Module 3:  Teams and Teamwork

Objectives

  1. Appreciate the unique skill sets, viewpoints, values, and beliefs of colleagues from various professions.
  2. Recognize the benefits highly-functioning health care teams bring to patient care.
  3. Identify effective and ineffective interprofessional teamwork patterns.
  4. Identify strategies for incorporating effective teamwork skills into existing curricula.

Overview

As defined in the Institute of Medicine’s (IOM) Report, Health Professions Education: A Bridge to Quality, (2003) an interdisciplinary (interprofessional) team is “composed of members from different professions and occupations with varied and specialized knowledge, skills, and methods.” (p. 54).  Members of an interprofessional team communicate and work together as colleagues, to provide quality, individualized care for patients.  Interprofessional teamwork as defined by the IOM (2003), is “a collaborative interaction among interprofessional team members to provide quality, individualized care for patients” (Texas Tech University HSC, 2012). Teamwork is necessary in any setting where health professionals interact with the shared goal of providing care for patients or communities. “Teamwork behaviors involve cooperating in the patient-centered delivery of care; coordinating one’s care with other health professionals so that gaps, redundancies, and errors are avoided; and collaborating with others through shared problem-solving and shared decision making, especially in circumstances of uncertainty” (IPEC, 2011, p. 24). Interprofessional teamwork is an essential part of patient-centered primary care, and “high-functioning teams require collaboration between physicians, nurses, pharmacists, social workers, clinical psychologists, case managers, medical assistants, and clinical administrators…” (Department of Veterans Affairs, 2010, p. 2).  Interprofessional collaborative practice is viewed “as key to the safe, high quality, accessible, patient-centered care desired by all” (IPEC, 2011, p. i). To make this a reality, health professions students will need to develop interprofessional competencies as part of the learning process, in order to be ready to practice effective teamwork and team-based care when they enter the workforce.  The Core Competencies for Interprofessional Collaborative Practice address Teams and Teamwork of the interprofessional team as Competency Domain #4, and state “Learning to be interprofessional means learning to be a good team player” (IPEC, 2011, p. 24).  The purpose of this module is to introduce the role of teams and teamwork in effective interprofessional practice.

Issues Impacting Teams and Teamwork

Leaders in team-based care value the potential contributions of all team members in meeting patient and community needs. Leaders interact with team members in ways that draw out potential contributions and build support for working together through an understanding of the dynamics of the team (Zaccaro, Heinen, & Shuffler, 2009). “Working in teams involves sharing one’s expertise and relinquishing some professional autonomy to work closely with others, including patients and communities, to achieve better outcomes. Shared accountability, shared problem-solving, and shared decision are characteristics of collaborative teamwork and working effectively in teams” (IPEC, 2011, p. 24). Diversity of expertise areas and professional abilities can be a potential source of conflict among team members.  “Conflicts may arise over leadership, especially when status or power is confused with authority based on professional expertise…staying focused on patient-centered goals and dealing with the conflict openly and constructively through effective interprofessional communication and shared problem-solving strengthen the ability to work together and create a more effective team” (IPEC, 2011, p. 24).

What does your profession bring to the interprofessional team? View this video Interprofessional Practice.

 

Benefits of Effective Healthcare Teams

Many health professionals are familiar with the series of Institute of Medicine (IOM) reports that focused on medical errors, quality care & patient safety; beginning with “To Err is Human” in 1999.  A major premise of this report was building safety into processes of care is a more effective way to reduce errors, rather than blaming individuals.  This report concluded that tens of thousands of Americans die each year as a result of preventable mistakes in their care, and linked reducing errors and improving safety with effective team functioning.  Another IOM publication, “Closing the Quality Chasm” in 2001 recognized that the U.S. health care delivery system did not provide consistent, high-quality medical care to all people, due to factors such as rapid advancement of medical science and technology.  Poor organization of the health care system, and lack of clinical programs with an interprofessional infrastructure to provide the full array of services needed by people with common chronic conditions also contributed to this development.  Recommendations on how the health system could be reinvented to improve the delivery of care involved six aims for health care delivery – safe, effective, patient-centered, timely, effective, and equitable care. Patients would experience care that is “safer, more reliable, more responsive to their needs, more integrated, and more available, and they could count on receiving the full array of preventive, acute, and chronic services that are likely to prove beneficial” (IOM, 2001).  In 2003, Health Professions Education (another IOM publication) outlined five competencies that focused on patient centered care, effective teamwork, evidence-based practice, informatics, and quality improvement as strategies for restructuring clinical education to be consistent with the principles of the 21st-century health system. “Educators and accreditation, licensing and certification organizations should ensure that students and working professionals develop and maintain proficiency in these five core areas” (IOM, 2003).

