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![28/01/2014
Adverse Outcomes in Belgian Acute Hospitals
Medical patients:
Prevalence of 7.1%
Wmean
32.3
12.4
14.0
P90/P10
4.5
3.6
2.4
95%CI [3.5;5.4] [2.9;4.2] [2.1;2.8]
CGain
15539
3194
3178
13.8
3.6
[2.9;4.2]
4226
12.7
5.7
[4.2;7.3]
5945
6.7
3.0
[2.4;3.5]
1991
8.2
5.4
[4.0;6.8]
3693
Surgical patients :
Prevalence of 6.3%
6.2
1.7
[1.5;1.8]
2320
Wmean
17.6
12.2
13.5
P90/P10
5.1
4.0
3.3
95%CI [3.8;6.4] [3.1;4.9] [2.7;3.9]
CGain
5938
1943
5026
13.2
5.2
5.3
3.0
6.5
2.4
[2.4;3.5] [4.3;8.6] [2.0;2.8]
3016
1875
1336
3.6
7.9
[4.9;11.0]
1025
3.4
3.5
[2.7;4.2]
828
14.7
4.0
[3.2;4.8]
5983
Each dot represents one of 123 Belgian acute hospitals. Risk adjustment was done via indirect standardization with APR-DRG and SOI and
Bayesian hierarchical modeling. Abbreviations: Wmean, weighted mean; 95% CI, 95% Credibility Intervals; CGain, centile gains; UTI,
urinary tract infection; PU, pressure ulcers; PNE, hospital, acquired pneumonia; SEP, hospital, acquired sepsis; CNS, central nervous
system complications; S/CA, shock or cardiac arrest; UGB, upper gastrointestinal bleeding; DVT, deep venous thrombosis; PF, pulmonary
failure; MD, metabolic derangement; WI, wound infection.
9.0
4.7
[3.5;5.8]
3404
7.9
3.5
[1.7;2.1]
2786](https://image.slidesharecdn.com/presentatiesvindeneckereitineraevent2-140206050341-phpapp01/75/Presentatie-Svin-Deneckere-28-01-2014-6-2048.jpg)
![28/01/2014
RQ2 (study 3): Cluster RCT: results of multilevel analysis
Teams that developed a care pathway for COPD/PFF:
Perceived themselves more as being a real team (β=0.30 (0.91); 95% CI 0.11 to 0.49)
Better quality of work environment (β=0.40 (0.14); 95% CI 0.11 to 0.69)
TEAM
Better management support (β=0.52 (0.11); 95% CI 0.29 to 0.74)
Better structured leadership (OR= 4.27; 95% CI 1.02 to 17.86)
More frequent team meetings (OR= 5.83; 95% CI 1.33 ; 25.68)
Better team composition (β=0.11(0.04); 95% CI 0.0.03 to 0.18]
No significant difference in team size
Better conflict management (β=0.30 (0.11); 95% CI 0.08 to 0.53)
Higher team climate for innovation (β=0.29 (0.10); 95% CI 0.09 to 0.49)
No significant differences in leadership qualities and relational coordination
Higher level of organization of care (β=5.56 (2.05); 95% CI 1.35; 9.76)
Lower emotional exhaustion (β= -0.57 (0.21); 95% CI -1.00 to -0.14)
Higher level of competence (β=0.147; 95% CI 0.147 to 0.640).
