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28/01/2014

Doctoral thesis in Biomedical Sciences, KU LeuvenPromoter: Prof. Dr. Walter Sermeus; Co-Promoters: Prof. Dr. Martin Euwema & Dr. Kris Vanhaecht

MAKING TEAMS WORK:Care pathways as a tool to improve teamwork and

prevent burnout

dr. Svin Deneckere

06/02/14

MAKING TEAMS WORK

OUTLINE

Growing need for teamwork in healthcareHow could care pathways improve teamwork?Setting of the PhD-studyObjectives, research questions and included studiesStudy resultsGeneral discussion and recommendations

06/02/14

Why teamwork in healthcare?As many as 44.000 to 98.000 people die in hospitals each year as the result of medical errors. Medical errors are the eighth leading cause of death in U.S. – much higher than motor vehicle accidents (43.458), breast cancer (42.297), or AIDS (16.516).About 10% of patients hospitalized were harmed by the care they received Kohn et al. (1999). To Err Is Human:

Building A Safer Health System. Washington DC: National Academic Press.

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1

10

100

1000

10000

100000

1 10 100 1000 10000 100000 1000000 10000000

Number of encounters for each fatality

To

tal

live

s lo

st

per

yea

r

DANGEROUS(> 1/1000)

REGULATED ULTRA-SAFE(< 1/100K)

Bungee Jumping

MountainClimbing

Healthcare

Driving

Chartered Flights

Chemical Manufacturing

Scheduled Airlines

European Railroads

Nuclear Power

Healthcare

(bron: L. Leape, 2/2001)

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Improving quality and safety of patient care is still an important issue:– IOM-reports (1998, 2001): adverse events (AE)-rate in 3% to 4% of

patients hospitalized in the US– Langelaan et al. (2008): 8% AEs; 2.9% preventable AEs; 5.5% preventable

deaths– Levinson et al. (2010): 13.5 % AEs in hospitalized Medicare beneficiaries;

44% of AEs are preventableJoint Commission (2007): poor communication among team members was a contributing factor in almost 2/3 of AEs

“Patient care is a team sport. However healthcare is unique in that no other team sport has greater potential for catastrophic outcomes”. (Salas et al., 2008)

Why teamwork in healthcare?

MAKING TEAMS WORK

06/02/14

Adverse Outcomes in Belgian Acute Hospitals

Wmean 32.3 12.4 14.0 13.8 12.7 6.7 8.2 6.2 P90/P10 4.5 3.6 2.4 3.6 5.7 3.0 5.4 1.7 95%CI [3.5;5.4] [2.9;4.2] [2.1;2.8] [2.9;4.2] [4.2;7.3] [2.4;3.5] [4.0;6.8] [1.5;1.8] CGain 15539 3194 3178 4226 5945 1991 3693 2320

Wmean 32.3 12.4 14.0 13.8 12.7 6.7 8.2 6.2 P90/P10 4.5 3.6 2.4 3.6 5.7 3.0 5.4 1.7 95%CI [3.5;5.4] [2.9;4.2] [2.1;2.8] [2.9;4.2] [4.2;7.3] [2.4;3.5] [4.0;6.8] [1.5;1.8] CGain 15539 3194 3178 4226 5945 1991 3693 2320

Wmean 17.6 12.2 13.5 13.2 5.2 5.3 3.6 3.4 14.7 9.0 7.9 P90/P10 5.1 4.0 3.3 3.0 6.5 2.4 7.9 3.5 4.0 4.7 3.5 95%CI [3.8;6.4] [3.1;4.9] [2.7;3.9] [2.4;3.5] [4.3;8.6] [2.0;2.8] [4.9;11.0] [2.7;4.2] [3.2;4.8] [3.5;5.8] [1.7;2.1] CGain 5938 1943 5026 3016 1875 1336 1025 828 5983 3404 2786

Wmean 17.6 12.2 13.5 13.2 5.2 5.3 3.6 3.4 14.7 9.0 7.9 P90/P10 5.1 4.0 3.3 3.0 6.5 2.4 7.9 3.5 4.0 4.7 3.5 95%CI [3.8;6.4] [3.1;4.9] [2.7;3.9] [2.4;3.5] [4.3;8.6] [2.0;2.8] [4.9;11.0] [2.7;4.2] [3.2;4.8] [3.5;5.8] [1.7;2.1] CGain 5938 1943 5026 3016 1875 1336 1025 828 5983 3404 2786

Each dot represents one of 123 Belgian acute hospitals. Risk adjustment was done via indirect standardization with APR-DRG and SOI and Bayesian hierarchical modeling. Abbreviations: Wmean, weighted mean; 95% CI, 95% Credibility Intervals; CGain, centile gains; UTI, urinary tract infection; PU, pressure ulcers; PNE, hospital, acquired pneumonia; SEP, hospital, acquired sepsis; CNS, central nervous system complications; S/CA, shock or cardiac arrest; UGB, upper gastrointestinal bleeding; DVT, deep venous thrombosis; PF, pulmonary failure; MD, metabolic derangement; WI, wound infection.

