of our latent aggression or passivity, and behaviour, and hence teamwork, tends to improve.

We all recognise when we are in a dysfunctional team, characterised by some or all of the following factors; autocratic or weak leadership, defensive or introverted behaviour, lack of self-criticism (often associated with inadequate or poor data to review), lack of focus on the patient/client, inconsistent or absent strategic vision and context, lack of measurable goals and a tendency to blame, the last being extremely destructive. All of these are avoidable but do require leadership and vision.
Hogan and Hogan considered what characterises a strong leader in contrast to what they described as a derailing leader.

Most people presented with this table clearly state that they would prefer to work for the leader on the left. But it is interesting to consider the similarity between some of the characteristics, e.g., careful: cautious, or vivacious: dramatic. Considered as a whole, however, the list works well. Indeed, the right-hand column might easily characterise a well-known current world leader.

It is interesting to consider the similarity between some of the characteristics, e.g., careful: cautious, or vivacious: dramatic. Considered as a whole, however, the list works well.

By both defining and describing aspects of teamwork and leadership and being open to change it should be possible to improve both in any professional or corporate environment if the organisational will and appropriate leadership exist.

To bring these concepts to life, I will use an example of institutional failure and the (successful) lessons learned from it to demonstrate the fundamental importance of human factors in teamwork. During the 1980s and 1990s, the best paediatric cardiac units in the world began preferentially to operate on neonates, rather than infants or older children, to correct congenital anomalies as early as possible and thus avoid adverse consequences of living with an inefficient heart or circulation. Such changes required significant new skills, equipment, facilities and differently trained personnel. The ability of units to operate on neonates became a currency of success for individual surgeons and teams. Considerable pressure (individual, peer, and community) was felt by surgeons to make this transition, and in some cases neonatal surgery was begun when the underlying infrastructure and culture were inappropriate or incompletely trained.

Such was the case in Bristol at around the turn of the century when many children with congenital heart disease suffered death or harm at Bristol Royal Infirmary. The subsequent Public Inquiry was chaired by Professor Sir Ian Kennedy (a fellow Honorary Bencher of The Inner Temple). His excellent and comprehensive report made 198 recommendations to improve the care of children, most of which have gone on to do just that.

In his report, Kennedy observed that “the transfer from the operating room to the intensive care unit is one of the most difficult stages in the care of a child.” This came as a bit of a surprise to most of us in the field. The surgery itself was self-evidently dangerous, and intensive care after surgery is complicated and has its own well-described hazards. But the journey between the two? Surely not. However, in a landmark study of human factors in paediatric cardiac surgery, my predecessor at Great Ormond Street, Marc de Leval and colleagues observed similar risks in all the units in the UK.
During surgery, the close-knit surgical team of anaesthetists, nurses, surgeons, perfusionists and technicians work for several hours on one child. The child is intensively monitored, receives multiple and varying drugs and fluids, and is subject to dramatic temperature changes and changes in blood flow. It is a complex, highly monitored and controlled environment. The team learns how that baby ‘works’ and how it responds to the stimuli, beneficial or adverse. That knowledge is hard to acquire and hard to express but is deeply understood by the team members.

When the surgery is complete, the child is prepared for a move along the corridor to the Intensive Care Unit (ICU). Syringe pumps are moved from AC to battery power, the baby is disconnected from a mechanical ventilator and the anaesthetist has to squeeze a bag manually to ventilate the child (significantly altering the physiology), and the warm cocoon in which the baby has been resting is changed for an open trolley ready for the journey. This is a shock to the baby’s system…its stable environment changed.

Once the baby arrives in the ICU, all these processes are reversed, in a logical order, before the additional key stop of transferring information from the surgical to the ICU team is carried out. As you will read, we did not do this well.
At the Great Ormond Street Hospital for Children, London one Sunday lunchtime (now 20 years ago), after operating all day Saturday, most of the night and on Sunday morning, my colleague Allan Goldman and I found ourselves watching the Spanish Grand Prix and seeing the MacLaren team change four tyres and refuel the car in the pits in 6.8 seconds. That observation, combined with a bird’s eye view of a pitstop, with the driver in the car surrounded by people doing their jobs to peak efficiency, made us ask the question, “if they can do that, why can’t we move a baby safely?”The aerial view could have been superimposed onto our precious baby on its trolley with skilled people around it trying to do their best.

