Team dynamics within quality improvement teams: a scoping review.

PURPOSE: This scoping review examines what is known about the processes of quality improvement (QI) teams, particularly related to how teams impact outcomes. The aim is to provide research-informed guidance for QI leaders and to inform future research questions. DATA SOURCES: Databases searched included: MedLINE, EMBASE, CINAHL, Web of Science and SCOPUS. STUDY SELECTION: Eligible publications were written in English, published between 1999 and 2016. Articles were included in the review if they examined processes of the QI team, were related to healthcare QI and were primary research studies. Studies were excluded if they had insufficient detail regarding QI team processes. DATA EXTRACTION: Descriptive detail extracted included: authors, geographical region and health sector. The Integrated (Health Care) Team Effectiveness Model was used to synthesize findings of studies along domains of team effectiveness: task design, team process, psychosocial traits and organizational context. RESULTS OF DATA SYNTHESIS: Over two stages of searching, 4813 citations were reviewed. Of those, 48 full-text articles are included in the synthesis. This review demonstrates that QI teams are not immune from dysfunction. Further, a dysfunctional QI team is not likely to influence practice. However, a functional QI team alone is unlikely to create change. A positive QI team dynamic may be a necessary but insufficient condition for implementing QI strategies. CONCLUSIONS: Areas for further research include: interactions between QI teams and clinical microsystems, understanding the role of interprofessional representation on QI teams and exploring interactions between QI team task, composition and process.

Interprofessional education and practice guide No. 5: Interprofessional teaching for prequalification students in clinical settings.

The importance of interprofessional education in health professions training is increasingly recognised through new accreditation guidelines. Clinician teachers from different professions may find themselves being asked to teach or supervise learners from multiple health professions, focusing on interprofessional dynamics, interprofessional communication, role understanding, and the values and ethics of collaboration. Clinician teachers often feel prepared to teach learners from their own profession but may feel ill prepared to teach learners from other professions. In this guide, we draw upon the collective experience from two countries: an institution from the United States with experience in guiding faculty to teach in a student-run interprofessional clinic and an institution from Canada that offers interprofessional experiences to students in community and hospital settings. This guide offers teaching advice to clinician educators in all health professions who plan to or already teach in an interprofessional clinical setting. We anticipate that clinician teachers can learn to fully engage learners from different professions, precept effectively, recognise common pitfalls, increase their confidence, reflect, and become role models to deliver effective teaching in interprofessional settings.

Exploring attitudes of Canadian radiation oncologists, radiation therapists, physicists, and oncology nurses regarding interprofessional teaching and learning.

The purposes of this exploratory study were to investigate the attitudes of radiation oncology professionals regarding interprofessional (IP) teaching and interprofessional education (IPE), to identify the challenges faced by radiation oncologists who teach within an IP context, and to discover new strategies to aid professionals teaching IP students. A questionnaire was developed through the review of existing literature on IPE using Medline. The proposed group of questions was selected by educators from different professions actively involved in IPE. The final revised questionnaire consisted of three main domains assessing the understanding of IP concepts, attitudes toward IP teaching and learning environments, and attitudes toward health-care teams. An open-ended comment section was included. The questionnaire was administered to health-care professionals (physicists, radiation oncologists, and radiation therapists) nationally through SurveyMonkey® (electronic survey). A total of 220 respondents provided demographic information. Half of these respondents indicated that they previously received education relating to IPE. A high level of agreement was received for nearly all the questions. There were no significant statistical differences among the three different professional respondent groups for any question. Overall, most of the respondents demonstrated a good knowledge and understanding of IP concepts and advocated IP training and collaboration.

Evaluation of perceived collaborative behaviour amongst stakeholders and clinicians of a continuing education programme in arthritis care.

