123. How to Create a Team in 10 Seconds | Why time is not linear and every second not worth the same

How do you build a team in the critical first moments of a crisis? The balance between rapid response and thoughtful planning is delicate, especially when understanding what defines a crisis and acknowledging when you’re in the midst of one. This conversation delves into the complexity of emergency team dynamics, emphasizing that the composition and organization of these teams are deeply influenced by their members’ specific skills and contexts, with lasting implications long after the crisis has passed.

We introduce ‘Name, Claim, Aim’—a straightforward, three-step framework designed to streamline team organization under pressure. It’s about rapid situational assessment, clear role delegation, and setting concise objectives. The discussion extends to effective leadership in high-stakes situations, including establishing command, ensuring effective communication from the start, and striking the right balance to encourage team input without compromising decisiveness.

Exploring the subtleties of crisis leadership, we’ll discuss the strategic balance needed for effective oversight and the practicality of ‘Name, Claim, Aim’ as a distilled version of more complex crisis management theories tailored for the immediacy of emergency care. The conversation will also cover the practical implementation of this framework, from team huddles to understanding the profound impact of the first few seconds on the trajectory of team success.

This episode builds on episode 115 – Zero Warning | Frameworks for no notice critical patients

Guest Bio:

Lon Setnik, MD, is an emergency physician practicing in New Hampshire and the associate director of clinical programs at the Center for Medical Simulation. Lon is a Stimulus fan favorite. Here are some of his most popular episodes:

• Listening to Understand versus Listening to Win
• Feedback can be hard to give and harder to receive. Here are techniques to do both better
• Take the Suck out of Documentation | Making the most of scribes, documenting in the room (and in front of the patient), efficient workflows

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We Discuss:

The tension between planning and action

• There is a natural conflict between the need for planning and the urge to take immediate action.
• High performers find comfort in action due to their expertise but may overlook the importance of planning.
• Effective functioning requires balancing planning and action, especially in critical situations.
• The entry criteria for deploying a technique in a crisis involve recognizing the crisis itself.

What defines a crisis?

• A crisis lacks a universal definition but often involves rapid changes that outpace a team’s ability to adapt.
• The speed of the situation’s evolution is key to identifying a crisis.
• A crisis may be characterized by a discrepancy between available resources and the situation’s needs or a gap between the team’s response capabilities and the demands of the situation indicates a crisis.

How do you know when you’re in a crisis?

• Personal physical reactions, like sweating, can indicate being in a crisis.
• A crowded room or a significant increase in the number of people present may signal a crisis.
• High noise levels during a resuscitation are a key sign that team organization is necessary.
• An abrupt change in a patient’s clinical status should trigger efforts to effectively organize and manage the team.
• Previous experiences and attunement to emergency situations enhance the ability to recognize crises.

Teams are contextual in their skill sets

• Teams’ effectiveness depends on the specific context and their collective skill sets.
• In some hospitals, dealing with drop-off shootings has become a routine part of their operations due to frequency.
• Incidents like drop-off shootings are rare but highly challenging in hospitals where they are not common.
• Such difficult moments underscore the need for structured tools and approaches for team management.
• The “name, claim, aim” strategy is discussed as a method to systematically address and manage crises, emphasizing the need to slow down and methodically build it into practice.

How you organize a team in a crisis has ripples after the event has ended

• The aftermath of such events is significant, with leaders reflecting on whether they effectively harnessed the team’s potential and provided exemplary care.

The three steps to organizing teams in a crisis: Name, Claim, Aim

• The leader explicitly identifies the situation (“Name”), asserts their role in coordinating the response (“Claim”), and sets the direction for action (“Aim”).
• Clear communication is emphasized, including the need for quiet in the room and closed-loop communication to ensure understanding and adherence to instructions.
• Team members are assigned specific roles, such as bagging, intubation checks, IV and vital sign monitoring, decision-making for surgery or imaging, and family communication.
• The leader asks for input and confirmation from the team, promoting an inclusive environment where all members can contribute and express concerns.
• The “Name, Claim, Aim” framework facilitates structured and effective team organization and response in critical situations, promoting clarity, cooperation, and collective problem-solving.