It is a complex, highly monitored and controlled environment. The team learns how that baby ‘works’ and how it responds to the stimuli, beneficial or adverse. That knowledge is hard to acquire and hard to express but is deeply understood by the team members.

After exploring a financially unsustainable engineering solution with MacLaren, we were lucky enough to be introduced to Ferrari and obtained grants to learn how they made pitstops work, and thus how we could improve. Ferrari’s observations were humbling (and often unprintable), but largely related to unstructured communication, lack of appropriate checklists, unclear leadership at various phases, a tendency to get in each other’s way, lack of rehearsal or practice, and not being clear enough about the importance of everyone being able to speak up if problems were noted. There is not space to list the detail of what we learned and changed; read the reference if you wish at the end of this article. Suffice it to say that the application of Ferrari’s human factors approach to teamwork resulted in a fourfold reduction in multiple errors; the process has proved reproducible and now a standard of care worldwide.

It is no coincidence that the extraordinary safety of commercial airline systems is also dependent on human factors research. Aircrew are regularly assessed on their Crew Resource Management (CRM). The components of CRM are communication, leadership skills, decision-making, situational awareness, teamworking, managing stress and fatigue and understanding one’s limitations. These are non-technical skills assessed in addition to the expected simulations. Few of us in medicine or the law are subjected to such regular assessment. Formula 1 and the airline industry have come to exemplify safety and excellence. Both emphasise the importance of each team member (even the most junior) being encouraged to speak up if they see something which is a potential or actual risk. Both emphasise the importance of rehearsal and repetition. Practice does indeed make perfect.

Regular open team meetings to review performance with hard data provide a great stimulus to continued improvement. Secrecy does not create the trust that is required to sustain a successful team. In paediatric cardiac surgery the results of the various teams in the UK are now available online and in considerable detail
(www.childrensheartsurgery.info). This meets some of Kennedy’s recommendations after Bristol and has resulted in an extraordinarily uniform high standard across the UK.

At Great Ormond Street, our joint cardiac conferences (JCCs) formed the nucleus of our work. Even though they were highly successful, we still learned lessons from F1 and the airline industry and continue to seek improvement. I would like to quote Professor Kenneth Catchpole, the organisational psychologist who led our teamwork studies.

“The JCCs – especially when it came to end-of-life considerations – were some of the most amazing conversations I’ve ever had the privilege to observe. Surgeons, Intensivists, Cardiologists, Nurses – all with different backgrounds, perspectives, attitudes and motivations – all focused on the best thing for the child. Even if it meant that nothing further could be done and that the most caring thing was to let nature take its course. In many respects, clinical teams are even more astounding than F1 or aviation. The teams are large and diverse, and have to deal with immense complexity, risk and uncertainty with both rationality and compassion.”

It has become clear that strong teamwork builds an atmosphere of trust, and transparency around performance, as a team, results in an overall improvement in the quality of our work. I see no reason why these lessons, drawn from disparate workplaces and professions, should not apply to the legal profession.
I am grateful to Professor Kenneth Catchpole of the Medical University of South Carolina for his continued advice and excellent criticism of this article in draft form.

Professor Martin Elliott MD FRCS FGC
Professor Emeritus of Cardiothoracic Surgery
at University College London
Professor Emeritus at Gresham College, London
Former Paediatric Cardiothoracic Surgeon at The Great Ormond Street Hospital for Children, London

For further reading:
www.econlib.org/archives/2006/04/best_line_ive_r.html
Giddings, AEB, Williamson, C
The Leadership and Management of Surgical Teams
www.rcseng.ac.uk/-/media/files/rcs/library-and-publications/non-journal-publications/leadership–management.pdf
Hogan R, Hogan J. Hogan Development Survey Manual.
Tulsa: Hogan Assessment Systems; 1997
Catchpole, KR et al. Pediatric Anesthesia 2007 17: 470–