Keeping Patients Safe Transforming the Work Environment of Nurses (2004) / Chapter Skim
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Appendix B: Interdisciplinary Collaboration, Team Functioning, and Patient Safety
Appendix B: Interdisciplinary Collaboration, Team Functioning, and Patient Safety
Pages 341-383
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From page 341... ...
What has been less evident is what constitutes effective team performance, how it is created and nurtured, and how it directly or indirectly influences care delivery outcomes. These unknown attributes and products of work teams should be explored thoroughly to enable sound recommendations concerning the promotion of interdisciplinary teams and collaborative work groups as a measure for .
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From page 342... ...
Theories of Work Team Effectiveness A number of theories exist concerning the ways in which teams work and how they produce favorable outcomes. Some of the more prominent theories relevant to the discussion of decision making for patient safety and for the creation of desirable care delivery outcomes are reviewed below.
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From page 343... ...
They found that better outcomes were perfectly rank-correlated with less hierarchy in the interaction patterns of team members. In focusing on other group processes that can undermine the effectiveness of team performance, Heinemann and colleagues (1994a)
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From page 344... ...
According to the original conceptualization, mistakes and lapses arise in the planning and thinking process, whereas slips occur primarily in the execution phase. Mistakes and lapses are more likely to occur during team processes, whereas slips are caused primarily by individuals (Sasou and Reason, 19991.
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From page 345... ...
Excessive authority gradient was the most dominant factor in failures to inclicate and correct errors, although excessive professional courtesy also leci to team member reluctance to challenge error makers. Shared errors commonly occurred cluring the human-machine interface, where low task awareness, low situational awareness, and excessive adherence to overreliance on established practices contributed to mistakes.
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From page 346... ...
Full integration of these fail-safe measures requires the development of cohesive work teams that emphasize integrity, trust, and cooperation (Bee, 19981. Necessary also are sufficient training of members who have direct influence over the system's safety; the development of positive economic and psychological incentives that promote safety behaviors; the development of effective internal and external checking and verification procedures; and standards of performance, including procedures for disciplinary action when rules are breached and the introduction of methods to promote early identification of and response to emerging risks.
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From page 347... ...
In the case of health care teams designed according to hierarchical reporting determiners, procedural justice is influenced considerably by the senior members of the team. If the senior members routinely seek and incorporate junior memhers' opinions in decision making, junior members are more likely to perceive the team process as just and supportable.
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From page 348... ...
Organizational Behavior and Team Performance More recent theories have been proposed concerning the ways in which organizations and work groups successfully reduce the potential for error. Some of these theories center on high-reliability organizations, defined as organizations that operate relatively free of error for long periods of time, frequently in hazardous environments (Bee, 1998; Gaba, 20001.
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From page 349... ...
Weick and Roberts suggest that this process has important implications for team development strategies in which training may be focused exclusively on content rather than heedful behaviors. They also recommend that training programs include attention to the social processes and dynamics of the work group.
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From page 350... ...
An emphasis on patient safety, health professional education, and awareness of the impact of the external environment also were evident at these institutions. Nelson and colleagues (2002)
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From page 351... ...
Interdisciplinary teams can be viewed as one specific form of collaboration that is relevant to certain situational circumstances of health care delivery. Questions can then be raised about other forms of collaboration between disciplines and the effects of that collaboration on care delivery outcome.
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From page 352... ...
Generally, the literature concerning collaboration in health care focuses primarily on nurse-physician interaction, whereas the literature on interdisciplinary teams focuses on a broader array of disciplines involved in care delivery. To develop a full appreciation of the impact of collaboration on safety outcomes, research must be expanded (as in Gittell et al.'s t2000]
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From page 353... ...
Six integrative reviews of research concerning interdisciplinary teams and care delivery outcomes were found in a search of medical, nursing, psychology, sociology, education, and business electronic databases. In the following summary of these integrative reviews, additional reports relevant to the content of the reviews are incorporated.
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From page 354... ...
. Of the 11 studies included, the results from 7 demonstrated greater effectiveness with the team approach; results of 3 studies indicated that team care is similar to or more effective than (depending on the outcome studied)
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From page 355... ...
interdisciplinary teams on patient outcomes (Cohen et al., 2002) , the core team members were clearly defined, and the elements of the intervention were well scripted.
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From page 356... ...
Of these, 55 were labeled as descriptive because they addressed some aspect of interdisciplinary teams but did not include a specific description of team process or any empirical data on process or outcome. Fifty-one articles were identified as process-focused because they contained descriptions of interdisciplinary team processes but no formal data.
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From page 357... ...
was designed by an interdisciplinary continuous quality improvement team for the purposes of improving patient care on the inpatient medicine units of one hospital. This investigation was a randomized controlled firm trial of daily interdisciplinary rounds that included all disciplines involved in patient care, with order writing occurring during rounds.
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From page 358... ...
Despite its exclusion, this study is only one of a few attempts to assess team interventions in long-term care settings. One other clinical trial of an interdisciplinary team intervention in a long-term care setting occurred much earlier
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From page 359... ...
introduced in 11 freestanding, not-for-profit long-term care facilities in eastern Wisconsin, which included interdisciplinary teams within and across sites. The investigators used both qualitative and quantitative means to measure program impact.
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From page 360... ...
Nurse retention rates also improved significantly following implementation of the model, as compared with reductions in nurse retention rates in non-Wellspring sites (Stone et al., 20021. Integrative Review # 6 A sixth integrative review focused on innovative models of health care delivery, including the use of interdisciplinary teams (Wadhwa and LavizzoMourey, 19991.
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From page 361... ...
In the studies of interdisciplinary team outcomes described in previous sections, medical error reduction is not examined directly. It appears reasonable to assume, however, that some overlap exists in the outcomes studied and patient safety outcomes.
