Challenges in Linking Team Challenges in Linking Team Effectiveness and Health Effectiveness and Health

Outcomes ResearchOutcomes ResearchG. Ross Baker, Ph.D.G. Ross Baker, Ph.D.

Deborah Tregunno, Ph.D.Deborah Tregunno, Ph.D.Madelyn Law, M.A.Madelyn Law, M.A.

University of TorontoUniversity of TorontoAcademy Health ConferenceAcademy Health Conference

June 9, 2004June 9, 2004

Supported in part by a grant from the Connaught Foundation Contributions from work by L. Lemieux-Charles, M. Murray and D.

Irvine Doran are gratefully acknowledged

The Impact of Teams on Outcomes The Impact of Teams on Outcomes

The importance of teamwork to high quality patient care is The importance of teamwork to high quality patient care is frequently assertedfrequently asserted But much of the teamwork literature is exhortatory, prescriptive But much of the teamwork literature is exhortatory, prescriptive

and anecdotaland anecdotal There is a considerable research literature examining There is a considerable research literature examining

health care team effectivenesshealth care team effectiveness But much of that literature does not examine the impact of But much of that literature does not examine the impact of

teams on patient care outcomesteams on patient care outcomes There is a growing literature on patient care outcomesThere is a growing literature on patient care outcomes

But few articles that study teams and team characteristics as But few articles that study teams and team characteristics as determinants of these outcomesdeterminants of these outcomes

More research is needed that incorporates valid and More research is needed that incorporates valid and reliable measures of team attributes reliable measures of team attributes and and clinical outcomesclinical outcomes

The Healthcare Team ParadoxThe Healthcare Team Paradox

While many see improved teamwork as a critical While many see improved teamwork as a critical strategy for creating better quality healthcare strategy for creating better quality healthcare there are few studies that demonstrate what there are few studies that demonstrate what team aspects contribute to quality care, or what team aspects contribute to quality care, or what interventions will improve team performanceinterventions will improve team performance

Why is that?Why is that?

What are some useful steps to bridge this divide?What are some useful steps to bridge this divide?

Criteria for Healthcare TeamworkCriteria for Healthcare Teamwork

1.1. Multiple health disciplines are involved in the care Multiple health disciplines are involved in the care of the same patientsof the same patients

2.2. The disciplines encompass a diversity of dissimilar The disciplines encompass a diversity of dissimilar knowledge and skills required by the patientsknowledge and skills required by the patients

3.3. The plan of care reflects an integrated set of goals The plan of care reflects an integrated set of goals shared by the providers of careshared by the providers of care

4.4. Team members share information and coordinate Team members share information and coordinate their services through a systematic communication their services through a systematic communication processprocess

Schmitt, Farrell and Heinemann, 1988

Problems in Healthcare TeamworkProblems in Healthcare Teamwork

Failure to appreciate the value of different rolesFailure to appreciate the value of different roles Power differentials inhibit communicationsPower differentials inhibit communications Professional autonomy concerns limit roles of some team Professional autonomy concerns limit roles of some team

membersmembers Professional roles limit participation in decision makingProfessional roles limit participation in decision making Conflict and conflict avoidance limit team effectivenessConflict and conflict avoidance limit team effectiveness Frequent staff changes complicate team learning and Frequent staff changes complicate team learning and

developmentdevelopment Effective team work may be compromised by a predominance Effective team work may be compromised by a predominance

of less experienced workersof less experienced workers

Adapted from Opie, 1997

Three Types of WorkgroupsThree Types of Workgroups Task forcesTask forces

Temporary groups that are assigned projects (and deadlines)Temporary groups that are assigned projects (and deadlines) CrewsCrews

Short terms groups composed of specialized personnel assembled in Short terms groups composed of specialized personnel assembled in modular fashion from a larger poolmodular fashion from a larger pool

Members fill “slots” until their shift or assigned time is upMembers fill “slots” until their shift or assigned time is up TeamsTeams

Work groups whose “lifetime” spans many projects and is typically Work groups whose “lifetime” spans many projects and is typically open endedopen ended

Strong need to become cohesive and require tools for communication, Strong need to become cohesive and require tools for communication, coordination and conflict resolutioncoordination and conflict resolution

““Team building exercises” are most often focused on the member Team building exercises” are most often focused on the member network at this levelnetwork at this level

Arrow, McGrath and Bendahl, 2000

Lemieux-Charles,et al 2004

Three Types of Healthcare Team Three Types of Healthcare Team StudiesStudies

Studies of team structure, work processes and team Studies of team structure, work processes and team processes (what makes teams effective?)processes (what makes teams effective?)