IPEC-2

There is an urgent need for high-functioning teams.  Utilization of multiple perspectives in health care offers the benefit of diverse knowledge and experience; however, shared responsibility without high-quality teamwork can result in problems.  For example, “handoffs,” where one clinician gives over to another the primary responsibility for care of a hospitalized patient, are associated with avoidable adverse events and “near misses,” partly due to inadequate communication among clinicians (Mitchell, 2012).  Frequently uncoordinated care provided by groups of people who have not developed team skills, lead some clinicians report that team care can be cumbersome and may increase medical errors (Audet, 2006).  “By acknowledging the aspects of collaboration inherent in health care and striving to improve systems and skills, identification of best practices in interdisciplinary team-based care holds the potential to address some of these dangers, and might help to control costs” (Boult, 2009; Famadas, 2008).  “The high-performing team is now widely recognized as an essential tool for constructing a more patient-centered, coordinated, and effective health care delivery system” (Mitchell, et al 2012).  Many models have been created and implemented to coordinate the activities of health care providers.  The skill and reliability with which team members work together is very fundamental to the success of a model of team-based care.  Team function has been described as a spectrum spanning from parallel practice with clinicians working separately, to integrative care with an interprofessional team approach predominates, with nonhierarchical consensus building utilized (Boon, et al, 2004).

Effective vs. Ineffective Interprofessional Teams

In addition to behaviors that facilitate the function of the team, certain personal values are necessary for individuals to function well within the team. Five personal values that characterize the most effective members of high-functioning teams in health care: honesty in team communications; discipline in carrying out roles and responsibilities; creativity in taking on new or emerging problems; humility in awareness of each team member’s differences in training, potential for mistakes or failure, and reliance of each other to help recognize and avert failures; and curiosity in willingness to reflect on lessons learned for continuous improvement in their work and the functioning of the team.  Principles of team-based health care have been identified as:  shared goals that reflect the patient and family priorities, clear roles and expectations for team members, mutual trust, effective communication, and measurable processes and outcomes to track and improve team performance over time (Mitchell et al., 2012). 

Team work can present many challenges but can be effective when the team builds on the strengths of the group members. In collaboration, the team devises a plan for working together, then individual members work to ensure they can contribute to the group and works together with the team on assignments. 

In module 2, you viewed videos that demonstrated both good and bad team behaviors.  Let’s focus on evaluating team functioning by viewing the following video.  While you view the video, use this rubric to determine if the team members are functioning optimally or not: Interprofessional Collaborator Assessment Rubric (ICAR)  

Now that you have evaluated team functioning, a question to consider is are you a member of a highly-functioning team?  Take this Team Fitness Test to find out.

 

Incorporating Effective Teamwork Skills into Health Professions Curricula

Health professionals agree on the benefits of effective teamwork in attaining desired outcomes in health care for patients.  However, a question that is important for each educational institution and educational program to address is ‘How can interprofessional education and collaborative practice elements be effectively incorporated into existing curricula’?  Each institution has unique characteristics that will factor into the answers of when, how, and what regarding what interprofessional education and collaborative practice experiences will look like for their particular institution.  The same health professions programs available in one institution may not be available in another institution, hence the mix of health professions programs will be different among the various institutions and impact the design and implementation of interprofessional education and collaborative practice components.  Bridges, Davidson, Odegard, Maki, and Tomkowiak (2011) describe three training curricula models of collaborative and interprofessional education from three universities that represent a didactic program, a community-based experience, and an interprofessional-simulation experience.

