Improving Interdisciplinary Relationships in Primary Care With the Implementation of TeamSTEPPS
Siddons, Nicole M.
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Session presented on Thursday, July 21, 2016: Healthcare organizations face many diverse challenges, perhaps one of the most problematic of these is the lack of interdisciplinary collaboration plaguing healthcare. This issue results in serious complications with the safety and quality of care (IOM, 1999). One example depicting ineffective collaboration among healthcare teams occurred in an urban Midwest United States city, where a Native American community clinic recently transformed their care model by adding registered nurses to their team. As a result, issues with interprofessional collaboration and teamwork arose threatening healthcare outcomes and employee engagement. The Institute of Medicine (IOM) report, To Err is Human: Building a Safer Health System (1999) shows that errors often occur due to lapses in teamwork including collaboration, partnership, and team communication. The amount of evidence to support these claims has grown exponentially since this sentinel report. Yet, there is data that suggests healthcare organizations may be able to turn this undesirable trend around. Evidence indicates that when patients are taken care of by collaborative interprofessional teams, they are safer, receive a higher quality of care, and are more satisfied with the care they receive (Eisler & Potter, 2014; IOM, 2001). Additionally, employee satisfaction and engagement improve when there is effective interprofessional collaboration (Eisler & Potter, 2014). According to the World Health Organization [WHO] (2010), collaborative practice can improve access and coordination of health services, appropriate use of specialist resources, chronic disease outcomes, patient care and safety, patient satisfaction, and caregiver satisfaction. The WHO (2010) also shares that collaborative practice can decrease the total patient complaints and complications, redundant testing, length of stay, mortality and morbidity, clinical error rates, hospitalizations, staff turn over, and tension and conflict among staff. The consequences attributable to a lack of collaboration among healthcare professionals are very serious and often detrimental. Yet, the prospect of effective collaboration and partnership yields hope. The poor outcomes resulting from the absence of teamwork are simply unacceptable. It is essential that healthcare organizations strive to promote, educate, and maintain effective and efficient interdisciplinary teams (Eisler & Potter, 2014; IOM, 2001; WHO, 2010). After brainstorming, the clinic's leadership understood that the staff was in dire need of a partnership model, as well as coaching in various teamwork methods. It was necessary for staff to work effectively together in interdisciplinary teams to positively affect patient outcomes. Clinic leadership decided the time to take action was now. In 2001, the IOM issued Ten New Rules for Redesign; one of these guidelines indicates that cooperation among healthcare teams is imperative. The report states, 'Clinicians and institutions should actively collaborate and communicate to ensure an appropriate exchange of information and coordination of care' (p. 4). Joanne Disch, past president of the American Academy of Nursing reports that one of the five fundamental proficiencies necessary for healthcare professionals is the capacity to care for patients in interdisciplinary teams (Disch, 2012). Therefore, when discriminating among the various tools, it was important to utilize a tool that was based on partnership. One such tool or intervention, targeted to positively impact and optimize staff relationships and collaboration is a valid, evidence-based framework called TeamSTEPPS (AHRQ, 2008, 2010, 2014, n.d.). The acronym TeamSTEPPS signifies Team Strategies and Tools to Enhance Performance and Patient Safety (AHRQ, 2008). This program was designed by the Department of Defense, Duke University, and the Agency for Healthcare Research and Quality (AHRQ, 2010). This framework offers employees a shared mental model, a way to build mutual trust, team orientation, shared goals, and a common language (AHRQ, 2008). To enrich this process, IDEO's (2015) elements of human centered design were employed to customize TeamSTEPPS for the subject clinic, as well as engage staff members in the process of shifting the organizational culture to a partnership paradigm. An innovative design was used to enhance uptake and sustainability: frontline staff was asked to play a key role in customizing the program. Each week this group met to create curriculum specific to the needs of their clinic. They utilized principles of Human Centered Design (IDEO, 2015), where empathy and understanding one another's unique needs where used to develop the TeamSTEPPS program. The implementation team then taught the clinic staff the TeamSTEPPS content that was customized. There were three, 60-minute sessions for