Successful implementation of new extended practice roles which transcend conventional boundaries of practice entails strong collaboration with other healthcare providers. This study describes interprofessional collaborative behaviour perceived by advanced clinician practitioner in arthritis care (ACPAC) graduates at 1 year beyond training, and relevant stakeholders, across urban, community and remote clinical settings in Canada. A mixed-method approach involved a quantitative (survey) and qualitative (focus group/interview) evaluation issued across a 4-month period. ACPAC graduates work across heterogeneous settings and are on teams of diverse size and composition. Seventy per cent perceived their team as actively working in an interprofessional care model. Mean scores on the Bruyère Clinical Team Self-Assessment on Interprofessional Practice subjective subscales were high (range: 3.66-4.26, scale: 1-5 = better perception of team's interprofessional practice), whereas the objective scale was lower (mean: 4.6, scale: 0-9 = more interprofessional team practices). Data from focus groups (ACPAC graduates) and interviews (stakeholders) provided further illumination of these results at individual, group and system levels. Issues relating to ACPAC graduate role recognition, as well as their deployment, integration and institutional support, including access to medical directives, limitation of scope of practice, remuneration conflicts and tenuous funding arrangements were barriers perceived to affect role implementation and interprofessional working. This study offers the opportunity to reflect on newly introduced roles for health professionals with expectations of collaboration that will challenge traditional healthcare delivery.

Reducing length of stay in patients following liver transplantation using the model for continuous improvement.

Length of stay (LOS) is a significant contributor to overall patient outcomes for patients undergoing liver transplantation. This study documents a quality improvement project aiming to reduce the median post-transplant LOS for liver transplant patients. We instituted five Plan-Do-Study-Act cycles with the goal of reducing LOS by 3 days from a baseline median of 18.4 days over 1 year. Balancing measures such as readmission rates ensured any decrease in stay was not associated with significantly increased patient complications. Over the 28-month intervention period and 24-month follow-up period, there were 193 patients discharged from hospital with a median LOS of 9 days. The changes appreciated during quality improvement interventions carried over to sustained improvements, with no significant variability in LOS postintervention. Discharge within 10 days increased from 18.4% to 60% over the study period, with intensive care unit stay decreasing from a median of 3.4-1.9 days. Thus, the development of a multidisciplinary care pathway, with patient engagement, led to improved and sustained discharge rates with no significant differences in readmission rates.

Promoting Interprofessional Education and Collaborative Practice in Rural Health Settings: Learnings from a State-Wide Multi-Methods Study.

Evidence is mounting regarding the positive effects of Interprofessional Education and Collaborative Practice (IPECP) on healthcare outcomes. Despite this, IPECP is only in its infancy in several Australian rural healthcare settings. Whilst some rural healthcare teams have successfully adopted an interprofessional model of service delivery, information is scarce on the factors that have enabled or hindered such a transition. Using a combination of team surveys and individual semi-structured team member interviews, data were collected on the enablers of and barriers to IPECP implementation in rural health settings in one Australian state. Using thematic analysis, three themes were developed from the interview data: IPECP remains a black box; drivers at the system level; and the power of an individual to make or break IPECP. Several recommendations have been provided to inform teams transitioning from multi-disciplinary to interprofessional models of service delivery.

What's so great about rehabilitation teams? An ethnographic study of interprofessional collaboration in a rehabilitation unit.

OBJECTIVE: To explore team structures, team relationships, and organizational culture constituting interprofessional collaboration (IPC) in a particular rehabilitation setting; to develop a description of IPC practice that may be translated, adapted, and operationalized in other clinical environments. DESIGN: An ethnographic study involving: Field observations: 40 hours, over 4 weeks, daily activities, 7 interprofessional meetings, 3 care planning meetings, 1 business meeting, and 3 family meetings; Individual observations: a physiotherapist, an occupational therapist, and a social worker individually observed for 45 minutes to an hour; and Interviews: 19 participants, 11 professions, 27 informal, 5 formal interviews. Data analysis consisted of an iterative process involving coding field notes for themes by 3 members of the research team by qualitative analysis software. SETTING: Single inpatient spinal cord rehabilitation care unit in a Canadian urban academic rehabilitation hospital. PARTICIPANTS: Purposive convenience sample of core team, more than 40 professionals: physiatrist, over 21 nurses, 3 physiotherapists, 3 occupational therapists, 2 social workers, chaplain, psychologist, therapeutic recreationist, program assistant, program manager, pharmacist, advanced practice leader, 6 students (1 pharmacy, 4 registered nurse, and 1 psychology), and on-site community organizations. After university and hospital ethical approvals, all staff members were recruited to participate in the study. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Not applicable. RESULTS: Recurrent examples of IPC fit 2 dominant themes: team culture (divided into leadership, care philosophy, relationships, and the context of practice) and communication structures (both formal and informal). CONCLUSIONS: IPC practice in rehabilitation care is supported by clinical, cultural, and organizational factors. This understanding of daily IPC work may guide initiatives to promote IPC in other clinical team settings.

