Understanding the EM Team

To understand team leadership, it is important to understand the nature of EM teams. Emergency medicine teams fall into a specific category of teams called interdisciplinary action teams.^20,23 These teams contain highly specialized members who must cooperate to execute critical tasks under highly dynamic situations, often while simultaneously training and developing more novice team members, such as students and residents. This is distinct from a more general leadership construct that often refers to motivational and mentoring skills, content expertise, and project/program management.^10,24 While these general forms of leadership are important, they do not capture leader functions critical to the acute management of a single patient (eg, code team leadership) or multiple patients (eg, mass casualty incident command).

Evidence from the team science literature supports several key characteristics of effective leadership within interdisciplinary action teams. Team leadership is (1) functional, (2) contingent, (3) shared, and (4) dynamically delegated. First, leadership is functional, meaning it is the job of the team leader to ensure that team members are getting their tasks accomplished and to step in when things are not being adequately handled.^2,25 Team leaders provide overall structure and direction to the team, monitor the task and other team members' activities, coach team members as appropriate, and occasionally perform necessary hands-on patient care.¹⁵ Implicit in this description is that the team leader possesses clinical competency. Second, leadership is contingent. In action teams, which team leadership behaviors are effective is contingent on multiple factors, such as patient condition and stability, characteristics of team members (eg, experience level, familiarity), and environmental status (eg, current census, overall emergency department patient acuity, availability of additional resources).^20,26 Third, EM team leadership in academic settings often is shared between formal leaders and trainees, with supervising physicians delegating leadership roles, implicitly or explicitly, to residents. Finally, in more dynamic situations, the team leader can change on a minute-by-minute basis, but effective leadership is always delegated and never shared simultaneously.²⁰ Team leadership in academic EM teams is therefore said to be dynamically delegated, with more experienced physicians assuming leadership when dictated by a combination of patient, team, and environmental factors.²⁰ Leadership characteristics vary with team type, which makes understanding the leadership characteristics specific to EM teams essential to designing and implementing appropriate leadership training and assessment tools.

Team Leadership Conceptual Models

Conceptual models play an important role in formulating well-grounded solutions to education problems by guiding design principles and helping to identify important variables and potential relationships that need to be considered during measure development.²⁷ During the 2008 Academic Emergency Medicine Consensus Conference on “The Science of Simulation in Healthcare,” Fernandez et al¹⁹ proposed a model and taxonomy of EM teamwork based on evidence from the team science literature.^28,29 In this model, different teamwork behaviors are critical depending on the task work required.¹⁹ During episodes of care when the demand for task work is high, teamwork is characterized by action processes (monitoring, coordinating, backup) that facilitate accomplishing team goals. These episodes of high activity are separated by periods where teams execute transition processes (planning and evaluation) that facilitate planning and reflection. Underlying both action and transition processes are interpersonal factors (conflict resolution, communication, team building) that influence all team activities. A recent review cited this model and taxonomy as a rigorously developed framework for EM team processes.³⁰ This taxonomy is supported by evidence of validity within health care.³¹

The team science literature provides a team leadership model that helps describe the link between teamwork and team leadership. It considers the dynamic, functional nature of action teamwork and leadership, where teamwork translates individual team member and patient characteristics (inputs) into patient care and outcomes (outputs), and outputs from one team event feedback as inputs into the next (figure 1).^15,29,32 Such feedback is necessary if teams are to adapt effectively. The ability for teams to adapt from one event to the next is critical in EM teams, where events rapidly cycle and overlap (eg, intubation, chest tube placement, ultrasound examination), and outcomes from one event impact decision making and team functioning on the following events.^16,33,34 In this model, team leaders support the maintenance, development, and effectiveness of teams.¹⁵ The leader is in a position to impact outcomes by directly influencing team inputs and teamwork behaviors (figure 1).

This team leadership effectiveness model provides a framework for understanding where leaders can influence EM team effectiveness; however, it does not clearly describe which leadership behaviors are most effective. Morgeson et al¹⁸ described a functional team leadership taxonomy that is structured around transition behaviors, action behaviors, and interpersonal skills. Observational studies and reviews of health care leaders have identified components of this taxonomy important to health care team leadership.^35–38 Team leaders develop team structure, help establish goals, set team priorities, and assign roles (transition behaviors); monitor the team's progress, coordinate complex activities, and assist teammates when needed (action behaviors); and facilitate conflict resolution and build team cohesion (interpersonal skills).^16,18 While Morgeson et al's taxonomy is domain independent and not specific to EM teams, it does support maintaining a transition and action process structure and provides a starting point for identifying effective EM team leadership behaviors.¹⁸

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Current Assessment Practices in EM

Despite a growing focus on assessment of leadership skills, there is little research specific to EM.¹⁴ One attempt to standardize resident assessment is the ACGME Milestone Project for EM, created in 2012.²² Building on the original ACGME competencies, the milestones provide specialty-specific detail to each core competency.^39–44 Each competency is divided into 1 or more subcompetencies. For example, the interpersonal and communication skills competency has 2 subcompetencies: (1) patient-centered communication, and (2) team management. The subcompetencies are further broken down into milestones, which range from level 1 (anticipated skill level of an incoming intern) to level 5 (skill level of an experienced physician). Level 4 milestones represent competency and are the targeted, but not required, level for graduation. EM residency programs are responsible for evaluating residents on the milestones on a semiannual basis and reporting the results to the ACGME. Figure 2a provides a representation of the team management subcompetency.

