1. TEAM BASED
COLLABORATIVE CARE
BEATRICE KALISCH, RN, PHD, FAAN
TITUS DISTINGUISHED PROFESSOR AND
DIRECTOR, INNOVATION AND EVALUATION
UNIVERSITY OF MICHIGAN
ANN ARBOR
OMNI LEADERSHIP FORUM
CHICAGO, ILLINOIS
OCTOBER 3-5, 2012

2. Workplace
Collaboration
 Working together to achieve a
goal. It is a recursive process
where two or more people or
organizations work together to
realize shared goals.

3. Presentation
Outline 1. Teamwork and patient
safety and outcomes
2. What does teamwork
look like?
3. How can teamwork be
achieved?

4. A team is …
Two or more people working
collaboratively with a Two different
common purpose. competencies required
However • Expert clinically
teams of • Expert team player
experts often
fail to evolve
into expert
teams (Salas)

5. Teamwork and Patient Safety
One person’s
vulnerabilities
are offset by
another person’s
strengths.

6. Aviation example: Which team
made more mistakes?
Team that worked Team who did not work
together and tired together and rested

7. Swiss Cheese Model

8. Impact of Teamwork on Safety
 Strongest evidence is from cross sectional studies in the
ICU (because adverse events occur more often)
 Lower risk adjusted mortality rates
 Lower LOS for medical (not surgical) patients
 Group-type hospital culture predicted fewer patient falls
with injury Brewer, 2006
 Decreased errors with transfusions, needle sticks, wrong
medications, etc. Deering, 2011
 Decreased missed nursing care (errors of omission) Kalisch, 2011
 High teamwork has been associated with a safety culture
Blegen et al, 2009

9. Impact of Teamwork on Patient Outcomes
 The ultimate outcomes of interest
 Rand Corporation Study, Outcome Measures for
Effective Teamwork (2008)
 Teamwork has been associated with
 Patient satisfaction (Meterko, et al, 2004)
 Patient perceived quality of care (Friedman et al, 2004; Gittel et
al., 2000; Goni, 1999)
 Provider-reported quality of care (Deeter-Schmelz and
Kennedy, 2003; Shortell et al., 1994)

10. Impact of Teamwork on Patient Outcomes
(continued)
 Teamwork has been associated with (continued)
 Shorter LOS (Shortell et al, 1994; Boyle, 2004; Gitell, 2000; Friedman et al,
2004; Pronovost et al, 2003)
 Lower risk adjusted mortality for ICU and other
patients (Wheelan, 2003; Uhlig, et al, 2002)
 Decreased surgical morbidity (Young-Xu, 2011; Wheelan,
2003)
 Higher ability to meet family member needs
 Better functional outcomes (Shortell, et al, 2000; Mukamel, et
al, 2006)
 Decreased readmissions to the ICU (Baggs)

11. Impact of Teamwork on Patient Outcomes
(continued)
 Teamwork has been associated with (continued)
 Lower rates of pressure ulcers, falls, pneumonia
and death and catheter related blood stream
infections (Pronovost et al, 2006)
 Neonatal resuscitation quality (Thomas et al, 2006)
 Surgical task completion (Undre, et al, 2006)
 Decreased malpractice claims (Mann et al, 2006)
 Lower cost (Young et al, 1998)

12. Impact of Teamwork on Patient Outcomes
(continued)
 Review of medical malpractice claims in Emergency
Departments showed that: (Risser, 1999)
 Appropriate teamwork might have averted more that 60% of
deaths and major permanent impairments
 Lack of performance monitoring major cause of errors in 35%
of cases
 Lack of assertiveness of caregiver 28% of cases

13. Teamwork and job satisfaction
 Several studies have shown that higher levels of
teamwork results in greater job satisfaction (Rafferty et
al, 2001; Amos et al, 2005; Chang et al, 2009; Collette, 2004; Blegen, et al,
2008).
 Study with 3,769 staff ; 95 patient care units; 6
hospitals (Kalisch et al, 2012)
• The more satisfied with current position, the
higher the teamwork (F [4, 212.727] = 113.256, p < 0.001)
• The more satisfied with being nurse, the higher
the teamwork (F [4, 3699] = 30.709, p < 0.001)
• The higher the teamwork, the less likely to leave (F
[2, 541.891] = 25.475, p < 0.001)

