TEAM BASEDCOLLABORATIVE CARE BEATRICE KALISCH, RN, PHD, FAAN TITUS DISTINGUISHED PROFESSOR AND DIRECTOR, INNOVATION AND EVALUATION UNIVERSITY OF MICHIGAN ANN ARBOR OMNI LEADERSHIP FORUM CHICAGO, ILLINOIS OCTOBER 3-5, 2012
WorkplaceCollaboration Working together to achieve a goal. It is a recursive process where two or more people or organizations work together to realize shared goals.
PresentationOutline 1. Teamwork and patient safety and outcomes 2. What does teamwork look like? 3. How can teamwork be achieved?
A team is …Two or more people workingcollaboratively with a Two differentcommon purpose. competencies required However • Expert clinically teams of • Expert team player experts often fail to evolve into expert teams (Salas)
Teamwork and Patient Safety One person’s vulnerabilities are offset by another person’s strengths.
Aviation example: Which team made more mistakes?Team that worked Team who did not worktogether and tired together and rested
Impact of Teamwork on Safety Strongest evidence is from cross sectional studies in the ICU (because adverse events occur more often) Lower risk adjusted mortality rates Lower LOS for medical (not surgical) patients Group-type hospital culture predicted fewer patient falls with injury Brewer, 2006 Decreased errors with transfusions, needle sticks, wrong medications, etc. Deering, 2011 Decreased missed nursing care (errors of omission) Kalisch, 2011 High teamwork has been associated with a safety culture Blegen et al, 2009
Impact of Teamwork on Patient Outcomes The ultimate outcomes of interest Rand Corporation Study, Outcome Measures for Effective Teamwork (2008) Teamwork has been associated with Patient satisfaction (Meterko, et al, 2004) Patient perceived quality of care (Friedman et al, 2004; Gittel et al., 2000; Goni, 1999) Provider-reported quality of care (Deeter-Schmelz and Kennedy, 2003; Shortell et al., 1994)
Impact of Teamwork on Patient Outcomes (continued) Teamwork has been associated with (continued) Shorter LOS (Shortell et al, 1994; Boyle, 2004; Gitell, 2000; Friedman et al, 2004; Pronovost et al, 2003) Lower risk adjusted mortality for ICU and other patients (Wheelan, 2003; Uhlig, et al, 2002) Decreased surgical morbidity (Young-Xu, 2011; Wheelan, 2003) Higher ability to meet family member needs Better functional outcomes (Shortell, et al, 2000; Mukamel, et al, 2006) Decreased readmissions to the ICU (Baggs)
Impact of Teamwork on Patient Outcomes (continued) Teamwork has been associated with (continued) Lower rates of pressure ulcers, falls, pneumonia and death and catheter related blood stream infections (Pronovost et al, 2006) Neonatal resuscitation quality (Thomas et al, 2006) Surgical task completion (Undre, et al, 2006) Decreased malpractice claims (Mann et al, 2006) Lower cost (Young et al, 1998)
Impact of Teamwork on Patient Outcomes (continued) Review of medical malpractice claims in Emergency Departments showed that: (Risser, 1999) Appropriate teamwork might have averted more that 60% of deaths and major permanent impairments Lack of performance monitoring major cause of errors in 35% of cases Lack of assertiveness of caregiver 28% of cases
Teamwork and job satisfaction Several studies have shown that higher levels of teamwork results in greater job satisfaction (Rafferty et al, 2001; Amos et al, 2005; Chang et al, 2009; Collette, 2004; Blegen, et al, 2008). Study with 3,769 staff ; 95 patient care units; 6 hospitals (Kalisch et al, 2012) • The more satisfied with current position, the higher the teamwork (F [4, 212.727] = 113.256, p < 0.001) • The more satisfied with being nurse, the higher the teamwork (F [4, 3699] = 30.709, p < 0.001) • The higher the teamwork, the less likely to leave (F [2, 541.891] = 25.475, p < 0.001)
Teamwork Intervention Study Turnover and Vacancy Rate Before and After Intervention* Percent Turnover or Vacancy 14.00% 13.14% 12.00% 10.00% 8.05% 8.00% Turnover 6.14% 6.00% Vacancy 5.23% 4.00% 2.00% 0.00% Before After* Turnover t = 2.18, df = 63, p= .033; Vacancy t = 4.55, df= 58, p= .0000
Salas et al Big Five Theory of Teamwork THE CORE Closed Loop Team Mutual Communication Leadership Trust Team Mutual Back-Up Orientation Performance Behavior Monitoring Adaptability Shared Mental Models
Team Orientation Team’s success takes precedence over individual’s performance and desires Do not view themselves as isolated individuals Team members first Part of everyone‟s job is to ensure that everyone on the team can and does get their work done in a quality way. .
