Team Functioning in a Health Care Setting

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Team Functioning in a Health Care Setting

• Alan B. Stevens, PhD
• Director, Dementia Care Research Program
• Associate Professor
• Division of Gerontology and Geriatric Medicine
• University of Alabama at Birmingham

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Health Care Teams

• Response to specialization and technological
  complexity in health care
• Prevalent in the management of chronic conditions
  (e.g., diabetes, congestive heart failure,
  depression)
• Little is known about the organizational
  structure and the process of teamwork, and the
  resulting impact of teamwork on clinical outcomes

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The Challenge of Effectiveness

• Intensive Care Units
• Emergency Departments
• VA Surgical Services
• Geriatric Assessment Units.

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Team Characteristics and Patient Outcomes on VA
Rehabilitation Services (E-953 / E-1101)Team
Functioning and Patient Outcomes an RCT in
Process Improvement (E2367R)

• Dale C. Strasser, M.D. Principal Investigator
• Susan E. Bowen, Ph.D. Project Manager
• Judith Falconer, Ph.D, MPH, OT/R Investigator
• Jeph Herrin, Ph.D. Investigator
• Rebekah N. Johns, OTR/L, MS Research Associate
• Alan Stevens, Ph..D Investigator
• Stan Smitts, Ph.D Consultant
• Jay Uomoto, Ph.D Investigator

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Model of Treatment Effectiveness inInpatient
Stroke Rehabilitation (Strasser 1997)
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A Model of Team Functioning

• Relations
• Social Climate
• Interprofessional
• Actions
• Leadership
• Managerial Practices

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Team Relations Social Climate and
Interprofessional Relations

• Person
• Assumed Role
• Interpersonal
• Social Climate

• Profession
• Codified Role
• Interprofessional
• Rehab Business

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Team ActionsLeadership and Managerial Practices

• Team
• Procedures
• Communicate
• Coordinate
• Problem-solve
• Managerial Leadership

• Expert
• Trust
• Motivate
• Prioritize
• Unify
• Practices

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Staff Surveys and Patient Outcome Data from a
National VA Data Base

• Demographics and Measures of
• Organizational Culture (Hospital Influences)
• Physician Leadership (Actions)
• Managerial Practices (Actions)
• Social Climate (Relations)
• Interprofessional Relations (Relations)
• Patient Outcomes
• FIM Motor Scores
• Length of Stay
• Discharge Destination

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Summary of Participants

• 46 teams representing 46 inpatient rehab units
• 766 team members representing 6 core disciplines
• 1627 stroke patients

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Summary of Findings

• Three measures of team functioning were
  significantly associated with patient functional
  improvement
• task orientation (P 0.031)
• order and organization (P 0.021)
• utility of quality information (P 0.004)
• One measure of team functioning, teamness, was
  significantly associated with LOS ( P 0.022).
  
• Neither of two measures of hospital influences
  were associated with patient functional
  improvement or LOS.
• None of the team variables predicted discharge
  destination.

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Conclusions

• Multiple characteristics of team functioning
  appear to be related to patient outcomes.
• Efforts directed toward improving
  multidisciplinary activities and relationships,
  including collaborative planning and problem
  solving, and the use of feedback information, may
  enhance service delivery and patient outcomes.

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Team Functioning in the Nursing Home

• Nursing homes and inpatient rehabilitation have
  common treatment delivery and patient
  characteristics (e.g., treatment plans and goals
  for cognitively impaired patients).
• Multiple levels of nursing staff develop and
  implement plans of care for residents.
• Motivational systems for nursing staff have
  proven effectiveness.

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A Behavioral Supervision Motivational System for
Nursing Homes

• Clear definition of goals and tasks
• Self- and supervisory monitoring
• NA self-monitoring forms
• LPN supervisor monitoring forms
• Verbal and written performance feedback
• Immediate verbal feedback to individual NAs
• Weekly graphed feedback to individuals, unit
  groups, and administrative supervisors
• Written monthly feedback in personnel files
• Contingencies for CNA performance

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General Observations from Nursing Home Studies

• Generally, formal staff motivational systems
  produced superior performance than conventional
  nursing home supervision models.
• Direct observation of CNA performance suggests a
  marked therapeutic change in communication skills
  and a decreased use of ineffective strategies.
• Interventions have been associated with a
  significant decrease in agitation immediately
  post training and improvement in positive
  resident behaviors such as social interaction and
  active engagement in activities.