How to declare yourself as a team leader

• Declaring oneself as the team leader in a crisis involves first recognizing the situation and expressing the need for organization.
• Asserting leadership (“I’m going to get us organized”) must be done confidently, but adapting the language to fit the context and personal comfort level is crucial.
• Different settings may prefer different terms for leadership, such as “organizer” in more flat hierarchical structures like anesthesiology teams or “event manager” in large-scale emergencies.
• Less experienced team members might use phrases that imply temporary leadership until more senior personnel arrive, ensuring some level of immediate structure and organization.
• The act of declaring leadership not only helps organize the team but also focuses the individual’s attention on the dynamics and roles within the team.
• It’s essential to request and expect a response from the team to ensure engagement and closed-loop communication; lack of response requires further action to engage team members.
• The choice of terminology (“leader” vs. “organizer” vs. “event manager”) can affect the individual’s perception of their role and the team’s response.

Modeling closed-loop communication from the first moments of team formation

• The leader seeks explicit permission from the team to take charge, reinforcing the importance of mutual consent in crisis management.
• Repetition and persistence are used to elicit a response when initially faced with silence, demonstrating the necessity of overcoming communication barriers.
• Modeling closed-loop communication from the outset establishes a standard for team interactions, emphasizing the leader’s expectation of reciprocal communication.
• The awkwardness associated with closed-loop communication, uncommon in casual conversations, is acknowledged yet deemed essential for team effectiveness.
• The leader’s request for help is clarified and reiterated to ensure understanding, illustrating the importance of clarity and explicitness in high-stress situations.
• Verbal cues like “okay” are explored, highlighting their varied interpretations and the need for explicit acknowledgment from team members.
• The leader balances the imperative to be assertive with the desire to maintain collegiality, navigating the fine line between authoritative and overbearing leadership styles.

The balance between being a tyrant vs an effective leader and how to avoid suppressing speaking-up behaviors

• Balancing assertive leadership with encouragement of team input avoids suppressing valuable speaking-up behaviors.
• More directive leadership is necessary in the initial phase of a crisis to manage the inherent chaos effectively.
• Allowing team members to contribute ideas and observations ensures diverse perspectives are heard and valued.
• Assigning specific tasks and roles to individuals clarifies expectations and organizes the team’s response to the crisis in a structured manner.
• The leader prompts for additional input or alternative ideas after task delegation to foster an inclusive environment where all suggestions are welcome.
• The phrase “What am I missing?” invites further contributions, reinforcing the leader’s openness to feedback and collaboration.

The two pillars of Aiming what we want to achieve and who is going to do what to get us there

• Aiming involves establishing clear goals for the immediate future and assigning specific roles to achieve these objectives.
• The first pillar of aiming is defining what the team aims to achieve, such as managing the airway, assessing the need for imaging or transfer, and ensuring basic life support measures are in place.
• The second pillar focuses on who will undertake specific tasks, ensuring clarity in roles and responsibilities to reach the set objectives.
• Connecting the overall goals with individual responsibilities helps team members understand the rationale behind their tasks, fostering engagement and relevance.
• The strategy begins with a broad overview (“forest”) before delving into the specifics (“trees”), ensuring a comprehensive approach to crisis management.
• The situation’s urgency requires a balance between thorough planning and swift action to prevent delays in critical interventions.

Name, Claim, Aim needs to be fast and efficient; otherwise, people will just start getting to work without organizing

• Initial instincts may focus on immediate medical interventions, like checking for a pulse and starting CPR, but team organization is also critical.
• Balancing the roles of a primary operator and a team leader is challenging, especially when the clinician is the only healthcare professional present initially.
• The leader must quickly assess the situation and communicate it to the team (“Name”), establish their role (“Claim”), and delegate tasks effectively (“Aim”).