14. Teamwork Intervention Study
Turnover and Vacancy Rate Before
and After Intervention*
Percent Turnover or Vacancy
14.00%
13.14%
12.00%
10.00%
8.05%
8.00% Turnover
6.14%
6.00% Vacancy
5.23%
4.00%
2.00%
0.00%
Before After
* Turnover t = 2.18, df = 63, p= .033; Vacancy t = 4.55, df= 58, p= .0000

15. What does teamwork look like?

16. Salas et al Big Five Theory of Teamwork
THE CORE
Closed Loop Team Mutual
Communication Leadership Trust
Team
Mutual Back-Up
Orientation
Performance Behavior
Monitoring
Adaptability
Shared Mental
Models

17. Team Orientation
 Team’s success takes precedence over
individual’s performance and desires
 Do not view themselves as isolated individuals
 Team members first
 Part of everyone‟s job is to ensure that
everyone on the team can and does get
their work done in a quality way.
.

18. Team Orientation (continued)
Example comments when NOT present:
 Unit Secretary: The nurses count the number of
patients assigned to them at the beginning of the
shift and they say „You have 4 patients and I have 5,
why is that?‟
 RN: Days left the blood for me to hang.
 NA: The RN could put the patient on the bedpan in
a minute but instead spends 10 minutes looking all
over the unit for me to do it.
 RN: Even though we keep reminding him, this
physician keeps writing orders that no one can read.

19. Team Orientation (continued)
Example comments when NOT present (continued)
 RN: It is physical therapy‟s job to ambulate the
patient.
 MD: The nurses call me and they don‟t even have the
information together to give to me. They don‟t even
know the vitals.
 RN: If I stop and help the nursing assistant, I won‟t get
my “RN” work done.
 RN: I see an order that is not correct but that doctor is
so rude, I don‟t let him know. It is his responsibility.

20. Team Leadership
 Team leadership refers to the structure,
direction and support provided by both the
formal leader and/or on the part of team
members.
 Who should be the team leader?
 Everyone should act as a leader at some point.

21. Team Leadership
 Example comments when NOT present
 RN: We all take turns being in charge so when I am in
charge, I don’t want to upset my fellow nurses because
they will take it out on me the next time. I will wind up
with all of the heaviest patients.
 NA: I tell the RN a patient is in pain but she doesn’t do
anything. The next time I don’t even try to get her to
help the patient.

22. Mutual Performance Monitoring
 The observation and awareness of team members
of one another.
 Keep track of fellow team members’ work while
completing their own work.
 Could be interpreted in negative terms (e.g. spying,
trying to find problems etc.) but it is accepted as
part of a “psychological contract”
 Maximize the overall performance

23. Mutual Performance Monitoring (continued)
Example comments when NOT present
 RN: I don’t think the NA takes accurate vital signs but I
don’t have time to recheck her work. I have too much to do
with my work. I take what she gives me. It turned out to be
a disaster last week—a patient had a BP of 200 over 165.
 MD: I don’t know what is happening. I just get in and out
as fast as I can.
 RN: The medical staff hide out in the conference room.

24. Back-Up
 Team members help
one another with
their tasks and
responsibilities
including giving
feedback.
 Unable to perform
work or carry out
responsibilities and
another team member
steps in

25. Back-Up (continued)
 Requires willingness to provide and seek
assistance.
 Willingness to jump in and help and accept help
without fear of being perceived as weak.
 Needs to occurs no matter the status, rank or
tenure of the staff member

26. Back up (continued)
Example comments when NOT present
 RN: I will see a physical therapist forget to wash her hands
but I won‟t say anything.
 NA sees a medication (Glucophage. oral insulin) left in a
cup on a patient’s bed stand and throws it way, never
telling the RN. The patient’s blood sugar is elevated on
the next blood test and the RN cannot understand why.
The dose of Glucophage is increased.