the entire staff. Outcomes were measured with valid tools, the TeamSTEPPS Teamwork Attitudes Questionnaire (TTAQ) and the TeamSTEPPS Teamwork Perceptions Questionnaire (TTPQ), that are specific and sensitive. These tools measure teamwork beliefs and behaviors in the setting respectively. Data was collected two weeks prior to the implementation of the TeamSTEPPS curriculum and five weeks post. In addition to this pre/post intervention data, the implementation team also evaluated the organizations quality scorecards. The implementation team found that results were noteworthy, even if perhaps they were not all statistically significant. They felt there was clinical importance in all of the data. For each paradigm (team structure, leadership, situation monitoring, mutual support, and communication) in both the TTAQ and the TTPQ, there was positive movement. This can be appreciated in Tables 1 and 2. After breakdown of pre-test results, the team understood that the staff's teamwork attitudes were already very high, meaning there might not be any statistical differences even with improvement. The analysis of pre- and post- test results was statistically insignificant for the TTAQ. However, it was most vital to affect the interdisciplinary collaboration behaviors, which would be measured by the TTPQ. There were statistical differences in two of the five domains in the TTPQ when comparing pre- to post- test. The differences were noted in team structure and situation monitoring. Mutual support (p-value 0.081) was nearing statistical significance but did not quite meet the necessary p-value of 0.05. These results can be visualized in Table 2. The subject clinic also reports quality data related to patient outcomes on a monthly and quarterly basis through a 'quality dashboard' method. It was important to take note of any quality improvement that could be attributed to shifting the organizational culture to a partnership paradigm through TeamSTEPPS. The dashboard metrics showed that the team met and exceeded quality goals after the TeamSTEPPS partnership training for early entry into prenatal care at 97% (goal of 70%), childhood immunizations at 71.4% (goal of 65%), tobacco use intervention 91% (goal of 40%), pharmacologic treatment of asthmatics 100% (goal of 100%), hypertension management 78% (goal of 75%), diabetes screening 87% (goal of 70%), and completion of post partum exam 55% (goal of 50%). Additionally, the clinic was noticing positive movement in other quality metrics: weight assessment and counseling for children and adolescents at 24.34% (previously at 16%), ischemic vascular disease aspirin therapy 84.09% (previously at 60%), and depression screening and follow up 37.39% (previously at 28%). The subject clinic leadership felt that these improvements could be attributed to the successful implementation of TeamSTEPPS, especially due to the fact that there weren't any other interventions or communications happening during this time period. Evidence is not merely research-based statistics, but also includes expert opinion, clinical experience, local data, and the patient experience (Rycroft-Malone, 2004). The strength of this collective evidence helps to substantiate this quality improvement project. Qualitative data from leadership at the clinic point to positive results and a shift towards effective teamwork. The clinic leaders and implementation team believe that the greatest indication of the success of TeamSTEPPS is based on subjective data and the quality dashboard. Several staff members have shared observations in relation to the transformation of the clinic's culture towards that of teamwork and interdisciplinary collaboration, truly shifting towards a partnership paradigm. The staff members feel that there have been many positive changes in the organizational culture. They share that this is appears to be direct reflection of TeamSTEPPS implementation, which taught the clinic staff how to partner together and become effective interdisciplinary collaborators and communicators. One of the greatest compliments the leadership received from staff was that they were pleased that every staff member was afforded the opportunity to be full partners in this process. Eisler and Potter (2014) share that equal partnership is a core component of partnership systems. The clinic staff appreciated that they were able to choose to be a part of the implementation team, where they were able to be frontline champions and leaders, as well as equal partners. Expert opinion and other quality studies align with this quality improvement project, providing a clear indication that healthcare professionals must engage in interdisciplinary collaboration to improve patient outcomes and staff engagement. Again, it has become abundantly clear that healthcare organizations must commit great effort to the promotion, education, and maintenance of effective and efficient interdisciplinary teams for the advancement of healthcare and consumer health (Eisler & Potter, 2014; IOM, 2001; WHO, 2010).