Balancing the balcony and the dance floor | The impulse in crisis is to do. The leader does not have to be the primary operator, but it’s hard to hold back!

• The challenge for leaders in a crisis is balancing the urge to directly engage in tasks (“dance floor”) with the need to oversee and coordinate the team’s efforts (“balcony”).
• The instinct to “do something” directly for the patient can conflict with the role of organizing and guiding the team, which may not feel as immediately impactful.
• Without clear leadership and prioritization, team members may default to less critical tasks that can interfere with more urgent interventions, highlighting the need for a structured approach to crisis management.
• Valuing the role of an organizer and resisting the urge to intervene physically allows the leader to maintain a broader perspective and ensure the team addresses the most critical tasks effectively.
• Techniques to help leaders resist the impulse to become hands-on operators include mental discipline, physical positioning, and verbal communication strategies to direct the team’s efforts.

As a team leader, it’s ideal to keep your hands off the patient during the beginning of a resuscitation

• Keeping hands off the patient allows the team leader to maintain a broader perspective and effectively coordinate the team’s efforts.
• Positioning oneself at the head of the bed can offer a good vantage point for overseeing the team while staying ready to perform critical tasks like intubation.
• Symbols like not putting on gloves can remind the leader to stay out of direct patient care, reinforcing their role in team coordination.
• Standing next to a documentation area, like a podium nurse station, can enhance communication and logistics management without engaging in hands-on care.
• Balancing leadership with performing essential procedures requires acknowledging the challenges and developing strategies to manage both roles effectively.

Distributing decision-making across time and space, explicitly transferring authority when you need to put your cognitive load elsewhere

• Delegating decision-making to a surrogate leader during critical tasks, like intubation or communicating with a patient’s family, ensures continuous team coordination and patient care.
• An explicit transfer of authority, such as instructing a team member to continue with ACLS protocols while engaged in another task, allows for maintaining situational awareness and patient safety.
• Engaging in procedures that demand full cognitive focus can lead to a temporary “dream state” in which awareness of the surrounding environment and ongoing team actions diminishes.
• Anesthesia research indicates that during focused tasks like intubation, practitioners can lose track of critical patient parameters such as oxygen levels and blood pressure.
• In small teams, a simple directive to continue current actions and report any needs can suffice. Still, larger teams often have the capacity to designate a specific individual for situational oversight.
• Setting clear parameters, such as instructing a team member to intervene if oxygen saturation drops below a certain level, helps maintain patient safety while the leader’s attention is elsewhere.

Resetting Name, Claim, Aim at the first lull in action

• The Name, Claim, Aim process is cyclical, not linear, and should be revisited and adjusted as the situation evolves.
• A natural point for reassessment often occurs after the initial set of actions has been completed, such as after the first round of interventions in a code situation.
• The arrival of additional personnel, like specialists or leaders from other departments, can signal a need to reestablish roles and update the plan.
• Renaming involves reassessing the current situation and identifying the next set of priorities based on the latest developments.
• Reclaiming may be necessary when new team members join or when leadership roles shift, ensuring clarity in team coordination.
• Reaiming involves setting new immediate objectives, such as the next steps in patient care, and assigning specific tasks to team members.
• Times of increased noise or stress in the room also indicate a need to reset the process, which can help reduce anxiety and improve team focus.
• The cyclical revisit of Name, Claim, Aim maintains clarity, reduces room tension, and ensures that the team’s efforts are effectively coordinated toward the patient’s changing needs.

Crisis resource management transformed how teams function, but it has a lot of steps and can be hard to deploy in a flash. Name, Claim, Aim is a simple distillation of CRM that can be used in the point of care

• Crisis Resource Management (CRM) has been foundational in healthcare teamwork for the past 30 years, introducing vital principles for team coordination during crises.
• Despite its importance, CRM’s complexity, with its 11 principles, can make it challenging to apply effectively in the heat of a crisis, given the typical level of training healthcare professionals receive.
• Name, Claim, Aim simplifies these CRM principles into a more accessible and actionable format that can be quickly deployed in emergency situations.
• To integrate Name, Claim, Aim into daily practice, start with focused, small-scale activities that reinforce its components, gradually increasing complexity.
• This approach mirrors how sports teams train, breaking down complex strategies (like switching from man-to-man to zone defense in lacrosse) into focused drills and progressively more challenging scenarios.
• The goal is to make Name, Claim, Aim a natural part of the team’s response by practicing it in various contexts, ensuring it’s readily available during a crisis.
• By distilling CRM into a more manageable framework, Name, Claim, Aim aims to enhance team performance and decision-making in critical healthcare settings.