27. Back-Up (continued)
Example comments when NOT present:
 RN: Sometimes I feel bad asking for help. It looks like I am
just not able to handle my job, that I am not a good nurse.
 ED RN: I call up to the unit where the patient is to go and
no one will take report. They think if they don‟t respond,
we won‟t bring the patient up. Meanwhile we have patients
who really need care are waiting. We can‟t refuse to take
patients.
 PT: I believe the patient needs an MRI but I have to tip toe
to ask the doctor. He doesn‟t think we know much.
.

28. Back-Up (continued)
 Giving and receiving feedback poor
 Needs to be norm for all team members and
seen as part of their role
Example comments when NOT present:
 RN: If I say anything to correct an NA, I pay for it. She
won’t do anything for my patients.
 MD: There are some strong personalities in nursing and
it isn’t worth the effort to tell them they did something
wrong.

29. Adaptability
 Ability to adjust strategies and resource
allocation on the basis of the information
gathered from the environment.
 Examples when NOT present
 RN: We have staff on both 8- and 12-hour shifts and
instead of reassigning patients so the nurse coming on
doesn‘t have patients on all three wings, we let her run.
 Radiology tech: The patients are late because they say
they have an emergency but we have a schedule to keep.

30. Closed Loop Communication
 The active exchange of information between two
or more team members where both parties have
the same understanding of what was
communicated (closed loop).
 For a team to act in concert to achieve common
goals, the team must have shared information.
 2,455 sentinel events reported to the Joint
Commission
 75% of the incidences resulted in death.
 70% of the incidents had communication failure as the
primary root cause

31. Closed Loop Communication (continued)
 Conflict inevitable
 Without it, no way to draw attention to problems.
 Flow of information between healthcare providers of
different degrees of status
 Individuals lower on the hierarchy are not often asked
for relevant information that only they have.
 Physicians more satisfied with teamwork than nurses (Thomas
et al, 2003).
 Nurses say difficult to speak up, disagreements are not
appropriately resolved, need more input into decision making,
and nurse input not well received

32. Closed Loop Communication (continued)
Examples when NOT present:
 A patient in intense pain is brought up to the unit from
the ED by a transporter who does not inform the nurse.
No one saw that patient for 2 hours.
 MD: The nurses do not seek me out to resolve issues with
orders.
 RN: You send an order to pharmacy and just pray the med
will appear. It doesn’t matter that I didn’t get the med, I
get blamed because the patient didn’t get their med.
 MD: There is no effective way to alert the nursing staff
about stat orders.
 MD: I need to know about the patient but I can’t find
anyone to give me the information.
 RN: The physicians don’t update us on the patient’s
condition.

33. Shared Mental Models
What people use to organize information about the
environment, the team purpose and team
interdependencies.
Example when NOT present:
 RN: A nurse floated to our unit and did things the way
they do on her floor. She thought the other staff members
would give her patients their medications when she took a
break. She found out several hours later this was not the
case.

34. Mutual Trust
 Members will perform actions necessary to
reach interdependent goals
 and act in the interest of the team.
 Without trust, team members expend time
and energy protecting, checking and
inspecting each other as opposed to
collaborating.
 Physicians more satisfied with teamwork than
nurses (Thomas et al, 2003).
 Nurses say difficult to speak up, disagreements are not
appropriately resolved, need more input into decision
making, and nurse input not well received

35. Mutual Trust (continued)
 Examples when NOT present:
 RN: If I work with certain people, I am afraid things are not
being done.
 RN: I would like to believe the aide when she tells me she
ambulated the patient, but I am not sure.
 MD: Some of the nurses are just not that good. I worry
about my patients.

