Creating and improving highly effective endoscopic teams

In this issue of Endoscopy, Ravindran and colleagues from the TEAM-ENTS working group present a framework for core relevant non-technical skills (NTS) for endoscopy teams, derived from a two-phase qualitative mixed-method process involving the development of an NTS taxonomy for endoscopy teams, and refinement into a behavioral marker system (BMS) using Delphi methodology [1]. The authors’ approach in this paper is robust – beginning with a systematic review, which included 14 team-based BMSs from other health disciplines – and has resulted in the creation of an endoscopy-specific team BMS that is applicable in numerous circumstances, ranging from generic everyday diagnostic endoscopy to emergency lifesaving procedures.

“The TEAM-ENTS BMS is an especially valuable resource in two areas: team-based endoscopy training and assessment of endoscopy teams.”

Medicine has drawn from other spheres, including business, sports, and other industries, in the preliminary development of schemata of highly effective healthcare teams [2]. One of the most referenced of these is crew resource management (CRM), a series of procedures from the aviation industry, which aims to ensure a high level of team performance, particularly in NTS, in a field where errors can lead to devastating adverse effects.

In gastroenterology, we are perhaps more familiar with multidisciplinary teams in the delivery of care for patients with complex diseases, such as inflammatory bowel disease, cancer, or cirrhosis. However, endoscopy itself is performed by teams with varying roles, including endoscopists, nurses, trainees, technicians, allied healthcare staff, and other professionals. Furthermore pre-endoscopy care, such as bowel preparation and anticoagulation management, and post-endoscopy care are performed by teams that may either include members of the endoscopy team, work closely with the team, or be completely disparate from them. Endoscopy teams are often created ad hoc and may not be constructed with specific roles in advance. Team members may not have worked together, much less trained together. Understanding how these teams work through a structured behavioral framework is critical, especially as the vast majority of errors in endoscopy occur because of deficiencies in NTS in the team environment [3].

The TEAM-ENTS BMS is an especially valuable resource in two areas: team-based endoscopy training and assessment of endoscopy teams. Similarly to how NTS and human factor frameworks have informed endoscopy NTS (ENTS) and human factor-specific simulation training [4,5], the TEAM-ENTS BMS can be used to create dedicated curricula for simulation-based endoscopy team training. This can be envisioned as immersive simulation, wherein teams are trained together using scenarios crafted to highlight specific behaviors in the TEAM-ENTS BMS; didactic sessions around specific TEAM-ENTS; and endoscopy-specific leadership training.

Using the TEAM-ENTS BMS for assessment raises a number of interesting questions. We know that deficiencies in NTS in teams are associated with error; however, using the BMS to clarify specific behaviors associated with an error would potentially allow for more structured post-procedural debriefings or even the targeting of training interventions toward the specific area that may have led to the error in that team. As an example, if a TEAM-ENTS BMS structure debrief identified a specific concern in the control and responsibility element, where the team leader demonstrated a behavior where they were not calm under challenging circumstances, this could potentially be targeted with interventions such as mental rehearsal [6], coaching around anxiety mitigation, or preprocedure mindfulness training [7], which have been shown to decrease stress and anxiety in complex procedures.

Understanding how performance in team ENTS in aggregate is associated with poor performance or error in particular endoscopy circumstances would advance our knowledge on how to specifically avoid such errors or poor performance through training or intervention. Assessment constructs, such as video review of team performance using the TEAM-ENTS BMS as a basis of assessment, would allow for a regimented method of ensuring continuous quality improvement for teams [8].

It is interesting to speculate how artificial intelligence (AI), such as endoscopic image AIs and machine-learning assessments of quality (e. g. endoscopy panopticons or “black boxes”), can be incorporated into the TEAM-ENTS BMS or processes. It is still uncertain how to incorporate decision support from computer-aided diagnosis into team NTS taxonomies. As AI evolves, should it even be incorporated as a “team member”? Can machine-learning assessment of “black box” components of endoscopy team performance (assessment of video of team members; tonality and frequency of comments as a surrogate for open dialogue or identification of closed loop communication; verbalization of the situation as it evolves to characterize situation awareness) improve team behaviors or even provide intraprocedural feedback on areas to focus on as a team?

The first step in creating, developing, and improving endoscopy teams through training and assessment is however understanding the behaviors associated with strong teams. The TEAM-ENTS BMS, created with a validated and robust methodology, is an excellent starting point for developing and iterating curricula and tools for these purposes.

Publication History

Article published online:
03 February 2023

• References

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