INPUTS
TEAM PROCESSES
TEAM OUTPUTS](https://image.slidesharecdn.com/presentatiesvindeneckereitineraevent2-140206050341-phpapp01/75/Presentatie-Svin-Deneckere-28-01-2014-27-2048.jpg)
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Presentatie Svin Deneckere 28/01/2014
This document outlines a PhD thesis examining how care pathways can improve teamwork in healthcare and prevent burnout. It begins with an introduction describing the growing need for effective teamwork in healthcare due to high rates of medical errors. Barriers to teamwork like fragmented structures and high workload are discussed. The thesis then explores how care pathways, as a type of organizational intervention, may improve teamwork by facilitating communication and coordination among healthcare teams. The PhD study involved four studies to examine indicators of teamwork, the impact of care pathways on teamwork, and conditions influencing care pathway implementation. A cluster randomized controlled trial found that teams using care pathways perceived themselves as more of a real team and had a better quality work environment than control teams
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- 1. 28/01/2014 MAKING TEAMS WORK: Carepathways as a tool to improve teamwork and prevent burnout dr. Svin Deneckere Doctoral thesis in Biomedical Sciences, KU Leuven Promoter: Prof. Dr. Walter Sermeus; Co-Promoters: Prof. Dr. Martin Euwema & Dr. Kris Vanhaecht
- 2. 28/01/2014 OUTLINE Growing need forteamwork in healthcare How could care pathways improve teamwork? Setting of the PhD-study Objectives, research questions and included studies Study results General discussion and recommendations MAKING TEAMS WORK
- 3. 28/01/2014 Why teamwork inhealthcare? Kohn et al. (1999). To Err Is Human: Building A Safer Health System. Washington DC: National Academic Press. As many as 44.000 to 98.000 people die in hospitals each year as the result of medical errors. Medical errors are the eighth leading cause of death in U.S. – much higher than motor vehicle accidents (43.458), breast cancer (42.297), or AIDS (16.516). About 10% of patients hospitalized were harmed by the care they received
- 4. 28/01/2014 DANGEROUS (> 1/1000) 100000 REGULATED ULTRA-SAFE (< 1/100K) Healthcare Healthcare Driving Totallives lost per year 10000 1000 Scheduled Airlines 100 Mountain Climbing 10 Chemical Manufacturing Bungee Jumping European Railroads Chartered Flights Nuclear Power 1 1 10 100 (bron: L. Leape, 2/2001) 1000 10000 Number of encounters for each fatality 100000 1000000 10000000
- 5. 28/01/2014 Why teamwork inhealthcare? “Patient care is a team sport. However healthcare is unique in that no other team sport has greater potential for catastrophic outcomes”. (Salas et al., 2008) Improving quality and safety of patient care is still an important issue: – IOM-reports (1998, 2001): adverse events (AE)-rate in 3% to 4% of patients hospitalized in the US – Langelaan et al. (2008): 8% AEs; 2.9% preventable AEs; 5.5% preventable deaths – Levinson et al. (2010): 13.5 % AEs in hospitalized Medicare beneficiaries; 44% of AEs are preventable Joint Commission (2007): poor communication among team members was a contributing factor in almost 2/3 of AEs MAKING TEAMS WORK
- 6. 28/01/2014 Adverse Outcomes inBelgian Acute Hospitals Medical patients: Prevalence of 7.1% Wmean 32.3 12.4 14.0 P90/P10 4.5 3.6 2.4 95%CI [3.5;5.4] [2.9;4.2] [2.1;2.8] CGain 15539 3194 3178 13.8 3.6 [2.9;4.2] 4226 12.7 5.7 [4.2;7.3] 5945 6.7 3.0 [2.4;3.5] 1991 8.2 5.4 [4.0;6.8] 3693 Surgical patients : Prevalence of 6.3% 6.2 1.7 [1.5;1.8] 2320 Wmean 17.6 12.2 13.5 P90/P10 5.1 4.0 3.3 95%CI [3.8;6.4] [3.1;4.9] [2.7;3.9] CGain 5938 1943 5026 13.2 5.2 5.3 3.0 6.5 2.4 [2.4;3.5] [4.3;8.6] [2.0;2.8] 3016 1875 1336 3.6 7.9 [4.9;11.0] 1025 3.4 3.5 [2.7;4.2] 828 14.7 4.0 [3.2;4.8] 5983 Each dot represents one of 123 Belgian acute hospitals. Risk adjustment was done via indirect standardization with APR-DRG and SOI and Bayesian hierarchical modeling. Abbreviations: Wmean, weighted mean; 95% CI, 95% Credibility Intervals; CGain, centile gains; UTI, urinary tract infection; PU, pressure ulcers; PNE, hospital, acquired pneumonia; SEP, hospital, acquired sepsis; CNS, central nervous system complications; S/CA, shock or cardiac arrest; UGB, upper gastrointestinal bleeding; DVT, deep venous thrombosis; PF, pulmonary failure; MD, metabolic derangement; WI, wound infection. 9.0 4.7 [3.5;5.8] 3404 7.9 3.5 [1.7;2.1] 2786
- 7. 28/01/2014 Cost of poorquality? The Netherlands ‘Monitor Zorgerelateerde Schade 2011/2012’: – Total cost for adverse events of €523 million per year and €126 million per year potentially preventable adverse events. – 2,2% of yearly budget for hospital healthcare; 0,5% for potentially preventable adverse events Study on medical claims in USA: – $17,1 billion in 2008 – 0,72% of total healthcare budget in USA – Highest cost due to postoperative infections ($3,4 billion) and pressure ulcers ($3,3 billion) Langelaan M, Baines R, Broekens M, Siemerink K, van de Steeg L, Asscheman H et al. (2013). Monitor Zorggerelateerde Schade 2011/2012. Dossieronderzoek in Nederlandse Ziekenhuizen. Amsterdam, NIVEL en EMGO+ Instituut. Van Den Bos J., Rustagi K., Gray T., Halford M., Ziemkiewicz E., Shreve J. (2011) The $17.1 Billion Problem: The Annual Cost Of Measurable Medical Errors. Health Affairs, 30, 4:596-603.
