Gatefold
Health care is a team sport, but too often practitioners act as individual players. This foldout considers the barriers to collaboration and how to overcome them.
Research by Matthew Weinstock
Health care is a team sport, but all too often practitioners act as individual players. They're siloed from the time they walk into medical, nursing or pharmacy schools to the time they touch their first patient. And while they may interact with each other in the care of a patient or a group of patients, those collaborations typically occur in short bursts and can result in communication lapses. Studies from the Joint Commission, Veterans Health Administration and others point to poor communication between caregivers as one of the top causes of medical errors and near misses. Add to that staffing shortages in almost every discipline, the growing interest from payers—including Medicare—to bundle payments, and the push toward accountable care organizations and it quickly becomes evident that fostering an environment that embraces teamwork is of critical importance.
"We have rapid in-and-out of the hospital and sicker patients," says Robert Wise, M.D., vice president, division of standards and survey methods at the Joint Commission. "The environment makes it harder to be heard and make sure that everyone knows what everyone else is doing."
The concept of team-based care isn't new. The Institute of Medicine highlighted the importance of the concept in its 2001 report, Crossing the Quality Chasm: A New Health System for the 21st Century. Others have been promoting team-based care for even longer. The challenge is implementation. There are a host of innovations being used now to encourage better communication—huddles; briefings before a patient handoff; timeouts before a surgery; the SBAR technique, situation background assessment recommendation—but there's still a need to build a foundation of teamwork to ensure that those types of activities are meaningful and successful, says James Battles, social science analyst for patient safety at the Agency for Healthcare Research and Quality.
AHRQ, along with the Department of Defense, has been giving hospitals and practitioners a boot camp in team-based care since 2006. The TeamSTEPPS program focuses on building up core competencies in teamwork. The aim is to improve the quality and safety of care. There are other initiatives under way, including one driven by hospitalists at the University of California San Diego Medical Center. The Joint Commission also has a keen interest in team-based care.
"The expectation of our standards is that you have some type of team-based care going on," Wise says. "And that is based on having a leadership that supports it and is trying to move it forward." Wise points to such policies as eliminating disruptive behavior and the universal protocol for preventing wrong-site surgery as examples.
This foldout focuses primarily on quality and safety aspects, but team-based care certainly extends beyond those issues, especially as health care becomes more integrated. A multidisciplinary approach will likely become the norm. Groups such as the American College of Physicians are developing models that incorporate team-based care into a doctor's daily practice.
In the early 2000s, the Agency for Healthcare Research and Quality and the Department of Defense began working together on a patient safety initiative aimed at improving teamwork in health care settings. The result was TeamSTEPPS, or Team Strategies and Tools to Enhance Performance and Patient Safety. The joint program officially launched in November 2006 and has thus far involved more than 1,500 organizations and 12,000 individual professionals. The premise behind TeamSTEPPS is simple—physicians, nurses, pharmacists, technicians and anyone else who touches a patient must work together to ensure safe and high-quality care. "Frequently what happens is we work as a group, but not a well-defined team," explains Andrew Kosseff, M.D., medical director of system clinical improvement at SSM Health Care. The 13-hospital system has been deploying TeamSTEPPS for the past couple of years. Put another way, caregivers are rarely trained together and end up focusing on their independent tasks. TeamSTEPPS teaches staff to understand one another's roles and come together in collaborative ways to improve quality and safety. The first step, says James Battles, social science analyst for patient safety at AHRQ and head of TeamSTEPPS, is to make sure that the organization is ready for change. "If you are not ready, don't even bother going forward," he says. "You'll do more damage by introducing something that people haven't bought into."
| Phase I: Assessment |
Phase II: Planning, training and implementation |
Phase III: Sustainment |
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Andrew Kosseff, M.D., is a true believer in teamwork. "It is my belief that this is one of the most important things we can do for patient safety," says Kosseff, medical director of system clinical improvement at SSM Healthcare. "What we tend to do is take separate issues and work on them; we are not creating an environment where safety is the central issue. If we get that as the core, then each of the small issues won't be as big."
To that end, SSM embraced the AHRQ-DoD TeamSTEPPS program in October 2007. Since that time, the system has trained 400 physicians and 11,000 nurses and other clinical professionals. By the end of March, there will be a STEPPS-trained unit at all 13 hospitals. Most are high-risk units such as obstetrics, operating room or emergency department. Because of the nature of the care in those units, caregivers are generally more interdependent than on an inpatient floor.
Kosseff identifies some keys along each step in the process:
Kosseff believes that part of the success behind STEPPS is its focus on patient safety. "This seems more acceptable to practitioners than if I called and said, 'I want to do some communication training with you.' "
Between 2005-2007, Katherine Jones worked with rural Nebraska hospitals to implement AHRQ's Partnerships in Implementing Patient Safety program, or PIPS. She says the goal was to teach the institutions how to be learning organizations. They made significant strides in encouraging staff to report problems and in developing a just culture.
"There wasn't much progress on teamwork," says Jones, assistant professor in the division of physical therapy education, School of Allied Health, the University of Nebraska Medical Center. "That wasn't really part of the project, but if you are going to be a learning institution you need to know about four behaviors: reporting, just culture, teamwork and learning. I see teamwork as the connective tissue."
Since March 2008, Jones has been working to train Nebraska's rural hospitals in the TeamSTEPPS model. Thus far, she's trained 35 critical access hospitals. Follow-through is important, she says. It can create serious problems if staff go back to their institutions and the concepts don't get fully implemented.
"You've heightened expectations of what ought to occur," she says.
Training a rural hospital presents some unique challenges and opportunities. Pulling together training sessions without compromising patient care can be difficult. Training often occurs at night or on the weekends. At the same time, changing culture can be easier in a small institution, Jones says.
"It's a lot easier to turn a motorboat than a battleship," she says.
More than 2 million Americans suffer from venous thromboembolism—blood clot—each year. More than half of those patients develop the condition in the hospital or 30 days after discharge, according to AHRQ. One in 10 patients developing deep vein thrombosis dies from pulmonary embolism. A well-designed prevention program can help hospitals avoid many of those unnecessary deaths.
The division of hospital medicine at the University of California San Diego Medical Center developed a team-based approach that resulted in 98 percent of inpatients getting clot prevention regimens and a significant drop in hospital-acquired blood clots. The program earned the medical center the Society of Hospital Medicine's first Team Approaches in Quality Improvement Award in 2008.
"The process here involves getting people on the same page," says Greg Maynard, M.D., chief, division of hospital medicine and clinical professor of medicine, UCSD Medical Center. "We built order sets that help physicians on every service strategize the DVT risks."
Under the protocol, patients are evaluated for a risk of clotting and appropriate treatments are ordered. Nurses, pharmacists and physicians came together to develop the order sets. Hospitalists drove the process. Nurses act as a second line of defense and have the ability to double-check orders with physicians.
"Nurses can't feel like they are going to get their heads bitten off if they call the doctor," Maynard says. Even if the order is correct, that no prophylaxis is necessary, the doctor should thank the nurse for caring for the patient, he adds.
The division of hospital medicine is mirroring this kind of team building in several other areas—transitions of care, glycemic controls for diabetics, delirium, osteoporosis and pneumonia. With osteoporosis, an outpatient primary care physician approached Maynard for help because it is common across health care settings to misdiagnosis or just miss the condition. The team brings together internal medicine, endocrinology, orthopedics and geriatrics.
This article 1st appeared in the March 2010 issue of HHN Magazine.
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