Team Orientation (continued)Example comments when NOT present: Unit Secretary: The nurses count the number of patients assigned to them at the beginning of the shift and they say „You have 4 patients and I have 5, why is that?‟ RN: Days left the blood for me to hang. NA: The RN could put the patient on the bedpan in a minute but instead spends 10 minutes looking all over the unit for me to do it. RN: Even though we keep reminding him, this physician keeps writing orders that no one can read.
Team Orientation (continued)Example comments when NOT present (continued) RN: It is physical therapy‟s job to ambulate the patient. MD: The nurses call me and they don‟t even have the information together to give to me. They don‟t even know the vitals. RN: If I stop and help the nursing assistant, I won‟t get my “RN” work done. RN: I see an order that is not correct but that doctor is so rude, I don‟t let him know. It is his responsibility.
Team Leadership Team leadership refers to the structure, direction and support provided by both the formal leader and/or on the part of team members. Who should be the team leader? Everyone should act as a leader at some point.
Team Leadership Example comments when NOT present RN: We all take turns being in charge so when I am in charge, I don’t want to upset my fellow nurses because they will take it out on me the next time. I will wind up with all of the heaviest patients. NA: I tell the RN a patient is in pain but she doesn’t do anything. The next time I don’t even try to get her to help the patient.
Mutual Performance Monitoring The observation and awareness of team members of one another. Keep track of fellow team members’ work while completing their own work. Could be interpreted in negative terms (e.g. spying, trying to find problems etc.) but it is accepted as part of a “psychological contract” Maximize the overall performance
Mutual Performance Monitoring (continued)Example comments when NOT present RN: I don’t think the NA takes accurate vital signs but I don’t have time to recheck her work. I have too much to do with my work. I take what she gives me. It turned out to be a disaster last week—a patient had a BP of 200 over 165. MD: I don’t know what is happening. I just get in and out as fast as I can. RN: The medical staff hide out in the conference room.
Back-Up Team members help one another with their tasks and responsibilities including giving feedback. Unable to perform work or carry out responsibilities and another team member steps in
Back-Up (continued) Requires willingness to provide and seek assistance. Willingness to jump in and help and accept help without fear of being perceived as weak. Needs to occurs no matter the status, rank or tenure of the staff member
Back up (continued)Example comments when NOT present RN: I will see a physical therapist forget to wash her hands but I won‟t say anything. NA sees a medication (Glucophage. oral insulin) left in a cup on a patient’s bed stand and throws it way, never telling the RN. The patient’s blood sugar is elevated on the next blood test and the RN cannot understand why. The dose of Glucophage is increased.
Back-Up (continued)Example comments when NOT present: RN: Sometimes I feel bad asking for help. It looks like I am just not able to handle my job, that I am not a good nurse. ED RN: I call up to the unit where the patient is to go and no one will take report. They think if they don‟t respond, we won‟t bring the patient up. Meanwhile we have patients who really need care are waiting. We can‟t refuse to take patients. PT: I believe the patient needs an MRI but I have to tip toe to ask the doctor. He doesn‟t think we know much..
Back-Up (continued) Giving and receiving feedback poor Needs to be norm for all team members and seen as part of their roleExample comments when NOT present: RN: If I say anything to correct an NA, I pay for it. She won’t do anything for my patients. MD: There are some strong personalities in nursing and it isn’t worth the effort to tell them they did something wrong.
Adaptability Ability to adjust strategies and resource allocation on the basis of the information gathered from the environment. Examples when NOT present RN: We have staff on both 8- and 12-hour shifts and instead of reassigning patients so the nurse coming on doesn‘t have patients on all three wings, we let her run. Radiology tech: The patients are late because they say they have an emergency but we have a schedule to keep.