The didactic program emphasizes interprofessional team building skills, knowledge of professions, patient centered care, service learning, the impact of culture on healthcare delivery and an interprofessional clinical component. The community-based experience demonstrates how interprofessional collaborations provide service to patients and how the environment and availability of resources impact one's health status. The interprofessional-simulation experience describes clinical team skills training in both formative and summative simulations used to develop skills in communication and leadership.

Rosalind Franklin, University of Medicine and Science, designed a one-credit-hour, pass/fail course HMTD 500: Interprofessional Healthcare Teams.  This is a required course which meets August-March each year, and experiential learning allows the students to interact in interprofessional teams, and focus on collaboration in patient-centered care, and emphasis is placed on team interaction, communication, service learning, evidence-based practice, and quality improvement.  The service learning component requires in an interprofessional team to identify a community partner and engage in a community service project.  The clinical component allows three students from different professional programs to attend four sessions at a clinical site; which assists them to put their didactic knowledge into practice in patient care (Bridges et al, 2011).  A common theme identified as leading to a successful experience among the three interprofessional models included “helping students to understand their own professional identity while gaining an understanding of other professional's roles on the health care team” (Bridges et al, 2011).  Some other important factors identified as critical for a successful program included commitments from departments and colleges, mentor and faculty training, adequate physical space, technology, and community relationships.  Recommendations for best practices included the “need for administrative support, interprofessional programmatic infrastructure, committed faculty, and the recognition of student participation as key components to success for anyone developing an IPE centered program” (Bridges et al, 2011).  Furthermore, Bridges et al relate a prevailing belief that students who are trained using an IPE approach are “more likely to become collaborative interprofessional team members who show respect and positive attitudes towards each other and work towards improving patient outcomes”. The University of Florida offers a required two semester Interdisciplinary Family Health course which provides interprofessional community-based learning experiences for all first-year students from several colleges – medicine, dentistry, pharmacy, accelerated and traditional nursing students, physical therapy and clinical and health psychology students from public health and health professions, nutrition graduate students and veterinary medicine students who participate as volunteers. Dentistry and pharmacy include the course as part of a larger first year course, while it is a stand alone course in medicine and nursing.  Students complete four home visits over two semesters with volunteer families, approximately 60% of the families are underserved. The University of Washington has six health professions schools – medicine, pharmacy, nursing, social work, public health, and dentistry; and offer over 50 collaborative interprofessional offerings for students in the health sciences, addressing issues such as treatment of alcoholism to care for medically underserved populations.  A grant from the Josiah Macy Foundation is supporting a simulation to promote interprofessional teamwork via a clinical team training and skills assessment simulation for the core curriculum of the medicine, nursing, and pharmacy programs (Bridges et al, 2011).

These schools noted in the preceding section represent a sampling of the many methods and structures that have been utilized to implement interprofessional education and collaborative practice experiences in a variety of institutions.  Many faculty may also have an interest in incorporation of interprofessional education and collaborative practice experiences into their particular course, or within a program in their college or university.  Case-based learning activities can be effective for learning about the unique contributions each profession brings to the health care provided to patients.  Review the two case studies described below, and respond to the prompt questions for each case presented.  Also respond to the questions for reflection after working through both of the cases.  As a didactic learning activity, students can be assigned to different professional roles and asked to address the care of the patients in each scenario (See Teaching Tip below).

Reflection:

As you reflect upon the two case activities, please also consider these questions:

1. What is the meaning and significance of the inclusion or lack of inclusion of your profession, or other professions in each of the interprofessional care planning conferences? To the family?

2. What do you believe about team roles regarding taking responsibility for ensuring that effective, high quality care is provided to patients?

Patient-Centered Care

Many times we think of the healthcare team as those professionals that contribute their medical expertise.  However, we should not forget that our care needs to be centered on the patient and caregivers—they are also part of the healthcare team.

Teaching Tip 

These Teamwork Exercises can be modified for use as an instructional tool for your students. Simply assign students to represent a variety of professions, while strategically omitting some professions whose expertise would be crucial in the care planning process. Provide a brief script and include some prompts that may potentially guide dialogue, leading to inclusion of professions who were left off of the original interprofessional team, who may make substantial contributions to the plan of care.