Exercise Training for Liver Transplant Candidates.

BACKGROUND AND AIMS: Frailty is associated with increased morbidity and mortality, and this is tightly linked to liver decompensation and increased complication rates among liver transplant (LT) candidates. The aim of the study was to evaluate the efficacy of a structured in- and outpatient exercise training program for cirrhotic patients who were referred for liver transplant evaluation. METHODS: We retrospectively reviewed 458 consecutive LT patients. There were 200 patients who underwent LT prior to the implementation of an exercise training program (non-ETP) and 258 LT patients who underwent a comprehensive exercise training program (ETP). Baseline characteristics, readmission rate, and length of hospital stay (LOS) were analyzed and compared between the 2 groups. RESULTS: The ETP group were more likely to have diabetes mellitus and coronary artery disease. However, there was no significant difference in the postoperative complication rates between the 2 groups except for more infections in the ETP group compared to the non-ETP group. There was a trend toward lower 90-day readmission rate in the ETP group (17.9% vs 20%) and shorter LOS (14 vs 17 days). CONCLUSION: There was a trend toward reduced 90-day readmission and shorter length of stay after implementation of an exercise training program.

Effectiveness of an Adapted SBAR Communication Tool for a Rehabilitation Setting.

Effective communication and teamwork have been identified in the literature as key enablers of patient safety. The SBAR (Situation-Background-Assessment-Recommendation) process has proven to be an effective communication tool in acute care settings to structure high-urgency communications, particularly between physicians and nurses; however, little is known of its effectiveness in other settings. This study evaluated the effectiveness of an adapted SBAR tool for both urgent and non-urgent situations within a rehabilitation setting. In phase 1 of this study, clinical staff, patient and family input was gathered in a focus-group format to help guide, validate and refine adaptations to the SBAR tool. In phase 2, the adapted SBAR was implemented in one interprofessional team; clinical and support staff participated in educational workshops with experiential learning to enhance their proficiency in using the SBAR process. Key champions reinforced its use within the team. In phase 3, evaluation of the effectiveness of the adapted SBAR tool focused on three main areas: staff perceptions of team communication and patient safety culture (as measured by the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture), patient satisfaction (as determined using the Client Perspectives on Rehabilitation Services questionnaire) and safety reporting (including incident and near-miss reporting). Findings from this study suggest that staff found the use of the adapted SBAR tool helpful in both individual and team communications, which ultimately affected perceived changes in the safety culture of the study team. There was a positive but not significant impact on patient satisfaction, likely due to a ceiling effect. Improvements were also seen in safety reporting of incidents and near misses across the organization and within the study team.

Exploration of patient safety phenomena in rehabilitation and complex continuing care.

Patient safety has been relatively unexplored in rehabilitation and complex continuing care (CCC) settings. From the perspectives of staff members, this qualitative study aimed to explore patient safety phenomena that exist within rehabilitation/CCC and to identify the characteristics of the current workplace culture that act as enablers of or barriers to patient safety. Sixty-six staff members in a large, multisite, academic rehabilitation/CCC health centre volunteered to participate in one of six interprofessional focus groups, designed to model patient care teams that exist within the clinical programs; one focus group was also conducted with support services staff. Thematic analysis revealed that rehabilitation/CCC settings present with distinct patient safety issues due to the unique and increasingly complex populations that are served, and the place of rehabilitation/CCC along the continuum of care. Enablers and barriers identified related to teamwork, culture, resources and organizational and individual responsibility. Results of this study have helped form the foundation for future patient safety initiatives within our settings, with clear emphasis on enhancing an open and just culture in which to discuss safety issues through development of improved leadership-staff relations, teamwork and communication and clearer processes and structures for accountability. The approach to addressing these issues must fit within our rehabilitation models of care.