Medical patients:Prevalence of 7.1%

Surgical patients :Prevalence of 6.3%

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Cost of poor quality?The Netherlands ‘Monitor Zorgerelateerde Schade 2011/2012’: – Total cost for adverse events of €523 million per year and €126

million per year potentially preventable adverse events. – 2,2% of yearly budget for hospital healthcare; 0,5% for potentially

preventable adverse events

Study on medical claims in USA:– $17,1 billion in 2008– 0,72% of total healthcare budget in USA– Highest cost due to postoperative infections ($3,4 billion) and

pressure ulcers ($3,3 billion)Langelaan M, Baines R, Broekens M, Siemerink K, van de Steeg L, Asscheman H et al. (2013). Mo nito r Zo rg g e re la te e rd e Scha de 2 0 1 1 /2 0 1 2 . Do s s ie ro nd e rz o e k in

Ne d e rland s e Zie ke nhuiz e n. Amsterdam, NIVEL en EMGO+ Instituut.

Van Den Bos J., Rustagi K., Gray T., Halford M., Ziemkiewicz E., Shreve J. (2011) The $ 1 7 . 1 Billio n Pro ble m : The Annua l Co s t O f Me a s ura ble Me d ic a l Erro rs . Health Affairs, 30, 4:596-603.

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PotentialProblem

Acc

iden

t

Problems with legal procedures

Incomplete Procedures

Unclear roles and tasks

Workload

Unclear accountability

Inadequate training

Divertion due to other problems Inappropriate

maintenanceUnstable technology

Conflicts in Goals

System problems call for system solutions

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Why teamwork in healthcare?

WHO World Alliance for Patient Safety: lack of communication and coordination as priority number one in patient safety research for developed countries (Bates, D. 2009)

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Several barriers to effective teamwork in healthcare:– Fragmented, disconnected organizational structures– No incentives in financing system to collaborate– Increasing job demands, high workload, different work schedules– Low level of agreement and low level of predictability – High specialization, high task interdependence, high functional

diversity– Interprofessional boundaries, different educational backgrounds– Power- and status differences, high competitive power– Unclear leadership structures– Temporary, ad hoc teams with low group identity, lack of role clarity and

poorly trainedRegular team conflicts: task /relation / process conflictsPseudo-teams in healthcare

Growing need for teamwork in healthcare

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06/02/14

Nugus et al, 2010

Lack of informal interaction

Power distributions

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Increasing job demands and high workload (RN4CAST-study KUL)

Within EU there will be shortage of one million healthcare workers RN4CAST:

– Study on nurse staffing in which 61.168 nurses and 131.318 patients participated, in more than 1.000 hospitals in 13 countries.

– Some Belgian results:• Nurse staffing level: 11 patients for each nurse (US 5/1, the Netherlands 7/1)• Number of nurses that are dissatisfied with their job: 22%• Number of nurses that are intended to leave their job: 30%• Number of nurses that report having a burnout: 24%• Prevalence of nursing care left undone in Belgium: 58% comfort talks with

patients, 44% patient education and 43% update care plans

FOD Healthcare: – 1198 medical doctors, 4635 nurses in 37 hospitals– medical doctors (5,4% burnout; 17,8 risk of burnout), nurses (6,9% burnout; 12,4%

risk of burnout). Aiken, L. H., Sermeus, W., Van den Heede, K., Sloane, D. M., Busse, R., McKee, M., … Kutney-Lee, A. (2012). Pa tie nt s a fe ty , s a tis fa c tio n , a nd q ua lity o f ho s p ita l c a re : c ro s s s e c tio na l s urve y s o f nurs e s a nd p a tie nts in 1 2 c o untrie s in Euro p e a nd the Unite d Sta te s . British Medical Journal, 344, e1717.

06/02/14

MAKING TEAMS WORK

OUTLINE

Growing need for teamwork in healthcareHow could care pathways improve teamwork?Setting of the PhD-studyObjectives, research questions and included studiesStudy resultsGeneral discussion and recommendations

06/02/14

Team improvement interventions (Buljac-Samardzic et al. 2010)

(1) Teamwork training programs: these involve a systematic process through which a team is trained to master and improve team competencies (e.g. crew resource management);

(2) Structured communication protocols: tools which seek to improve the reliability of transferring critical information (e.g. briefing and debriefing checklists)

(3) Organizational interventions: these are interventions that seek to change work processes and structures so that they support more effective communication.

