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Best Practices for Team Dynamics and Teamwork

SITES ProgramCreighton University

Gail M. Jensen, PT, PhD, FAPTA, FNAP; Dean, Graduate School and College of Professional

Studies; Vice Provost for Learning and Assessment; Professor of Physical Therapy,

Creighton University, Omaha, NE ; GailJensen@creighton.edu

• Identify key challenges (and opportunities)facing health professions education across academic and clinical environments in building teams

• Identify and discuss evidence-based best practices for team dynamics and teamwork

• Explore 2-3 action steps you will apply

Learning Objectives

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Today, greater emphasis is being placed on collaboration, higher quality, more affordable care, and “proven approaches,” particularly in caring for high-need, high-cost patients. Emerging attributes point to communication and coordination among members of the care team.

These emerging models of care are novel and complex and not easily transferrable because they require cultural adaptation in individual environments …..Therefore, health systems are seeking hard data and evidence that links processes of care, which may or may not be team-based, to outcomes, to report to government agencies and Third-payer insurers. ….

They are seeking data to make decisions about the composition of health professionals in their workforce, how they work together, and how to train them in real time.

Experts in teamwork and interprofessional approaches have much to bring to these conversations, particularly around the measurement of team functioning and how to use proven tools in practice to link to evidence around outcomes, quality, affordability, and access to care.“

Barbara Brandt and Connie Schmitz published a guest editorial in the Journal of Interprofessional Care in 2017

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What is a team?

What is teamwork?

What kind of health care teams have you experienced?

Interprofessionaleducation (IPE)

Learners from 2 or more professions learn from and with each other to enable effective collaboration and improve health outcomes

Collaborative Practice (CP)

Happens when multiple health-related workers from different professional backgrounds work together with patients, families, care givers and communities to deliver the highest quality of care

Basic Concepts

(WHO, 2010)

CHALLENGEAnd

Opportunity

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• Patient safety (IOM Report, to Err is Human, 2000)

• Adverse events are preventable

• Fragmented care

• Failures in team communication

• Acceptance of Triple Aim (now quadruple)

Why IPE and CP?

• 1 in 10 patients develop a health acquired condition during hospitalization – (eg, infection, pressure ulcer, fall, adverse drug event)

• The resulting report calls for the establishment of a total systems approach– a culture of safety– calls for action by government, regulators, health

professionals– place higher priority on patient safety science and

implementation.

15 Years after TO Err is HumanNational Patient Safety Foundation - http://www.npsf.org/?page=freefromharm

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• Quality of Care

• Improved outcomes

• Cost effective– Practice at top of license

Interprofessional Care is Critical for….

http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx

Health is More than Health Care

Source: Schroeder, S. A. (2007). We can do better—Improving the health of the American people. New Eng J Med, 357(12), 1221–1228.

Social Determinants account for large proportion of premature mortality

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Motivations for Triple Aim

Too many people lack health

coverage & care

System focuses on treatment instead

of prevention

Lack of attention to SDoH, health

disparities

Inefficient delivery and payment

system

U.S. healthcare spending is

unsustainable

Low-ranking U.S. health outcomes

Source: “Why do we need the Affordable Care Act,” at http://www.apha.org/advocacy/Health+Reform/ACAbasics/.

From The Role of Accreditation in Achieving the Quadruple AimBy Malcolm Cox, Ann Scott Blouin, Patricia Cuff, Miguel Paniagua, Susan Phillips, and Peter H. VlassesOctober 02, 2017 | Discussion Paper

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• Professions disconnect and hierarchy

• Need to change HOW professions relate to each other before they can work together in collaborative teams

BUT……Barriers

Interprofessionalteamwork:The levels of cooperation, coordination and collaboration characterizing the relationships between professions in delivering patient-centered care.

Interprofessionalteam-based care: Care delivered by intentionally created, usually relatively small work groups in health care who are recognized by others as well as by themselves as having a collective identity and shared responsibility for a patient or group of patients(e.g., rapid response team, palliative care team, primary care team, and operating room team).

Basic Concepts

(IPEC, 2011)

TEAMSMATTER

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• Interprofessional education is a GREAT truth awaiting scientific confirmation

– John Gilbert

Does IPE lead to Collaborative Practice?