Closed Loop Communication The active exchange of information between two or more team members where both parties have the same understanding of what was communicated (closed loop). For a team to act in concert to achieve common goals, the team must have shared information. 2,455 sentinel events reported to the Joint Commission 75% of the incidences resulted in death. 70% of the incidents had communication failure as the primary root cause
Closed Loop Communication (continued) Conflict inevitable Without it, no way to draw attention to problems. Flow of information between healthcare providers of different degrees of status Individuals lower on the hierarchy are not often asked for relevant information that only they have. Physicians more satisfied with teamwork than nurses (Thomas et al, 2003). Nurses say difficult to speak up, disagreements are not appropriately resolved, need more input into decision making, and nurse input not well received
Closed Loop Communication (continued)Examples when NOT present: A patient in intense pain is brought up to the unit from the ED by a transporter who does not inform the nurse. No one saw that patient for 2 hours. MD: The nurses do not seek me out to resolve issues with orders. RN: You send an order to pharmacy and just pray the med will appear. It doesn’t matter that I didn’t get the med, I get blamed because the patient didn’t get their med. MD: There is no effective way to alert the nursing staff about stat orders. MD: I need to know about the patient but I can’t find anyone to give me the information. RN: The physicians don’t update us on the patient’s condition.
Shared Mental ModelsWhat people use to organize information about theenvironment, the team purpose and teaminterdependencies.Example when NOT present: RN: A nurse floated to our unit and did things the way they do on her floor. She thought the other staff members would give her patients their medications when she took a break. She found out several hours later this was not the case.
Mutual Trust Members will perform actions necessary to reach interdependent goals and act in the interest of the team. Without trust, team members expend time and energy protecting, checking and inspecting each other as opposed to collaborating. Physicians more satisfied with teamwork than nurses (Thomas et al, 2003). Nurses say difficult to speak up, disagreements are not appropriately resolved, need more input into decision making, and nurse input not well received
Mutual Trust (continued) Examples when NOT present: RN: If I work with certain people, I am afraid things are not being done. RN: I would like to believe the aide when she tells me she ambulated the patient, but I am not sure. MD: Some of the nurses are just not that good. I worry about my patients.
How can teamwork be achieved? What does it take to build more effective teams?1. Teamwork training2. Organizational systems changes
Teamwork Training Department of Defense IHI DoD and AHRQ together Improving perinatal care TeamSTEPPS Transforming care at the bedside VHA, Inc.: Transfor- mation of the OR Does team training Kaiser-Permanente: Pre- work? A Meta-analysis operative Safety Briefing Salas et al (2008) Based on 52 effect sizes Decreased wrong site representing 1,563 teams surgeries and nurse Team training was shown to have turnover a positive effect on team functioning
Team training is The best team training will notessential yield the desired outcomesbut not enough alone unless the organization is aligned to support teamwork. Team training accounts for 20% of the team performance variance 80% other organizational systems
An organization’s ability toOrganizational support collaboration is highlyCulture dependent on its organizational culture. Some cultures foster collaboration while others stop it dead in its tracks. Only need to purchase collaboration software to foster collaboration but . . . Fails because people don’t know how to collaborate effectively or because their culture works against it
What are some of the organizational systems? Positive transfer of training Team size Physical space Team membership stability Rewards, recognition Disruptive and intimidating behavior Opportunity to communicate Groupware tools Involvement of patients/families
Organizational systems Positive transfer of training Learning alone is not sufficient Bulk of training expenditures do not seem to transfer to the job Estimates are only 10% of training expenditures transfer to the job Glaring gap between training efforts and organizational outputs Strategies Cues that prompt trainees to use new skills Situational cues (manager goals, peer support, equipment availability and opportunity to practice trained skills) Consequent cues (positive and negative feedback following the application of trained skills) Remediation for the incorrect or lack of use
Organizational systems (continued) Transfer of training (continued) Provide opportunities to perform Leader role is largest contributor to transfer Goal setting: Prior to training, leaders should communicate goals, behavior expected after the training; After training, managers need to prompt staff to set proximal and distal goals for applying newly acquired knowledge Recognition, encouragement and rewards and modeling trained behaviors Train the trainer Post training follow up Job aids (tools designed to assist with job performance and facilitate the transfer of training; reduce the mental workload required to apply new skills) Informational aids Procedures aids Decision making and coaching aids
Organizational systems (continued) Team size FR EQ 300 UE The number of team members NC 250 Y (N u mb er 200 assigned to a given collective of oc cur an 150 ces ) Ideal size of a team 5-9 100 50 Research definitions: small 1-2, 0 2 3 4 5 6 7 8 9 10 medium 3-5 and large over 5 11 12 13 14 15 16 17 18 19 20 T E AM S IZ E 21 22 23 24 2,265 nursing staff on 53 units in four hospitals as high as 183 Average team size people with a mean of 87 across industries
Number of different staffworked with in one month
Organizational systems (continued) Negative consequences of large teams Decreased motivation Poorer decision making Poorer coordination Higher levels of conformity Social loafing The “dilution effect” (free riding, getting lost in the crowd, shirking work, etc.)
