Transcript Inter-professional practice in health care

Inter-professional practice in health care
David Patrick Ryan, Ph.D.
Director of Education & Knowledge Processes, Regional Geriatric
Program of Toronto
Assistant Professor, Faculty of Medicine, University of Toronto
What is an interprofessional team?
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People from several professions
Each trained to use different tools and concepts
Whose labor organized around a common problem
With continuous communication and frequent reflection
on both the groups work and its process
• Usually with group responsibility for the final product
Interest in Teamwork Ebbs and Flows (Ryan 1996)
50
25+
23
20
16
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# of
Articles
11
10
Estimate
2000-2010
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5
5
6
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0
30s
From moral
treatment to
mental
hospitals
The medical
model and the
orthopsychiatric
trinity
40s
The Trinity
won the
right to treat
50s
Sociotherapy
and
broadening of
the mental
health team
60s
Community
Mental Health
and
sociotherapy’s
democracy
70s
Hospitals
emptied and
community
mental health
funding dwindled
80s
90s
00s
DRG’s
managed care
and mental
health
fragmentation
Integrated
care and
inter-team
collaboration
Patient safety is
linked to the
quality of
collaboration
Decades
Teamwork Articles in the Journal of Orthopsychiatry by Decade
Since the Journal Began in 1930
Why Interprofessional Practice? Why Now?
Chronic Disease and Frailty
Patient Safety
Success of Quality Improvement
The Quality of Working Life
Local Health Integration Networks
HealthForce Ontario’s Inter-Professional Care Blueprint for Action
Primary Care and Family Health Teams
Current Initiatives in Interprofessional Care
Province-Wide investment in Inter-Professional Education
Inter-professional Mentoring
Inter-professional Coaching
Inter-professional Preceptorships
Inter-professional prevention of delirium in the ED
Impact inter-professional practice within primary care groups
Inter-Professional Practice and Hospital/LTC accreditation
The Journal of Inter-Professional Care
GiiC – the geriatrics, inter-professional practice & inter-organizational
collaboration initiative for family health teams and community health
centers
Barriers to interprofessional teamwork: practice
based issues
• There is a lack of preparation for interdisciplinary hostility . . . If
the practice of this specialized form of aggression is to be placed
on a higher level, at least as high as professional wrestling…the
subtle arts of patronage, insult and innuendo must be taught.
Brody & Weithorn, 1965
• Unrealistic expectations, lack of knowledge and perceived threats
to autonomy Fried & Leatt, 1986
• Professional jealousies and role boundary issues Strasser et al 1994
• We practice together but we train apart
Barriers to teamwork: professions think differently
Qualls and Czirr, 1988)
Logic of assessment: from ruling out to ruling in
Focus of efforts: from acute episodes to quality of life
Locus of Responsibility: from executive to collaborative
Pace of Action
Focus of attention: from task to process
Interprofessional stereotypes
Decision making expectations: from executive to consensus
Beliefs about professional independence: from autonomy to
interdependence
(from
Barriers to teamwork: Though we practice together until recently we
trained apart (from Cleary & Howell, 2003)
Management Teams
Ad hoc Inter-agency Shared Care Teams
Continuing care and Rehabilitation teams
Acute Care Teams
Specialized Geriatric Services Teams
Primary Care Teams
Customer
Focused
Outcomes
Internal
Focused
Outcomes
Financial
Focused
Outcomes
Innovation
Focused
Outcomes
Customer
Needs &
Interteam
Issues
Team
Member
Skills &
Strengths
Communication
&
Conflict
Management
Roles &
Interdependence
Clarity/
Coherence
of Goals
Decisions
Authority
Accountbility
THE DIMENSIONS OF TEAMWORK
A framework for examining teamwork
Perceived
Support from
Organization
History of Teamwork in Health Care
The Original Team - Romantic Era (circa 1900)
General Practitioner
History of Teamwork in Health Care
Classic Sequential Teamwork and the Specialist Era
(circa 1920)
Specialist
Nurse
Specialist
Nurse
History of Teamwork in Health Care
Sequential Multi-Professional Practice Teams
(circa 1930)
Specialist
Nurse
Psychology
Social
Work
Rehab
History of Teamwork in Health Care
Dynamic Multi-Professional Team (circa 1960)
from a cadre of professionals
Nurse
Social Work
OT
Physio
Physician
Pharmacy
SLP
Psychology
Nutrition
Dentist
Recreation
History of Teamwork in Health Care
Dynamic Multi-Professional Team (circa 1960)
a team is convened around the needs of a particular patient
Social Work
Nurse
OT
Physician
Psychology
SLP
History of Teamwork in Health Care
Dynamic Inter-Professional Team (circa 1985)
from a cadre of professionals
Nurse
Social Work
OT
Physio
Physician
Pharmacy
SLP
Psychology
Nutrition
Dentist
Recreation
History of Teamwork in Health Care
Dynamic Inter-Professional Team (circa 1985)
A team is convened around the needs of a particular
patient
Core skills
Physician
Pharmacy
Core skills
Core skills
Nurse
Social Work
Core Skills
Multiprofessional
• Independent practice
• Guided by professional
standards
• Professions report to
depts.