The learning continuum pre-licensure through practice trajectory

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• 1. Values/Ethics for Interprofessional Practice:– Work with individuals of other professions to maintain a climate of mutual respect and

shared values. • 2. Roles/Responsibilities:

– Use the knowledge of one’s own role and those of other professions to appropriately assess and address the healthcare needs of the patients and to promote and advance the health of populations served.

• 3. Interprofessional Communication:– Communicate with patients, families, communities, and professional in health and

other fields in a responsive and responsible manner that supports a team approach to promotion and the maintenance of health and the treatment of disease.

• 4. Teams and Teamwork:– Apply relationship-building values and the principles of team dynamics to perform

effectively in different team roles to plan, deliver, and evaluate patient-/population-centered care and population health programs and policies that are safe, timely, efficient, effective, and equitable.

IPEC Competencies (revisions)

Organizational

Health System processes

Practice

Practice-based processes

Individual

Knowledge, Skills, Attitudes

• IMPACT on health outcomes

• IMPACT on care quality

• IMPACT on learner performance

Current focus Proposed focus

Research into Interprofessional Education and Collaborative Practice

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• Effectiveness of IPE CP

• Return on investment for IPE and CP

• What are effective TEAM models?

• Essential factors that promote IPECP change

• How IPECP engages patients and communities

• How IPECP Population health

Urgent needs for way forward

Critical importance of the LEARNING continuum

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National Center for InterprofessionalPractice and Education

TEAMWORKTeamingLearning

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Interprofessionalteamwork:The levels of cooperation, coordination and collaboration characterizing the relationships between professions in delivering patient-centered care.

Interprofessionalteam-based care: Care delivered by intentionally created, usually relatively small work groups in health care who are recognized by others as well as by themselves as having a collective identity and shared responsibility for a patient or group of patients (e.g., rapid response team, palliative care team, primary care team, and operating room team).

Teamwork….(both work and CARE)

(IPEC, 2011)

TEAMSLearn to

Team

Teamwork –

Think about a successful learning experience?

What made the difference?

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Teamwork –

Think about a successful practice experience?

What made the difference?

• Meta-analysis of healthcare team training effectiveness

• Analyzed 129 studies

• Used Kirkpatrick’s criteria– Reactions, learning, transfer, results

Team Training in health care:Does it work? (Hughes, Gregory, Marlow, Lacerenza, King, Joseph, Sonesh, Benishek, Salas; 2016)

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• Team training be initiated at any stage of career trajectory

• High-fidelity team training is NO more effective than low fidelity team training

• Specific task training content no more or less effective than “pure” teamwork only training

• Importance of LEARNING and assessment of learning before and after training

Team Training in health care:Does it work? (Hughes, Gregory, Marlow, Lacerenza, King, Joseph, Sonesh, Benishek, Salas; 2016)

Team trainingLEARNING Transfer RESULTS

Sequential model of Healthcare Training

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• Training• Professional values• Understanding of roles• Communication skills and norms• Disciplinary vocabulary differences• Approaches to problem solving• Understanding of critical issues

Barriers to Team Effectiveness

• Allied ------------------ Health professionals• Clinical ------------------ Experiential • Doctor ------------------ Physician• Interdisciplinary------- Interprofessional• Medical ---------------- Health• My ---------------------- Our• Patient ---------------- Participant

Seven Dirty Words(Cahn, Acad Med; 2017)

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• Internal states – influence individual’s choices/decisions to act in certain way

Attitudes

• Overt actions/displayed during interactions between team members – collection action

Behaviors

• Knowledge & experience for effective teamworkCognition

National Center for Interprofessional Practice and Education – Practice Guide: Vol 1

• 1-Team leadership (behavior)

• 2-Mutual respect (attitude)

• 3-Mutual trust (attitude)

• 4-Team decision making (cognition)

• 5-Information sharing (behavior)

• 6-Conflict management (behavior)

Core team competencies in IPCP:Priority order

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• 7 – Team orientation (attitude)

• 8 – Adaptability (behavior)

• 9 – Mutual support (behavior)

• 10 – Shared mental models (cognition)

• 11- Situation monitoring (behavior)

Core team competencies in IPCP:Priority order

Cognitive Processes

Coordination Processes

Team Leadership vs Individual Leadership

Team leadership involves a team member enhancing Team Problem Solvingthrough team processes……