- 8. 28/01/2014 System problems callfor system solutions Conflicts in Goals Inadequate training Unclear roles and tasks Workload Potential Problem Problems with legal procedures Unclear accountability Divertion due to other problems Inappropriate Unstable maintenance technology Accident Incomplete Procedures
- 9. 28/01/2014 Why teamwork inhealthcare? WHO World Alliance for Patient Safety: lack of communication and coordination as priority number one in patient safety research for developed countries (Bates, D. 2009)
- 10. 28/01/2014 Growing need forteamwork in healthcare Several barriers to effective teamwork in healthcare: – – – – – – – – – Fragmented, disconnected organizational structures No incentives in financing system to collaborate Increasing job demands, high workload, different work schedules Low level of agreement and low level of predictability High specialization, high task interdependence, high functional diversity Interprofessional boundaries, different educational backgrounds Power- and status differences, high competitive power Unclear leadership structures Temporary, ad hoc teams with low group identity, lack of role clarity and poorly trained Regular team conflicts: task /relation / process conflicts Pseudo-teams in healthcare
- 11.
- 12. 28/01/2014 Lack of informal interaction Powerdistributions Nugus et al, 2010
- 13. 28/01/2014 Increasing job demandsand high workload (RN4CAST-study KUL) Within EU there will be shortage of one million healthcare workers RN4CAST: – Study on nurse staffing in which 61.168 nurses and 131.318 patients participated, in more than 1.000 hospitals in 13 countries. – Some Belgian results: • Nurse staffing level: 11 patients for each nurse (US 5/1, the Netherlands 7/1) • Number of nurses that are dissatisfied with their job: 22% • Number of nurses that are intended to leave their job: 30% • Number of nurses that report having a burnout: 24% • Prevalence of nursing care left undone in Belgium: 58% comfort talks with patients, 44% patient education and 43% update care plans FOD Healthcare: – 1198 medical doctors, 4635 nurses in 37 hospitals – medical doctors (5,4% burnout; 17,8 risk of burnout), nurses (6,9% burnout; 12,4% risk of burnout). Aiken, L. H., Sermeus, W., Van den Heede, K., Sloane, D. M., Busse, R., McKee, M., … Kutney-Lee, A. (2012). Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States. British Medical Journal, 344, e1717.
- 14. 28/01/2014 OUTLINE Growing need forteamwork in healthcare How could care pathways improve teamwork? Setting of the PhD-study Objectives, research questions and included studies Study results General discussion and recommendations MAKING TEAMS WORK
- 15. 28/01/2014 Team improvement interventions(Buljac-Samardzic et al. 2010) (1) Teamwork training programs: these involve a systematic process through which a team is trained to master and improve team competencies (e.g. crew resource management); (2) Structured communication protocols: tools which seek to improve the reliability of transferring critical information (e.g. briefing and debriefing checklists) (3) Organizational interventions: these are interventions that seek to change work processes and structures so that they support more effective communication. MAKING TEAMS WORK
- 16. 28/01/2014 Team training interventions:Crew Resource Management ‘Ferrari pit stops saves lives’ Prof. Martin Elliot
- 17. 28/01/2014 Structured Communication Protocols:SBAR-Survey/Briefing Adapted by Kaiser Permanente from a communication tool that was adapted from the US Navy An effective and efficient way to communicate important information; A simple way to help standardize communication Allows parties to have common expectations related to what is to be communicated and how the communication is structured. S=Situation (a concise statement of the problem) B=Background (pertinent and brief information related to the situation) A=Assessment (analysis and considerations of options — what you found/think) R=Recommendation (action requested/recommended — what you want)
- 18. 28/01/2014 What are carepathways? A care pathway is a complex intervention for the mutual decision making and organization of care processes for a well-defined group of patients during a well-defined period. Defining characteristics of care pathways include: – An explicit statement of the goals and key elements of care based on evidence, best practice, and patients’ expectations and their characteristics; – the facilitation of the communication among the team members and with patients and families; – the coordination of the care process by coordinating the roles and sequencing the activities of the multidisciplinary care team, patients and their relatives; – the documentation, monitoring, and evaluation of variances and outcomes – the identification of the appropriate resources Vanhaecht K, Sermeus W, van Zelm R, Panella M. Care pathways are defined as complex interventions. BMC Medicine 2010; 8:31.