Studies of interventions that change team structures Studies of interventions that change team structures (how did new clinical roles or skills influence (how did new clinical roles or skills influence performance?)performance?)

Studies of how teams worked to improve quality of Studies of how teams worked to improve quality of care (how did new team skills or team focused care (how did new team skills or team focused interventions improve outcomes?)interventions improve outcomes?)

Team Effectiveness StudiesTeam Effectiveness Studies

Studies of the relationship of team composition, team Studies of the relationship of team composition, team task, team processes and team psycho-social traitstask, team processes and team psycho-social traits

Teams studied in range of different settingsTeams studied in range of different settings Varying instruments used to gather data with little Varying instruments used to gather data with little

overlapoverlap Richard Hackman’s model of team effectiveness used Richard Hackman’s model of team effectiveness used

in several studies, but complexity of model limits in several studies, but complexity of model limits focus to partial testingfocus to partial testing

Lemieux-Charles,et al 2004

Team Effectiveness StudiesTeam Effectiveness Studies ExampleExample: Gibson 2001: Gibson 2001 Methods:Methods: Multi-center study of relationship of goal Multi-center study of relationship of goal

setting training, self and group efficacy and setting training, self and group efficacy and individual and team effectiveness in 71 teams of 187 individual and team effectiveness in 71 teams of 187 nursesnurses

Findings:Findings: While self-efficacy was found to be related While self-efficacy was found to be related to individual effectiveness, and training raised self to individual effectiveness, and training raised self efficacy scores, the training did not affect team efficacy scores, the training did not affect team effectivenesseffectiveness

This study does not examine impact of team variables This study does not examine impact of team variables on objective outcomes, e.g., clinical statuson objective outcomes, e.g., clinical status

Gibson, CG, J. Org Behavior, 2001

Team Intervention StudiesTeam Intervention Studies

Studies that evaluate the impact of interdisciplinary Studies that evaluate the impact of interdisciplinary teams on clinical outcomesteams on clinical outcomes

RCT designs commonRCT designs common Outcome measures are reliable, valid but linked to Outcome measures are reliable, valid but linked to

specific populationsspecific populations Limited measures of team or psychosocial factorsLimited measures of team or psychosocial factors Unclear whether team performance improved or Unclear whether team performance improved or

whether addition of new skills was key (e.g., whether addition of new skills was key (e.g., physician on home care team)physician on home care team)

Lemieux-Charles,et al 2004

Team Intervention StudiesTeam Intervention Studies ExampleExample: Evans 2001 study of stroke units versus stroke team : Evans 2001 study of stroke units versus stroke team

carecare Methods:Methods: 267 patients with moderately severe ischemic stroke 267 patients with moderately severe ischemic stroke

were randomly allocated to stroke units or general medical were randomly allocated to stroke units or general medical units with stroke team supportunits with stroke team support

Mortality, other health outcome and resource use assessed at 3 Mortality, other health outcome and resource use assessed at 3 and 12 monthsand 12 months

Findings:Findings: Vary by stroke subtypes Vary by stroke subtypes Stroke unit mortality lower for patients with large vessel infarcts, but Stroke unit mortality lower for patients with large vessel infarcts, but

not for those with lacunar strokesnot for those with lacunar strokes Resource use is lower for patients with lacunar strokes on general Resource use is lower for patients with lacunar strokes on general

medical units with stroke teamsmedical units with stroke teams No assessment of team variables that might account for some No assessment of team variables that might account for some

of the differences in performance.of the differences in performance.Evans, Harraf, Donaldson, et al. Stroke, 2002

Quality Improvement Team StudiesQuality Improvement Team Studies

Studies of quality improvement teams and Studies of quality improvement teams and other teams focused on improving quality of other teams focused on improving quality of carecare

Most studies focus on team measuresMost studies focus on team measures Outcome variables are perceptions of impact or Outcome variables are perceptions of impact or

project activityproject activity Goldberg RCT looks at performance outcomesGoldberg RCT looks at performance outcomes

Complex analytical models Complex analytical models

Lemieux-Charles,et al 2004

Quality Improvement StudiesQuality Improvement Studies ExampleExample: Lemieux-Charles 2002 study of how quality : Lemieux-Charles 2002 study of how quality

improvement practices contribute to team effectivenessimprovement practices contribute to team effectiveness MethodsMethods: 506 team members of 97 quality improvement teams : 506 team members of 97 quality improvement teams

in 11 Ontario hospitals competed surveys about their work on in 11 Ontario hospitals competed surveys about their work on QI teamsQI teams

