Team-based care

Report
Teamness
Ron Stock MD MA
Associate Professor of Family Medicine
OHSU
[email protected]
April 12, 2013
Objectives
• Define what we mean by “teams” and “teambased care”
• Illustrate some attributes of “teamness”
• Understand how you might improve team care
in your practice
• Discuss important team “issues” or challenges
“Team-based health care is the provision of health
services to individuals, families, and/or their
communities by at least two health providers who work
collaboratively with patients and their caregivers—to
the extent preferred by each patient– to accomplish
shared goals within and across settings to achieve
coordinated high-quality care.”
IOM, 2012
What’s an example of a highly
effective team that you’ve been part
of?
Acute,
Chronic &
Consultative
Care
Senior
Health &
Wellness
Center
Team
Community
Geriatrics
Patient
Volunteers
Community
Connections
EMR
ACE Unit
PATIENT: Christa with Team
Pharmacist
Care
Coordination
Facility &
Workflow
Design
Six Themes Emerge from Transforming
Practices*
1. Practice adaptive reserve is critical to managing
change
2. Developmental pathways to success vary by practice
3. Motivation of key practice members is essential
4. The larger system can help or hinder
5. Practice transformation requires shifts in roles and
mental models
6. Practice change is enabled by the multiple roles that
facilitators play—consultant, coach, negotiator,
connector, and facilitator
*Crabtree et al. Summary of the NDP and Recommendations for the PCMH.
Ann Fam Med.2010.s80-s90
What is a team?
Multidisciplinary
Interdisciplinary
Interdependent
Team-Based Care vs. Teamwork
• “Teamwork” – a mode of functioning between
individuals (relationship-centric)
• “Team-based care”- a specific approach to the
delivery of health care that is based on
facilitating teamwork among participants, often
through structured protocols or processes
(process/task-centric)
Teamwork Model
(Baker et al, 2005)
Organization
Team
Individual
Individual Teamwork Skills
•
•
•
•
•
•
Personal skills & behaviors
Communication
Team Leadership
Mutual Performance Monitoring
Backup Behavior
Adaptability
Facilitative Leadership
• Practice leadership promotes an environment
that is an enjoyable place to work
• Leadership in this practice creates an
environment where things can be
accomplished
• Leadership strongly supports practice change
efforts
• The practice leadership makes sure that we
have the time and space necessary to discuss
changes to improve care
Leadership Roles & Behaviors
• Unambiguous support
• Set direction; teams are assigned authority
for the “means”
• Support Managers
• Create a learning environment
• Maintain boundaries
• Inspire/Reward/Celebrate
“HOW TO” Develop Teams
The Team Intervention “Bundle”
• Leadership Commitment
– Organization
– Practice/Unit level (MD and Site Leader Interview)
• Define Team, Leadership and Structure
– Meeting format & agenda (patients;performance;operations)
– Balance task and relationship
• The Team Development Measure
– Feedback to team with discussion
– Target improvements
• Intra-staff communication skills training
• Patient/case-focused care conferences or “huddles”
Exercise
The Team Development Measure
The Team Development
Measure (TDM)
• 31 Items
• Rasch survey measurement methodology:
– 0-100 scale;
– 4 response categories
• Psychometric testing:
– 145 different teams; n=1195 staff
– Classical Test Theory: Cronbach’s alpha=0.97;
• www.teammeasure.org
The Team Development Measure (TDM)
Fully
Developed
Stage 8
Stage 7
Stage 6
Team Primacy
Accomplishments of the team are placed above
individuals
Roles & Goals Clarity
Clearly defined roles/goals and expectations.
Stage 5
Stage 4
Stage 3
Stage 2
Stage 1
PreTeam
Communication
Team members…. Say what they feel and think; are
truthful, respectful and positive; address conflict
maturely
Cohesion
“…the social glue that binds the team members as
a unit.”
Cohesion
“…the social glue that binds the team members
as a unit.”
Interventions:
•
•
•
•
“Hiring for fit”
Understanding team members’ “passion”
Use the “we” language
Celebrate/reward
Communication
Team members….
Say what they feel and think; Are truthful,
respectful, and positive; Address conflict
maturely
Interventions:
• Workshop on communication “styles”
• Practice through care-planning, “huddles”
• Leadership modeling
Building Team Roles & Goals
Clearly defined roles/goals and expectations.
Interventions:
• Staff write roles and share/negotiate with
team
• Flowchart clinical processes to better
understand roles
• Expose team to different clinical roles
Team Primacy
Accomplishments of the team are placed above
individuals
Interventions:
• Understand organizational “Mission”
• Solicit input from all “roles” in team meetings
• Use team to develop QI agenda
• Demonstrate internal “transparency”
Team X
Typical 1st Assessment Results
Team Development (Baseline, August, 03)
7
Stages
6
Forming Cohesiveness
5
1
2
3
4
5
6
7
8
Full Development
4
3
2
1
8
4
-6
-2
0
-1
0
8
-9
96 94
92 0
-9
88 86
84 2
-8
80 8
-7
76 74
72 0
-7
68 6
-6
64 62
60 8
-5
56 4
-5
52 50
48 6
-4
44 2
-4
40 38
36 4
-3
32 0
-3
28 26
24 2
-2
20 8
-1
16 14
12
0
Team Development Score
Team X
Same Team 4 Months Later
Team Development (December, 03)
7
Stages
6
Forming Cohesiveness
5
1
2
3
4
5
6
7
8
Full Development
4
3
2
1
8
4
-6
-2
0
-1
0
8
-9
96 94
92 0
-9
88 86
84 2
-8
80 8
-7
76 74
72 0
-7
68 6
-6
64 62
60 8
-5
56 4
-5
52 50
48 6
-4
44 2
-4
40 38
36 4
-3
32 0
-3
28 26
24 2
-2
20 8
-1
16 14
12
0
Team Development Score
How Much Teamness Is There in Clinics?
Research on 42 Clinics
Mean Teamness Score of 42 Clinics
100
90
Mean Teamness
80
70
60
50
40
30
20
10
0
Clinic
Regardless of the topic, communication between the people in my work unit /
department is direct, truthful, respectful and positive.
100
90
80
Mean
70
60
50
40
30
20
10
0
Clinic
Organizational Health
Score
Team Intervention Clinic
100
90
80
70
60
50
40
30
20
10
0
85.1
81.3
62.4
2006
All Clinics
63.4
2007
Patient Satisfaction
In XXXX clinics the single strongest predictor of
overall satisfaction with care and service is:
“The teamwork of the clinic staff who took care of
you during your visit.”
Making “Teamwork” Development
Relevant:
1)The TDM Action Plan Worksheet;
2) Principles of Successful Teamwork
Important “Team” Issues
•
•
•
•
•
•
•
•
Communication training
Conflict management
What to do with the non-team player?
Where do patients and families fit in to the team?
Leadership: formal vs informal
Changing team membership
Balancing task vs relationship
Boundaries
Final Thoughts
•
•
•
•
•
Teams don’t just happen, training is necessary
Physician leadership and commitment is essential
Requires ongoing maintenance and practice
Need for continuous assessment and feedback
Teams are a prerequisite for sustainable quality
improvement
• Health and organizational health outcomes improve
Discussion

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