- 19. 28/01/2014 Care pathways asorganisational interventions to improve teamwork Deneckere S., Euwema, M, Van Herck P., Lodewijckx, C., Panella, M., Sermeus, W., and Vanhaecht, K. (2012). Care Pathways Lead to Better Teamwork: Results of a Systematic Review. Social Science & Medicine; 75(2):264-268.
- 20. 28/01/2014 OUTLINE Growing need forteamwork in healthcare How could care pathways improve teamwork? Setting of the PhD-study Objectives, research questions and included studies Study results General discussion and recommendations MAKING TEAMS WORK
- 21. 28/01/2014 Setting: European Qualityof Care Pathways (EQCP)-project International multicentre research project launched by the European Pathway Association (E-P-A) (http://www.E-P-A.org), supported with unrestricted educational grant of Pfizer NV/SA Objective: to study the effectiveness of CPs for COPD-exacerbation and Proximal Femur Fracture (PFF) Participating countries: Belgium, Ireland, Italy and Portugal Three trials: Trial 1: a cluster RCT on the impact of a CP for PFF on patient processes and outcomes Trial 2: a cluster RCT on the impact of a CP for COPD- exacerbation on patient processes and outcomes Trial 3: a cluster RCT on the impact of CPs on interprofessional teamwork in which both COPD-exacerbation and PFF-clinical teams are included MAKING TEAMS WORK
- 22. 28/01/2014 Three research questions RQ1:Which indicators can be used in order to study and follow up interprofessional teamwork in care processes? RQ2: What is the impact of care pathways on interprofessional teamwork in an acute hospital setting? RQ3: Which team and organizational conditions will influence the successful implementation of care pathways in an acute hospital setting? MAKING TEAMS WORK
- 23. 28/01/2014 Included studies Study 1 Study2 Study 3 Study 4 DESIGN RQ3: CP conditions Delphi-consensus method to support international expert panel Systematic literature review of articles on CP-effectiveness on teamwork Stratified post-test-only cluster randomized controlled trial Process evaluations of the implementation processes of the developed CPs • Each participant rated an initial list of 44 team indicators on a scale of 1 to 6. • Consensus was sought in two consecutive rounds based on the content validity index • Literature search of articles published between 1999 and 2009 • Both effect and exploratory studies included • Quality appraisal • Intervention teams METHODS RQ2: Impact of CPs on teamwork developed CP • Control teams provided ‘usual care’ • Summative evaluation of team indicators • Multi-level analysis • Semi-structured, oneto-one interviews with key stakeholders of each intervention team • Normalization Process Model used to guide the inductive thematic analysis SAMPLE RQ1: Team indicators • Purposive sample of 36 experts: 19 scientific researchers and 17 hospital managers • 13 different countries • 26 included studies • Mixed settings and patient groups • 20 team indicators used • 30 teams caring for COPD or PFF patients • 17 intervention and 13 control teams • 581 team members • Purposive sample of CP-facilitators, management and team members • 75 representatives
- 24. 28/01/2014 RQ2 (study 3):Cluster RCT on impact of CPs on interprofessional teamwork: methods
- 25. 28/01/2014 RQ2 (study 3):Cluster RCT on impact of CPs on interprofessional teamwork: sample Overall response rate was 78%: - 379 nurses - 94 allied health professionals - 75 medical doctors - 33 head nurses Deneckere S, Euwema M, Lodewijckx C, Panella M, Mutsvari T, Sermeus W., and Vanhaecht, K. (2012). Better interprofessional teamwork, higher level of organized care and lower risk of burnout in acute healthcare teams using care pathways: A cluster randomized controlled trial. Medical Care 2012; In Press.