MAKING TEAMS WORK

06/02/14

Team training interventions: Crew Resource Management

‘Fe rra ri p it s to p s s a ve s live s ’ Prof. Martin Elliot

06/02/14

Structured Communication Protocols: SBAR-Survey/Briefing

Adapted by Kaiser Permanente from a communication tool that was adapted from the US NavyAn effective and efficient way to communicate important information;A simple way to help standardize communicationAllows parties to have common expectations related to what is to be communicated and how the communication is structured.

S=Situation (a c o nc is e s ta te m e nt o f the p ro ble m ) B=Background (pertinent and brief information related to the situation) A=Assessment (a na ly s is a nd c o ns id e ra tio ns o f o p tio ns — wha t y o u fo und /think) R=Recommendation (a c tio n re q ue s te d /re c o m m e nd e d — wha t y o u wa nt)

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What are care pathways?

A care pathway is a complex intervention for the mutual decision making and organization of care processes for a well-defined group of patients during a well-defined period. Defining characteristics of care pathways include: – An explicit statement of the goals and key elements of care based on

evidence, best practice, and patients’ expectations and their characteristics;

– the facilitation of the communication among the team members and with patients and families;

– the coordination of the care process by coordinating the roles and sequencing the activities of the multidisciplinary care team, patients and their relatives;

– the documentation, monitoring, and evaluation of variances and outcomes– the identification of the appropriate resources

Vanhaecht K, Sermeus W, van Zelm R, Panella M. Care pathways are defined as complex interventions. BMC Me d ic ine 2010; 8:31.

06/02/14

Care pathways as organisational interventions to improve teamwork

Deneckere S., Euwema, M, Van Herck P., Lodewijckx, C., Panella, M., Sermeus, W., and Vanhaecht, K. (2012). Care Pathways Lead to Better Teamwork: Results of a Systematic Review. So c ia l Sc ie nc e & Me d ic ine ; 75(2):264-268.

06/02/14

MAKING TEAMS WORK

OUTLINE

Growing need for teamwork in healthcareHow could care pathways improve teamwork?Setting of the PhD-studyObjectives, research questions and included studiesStudy resultsGeneral discussion and recommendations

06/02/14

Setting: European Quality of Care Pathways (EQCP)-project

International multicentre research project launched by the European Pathway Association (E-P-A) (http://www.E-P-A.org), supported with unrestricted educational grant of Pfizer NV/SA Objective: to study the effectiveness of CPs for COPD-exacerbation and Proximal Femur Fracture (PFF) Participating countries: Belgium, Ireland, Italy and PortugalThree trials: Trial 1: a cluster RCT on the impact of a CP for PFF on patient processes

and outcomes Trial 2: a cluster RCT on the impact of a CP for COPD- exacerbation on

patient processes and outcomes Trial 3: a cluster RCT on the impact of CPs on interprofessional teamwork

in which both COPD-exacerbation and PFF-clinical teams are included

MAKING TEAMS WORK

06/02/14

Three research questions

RQ1: Which indicators can be used in order to study and follow up interprofessional teamwork in care processes?

RQ2: What is the impact of care pathways on interprofessional teamwork in an acute hospital setting?

 RQ3: Which team and organizational conditions will influence the successful implementation of care pathways in an acute hospital setting?

MAKING TEAMS WORK

06/02/14

Included studies

RQ1: Team indicators

RQ2: Impact of CPs on teamwork

RQ3: CP conditions

Study 1 Study 2 Study 3 Study 4Delphi-consensus method to support

international expert panel

Systematic literature review of articles on CP-effectiveness on

teamwork

Stratified post-test-only cluster randomized

controlled trial

Process evaluations of the implementation processes of the developed CPs

• Each participant rated an initial list of 44 team

indicators on a scale of 1 to 6.

• Consensus was sought in two consecutive

rounds based on the content validity index

• Literature search of articles published between 1999 and

2009• Both effect and

exploratory studies included

• Quality appraisal

• Intervention teams developed CP • Control teams

provided ‘usual care’• Summative

evaluation of team indicators

• Multi-level analysis

• Semi-structured, one-to-one interviews with key stakeholders of

each intervention team• Normalization Process Model used to guide the

inductive thematic analysis

• Purposive sample of 36 experts: 19 scientific researchers and 17 hospital managers

• 13 different countries

• 26 included studies• Mixed settings and

patient groups• 20 team indicators

used

• 30 teams caring for COPD or PFF patients• 17 intervention and

13 control teams• 581 team members

• Purposive sample of CP-facilitators,

management and team members

• 75 representatives

DES

IGN

MET

HO

DS

SAM

PLE

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RQ2 (study 3): Cluster RCT on impact of CPs on interprofessional teamwork: methods

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Overall response rate was 78%:- 379 nurses- 94 allied health professionals - 75 medical doctors- 33 head nurses

Deneckere S, Euwema M, Lodewijckx C, Panella M, Mutsvari T, Sermeus W., and Vanhaecht, K. (2012). Better interprofessional teamwork, higher level of organized care and lower risk of burnout in acute healthcare teams using care pathways: A cluster randomized controlled trial. Me dic a l Ca re 2012; In Press.