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• Assigning tasks

• Motivating team members

• Establishing a positive atmosphere

• Assessing team performance

• Developing knowledge, skills, and/or abilities in team members

Team Leadership: Behavioral markers

• Being open to new ideas, beliefs, abilities or others and valuing their input

• How to do this?– Understand team member preferences for

interdependent/collaborative work

– Establish clear team roles

– Understand the skills of each team member

Team Attitude: Mutual Respect

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• Shared team belief that team members will perform roles accurately and protect interests of team members

• How to do this?– Familiarity of working together– Face-to-face interactions– Team member attributes – integrity, ability,

and responsibility

Team Attitude: Mutual Trust

Situation Monitoring

Active process by which a situation awareness is obtained and continually updated

Situation AwarenessPerception of the elements in the environment within a volume of time and time; comprehension of meaning, project of status in near future

A Critical Skill…(self-awareness)

CommonOutcomes

Error correctionFeedbackAssistance

Reflective process

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LEARNING

Learner

Reflection

Self-monitoring

External information

seeking

Self-concept

Self-efficacy

Illusory superiority

Learning theories

Cognitive

Non-cognitive

Self-assessment skills

Self-directed learning skills

Influence Calibrate

Inform

Impact

Schumacher D, Englander R, Carraccio C, Acad Med. 2013;88:1635-1645

Novice Master

Adaptive LEARNER

Minimal Team Learning• Small group

learning activities and projects

Implicit team learning• Problem and team-

based learning• PBL

Explicit team learning• Simulation• Teams work

interdependently –clear goals; shared and common

3 Pedagogic Levels of Team Learning(Ernest, Williams, Aagaard, Acad Med, 2017)

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• Mandate for teamwork training is clear yet method and direction UNCERTAIN

• Most pedagogic methods fail to foster teamwork– Students are NOT interdependent in their work

– Curriculum is NOT explicit in addressing knowledge, skills and attitudes for performance

Pedagogy and Teamwork(Ernest, Williams, Aagaard, Acad Med, 2017)

• Lack of common teamwork models• TeamSTEPPS – skills based and fits best

in acute care settings• Weak theory• Weak evaluation tools• Critical need for longitudinal teamwork

competencies to create collaboration ready workforce

Pedagogy and Teamwork Challenges(Ernest, Williams, Aagaard, Acad Med, 2017)

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Professional Year 1

Professional Year 2

ProfessionalYear 3

Professional Year 4

Novice entry

Attitudes

Behaviors

Cognition

Learner Continuum – What should the learner progression look like across a professional Program?

• Aim High

• Team Up

• Fail Well

• Learn Fast

• Repeat

Teaming to Innovate (Edmondson, 2012)

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• Roles too narrowly focused, neglect the larger goals

• Different roles, think differently, communicate differently…complicates communication

• TEAMING- fast-paced communication

Challenge with Role-based coordination theory (Valentine, Edmondson, 2017)

• Minimal role-based structures – Team scaffolds

• Explicit shared goal

• Structure re-design facilitate team – co-located

• Need thoughtful leadership– Listening and learning together

Teaming (Valentine, Edmondson, 2017)

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Action Steps

• What is ONE thing you will do differently with students in the academic learning environment?

• What is ONE thing you will do differently with students in the clinical or community learning environment?

Expert teams Clinical protocols

Implement

Program IT with clinical protocols

IT system guides patient care

IT system actual care process data

Informs ongoing work of expert

teams

Example: Intermountain Healthcare/UtahFrom: Admondson A. Teaming, Jossey-Bass,2012

TEAMING Research Example

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Legacy Perspective

1,521 Patients with shoulder pain

*exercise habits

*patient age

*chronic disease co-morbidities

63 physical therapists

AgeGenderOCS certificationYears of experienceResidency training

Condition-Specific Outcome

Accounts for 6% of variation in shoulder

function outcome

Accounts for 26% of variation in shoulder

function outcome

Julie Fritz, PhD, PT, FAPTA, clinical outcomes research scientist at Intermountain HealthcareAssociate Dean for Research, College of Health, University of Utah