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From page 362... ...
Drug-related error data were collected for 6 months; team and nurse manager behaviors were assessed through nonparticipant observation and surveys distributed during the second month of the study. Detected error rates were found to be strongly associated with high scores on nurse manager direction setting and coaching, perceived unit performance outcomes, and quality of unit relationships.
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From page 363... ...
Clearly, interpersonal communication, regard for others, a strong focus on patient safety goals, and constant reassessment of the environment are important aspects of the relationship between team performance and care delivery outcomes.
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From page 364... ...
The effect of work team performance on product quality anu labor productivity has been tested in a few manufacturing (Banker et al., 1996; Shrednick et al., 1992) and service (Cohen and Ledford, 1994)
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From page 365... ...
CRM training in civilian aviation was developed in response to several investigations of airline accidents indicating that a considerable percentage of the accidents were crew-related (Aarons, 2002~. Discussions of CRM strategies for performance improvement and error reduction suggest it is particularly useful when newly trained individuals or persons unfamiliar with a complex process are placed in highly charged, specialized task performance conditions (George, 2002~.
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From page 366... ...
The concepts associated with CRM make intuitive sense and support health researchers' and authors' suggestions concerning the structure, training, and goal-focused approach needed for successful team outcomes in high-risk settings. CREATING EFFECTIVE TEAMS AND COLLABORATIVE WORK RELATIONSHIPS IN THE WORKPLACE Barriers to Effective Team Development and Performance One of the most difficult barriers to effective team performance in health care is the differences in world view that exist across participating health professionals (Baggs and Schmitt, 1997; Prescott and Bowen, 19851.
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From page 367... ...
Two particularly notable cases are cited as instances in which poor team decision making resulted in a disastrous outcome and the loss of public faith. In each of these cases the Ford Pinto recall and Challenger shuttle disaster the failure of team members to question other members' decision making and the fear of repercussions from senior management created an environment ripe for errors in decision making, as theorized within a groupthink framework.
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From page 368... ...
According to Roberts, this case is particularly important to the study of team decision making and safe practice because poor decisions were made by a highly skilled team in an organization that would be described in today's terms as highly reliable and decentralized. Facilitators of Effective Team Development and Performance Favorable attitudes toward team performance and collaborative patient management approaches maximize team outcomes.
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From page 369... ...
-Level of trust among team members -Knowledge of team members' experiences and expertise · Team norms that support a focus on quality and safety · Patterns of communication/information exchange -Processes for exchange and dissemination of information within and across teams -Amount and complexity of information exchanged -Information processing methods · Knowledge and cognitive skills of team members · Expected outcome or product -Goal or charge of group -Clarity of team expectations -Complexity of team expectations · History of team members' experiences with team performance and outcome Organization/systems-related · Mission and philosophy zero tolerance of risk and harm · Level of specialization · Technological complexity · Organizational culture and climate · Organizational structure -Centralized versus decentralized -Independent versus system-supported/derived
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From page 370... ...
A combination of strategies will be required to achieve the effective working relationships needed to reduce care delivery errors and optimize care delivery outcomes. Among these strategies are the development of clear position descriptions and explication of role expectations for all members of the team (Disch et al., 20011.
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From page 371... ...
Team development strategies also need to include some attention to individual members' assessment of personal strengths and weaknesses and how these contribute to team performance. Also important is self-assessment of perceptions about how error occurs, and how stress and team performance contribute to errors and error identification.
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From page 372... ...
At the University of Texas, an aviation model of threat and error has been adapted to the health care environment. According to the model developers, this approach fits with health care's input-process-outcomes concept of team performance.
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From page 373... ...
Strategies for evaluating team performance range from day-to-day quality assessment processes to formal investigations of team impact. Inherent in all discussions of the impact of interdisciplinary teams on patient safety and other care delivery outcomes, however, is the need for continuous assessment of team performance and impact.
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From page 374... ...
had been introduced as intended and how it evolved over time, while the verification and improvement practices would constitute the ongoing quality improvement monitoring associated with ensuring compliance and achieving safe practices. One method for assessment of safe and unsafe practices recommended by a non-health-related (aviation)
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From page 375... ...
As a result, their use in the assessment of how team behavior influences care delivery outcomes and safety behaviors is limited. According to Marks and colleagues attention needs to be shifted to team performance episodes, where inputs, actions, and outcomes occur in a continuous, dynamic process.
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From page 376... ...
framework of team processes and outcomes stresses the multidimensional and constantly changing nature of teamwork behavior. This constant movement of teams from periods of transition between existing and new goals makes the measurement of team performance difficult, especially if single one-shot assessments are performed.
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From page 377... ...
Such a focus also may make the measurement aspects of assessing multidimensional team performance more manageable. Patient Management and Oversight Responsibilities Consistent with a focus on collaboration, communication, and interpersonal relationships is attention to the most effective patient management and care delivery approaches for reducing patient error.
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From page 378... ...
Much of this beneficial impact is perceived to be related to the communication and collaboration skills of these individuals and the case manager's ability to overcome systems barriers. Additional information is needed to clarify the impact of models of care delivery on patient safety outcomes.
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From page 379... ...
Organizational environments of interdisciplinary health care teams: Impact on team development and implications for consultation. International Journal of Small Group ResearcI7, 4(1)
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From page 380... ...
Joint Commission Journal on Quality Improvement, 28, 55-71. Halstead LS.
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From page 381... ...
Joint Commission Journal on Quality Improvement, 28, 235-241. Kosseff A L, Niemeier S
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From page 382... ...
Joint Commission Journal on Quality Improvement, 28, 296-305. Posner KL, Freund PR.
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From page 383... ...
A systematic review. Joint Commission Journal on Quality Improvement, 25, 408-421.
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