When looking through the subcompetencies, team management appears to most closely match team leadership (figure 2a). However, on further examination, we found that the level 5 milestones relate to managerial type leadership rather than leading action teams (eg, “seeks leadership opportunities within professional organizations”). The majority of the other milestones relate to interpersonal skills, more specifically communication skills. This is consistent with the location of the team management subcompetency within the interpersonal and communication skills domain. While communication skills are an important focus in EM, they are not the only skills critical to effective team leadership.⁴¹ As noted earlier, transition processes (eg, evaluation and planning) and action processes (eg, patient and system monitoring) are critical to team effectiveness.^16,18 Only 1 of the milestones (level 4.1 “recommends changes in team performance as necessary for optimal efficiency”) describes a team leadership behavior beyond communication skills; in this case, the “action process” of monitoring team progress toward a goal. In light of the more comprehensive view of team leadership, the existing team management subcompetency alone is not sufficient for assessing action team leadership skills.

There are individual milestones located in other subcompetencies that could potentially represent team leadership behaviors if assessed in the appropriate context. For example, “involves appropriate resources in a timely manner” could exemplify the “action process” of systems monitoring if performed during the resuscitation of a critically ill patient. This behavior, however, is a milestone within the “disposition” subcompetency and is defined by the subheading “establishes and implements a comprehensive disposition plan that uses appropriate consultation resources; patient education regarding diagnosis; treatment plan; medications; and time and location specific disposition instructions.” In this setting, the behavior is not representative of action team leadership skills. This is more than just semantics: it is easy to imagine how an individual could be capable of arranging a timely outpatient appointment for a patient with asymptomatic hypertension, but struggle with mobilizing resources for an acutely hypotensive patient, or vice versa. These different skill sets highlight the importance of team and task typology when discussing leadership. There are additional examples of such context-dependent behaviors throughout the milestones. While the milestones are not meant to be comprehensive, the importance of team leadership to team performance and patient outcomes suggests this critical skill deserves more focus in the training and assessment of EM residents.

Moving beyond the ACGME milestones, there is a paucity of literature related to team leadership assessment in EM. The authors' review of team leadership assessments in health care action teams identified 15 assessment tools that focused on team leadership, with just 1 intended for EM teams.¹⁴ The Emergency Medicine Crisis Resource Management assessment tool was derived from its training course⁴⁵ and applied to trauma teams.^46,47 This tool includes 10 items, such as “utilization of information” and “communication with other team members” as well as overall global performance, with a scale from 1 (“not acceptable”) to 5 (“excellent”). The scale may prove useful; however, as it is currently described, the scale lacks behavioral anchors and has not been rigorously studied or widely applied to EM teams.

New Approach to Assessing Team Leadership in EM

We propose a novel framework for assessing EM team leadership that synthesizes the above work. The review of team leadership assessment tools identified 30 team leadership behaviors important to a variety of health care action teams, including EM teams, trauma teams, inpatient code teams, surgical teams, and obstetrical teams.^13,14 We collapsed these into 12 categories (table). From this list, 17 behaviors met inclusion criteria, including 5 related to transition processes (evaluation and planning), 6 related to action processes, and 6 related to interpersonal skills. The proposed team leadership subcompetency, using these behaviors as milestones, is presented in figure 2b.

table Team Leadership Behaviors From Health Care Action Teams¹⁴ Applied to Team Leadership Taxonomy

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It is necessary to clearly define these behaviors to facilitate a consistent interpretation and application of the proposed framework (provided as online supplemental material). This is important for 2 reasons. First, variations in interpretation could lead to different perceptions of the appropriate difficulty level of a given behavior. For example, “assigns roles to team members” is listed as a level 2 milestone. This skill involves assigning roles based on team member skills and task requirements, thus requiring knowledge of team structure beyond what one would expect of an intern. However, one could expand the definition of this behavior to also include role assignments that promote an even distribution of the workload. This simple modification requires a familiarity with the skill sets of the individual team members, monitoring of team activities, and role reassignment if a team member becomes overwhelmed. Second, some behaviors may appear to overlap with existing milestones. The subtleties of context are key to differentiating these behaviors. For example, “monitors team progression toward goals” has similar wording to some of the milestones in the observation and reassessment subcompetency, such as “evaluates effectiveness of therapies and treatments provided during observation.” In the existing milestone, the unit of focus is the patient rather than the team. Effectively monitoring team progress includes monitoring the actions of the team and its members and addressing delays in task completion, in addition to monitoring the condition of the patient. Explanations and clinical examples for all behaviors are provided as online supplemental material.