Population Health Perspective

PATIENT

Upstream Factors

Socioeconomic Factors

Physical Environment

Family/Social Context

Individual Factors

Genetic Factors

Behavioral Factors

Resiliency

Disease Factors

Co-occurring chronic

conditions

Health promotion/

wellnessHealth risk

management

Health Management Interventions

Care coordination/

advocacy

Tailored disease

interventions

Care Continuum Intermediate Outcomes

Long-Term Objective

IndividualHealth behaviors

Condition-specific function

Costs

PopulationCare access/

equity

Disease burden

Costs

Well-Being

Quality of Life

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Strategy Moving Forward

Legacy Perspective

• Advocate for physical therapy as entry point for all patients

• Critique other providers for clearly not understanding how to treat back pain

• Don’t change anything

• Blame patients if the anticipated saving fail to materialize

• Connect success in back pain to overall health

• Advocate for the role of physical therapy within an integrated practice unit focused on managing health

• Adapt to unique needs of patient population

• Leverage information to track performance

Population Health Perspective

Thank you…..questions?

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• Brandt B, Lutifiyya M, King J, Chioreso C. A scoping review of interprofessional collaborative practice and education using the lens of the triple aim. J Interprof Care. 2014; 28:393-399.

• Cahn P. Seven dirty words: hot-button language that undermines interprofessional education and practice. Acad Med. ahead of print. doi: 10.1097/ACM.0000000000001469

• Cox M, Cuff P, Brandt B, Reeves S, Zierler B. Measuring the impact of interprofessional education on collaborative practice and patient outcomes. J Interprof Care. 2016;30: 1-3.

• Earnest M, Pfeifle A. Addressing the irreducible needs of interprofessional education: creating and sustaining an institutional commons for health professions training. Acad Med. 2016; 91: 754-756.

• Earnest M, Williams J, Aagaard E. Toward an optimal pedagogy for teamwork. Acad Med. Doi.10.1097/ACM.0000000000001670. published online

• Edmondson AC. Teaming: How Organizations Learn, Innovate, and Compete in the Knowledge Economy. San Francisco,CA; Jossey-Bass, 2012.

• Hughes A, Gregory M, Marloe S, Lacerenza C, King H, Joseph D. Sonesh S, Benishel L, Salas E. Saving lives: a meta-analysis of team training in healthcare. Journal of Applied Psychology, 2016;101(9):1266-304.

• Institute for Healthcare Improvement. Available at: http://www.ihi.org/engage/initiatives/tripleaim/pages/default.aspxTripleAiM.

• Institute of Medicine of the National Academies. Measuring the Impact of Interprofessional Education on Collaborative Practice and Patient Outcomes. Available at http://iom.nationalacademies.org/Reports/2015/Impact-of-IPE.aspx;

• Jensen GM, Royeen CB, Purtilo RB. Interprofessional Ethics in Rehabilitation : The Dreamcatcher Journey. J Allied Health. 2010 ;39(3): 246-250

• Lutfiyya MN, Brandt B, Delaney C, Pechacek J, Cerra F. Setting a research agenda for interprofessional education and collaborative practice in the context of United States health system reform. J Interprof Care. 2016; 30:7-14.

• Lutfiyya MN, Brandt B, Cerra F. Reflection from the intersection of health professions education and clinical practice: the state of science of interprofessional education and collaborative practice. Acad Med. 2016; 91: 766-771.

• Nelson S, White CF, Hodges BD, Tassone M. Interprofessional team training at the prelicensure level: a review of the literature. Acad Med. 2017;92: 709-716

• Reiss-BrennanB, Brunisholz K, Dredge C, Briot P, Grzier K, Wilsox A, Savitz L, James B. Association of intergrated team-based care with health care quality, utilization, and cost. JAMA. 2016;316:826-834.

• Salas E, Rosen MA, Building high reliability teams: progress and some reflections on on teamwork training. BMJ Qual Saf. 2013;22: 369-373.

• Schumacher D, Englander R, Carraccio C. Developing the master learner: applying learning theory to the learner, the teacher, and the learning environment. Acad Med. 2013;88:1635-1645.

• Tilden V, Eckstrom E, DieckmannN. Development of the assessment for collaborative environments (ACE-15):a tool to measure perceptions of interprofessional teams. J Interprof Care. 2016; 30: 288-294.

• Valentine M, Edmonson A. Improving on-the-fly teamwork in healthcare. Harvard Business Review.Nov. 2016.

Selected References