36. How can teamwork be
achieved?
What does it take to build
more effective teams?
1. Teamwork training
2. Organizational systems changes

37. Teamwork Training
 Department of Defense  IHI
 DoD and AHRQ together  Improving perinatal care
 TeamSTEPPS  Transforming care at the
bedside
 VHA, Inc.: Transfor-
mation of the OR Does team training
 Kaiser-Permanente: Pre- work? A Meta-analysis
operative Safety Briefing Salas et al (2008)
Based on 52 effect sizes
 Decreased wrong site
representing 1,563 teams
surgeries and nurse
Team training was shown to have
turnover
a positive effect on team
functioning

38. Team training is  The best team training will not
essential yield the desired outcomes
but not enough
alone unless the organization is
aligned to support teamwork.
 Team training accounts for 20%
of the team performance
variance
 80% other organizational
systems

39.  An organization’s ability to
Organizational support collaboration is highly
Culture dependent on its organizational
culture.
 Some cultures foster collaboration
while others stop it dead in its tracks.
 Only need to purchase
collaboration software to foster
collaboration but . . .
 Fails because people don’t know
how to collaborate effectively or
because their culture works
against it

40. What are some of the
organizational systems?
 Positive transfer of training
 Team size
 Physical space
 Team membership stability
 Rewards, recognition
 Disruptive and intimidating behavior
 Opportunity to communicate
 Groupware tools
 Involvement of patients/families

41. Organizational systems
 Positive transfer of training
 Learning alone is not sufficient
 Bulk of training expenditures do not seem to transfer to the job
 Estimates are only 10% of training expenditures transfer to the job
 Glaring gap between training efforts and organizational
outputs
 Strategies
 Cues that prompt trainees to use new skills
 Situational cues (manager goals, peer support, equipment
availability and opportunity to practice trained skills)
 Consequent cues (positive and negative feedback following the
application of trained skills)
 Remediation for the incorrect or lack of use

42. Organizational systems (continued)
 Transfer of training (continued)
 Provide opportunities to perform
 Leader role is largest contributor to transfer
 Goal setting: Prior to training, leaders should communicate goals, behavior
expected after the training; After training, managers need to prompt staff to
set proximal and distal goals for applying newly acquired knowledge
 Recognition, encouragement and rewards and modeling trained behaviors
 Train the trainer
 Post training follow up
 Job aids (tools designed to assist with job performance and facilitate the
transfer of training; reduce the mental workload required to apply new
skills)
 Informational aids
 Procedures aids
 Decision making and coaching aids

43. Organizational systems (continued)
 Team size FR
EQ
300
UE
 The number of team members
NC
250
Y
(N u
mb
er 200
assigned to a given collective
of
oc
cur
an 150
ces
)
 Ideal size of a team 5-9
100
50
 Research definitions: small 1-2, 0
2 3 4 5 6 7 8 9 10
medium 3-5 and large over 5
11 12 13 14 15 16 17 18 19 20
T E AM S IZ E 21 22 23 24
 2,265 nursing staff on 53 units
in four hospitals as high as 183 Average team size
people with a mean of 87
across industries

44. Group Complexity
Size of Number
of
Group Sub-groups
4 11
8 247 70
60
66
16 65,519
55
Transaction Channels
50
45
24 16,777,191
40
36
30
28
20 21
15
10 10
6
0
1 2 3 4 5 6 7 8 9 10 11 12
Group Size

46. Number of different staff
worked with in one month

47. Organizational systems (continued)
 Negative consequences of large teams
 Decreased motivation
 Poorer decision making
 Poorer coordination
 Higher levels of conformity
 Social loafing
 The “dilution effect” (free riding, getting lost in the
crowd, shirking work, etc.)

48. Organizational systems (continued)
 Physical Environment
 Physical proximity offset each other’s vulnerabilities and
magnify each other’s strengths
 Physical distance reduces the possibilities for coordinated
action and teamwork
 Structure and layout of patient care units decreases or increase
the likelihood of teamwork
 Often no conference room space for communication
 Where do the medical staff hang out?
 Cost of engaging another team member

49. Organizational systems (continued)
 Team membership stability
 Intact versus ad hoc teams
 Length of time team members have worked together
 Shared history
 Teamwork has been shown to result in lower turnover, less
intent to leave and less absenteeism
 The less turnover and the fewer absences, the larger the
team can be and still achieve high performance.
 This represents a “which came first” situation

50. Organizational systems (continued)
 Potential solutions for size, distance and
stability
 In Norway, the “holy grail” of unit design has been the
sengetun ward, with between 6 and 10 private rooms arranged
around a decentralized nursing station(“Pods,” 2010).
 Cluster teams
 By reorganizing a 40-bed medical unit into four 10-bed mini-
units, the number of different people that staff had to work
with decreased by 75%, and patient and staff satisfaction
increased(Kalisch & Begeny, 2005).