Evaluating organizational readiness for change: a preliminary mixed-model assessment of an interprofessional rehabilitation hospital.

We conducted a Functional Organizational Readiness for Change Evaluation (FORCE) to assess the characteristics of readiness for change across two programs (N=216 employees) in an interprofessional rehabilitation hospital that was about to undergo strategic changes as part of a planned physical merger within the next two years. The study used a mixed-method approach: a quantitative survey, previously validated in a drug rehabilitation setting, followed by key informant interviews to further enlighten survey findings. Statistical analyses identified correlations between demographic variables (age, education and experience) and readiness for change, as well as the prevalence of specific organizational characteristics (motivation for change, access to resources, staff attributes, organizational climate, and exposure/ use of training opportunities) that facilitate or impede change. Findings were intended to better inform the tactics for successful implementation of upcoming initiatives. Much like assessing a patient prior to initiating a treatment, FORCE can serve as a management tool to direct the planning and implementation of changes intended to improve hospital performance.

Discharge criteria from perioperative physical therapy.

OBJECTIVES: To develop valid and reliable hospital discharge criteria and a scoring system that would be used to assess when a patient should be discharged from perioperative physical therapy (PT) care. DESIGN: We developed the postoperative physiotherapy discharge scoring tool (POP-DST), a tool composed of objective criteria and a scoring system that would be used to determine when a patient should be discharged from perioperative PT. It is a composite score of the following five subcategories: mobility; breath sounds; secretion clearance; oxygen saturation; and respiratory rate. The score for the POP-DST ranges from 6 to 15, with a score of > 13 indicating readiness for discharge. We examined the content validity of the the POP-DST using focus groups and a mailed survey. To determine interrater reliability, two therapists, who were blinded to each other's scores, assessed postsurgical patients. Validity was examined by comparing the decision to discharge based on the score on the POP-DST to the decision to discharge according to the therapist's judgment. In addition, subjects who were discharged from PT were followed-up 7 to 10 days later to determine whether they had developed any subsequent respiratory problems. PATIENTS: One hundred four surgical patients were assessed to determine the reliability and validity of the POP-DST. For the ability of the test to detect postoperative complications following discharge from PT, 204 surgical patients were followed-up after discharge from PT. RESULTS: Interrater reliability was moderately high (intraclass correlation coefficient = 0.76; r = 0.77). There was strong agreement between the decision to discharge the patient from PT based on the tool criteria compared to the therapist's judgment (kappa range, 0.91 to 0.96). The ability of the POP-DST to predict those patients who would not develop complications postoperatively was 94%. CONCLUSION: The results indicate that the POP-DST would facilitate clinical decision making related to PT discharge planning in postsurgical populations. The instrument demonstrated strong content validity and predictive validity, as well as high levels of interobserver agreement. This tool should be considered as a work in progress until it is more fully validated.

Conflicting messages: examining the dynamics of leadership on interprofessional teams.

PURPOSE: Despite the importance of leadership in interprofessional health care teams, little is understood about how it is enacted. The literature emphasizes a collaborative approach of shared leadership, but this may be challenging for clinicians working within the traditionally hierarchical health care system. METHOD: Using case study methodology, the authors collected observation and interview data from five interprofessional health care teams working at teaching hospitals in urban Ontario, Canada. They interviewed 46 health care providers and conducted 139 hours of observation from January 2008 through June 2009. RESULTS: Although the members of the interprofessional teams agreed about the importance of collaborative leadership and discussed ways in which their teams tried to achieve it, evidence indicated that the actual enactment of collaborative leadership was a challenge. The participating physicians indicated a belief that their teams functioned nonhierarchically, but reports from the nonphysician clinicians and the authors' observation data revealed that hierarchical behaviors persisted, even from those who most vehemently denied the presence of hierarchies on their teams. CONCLUSIONS: A collaborative approach to leadership may be challenging for interprofessional teams embedded in traditional health care, education, and medical-legal systems that reinforce the idea that physicians sit at the top of the hierarchy. By openly recognizing and discussing the tensions between traditional and interprofessional discourses of collaborative leadership, it may be possible to help interprofessional teams, physicians and clinicians alike, work together more effectively.