FindingsFindings: Quality improvement practices had a direct impact : Quality improvement practices had a direct impact on team effectiveness (as judged by team members, but not by on team effectiveness (as judged by team members, but not by external assessors)external assessors) Norms and process strategies mediated the impact of QI on team Norms and process strategies mediated the impact of QI on team

effectivenesseffectiveness Organizational context had a direct effect on QI practices and team Organizational context had a direct effect on QI practices and team

processesprocesses No measures of specific clinical outcomesNo measures of specific clinical outcomes

Lemieux-Charles, Murray, Baker, et al., J. Org Behavior, 2002

Key Methods Issues In Qualitative Key Methods Issues In Qualitative Studies of TeamsStudies of Teams

Team research requires complex analytical modelsTeam research requires complex analytical models Analyses are often multi-levelAnalyses are often multi-level Assessing interventions requires longitudinal dataAssessing interventions requires longitudinal data Valid and reliable instruments are not available for many Valid and reliable instruments are not available for many

constructsconstructs Where measures are available, they are often not used or other Where measures are available, they are often not used or other

measures not directly relevant are usedmeasures not directly relevant are used Measures of team require pooling data from team membersMeasures of team require pooling data from team members

Weighting team membershipWeighting team membership Increasing numbers needed when team is the unit of analysisIncreasing numbers needed when team is the unit of analysis

Sample sizes limit analysesSample sizes limit analyses

Key Research QuestionsKey Research Questions What are the key components of team effectiveness?What are the key components of team effectiveness? How does team effectiveness influence treatment How does team effectiveness influence treatment

outcomes, patient satisfaction with care and costs?outcomes, patient satisfaction with care and costs? What interventions improve team effectiveness?What interventions improve team effectiveness? What organizational supports improve team What organizational supports improve team

effectiveness and the relationship between effectiveness and the relationship between effectiveness and outcomes?effectiveness and outcomes?

What instruments provide valid and reliable measures What instruments provide valid and reliable measures of team effectiveness?of team effectiveness?

Some Useful Measurement ToolsSome Useful Measurement Tools Caregiver Interaction Questionnaire (Shortell, et al.,1994)Caregiver Interaction Questionnaire (Shortell, et al.,1994)

Leadership, communication, coordination and problem-solving/conflict Leadership, communication, coordination and problem-solving/conflict managementmanagement

Group Interaction Scale (Watson & Michaelson, 1988)Group Interaction Scale (Watson & Michaelson, 1988) Measures 5 dimensions of group interactionMeasures 5 dimensions of group interaction

Team Climate Inventory (Anderson & West, 1998)Team Climate Inventory (Anderson & West, 1998) Measures 4 factors linked to work group climate for innovation Measures 4 factors linked to work group climate for innovation

Operating Room Management Attitudes Questionnaire Operating Room Management Attitudes Questionnaire (Schaefer & Helmreich, 1993)(Schaefer & Helmreich, 1993) OR staff attitudes toward teamwork and safety, stress, hierarchy, OR staff attitudes toward teamwork and safety, stress, hierarchy,

teamwork and errorteamwork and error

Useful Measures, cont’dUseful Measures, cont’d Relational coordination (Gittell, 2000)Relational coordination (Gittell, 2000)

Four communications dimensions including request, timely accurate Four communications dimensions including request, timely accurate and problem solving and 3 relationship dimensionsand problem solving and 3 relationship dimensions

Coordination (Young, 1998; Alt-White, et al., 1983)Coordination (Young, 1998; Alt-White, et al., 1983) Measures 2 approaches to coordination, programming and feedbackMeasures 2 approaches to coordination, programming and feedback

Collaborative Practice (Weiss & Davis, 1985)Collaborative Practice (Weiss & Davis, 1985) Measures of collaboration between nurses and physiciansMeasures of collaboration between nurses and physicians

Quality in Action (Baker and Murray)Quality in Action (Baker and Murray) Five dimensions of culture related to improving care:Five dimensions of culture related to improving care:

Improvement orientationImprovement orientation Teamwork orientationTeamwork orientation Patient focusPatient focus Mission and goalsMission and goals Management styleManagement style

ConclusionsConclusions

While high quality care requires effective teams, While high quality care requires effective teams, there is little current research uses measures of team there is little current research uses measures of team behavior and culture in evaluating clinical behavior and culture in evaluating clinical interventions or quality improvementsinterventions or quality improvements

Identifying the types of constructs and measures of Identifying the types of constructs and measures of these constructs that can be used in health services these constructs that can be used in health services research will help to bridge the gap between team research will help to bridge the gap between team effectiveness research and clinical or quality effectiveness research and clinical or quality improvement studiesimprovement studies

For copy of papers and bibliography For copy of papers and bibliography

ross.baker@utoronto.caross.baker@utoronto.ca