You may also review the following resources for additional information on teams and teamwork:

Readings

Mindtools.com (2011). Forming, storming, norming and performing: Helping new teams perform effectively, quickly. View article here  

Barrett, J, Gifford, C, & Morey, J, Risser, D, & Salisbury, M (2001). Enhancing patient safety through teamwork training. Healthcare Risk Management, 21(4), 57-65. PMID:11729499

Hamilton S.S., Yuan, B.J., Lachman, N., Hellyer, N.J., Krause, D.A., Holllman, J.H., Youdas, J.W., & Pawlina, W. (2008). Interprofessional education in gross anatomy: Experience with first-year medical and physical therapy students at Mayo Clinic. Anatomical Sciences Education, 1(6), 258-63. PMID:19109855

Fitzgerald, A., & Davison G. (2008). Innovative health care delivery teams: learning to be a team player is as important as learning other specialised skills. Journal of Health Organization and Management, 22(2), 129-46. PMID:18700524

Hammick, M, Olckers, L., et al. (2009). Learning in interprofessional teams: AMEE Guide No. 38. Medical Teacher, 31(1), 1-12. PMID:19253148

     

References

Audet, A.M., Davis, K., Schoenbaum, S.C. (2006). Adoption of patient-centered care practices by physicians: Results from a national survey. Archives of Internal Medicine. 166(7), 754-759.

Boon, H., Verhoef. M., O'Hara, D., & Findlay, B. (2004). From parallel practice to integrative health care: a conceptual framework. BMC Health Services Research, 4(1),15.

Boult, C., Green, A.F., Boult, L.B., Pacala, J.T., Snyder, C., & Leff, B. (2009).  Successful models of comprehensive care for older adults with chronic conditions: Evidence for the Institute of Medicine's Retooling for an Aging America report. Journal of the American Geriatrics Society, 57(12), 2328-2337.

Bridges, D. R., Davidson, R. A., Odegard, P. S., Maki, I. V., & Tomkowiak, J. (2011). Interprofessional collaboration: three best practice models of interprofessional education. Medical Education Online, 16, 10.3402/meo.v16i0.6035. doi:10.3402/meo.v16i0.6035

Cranford, J., & Bates, T. (2015).  Infusing interprofessional education into the nursing curriculum. Nurse Educator, 40(1), 16-20.

Department of Veterans Affairs. Veterans Health Administration. (2010, August 26). VA requests proposals for primary care education centers of excellence. Program Announcement, Washington, DC: Author. Retrieved from http://www.va.gov/oaa/rfp_coe.asp

Famadas, J.C., Frick, K.D., Haydar, Z.R., Nicewander, D., Ballard, D., & Boult, C. (2008). The effects of interdisciplinary outpatient geriatrics on the use, costs and quality of health services in the fee-for-service environment. Aging Clinical and Experimental Research, 20(6), 556-561.

Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century.  A Report Brief.  Washington, DC: The National Academies Press.

Institute of Medicine. (2003). Health professions education: A bridge to quality. Washington, DC: The National Academies Press.

Institute of Medicine. (1999). To err is human: Building a better health system.  Washington, DC:  The National Academies Press.

Interprofessional Education Collaborative Expert Panel. (2011). Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, D.C.: Interprofessional Education Collaborative.

Ironside, P. (2007). Quality and safety education for nurses. Providing patient centered care through teamwork and collaboration.  Retrieved from http://qsen.org/providing-patient-centered-care-through-teamwork-and-collaboration/

Mitchell, P., Wynia, M., Golden, R., McNellis, B., Okun, S., Webb, C. E., Rohrbach, V… Von Kohorn, I. (2012). Core principles and values of effective team-based health care. Discussion Paper. Institute of Medicine, Washington, DC. Retrieved from www.iom.edu/tbc

Texas Tech Univ HSC Quality Enhancement Plan – Interprofessional Teamwork (2012). Retrieved from http://www.ttuhsc.edu/qep/teamwork.aspx

Zaccaro, S.J., Heinen, B., & Shuffler, M. (2009). Team leadership and team effectiveness. In Salas, E., Goodwin, G. F., & Burke, C. S. (Eds.) Team effectiveness in complex organizations (pp. 83-111). New York: Psychology Press.