Goals of Presentations. The Rehab Team Do We Need a Recharge? Recharging the Rehab Team: Strategies to Improve Team Care and Patient Outcomes

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1 Recharging the Rehab Team: Strategies to Improve Team Care and Patient Outcomes UDSMR Annual Conference - Thursday August 8, 2013 DALE STRASSER, MD ASSOC. PROFESSOR, REHABILITATION MEDICINE EMORY UNIVERSITY, ATLANTA GA JAY UOMOTO, PHD FACULTY NEUROPSYCHOLOGIST BARROW NEUROLOGICAL INSTITUTE ST. JOSEPH S HOSP AND MED CTR, PHOENIX, AZ FIM and UDSMR are trademarks of Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc. The Rehab Team Do We Need a Recharge? Initial experiences Eye of the beholder challenges to IRF based team care. Team Functioning the what and how of team work Leadership, goal direction, coordination, communication. Goals of Presentations Reawaken a commitment to team care Evaluate Team Functioning (TF) Improve patient outcomes through TF. 1

2 Specific Objectives 1. Analyze Team Functioning (TF). 2. Review evidence linking TF to patient outcomes. 3. Critique the utility of the diamond to analyze TF. 4. Compare Rehab Teams to Clinical Microsystems. 5. Develop action plans to address issues of TF. 6. Discuss the incorporation of TF into rehab QI. Background Team Care and Patient Outcomes Emergency Departments Critical Care Medicine and ICUs Geriatrics Mental Health Chronic Disease Management Rehabilitation Medicine VA Rehabilitation Teams Project Team Functioning and Patient Outcomes (Arch Phys Med Rehabil 2005; 86: 403-9) Team Training and Stroke Rehabilitation Outcomes: A Cluster Randomized Trial (Arch Phys Med Rehabil 2008;89:10-15) (VA Merit RR&D; Merit Reviews E1101R, B2367R and O3225R ) 2

3 Rehabilitation Treatment Effectiveness Hospital Characteristics Culture Structure Organizational Process Social Climate Treatment (Technology) Dosage Timing Specificity Efficacy Team Managerial Leadership Practices Professional Networks Patient Outcomes Participants Staff Patients Family Environment Modified from Strasser, Dale C. and Falconer, Judith A. (1997). Linking Treatment to Outcomes through Teams: Building a Conceptual Model of Rehabilitation Effectiveness. Topics in Stroke Rehabilitation, Vol. 4, No.1, pp Team Characteristics and Stroke Patient Outcomes (VA Merit Review 1101R) 530 staff on 46 units Social Climate Interprofessional Relations Physician Leadership Managerial Practices Organizational Context culture, support, expectations Stroke Patient Outcomes (n=1,688; VA FSOD) FIM instrument 13 motor items LOS Discharge Status Team Perceptions and Patient Outcomes Motor FIM gain - Team relations as measured by social climate scales (+order and organization; -task orientation) and a measure of the utility of quality information predicted functional improvement Length of Stay - Perceived Effectiveness had a positive correlation (p<0.02), while a measure of teamness showed a trend (p<0.06) towards a shorter LOS. 3

4 Cluster Randomized Trial 31 teams (n= 464 clinical staff) 15 intervention teams (n= 227 staff) 16 control teams (n= 237 staff) 587 stroke patients from 29 teams mean age 67.1 yrs; 97% male 60% white; 20% black; 18% Hispanic; 47% married; 26% divorced Initial motor FIM rating 47.5 (sd = 16.9) A Clinical Trial in Process Improvement: Team Functioning and Stroke Outcomes 31 VA Hospitals (15 intervention and 16 controls teams) Pre intervention staff surveys; stroke patient outcomes tracked. Six months intervention on skills training in team functioning. Post intervention staff surveys; stroke patient outcomes tracked. General Skills Training for Team Leaders 29 staff from 15 hospitals participated in 2.5 day workshop 12 MDs; 4PT / KTs; 3SLPs; 2OTs; 2RNs;1 SW; 1 Program Coordinator, and 1 other administrator Didactic and interactive role playing Vignettes patient, hospital, and national Conceptual model interwoven Problem solving strategies Action plan discussion 4

5 Action Plans - Common Themes Relations between therapists and nurses Nursing Staff Activities Family Education Leadership Functions Examples of Action Plan Activities Patient Information Board Recruitment of permanent staff Revised staff orientation procedures Team meetings Reconfigured social work position Therapists and nursing morning report Nursing and therapy goals placed at foot of bed Bulletin board with staff pictures and descriptions A regular rehabilitation roundtable meeting Monthly birthday parties Reconfigure unit secretary duties Social Climate Leadership Rehabilitation Team Functioning Managerial Practices Interprofessional Relations The Diamond 5

6 Team Functioning Lead MP Roles and Activities SC Team Relations Social Climate (SC) Team Personality Assumed Role Interpersonal relationships Team Actions PN Team Leadership (Lead) Physician Support Shared Leadership Motivated, Prioritize, Unify Professional Networks (PN) Prof vs Team Orientation Codified Role Interprofessional Relations Managerial Practices (MP) Communicate, Coordinate Problem solve, Procedures Process Improvement Clinical Trial Results Percentage of stroke patients gaining > 23 FIM points increased more in the intervention than control group (13.6%; p=0.032) Conclusions Stroke patients treated by staff who participated in team training were more likely to make functional gains than patients treated at control sites. Clinical Microsystems (JCAHO 2002; Mohr 2012) Small organized group of clinicians and staff working together with a shared clinical purpose The clinical purpose defines the essential parts of the microsystem. Clinical Microsystems are part of a larger organization and embedded in legal, financial, regulatory environment. 6