• Leadership by rank or
profession
• Rigid role boundaries
• Conflict attributed to
individuals
• Little attention to team
process
Interprofessional
• Interdependent practice
• guided by professional &
team standards
• Discussion &
collaboration
• Leadership by skill or
primary issue
• Flexible role boundaries
• Conflict is a team
responsibility
• Routine attention to team
process issues
Myths about Teamwork
• There are no leaders on teams; everyone is equal
• If we just work together, we will eventually become a
high performance team
• Everyone is accountable for everything on teams
• Teams take a long time to get up and running
• All team decisions must be made by consensus
• Conflict must be worked out for a team to be productive
• On the best teams, everyone likes everyone else
• The most important work takes place in team meetings
• Confrontation means conflict
Just putting people together to work in teams doesn’t
necessarily produce effective interprofessional teamwork
Some of the things a team can do to maximize performance
Develop expertise to facilitate interprofessional practice
Annually monitor and reflect on team culture
Balance attention to task and process functions
Develop clear goals and monitor outcomes
Understand the dynamic nature of team development
Recruit or develop the right mix of skills
Value professional and personal diversity
The Dimensions of Teamwork Annual Survey
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Customer and inter-team issues
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Team member strengths and skills
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Communication and conflict management
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Roles and interdependence
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Clarity of team goals
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Decision-making and leadership
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Perceived organizational support
Quarterly review of informal team role performance
Task Roles
Maintenance Roles
Individual roles
Initiating/energizing
Harmonizing
Blocking/aggression
Information/opinion
giving
Gate keeping
Out of field
Encouraging
Digressing
Following
Recognition seeking
Information seeking
Reality Testing
Coordinating
Orienting
Technician
Acclimatizing
Routinely reflect on the stage of team development
Stage
Leader
Behaviour and
Informal Style
Team Member
Behaviour and
Informal Roles
Emotional
Climate and Team
Ritual
The Teams Style
of Humour
Stage 1:
Forming
The leader seeks to
control and direct
Dependency seeking
characterizes team
member behaviour.
Refreshments
anxiety
Leaders joke to soften control
Member joke about the team
and about patients
Stage 2:
Storming
The leader tries to
convince the team.
Team members resist.
Scapegoating is evident
Clowning reduces
tension
Conflict emerge often in
response to minor issues
which take on broader
symbolic meanings.
Humour is often barbed and
personal, interspersed with the
clowns buffoonery.
Stage 3:
Norming
Leadership exercised
by coalitions of
members based on
Perceptions of competence
Members are colleagues
who are able to defer to a
each other’s relevant
experience.
Members provide mutual
support . Parties express
solidarity. Team symbols
emerge
Sharing of team deprecating
humor. Self-disparaging jokes.
In-jokes emphasize membership
Stage 4:
Performing
Authority exercised
by a coalitions depending on
skills and emergent needs
Members find
opportunities for
interdependence and
resist earlier activities
such as scapegoat and
clowning
Members have pride in the
teams accomplishments.
Team meetings become
constructive and enjoyable.
Team legends emerge
and team anniversaries
celebrated.
The team laughs at itself but
explains its in-jokes to new or
non-members. It enjoys it's own
funny stories and myths.
Humour typically at the expense
of the team but without loss of
task orientation.
reduce
Value one another's diverse personal styles
I get pretty excited and
energetic and tend to let my
thoughts and feelings show
I stay cool, calm and collected
and tend to keep my thoughts
and feelings to myself
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When new things come I
prefer to wait, watch, ask
questions and hear all sides
before reacting
I get into new things quickly,
make up my mind fast and
hate to wait.
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Value one another's diverse personal styles
Use the ratings to plot your place on the “So Simple” grid. The results can be amusing even insightful.
Remember we are not rating whether someone is good or bad. We are trying to better understand
difference.
React quickly and hate to wait
Stay cool
calm and
collected
DRIVERS prefer to
move ahead calmly,
watching results,
staying organized
and asking “what’s
next”
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ENTHUSIASTS like
to jump into new
things, sets everyone
on fire by “just doing
it” and asking “Why
not?”.
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ANALYSTS like to
hear the details,
see facts and
figures and asks
“How is this going
to work?”
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HARMONISTS like to
give everyone the
opportunity to express
themselves and their
opinions often asking
“how is everyone
feeling?”
Wait, watch, hear all sides
Let feelings
and emotions
show
To summarize
It has taken us more than 100 years to get to this point of recognizing
interprofessional interdependence
The provincial interprofessional care blueprint is removing barriers
Frailty and chronic disease demand high quality interprofessional practice
Effective teamwork doesn’t just happen it needs ongoing care and tending
Teamwork can enhanced by a few strategic interventions
GiiC provide family health teams and community health centres with
several useful tools
GiiC has embedded interprofessional thinking within each geriatric topic
GiiC provides a consultant to help you to facilitate your team