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Challenges to Psychosocial Nursing Home Research

• Measurement of Treatment Implementation (e.g.,
  behavioral strategy use)
• Conceptualization and measurement of resident
  outcomes (e.g., agitation)
• Feasibility of training protocol and staff
  motivational system in the current nursing home
  environment is questionable
• Reimbursement rates
• Staff-to-resident ratios
• Staff turnover

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Behavioral and Team Functioning to Meet Resident
NeedsA. Stevens and L. BurgioFunded by the
National Institute of Nursing Research

• Conceptualize resident problem behaviors more
  broadly
• Reduce staff training demands
• Individualized behavioral treatments
• Behavioral programs constructed by the NHs care
  plan team
• Support provided from a behavioral consultant
• Streamlined Behavioral Supervision techniques
• More contextually rich staff motivation system
• Supervisory skills training
• Team functioning skills training for all levels
  of the nursing staff

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Need-driven Dementia-compromised Behavior (NDB)

• Individuals with dementia have a unique set of
  needs that must be met by other people and the
  surroundings (environment) of the person with
  dementia.
• Each person has unique needs because of their
  background and their current situation.
• Problem behaviors develop when the individuals
  needs are not met.
• Identifying and meeting needs can be challenging
  for any caregiver.

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The W.A.I.T. ProjectWorking As Informed Teams

• Aim 1
• To evaluate the relative effects of the BPTF
  intervention as compared to minimal treatment
  control practices on CNA performance of specific
  behavioral strategies
• Aim 2
• To compare changes in NDBs (problematic
  behaviors) identified in residents
  individualized behavioral programs as well as
  changes in the residents overall level of
  problematic behavior across the two conditions.
• Aim 3
• To examine the effects of BPTF on the work milieu
  of the NH using standardized measures (Work
  Environment Scale, Perceived Effectiveness Scale)

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Eight Strategies for Managing Problem Behaviors

• Approach SkillsGetting off to a good start
• Physical Needs Making residents comfortable
• Adjust Stimulation Making a room pleasant
• Distraction Giving residents something else to
  do
• Single Steps Giving simple instructions
• Independent Behavior Getting residents involved
• Validation Responding to residents feelings
• Reinforcement Letting residents know they did
  well

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Resident Behaviors
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Resident Behaviors

• Target Behavior (duration)
• The behavior identified by the staff as most
  problematic for this resident.

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Behavioral Observations of Staff and Resident
Behaviors

• Observation system that allows event and duration
  coding using hand held computer (PDAs)
• Care routines are observed
• Time sampling during most problematic time for
  the resident (2 hour block)

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Behavioral Programming

• Behavioral programs to meet resident needs
• Training for Care Plan Team
• Web-based training and resource materials
• Inservice and hands-on training for nursing staff
  (Eight strategies)
• External cues to prompt strategy use
• Support from Behavioral Consultant

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Behavioral Supervision

• Supervisory and Self-monitor
• CNA and LPN bi-monthly performance evaluations
  and feedback from supervisors
• Incentives
• Performance-based lottery
• Immediate rewards for strategy usage

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Team Functioning

• Interactive training in core team work skills
• Leadership
• Communication
• Coordination
• Group problem solving
• Agenda-driven, structured unit meetings
• Team building activities (key rings, causal day,
  etc.)
• Organizational consultant

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Status of the Project

• Pilot conducted at a single nursing home
• Intervention Phase at first experimental
  condition nursing home
• Baseline Phase at first comparison condition
  nursing home, which includes aspects of
  behavioral programming
• Six additional nursing homes will be enrolled
  over the next three years