Effective teamwork is central to patient safety in health care1. Nowhere is this more important than in the operating room where effective team performance relies on the interaction of individuals from highly diverse backgrounds in terms of expertise, training and experience.
Through the analysis of closed malpractice claims, CRICO has found that communication breakdowns were the second most common factors identified in contributing to error, after technical performance, in the operating room. The cause of errors or accidents in the operating room is often not the result of a single active error but rather errors lying latent in the system. Errors are often tied to problems in information exchange (ability to speak clearly, concisely and in an unambiguous manner with other team members) and shared situational awareness (team’s ability to develop shared mental models of the environment to apply correct task strategies and anticipate future situations).
One method by which teams have effectively dealt with the challenge of maintaining clear communication is by using closed-loop communication.2
The History and Theory Behind Closed Loop Communication: Why it Works
The origin of closed loop communication is unclear. However, we are certain that it was used in early voice radio communication, particularly in the military long before it came to healthcare. Because radio was being used to pass messages far beyond the range of sight, it became critical to know that the message that you transmitted was actually received—you couldn’t see the signal flag or smoke signals anymore. The familiar words “Roger,” “WILCO,” “over,” and “out” became a part of radio talk specifically to meet the need to close the loop.
- Roger stands for the letter “R,” which was often difficult to understand over the radio—meant “message received.”
- Wilco meant “Will comply” with what you said.
- Over meant “I am done—now you can talk.”
- Out meant “I am done.”
To have a conversation you had to close the loop. Every transmission had a reply—and if there was no reply—you assumed that your transmission was not received and repeated it. That entire system was built to assure transmission and reception of information in an environment where communication was often confusing and pressured. Sounds familiar.
Closed loop communication consists of the team’s ability to exchange clear, concise information, to acknowledge receipt of that information, and to confirm its correct understanding. First cited in the health care literature by Salas4 in 1995, it is built on a similar strategy of verification that ensures that the message sent was received and interpreted as intended. Specifically:
- The sender initiates a message.
- The receivers interpret it and acknowledge its receipt.
- The sender follows up to ensure the intended message was received.
What is Closed Loop Communication? Example:
Dr. Smith: Jan, can you order an ICU bed?
Jan: Ok, I’ll order the ICU bed.
Dr. Smith: Thanks.
Effective teams engage in this specific closed loop explicit communication team behavior. This provides a pattern of communication that ensures that everyone is operating under the same goals, plans, and situational understanding.
High reliability organizations, including aviation and nuclear power generation industries, emphasize teamwork and team training. This has been translated in anesthesia, emergency medicine and the military health care system at large. 3-5
Research in high reliability teams has recognized that individual competence in clinical skills is not enough; team coordination, communication, and cooperation skills are essential to effective and safe performance. High reliability teams must use closed loop communication and other forms of information exchange to promote shared situational awareness regarding factors internal and external to the team. Sensitivity to operations is by definition ensuring that all team members know the “big picture.” Closed loop communication and well developed shared situation awareness are key within the environment of the operating room. For example, a surgical team with shared situation awareness can anticipate future contingencies before they escalate into a more critical situation.
Team Cognition/Shared Mental Model
As a component of team cognition, closed loop communication is also a mechanism that facilitates shared mental models. Elements of closed loop communication include the use of standardized terminology, standardized patterns of communication, and concise and implicit communication such as confirming and cross checking information.
Under high workload conditions, effective teams switch communication strategies from explicit closed loop communication, to implicit communication while maintaining high levels of performance. This reduction in the communication overhead, the workload of being involved in explicit communication, is made possible through the team’s shared understanding of team and task. Therefore, this shift in communication strategies in response to changing workload conditions, is an indicator of shared mental models. Through the promotion of shared cognition in which all members are continually monitoring, assessing, and communicating key environmental cues, performance is facilitated. This implies that if a critical event in the operating room is occurring, explicit closed loop communication may temporarily stop and implicit communication strategies will take its place until the workload conditions decrease, i.e. the patient stabilizes.6
Tips for all Team’s Members to Establish a Closed Loop Communication Practice 2, 7:
- The team leaders must encourage open information flow by creating a non-punitive “speak up” culture and by practicing explicit double check, or checking back, behaviors. Explicitly request closed loop communication until it’s practiced regularly.
- Use an agreed upon format for your closed loop communication. Closed loop communications, which include an explicit accuracy check with the recipient, are essential in environments with multiple information sources and multiple recipients.
- Set expectations for team performance. Help team members achieve goals by giving specific feedback, and verbally acknowledge improvement to the team.
- Provide periodic situation updates.
- Baker DP, Day R, Salas E. Teamwork as an Essential Component of High-Reliability Organizations. Health Services Research 2006; 41(4p2):1576-1598.
- Salas EW, Katherine A.; Murphy, Carrie E.; King, Heidi; Salisbury, Mary. Communicating, Coordinating, and Cooperating When Lives Depend on It: Tips for Teamwork Joint Commission Journal on Quality and Patient Safety 2008; Volume 34 (Number 6):pp. 333-341(9).
- Hunt EA, Shilkofski NA, Stavroudis TA, Nelson KL. Simulation: Translation to Improved Team Performance. Anesthesiology Clinics 2007; 25(2):301-319.
- Salas E, Klein C, King H, et al. Debriefing Medical Teams: 12 Evidence-Based Best Practices and Tips. Joint Commission Journal on Quality and Patient Safety 2008; Volume 34(Number 9):518-527(10).
- Alonso A, Baker DP, Holtzman A, et al. Reducing medical error in the Military Health System: How can team training help? Human Resource Management Review 2006; 16(3):396-415.
- Wilson KA, Salas E, Priest HA, Andrews D. Errors in the Heat of Battle: Taking a Closer Look at Shared Cognition Breakdowns Through Teamwork. Human Factors: The Journal of the Human Factors and Ergonomics Society 2007; 49(2):243-256.
- Salas E, Wilson KA, Murphy CE, et al. Communicating, Coordinating, and Cooperating When Lives Depend on It: Tips for Teamwork. Joint Commission Journal on Quality and Patient Safety 2008; 34:333-341.
CRICO Operating Room Team Training Collaborative: An Approach to Speaking Up
Safety Culture and Risk Reliability in Health Care
Accelerating Patient Safety Improvement
Forum: Reducing Risk During Handoffs
Volume 25, Number 1