- 26. 28/01/2014 RQ2 (study 3):Cluster RCT on impact of CPs on interprofessional teamwork: intervention
- 27. 28/01/2014 RQ2 (study 3):Cluster RCT: results of multilevel analysis Teams that developed a care pathway for COPD/PFF: Perceived themselves more as being a real team (β=0.30 (0.91); 95% CI 0.11 to 0.49) Better quality of work environment (β=0.40 (0.14); 95% CI 0.11 to 0.69) TEAM Better management support (β=0.52 (0.11); 95% CI 0.29 to 0.74) Better structured leadership (OR= 4.27; 95% CI 1.02 to 17.86) More frequent team meetings (OR= 5.83; 95% CI 1.33 ; 25.68) Better team composition (β=0.11(0.04); 95% CI 0.0.03 to 0.18] No significant difference in team size Better conflict management (β=0.30 (0.11); 95% CI 0.08 to 0.53) Higher team climate for innovation (β=0.29 (0.10); 95% CI 0.09 to 0.49) No significant differences in leadership qualities and relational coordination Higher level of organization of care (β=5.56 (2.05); 95% CI 1.35; 9.76) Lower emotional exhaustion (β= -0.57 (0.21); 95% CI -1.00 to -0.14) Higher level of competence (β=0.147; 95% CI 0.147 to 0.640). INPUTS TEAM PROCESSES TEAM OUTPUTS
- 28. 28/01/2014 RQ2 (study 3):Cluster RCT: results of multilevel analysis Intervention Group Control Group N of team members with risk of burnout 7,3% 12,5% N of team members with burnout 3,8% 6% Deneckere S, Euwema M, Lodewijckx C, Panella M, Mutsvari T, Sermeus W., and Vanhaecht, K. (2012). Better interprofessional teamwork, higher level of organized care and lower risk of burnout in acute healthcare teams using care pathways: A cluster randomized controlled trial. Medical Care; 51(1):99 107.
- 29. 28/01/2014 Job Demand Control modelvan Karasek “Wie tegen problemen oploopt in zijn werk (dus regelbehoefte heeft), moet die zelf kunnen oplossen (regelcapaciteit)”
- 30. 28/01/2014 Principles of InnovativeWork Organisation MAKING TEAMS WORK
- 31. 28/01/2014 Organizational model ofa care pathway as a multiteam system aligning professionals and teams within linked clinical microsystems (CM) with individual, team and system goals Deneckere, S., Sermeus, W. (sup.), Vanhaecht, K. (cosup.), Euwema, M. (cosup.) (2012). MAKING TEAMS WORK. The impact of care pathways on interprofessional teamwork in an acute hospital setting: A cluster randomized controlled trial and evaluation of implementation processes.
- 32. 28/01/2014 OUTLINE Growing need forteamwork in healthcare How could care pathways improve teamwork? Setting of the PhD-study Objectives, research questions and included studies Study results General discussion and recommendations MAKING TEAMS WORK
- 33. 28/01/2014 Implications for healthservices CPs are an effective intervention for improving interprofessional teamwork and conflict management, increasing the organizational level of care processes, and decreasing risk of burnout for healthcare teams in an acute hospital setting CPs have the potential to tackle several barriers against effective teamwork: – Disconnected organizational structure: CPs build a structured care plan that will improve information transfer between multiple teams and support the interprofessional decision making process – Professional boundaries: CPs can build an essential group identity, shared mental model and a safe culture for innovation – Unwarranted variation, high task uncertainty: organizing care and defining clear team goals – Increasing job demands: CPs seem to be able to create essential job resources that can buffer the impact of these increasing job demands in the current healthcare environment
- 34. 28/01/2014 Some policy advice Decentralizationof decision processes Deregularization on professional boundaries Training in team competencies in education and collaborative learning platforms Financing system with incentives for collaboration: pay for quality, bundled payment Towards integrated care systems and service-line driven organizational structures Support care innovation and care process organization Transparency of quality which leads to collective ambition for change MAKING TEAMS WORK
- 35. MAKING TEAMS WORK 28/01/2014 Theimpact of care pathways on interprofessional teamwork in an acute hospital setting: A cluster randomized controlled trial and evaluation of implementation processes. ________________ dr. Svin Deneckere “Talent wins games, but teamwork and intelligence wins championships.” (Michael Jordan) Doctoral thesis in Biomedical Sciences Department of Public Health, KU Leuven Leuven, 2012