Organizational systems (continued) Physical Environment Physical proximity offset each other’s vulnerabilities and magnify each other’s strengths Physical distance reduces the possibilities for coordinated action and teamwork Structure and layout of patient care units decreases or increase the likelihood of teamwork Often no conference room space for communication Where do the medical staff hang out? Cost of engaging another team member
Organizational systems (continued) Team membership stability Intact versus ad hoc teams Length of time team members have worked together Shared history Teamwork has been shown to result in lower turnover, less intent to leave and less absenteeism The less turnover and the fewer absences, the larger the team can be and still achieve high performance. This represents a “which came first” situation
Organizational systems (continued) Potential solutions for size, distance and stability In Norway, the “holy grail” of unit design has been the sengetun ward, with between 6 and 10 private rooms arranged around a decentralized nursing station(“Pods,” 2010). Cluster teams By reorganizing a 40-bed medical unit into four 10-bed mini- units, the number of different people that staff had to work with decreased by 75%, and patient and staff satisfaction increased(Kalisch & Begeny, 2005).
Organizational systems (continued) Rewards and recognition Creating a meaningful, cost-effective reward system is both one of the most important and one of the most frustrating challenges Appropriate rewards for teamwork should Be empowering not manipulative Work synergistically with intrinsic motivation Produce energy to achieve even more Make team members feel good about their current and past accomplishments Team rewards
Organizational systems (continued) Disruptive and intimidating behaviors Tradition of being indifferent to this; goes unreported Studies have linked patient complaints about unprofessional, disruptive behaviors and malpractice risk. (Hickson, et al, 2002, 2007; Stelfox, et al, 2005) 40% agreed physicians who generate high revenue, treated more leniently (Keogh, et al, 2004) Need zero tolerance Need process for addressing which includes interdisplinary team members
Organizational systems (continued) Opportunity to communicate Multidisciplinary daily rounds vs. traditional rounds (Curley et al, 1998) Lower LOS Lower average charges Reduced medication variance and adverse drug events (Sim & Joyner, 2002; Leape et al., 1999) Daily goals form as part of multidisciplinary daily rounds Formalized briefings about the details of surgery to be performed after patient anesthesized Briefings and debriefings
Organizational systems (continued) Groupware Instant messaging technologies Social media Cell phones Co-browsing Email Desktop sharing Pagers White boarding Tablet devices Group decision support Video Presence Management Allows individuals to alert others of Desk top video their willingness to communicate and conferencing preference for mode of communication Web conferencing tools
Organizational systems (continued) Smart phones Market penetration expanding rapidly 35% of public own smartphone 81% physicians (Manhattan Research) Is becoming an essential part of everyday communications in healthcare Web out, apps in—1500 mobile medical apps Health apps award ensuring safe transitions from hospital to home Pagers still needed in disasters (cellular networks down)
Organizational systems (continued) tele-ICU increased teamwork (Chu-Weininger et al 2010) Confident patients covered when off the unit I can reach physician Decrease in being interrupted to tell something I already know Remote intensivists resulted in improved rates of DVT prophylasis and tight GC (Bawawi, 2012)
Organizational systems (continued) Patient record (EHR) Timely information is central to teamwork EHRs that are connected across providers and systems has potential to increase information continuity, care coordination and transitions, system accountability and peer review EHRs potentially “Media Rich” communication technology that can promote teamwork Introducing EHRs changes workflows and processes and this likely affects teamwork but not well understood Interdisciplinary care plan Study of diabetic patients with multidisciplinary care plan shows greater adherence to diabetes guidelines, higher metabolic control and improved cardiovascular risk factor
Organizational systems (continued) Transforming from a push to a pull strategy Instead of sending information to those who may or may not use it Place information on line Team members look for information relevant to their work Research to date suggests healthcare teams can benefit from the use of groupware technologies The potential is only beginning to be tapped Issues Bandwidth required to deliver large amounts of data Issue of compromised health information/data security
Organizational systems (continued) Engaging patient and family as team members Study determining what patients could report on re: the care they received in the hospital, we found Fully reportable (e.g. mouth care, bathing, pain medication) Partially reportable (e.g. hand washing, vital signs, patient education) Not reportable (e.g, surveillance, assessment, intravenous site care) Will require a deeper understanding of consumer health literacy and the “workflow” of patients