51. Organizational systems (continued)
 Rewards and recognition
 Creating a meaningful, cost-effective reward system is both
one of the most important and one of the most frustrating
challenges
 Appropriate rewards for teamwork should
 Be empowering not manipulative
 Work synergistically with intrinsic motivation
 Produce energy to achieve even more
 Make team members feel good about their current and past
accomplishments
 Team rewards

52. Organizational systems (continued)
 Disruptive and intimidating behaviors
 Tradition of being indifferent to this; goes unreported
 Studies have linked patient complaints about unprofessional,
disruptive behaviors and malpractice risk. (Hickson, et al, 2002, 2007; Stelfox, et al,
2005)
 40% agreed physicians who generate high revenue, treated
more leniently (Keogh, et al, 2004)
 Need zero tolerance
 Need process for addressing which includes interdisplinary
team members

53. Organizational systems (continued)
 Opportunity to communicate
 Multidisciplinary daily rounds vs. traditional rounds (Curley et
al, 1998)
 Lower LOS
 Lower average charges
 Reduced medication variance and adverse drug events (Sim &
Joyner, 2002; Leape et al., 1999)
 Daily goals form as part of multidisciplinary daily rounds
 Formalized briefings about the details of surgery to be
performed after patient anesthesized
 Briefings and debriefings

54. Organizational systems (continued)
 Groupware  Instant messaging
technologies  Social media
 Cell phones  Co-browsing
 Email  Desktop sharing
 Pagers  White boarding
 Tablet devices  Group decision support
 Video  Presence Management
Allows individuals to alert others of
 Desk top video their willingness to communicate and
conferencing preference for mode of
communication
 Web conferencing tools

55. Organizational systems (continued)
 Smart phones
 Market penetration expanding rapidly
 35% of public own smartphone
 81% physicians (Manhattan Research)
 Is becoming an essential part of everyday communications in
healthcare
 Web out, apps in—1500 mobile medical apps
 Health apps award ensuring safe transitions from hospital to home
 Pagers still needed in disasters (cellular networks down)

56. Organizational systems (continued)
 tele-ICU increased teamwork (Chu-Weininger et al 2010)
 Confident patients covered when off the unit
 I can reach physician
 Decrease in being interrupted to tell something I already know
 Remote intensivists resulted in improved rates of
DVT prophylasis and tight GC (Bawawi, 2012)

57. Organizational systems (continued)
 Patient record (EHR)
 Timely information is central to teamwork
 EHRs that are connected across providers and systems has
potential to increase information continuity, care coordination
and transitions, system accountability and peer review
 EHRs potentially “Media Rich” communication technology
that can promote teamwork
 Introducing EHRs changes workflows and processes and this
likely affects teamwork but not well understood
 Interdisciplinary care plan
 Study of diabetic patients with multidisciplinary care plan shows
greater adherence to diabetes guidelines, higher metabolic control
and improved cardiovascular risk factor

58. Organizational systems (continued)
 Transforming from a push to a pull strategy
 Instead of sending information to those who may or may not
use it
 Place information on line
 Team members look for information relevant to their work
 Research to date suggests healthcare teams can
benefit from the use of groupware technologies
 The potential is only beginning to be tapped
 Issues
 Bandwidth required to deliver large amounts of data
 Issue of compromised health information/data security

59. Organizational systems (continued)
 Engaging patient and family as team
members
 Study determining what patients could report on re: the care
they received in the hospital, we found
 Fully reportable (e.g. mouth care, bathing, pain medication)
 Partially reportable (e.g. hand washing, vital signs, patient
education)
 Not reportable (e.g, surveillance, assessment, intravenous site
care)
 Will require a deeper understanding of consumer health
literacy and the “workflow” of patients

60. The End