RQ2 (study 3): Cluster RCT on impact of CPs on interprofessional teamwork: sample

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RQ2 (study 3): Cluster RCT on impact of CPs on interprofessional teamwork: intervention

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Teams that developed a care pathway for COPD/PFF:

Perceived themselves more as being a real team (β=0.30 (0.91); 95% CI 0.11 to 0.49)Better quality of work environment (β=0.40 (0.14); 95% CI 0.11 to 0.69)Better management support (β=0.52 (0.11); 95% CI 0.29 to 0.74)Better structured leadership (OR= 4.27; 95% CI 1.02 to 17.86)More frequent team meetings (OR= 5.83; 95% CI 1.33 ; 25.68)Better team composition (β=0.11(0.04); 95% CI 0.0.03 to 0.18]No significant difference in team size

Better conflict management (β=0.30 (0.11); 95% CI 0.08 to 0.53)Higher team climate for innovation (β=0.29 (0.10); 95% CI 0.09 to 0.49)No significant differences in leadership qualities and relational coordination

Higher level of organization of care (β=5.56 (2.05); 95% CI 1.35; 9.76)Lower emotional exhaustion (β= -0.57 (0.21); 95% CI -1.00 to -0.14)Higher level of competence (β=0.147; 95% CI 0.147 to 0.640).

RQ2 (study 3): Cluster RCT: results of multilevel analysis

TEAM INPUTS

TEAM OUTPUTS

TEAM PROCESSES

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RQ2 (study 3): Cluster RCT: results of multilevel analysis

Intervention Group Control Group

N of team members with risk of burnout

7,3% 12,5%

N of team members with burnout

3,8% 6%

Deneckere S, Euwema M, Lodewijckx C, Panella M, Mutsvari T, Sermeus W., and Vanhaecht, K. (2012). Better

interprofessional teamwork, higher level of organized care and lower risk of burnout in acute healthcare teams using care

pathways: A cluster randomized controlled trial. Me dic a l Ca re ; 51(1):99 107.

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Job Demand Control model van Karasek

“Wie te g e n p ro ble m e n o p lo o p t in z ijn we rk (dus re g e lbe ho e fte he e ft),

m o e t d ie z e lf kunne n o p lo s s e n (re g e lc a p a c ite it)”

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Principles of Innovative Work Organisation

MAKING TEAMS WORK

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Organizational model of a care pathway as a multiteam system aligning professionals and teams within linked clinical microsystems (CM) with individual, team and system goals

Deneckere, S., Sermeus, W. (sup.), Vanhaecht, K. (cosup.), Euwema, M. (cosup.) (2012). MAKING TEAMS WORK. The impact of care pathways on interprofessional teamwork in an acute hospital setting: A cluster randomized controlled trial and evaluation of implementation processes.

06/02/14

MAKING TEAMS WORK

OUTLINE

Growing need for teamwork in healthcareHow could care pathways improve teamwork?Setting of the PhD-studyObjectives, research questions and included studiesStudy resultsGeneral discussion and recommendations

06/02/14

Implications for health services

CPs are an effective intervention for improving interprofessional teamwork and conflict management, increasing the organizational level of care processes, and decreasing risk of burnout for healthcare teams in an acute hospital settingCPs have the potential to tackle several barriers against effective teamwork:

– Disconnected organizational structure: CPs build a structured care plan that will improve information transfer between multiple teams and support the interprofessional decision making process

– Professional boundaries: CPs can build an essential group identity, shared mental model and a safe culture for innovation

– Unwarranted variation, high task uncertainty: organizing care and defining clear team goals

– Increasing job demands: CPs seem to be able to create essential job resources that can buffer the impact of these increasing job demands in the current healthcare environment

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Some policy advice

Decentralization of decision processesDeregularization on professional boundariesTraining in team competencies in education and collaborative learning platforms Financing system with incentives for collaboration: pay for quality, bundled payment Towards integrated care systems and service-line driven organizational structuresSupport care innovation and care process organizationTransparency of quality which leads to collective ambition for change

MAKING TEAMS WORK

06/02/14MAKING TEAMS WORKThe impact of care pathways on interprofessional teamwork in an acute hospital setting: A cluster randomized controlled trial and evaluation of implementation processes.________________dr. Svin Deneckere

Doctoral thesis in Biomedical SciencesDepartment of Public Health, KU Leuven

Leuven, 2012

“Ta le nt wins g a m e s , but te a m wo rk a nd inte llig e nc e wins

cha m p io ns hip s . ” 

(Micha e l Jo rda n)