A graded introduction of Naming, Claiming, and Aiming

• Starting with “Naming” involves clearly stating the situation at hand in routine, low-stakes scenarios to enhance team understanding and coordination.
• This practice can begin with simple acknowledgments, such as identifying a patient’s condition (e.g., sepsis) and its implications for the team’s actions, like the need for cultures before antibiotics.
• Incremental practice of “Naming” in progressively challenging situations helps embed this skill into daily routines, ensuring it becomes second nature even in high-pressure contexts.
• “Claiming” leadership is often perceived as awkward in healthcare settings due to cultural norms around authority and teamwork, making it challenging for many practitioners.
• Practicing “Claiming” can start in simulation settings with low fidelity, focusing on the verbalization of taking the lead in a given scenario and then gradually introducing more complex or realistic simulations.
• The ultimate goal is to seamlessly integrate “Name, Claim, Aim” as a single action-oriented phrase that is instinctively used during emergencies, optimizing team response and patient care.

Practicing Name, Claim, Aim in team huddles

• Practicing the Name, Claim, Aim framework in pre-crisis situations, such as team huddles before a high-acuity patient arrives, can familiarize the team with the process and the leader’s script.
• This approach allows team members to become accustomed to organizing and preparing for specific roles and responsibilities before an emergency, enhancing overall readiness and coordination.
• Transparently communicating the intention to practice the framework (“I’m going to get us organized”) encourages team engagement and affirms the leader’s role in guiding the response.
• Even in these preparatory settings, including a call for feedback (“What am I missing?”) reinforces the culture of open communication and collective problem-solving.

Taking 10 seconds for the next 10 minutes | Time is not linear and every second is not worth the same amount

• The concept of “taking 10 seconds for the next 10 minutes” emphasizes the disproportionate value of spending a brief moment organizing and planning before proceeding with actions, especially in chaotic situations.
• The perspective that not all time is equal challenges the conventional view of time as linear, highlighting that moments spent in strategic organization can prevent prolonged periods of disorganization and inefficiency.

The consequences of not getting the first 10 seconds right

• Failing to properly organize a team in the initial moments of a crisis can lead to suboptimal patient care, potentially affecting patient and family outcomes significantly and sometimes irreversibly.
• For healthcare providers, the trauma of a poorly managed crisis can have lasting psychological effects, leading to self-doubt, decreased confidence, and an internal critical voice that questions their professional abilities.
• Organizations face considerable risks from disorganized crisis responses, including legal liabilities and damage to public reputation, especially when families perceive that care was mishandled or ineffective.
• The cumulative effect of chaotic incidents can erode team cohesion and trust, leading to a deteriorating department culture that impacts patient care and staff morale.

Team success is an emergent property

• Changing long-standing habits to improve crisis management will require time and deliberate effort.
• The ability to effectively organize a team can boost a leader’s confidence, regardless of their level of medical knowledge, by ensuring a cohesive and coordinated response.
• Team success is characterized by its emergent nature, where the collective outcome is greater than the sum of individual contributions. This enhances the team’s ability to adapt and support each other in varying circumstances.
• The Name, Claim, Aim process aims to foster active participation and prevent passive involvement, encouraging each team member to contribute meaningfully to the team’s collective success.
• Although the team leader may have the initial responsibility to initiate the process, the collaborative nature of Name, Claim, Aim facilitates shared ownership and momentum, reinforcing the team’s unity and effectiveness.