7 Clinical Microsystems and Treatment Teams Quality Literature Population based Performance Process Improvement Implies an inherent part of a larger system or systems. Clinician Driven Intuitive, common sense Qualitatively better Fewer measurements Quasi-independent of larger organization Team Functioning Model Clinical Vignettes Urinary Incontinence Rehab Direction Back to Floor Mobility Backslides What s going on? Evaluate Rehab Team Functioning (TF)? 7

8 Urinary Incontinence 77 y/o male with L MCA / CVA Wife bothered by urinary incontinence (UI) UI occurs with particular staff new to rehab. Wife frustrated, requests an extension. What s going on? Evaluate Rehab Team Functioning (TF)? Rehab Direction Acute transfers back to main hospital; LOS; staff turnover; patient satisfaction. Therapy staff complain about nursing services Downsizing of units into one unit Hands-off physician What s going on? Evaluate Rehab Team Functioning (TF)? Back to Floor PT brings patient to floor who needs toileting UI secondary to urgency Initial Team Conference bladder program What s going on? Evaluate Rehab Team Functioning (TF)? 8

9 Mobility Backslides 33 y/o female with MS PT and OT transfers sit to stand with rolling walker and contact guard. Nursing Unit transfers two persons moderate+ assistance Can t do it right What s going on? Evaluate Rehab Team Functioning (TF)? Summary Comments Problem-Solving Process Problem Definition / Formulation Solutions from Brainstorming Indentify Pros and Cons of Solutions Monitoring Progress / Definition of Success Connection with the Diamond 9

10 Vignettes Problem Solving Action Plans Good Staff Bad Staff Discharge Date Change Inappropriate Patient Hospital Bounce Backs The Quality Conundrum Medical errors and inappropriate care continue Wide variations of Costs and Outcomes Limited generalizability of successful projects Perceived limited relevance to daily activities Misconceptions of what it means. Definition of Quality Rehabilitation CAUTI, Pressure Sores, CLABSI The Quality Chasm The Institute of Medicine Medical Errors 44,000 98,000 deaths Med errors 7,000 deaths (workplace 6,000) $17 to $28 billion Variations Spine Surgery Acute MI Hip Fracture Colon Cancer CABG Hysterectomies Stroke Rehabilitation 10

11 Donabedian Framework The Next Step Team Functioning and Quality Improvement Measurement Quality Indicators Team Functioning Measures Rationale Utility in understanding and improving the black box of rehabilitation. Exploratory analysis from a clinical trial in stroke rehabilitation. Hypothesis -- TF measures collected one year apart predict changes in patient outcomes during this time period. 11

12 TF Measures Examined and Modified Original TFS - 11 scales; 87 items 8 Scales selected; 60 items; 2 scales dropped, 2 combined. 5 scales, 42 items. Physician Engagement (also called Physician Support) Physician participation the work of the team. Shared Leadership Flexible leadership structure; situational Supervisor Team Support The support of one s supervisor. Teamness Being a team member; Work together, Divergent opinions. Team Effectiveness Treatment Goals, Carryover, Family education Top Stroke Rehabil 2010; 17(4): Do Changes in TF Measures Track Changes in Patient Outcomes? Measurement Analysis and Modification Item Response Theory (IRT) team scores were calculated for each measure at each time point. Estimated for each patient outcome an HGLM incorporating all patient observations at each site with TF measures, measurement period (pre or post), and their interaction as independent variables. Linear and logistical models used. Predicted change calculated based on regression analysis. 12

13 Staff Characteristics (% or st dev) Time 1 (n=356) Time 2 (n=273) Age 44.3 (10.7) 43.7 (11.0) Female 275 (78.1) 212 (77.7) Years at facility 9.2 (7.5) 8.9 (7.8) Years on team 5.1 (5.2) 5.1 (5.3) Professional Training Occupational therapy 67 (19.0) 53 (19.4) Physical therapy 72 (20.5) 73 (26.7) SW/case management 28 (8.0) 21 (7.7) Speech-language path 30 (8.5) 23 (8.4) Nursing 121 (34.4) 79 (28.9) Attending physician 34 (9.7) 24 (8.8) Patients All patients on 27 VA Rehab Units. Time 1 = 4,266; Time 2 = 3,213 20% stroke HGLM Models (p values) TF Measures LOS D/C FIM Motor MD Engagement (-) Shared Leadership Teamness Tm Effectiveness Tm Supervisor

14 Predicted Change LOS Sent Home FIM Motor MD Engagement -0.73* Teamness * 0.03 Team Effectiveness * (* P value < 0.05) One point increase in Physician Engagement= 0.73 decrease in LOS One point increase in Teamness and Team Effectiveness = 4.5% and 4.3% increase in percentage sent home. TF Measures and Patient Outcomes Analysis of changes over one year TF Measures Physician Engagement Shared Leadership Supervisor Team Support Teamness Team Effectiveness Patient Outcomes LOS DC destination Motor FIM gain Results -LOS to MD Engagement (p=.017) + home to Tm Effectiveness (p=.045) +home to Teamness (p=.043) Limitations VA inpatient rehabilitation settings Retrospective analysis of modified scales TF measures were self-report. Survey burden not calculated. 14

15 Discussion and Summary Evidence that TF measures correspond to changes in patient outcomes, specifically measures of Physician Engagement, Teamness, and Team Effectiveness TF Measures Describe teams, predict outcomes, useful with process improvement. May capture a key process component of the clinical microsystem of the interdisciplinary rehabilitation team. 15