Rehabilitation in the context of HIV: an interprofessional multi-stakeholder process for curriculum development.

UNLABELLED: With longer survival, individuals living with human immunodeficiency virus (HIV) infection are facing a multitude of health-related challenges due to HIV, its associated concurrent health conditions, and treatments. Despite the need for rehabilitation, few rehabilitation professionals work with people living with HIV, with many feeling they lack adequate knowledge and skills to assess and treat this population. PURPOSE: We describe a national multi-stakeholder consultation used to inform the development of an interprofessional curriculum for rehabilitation professionals on HIV/AIDS. METHODS: We conducted a series of focus groups and key informant interviews (either in person or by telephone) with people living with HIV, rehabilitation professionals, physicians, curriculum experts, and other HIV stakeholders. Participants were asked to describe their perceived learning needs of rehabilitation professionals and to identify relevant content and delivery methods for a future interprofessional HIV/AIDS curriculum. RESULTS: Seven focus groups and 31 interviews with a total of 74 key informants were conducted, resulting in recommendations for content to include in HIV rehabilitation professional curricula and ways to deliver these curricula effectively. CONCLUSIONS: A national multi-stakeholder environmental scan was a useful preliminary step to inform the development of an interprofessional curriculum for rehabilitation professionals on HIV/AIDS. Recommendations serve as scaffold from which to build content and delivery of future curricula.

Interprofessional education: the student perspective.

The Toronto Rehabilitation Institute (Toronto Rehab) is a current leader in the movement of interprofessional education (IPE) initiatives in Ontario, Canada. Nine students from seven different health care disciplines, including medicine, nursing, occupational therapy, pharmacy, physiotherapy, social work, and speech language pathology participated in the second IPE clinical placement in the winter of 2005 on Toronto Rehab's Stroke inpatient unit. In an effort to increase interprofessional collaboration, improve communication skills, foster respect and enhance knowledge of the different roles each discipline plays on the health care team, these students met together over a five week period and participated in interprofessional group sessions led by different health care professional leaders from the unit. This paper discusses the students' perspectives on this IPE experience and the corresponding benefits and challenges. All participants in the study recognized the importance of interprofessional teamwork in patient care and agreed that all health care education should include opportunities enabling them to develop the skills, behaviours and attitudes needed for interprofessional collaboration.

Patient preference and gait efficiency in a geriatric population with transfemoral amputation using a free-swinging versus a locked prosthetic knee joint.

OBJECTIVE: To investigate patient preference, walking speed, and prosthetic use in a geriatric population with transfemoral amputation using a free-swinging prosthetic knee or a locked knee joint. DESIGN: Before-after trial. SETTING: Ambulatory patients at an amputee rehabilitation facility. PARTICIPANTS: A convenience sample of 14 geriatric individuals with a unilateral dysvascular transfemoral amputation (age range, 61-80y), who were using a prosthesis with a free-swinging knee in the community, 3 months after discharge from an amputee rehabilitation program. INTERVENTION: Change from a free-swinging knee to a locked knee. MAIN OUTCOME MEASURES: Patient preference, distance walked in 2 minutes, and prosthetic use as measured by the Houghton Scale. RESULTS: Eleven of 14 participants preferred the locked knee. Irrespective of preference, the mean 2-minute walk distance was 44.9 +/- 28.9m with the free-swinging knee and 54.4 +/- 35m with the locked knee (P = .001). Prosthetic use was greater with the locked knee (7.8 +/- 2.2) than with the free-swinging knee (6.6 +/- 2.5) (P = .01). CONCLUSIONS: Most geriatric participants with transfemoral amputation preferred locked knees and walked faster and used their prostheses more when using a locked knee prosthesis.