Inter-professional practice in health care

Inter-professional practice in health care David Patrick Ryan, Ph.D. Director of Education & Knowledge Processes, Regional Geriatric Program of Toronto Assistant Professor, Faculty of Medicine, University of Toronto

What is an interprofessional team? • People from several professions • Each trained to use different tools and concepts • Whose labor organized around a common problem • With continuous communication and frequent reflection on both the groups work and its process • Usually with group responsibility for the final product

Interest in Teamwork Ebbs andFlows (Ryan 1996) 50 25+ 23 20 16 15 # of Articles 11 10 8 Estimate 2000-2010 6 5 5 5 0 Decades 30s 40s 50s 60s 70s 80s 90s 00s From moral treatment to mental hospitals The medical model and the orthopsychiatric trinity The Trinity won the right to treat Sociotherapy and broadening of the mental health team Community Mental Health and sociotherapy’s democracy Hospitals emptied and community mental health funding dwindled DRG’s managed care and mental health fragmentation Integrated care and inter-team collaboration Patient safety is linked to the quality of collaboration Teamwork Articles in the Journal of Orthopsychiatry by Decade Since the Journal Began in 1930

Why Interprofessional Practice? Why Now? Chronic Disease and Frailty Patient Safety Success of Quality Improvement The Quality of Working Life Local Health Integration Networks HealthForce Ontario’s Inter-Professional Care Blueprint for Action Primary Care and Family Health Teams

Current Initiatives in Interprofessional Care Province-Wide investment in Inter-Professional Education Inter-professional Mentoring Inter-professional Coaching Inter-professional Preceptorships Inter-professional prevention of delirium in the ED Impact inter-professional practice within primary care groups Inter-Professional Practice and Hospital/LTC accreditation The Journal of Inter-Professional Care GiiC – the geriatrics, inter-professional practice & inter-organizational collaboration initiative for family health teams and community health centers

Barriers to interprofessional teamwork: practice based issues • There is a lack of preparation for interdisciplinary hostility . . . If the practice of this specialized form of aggression is to be placed on a higher level, at least as high as professional wrestling…the subtle arts of patronage, insult and innuendo must be taught. Brody & Weithorn, 1965 • Unrealistic expectations, lack of knowledge and perceived threats to autonomy Fried & Leatt, 1986 • Professional jealousies and role boundary issues Strasser et al 1994 • We practice together but we train apart

Barriers to teamwork: professions think differently(from Qualls and Czirr, 1988) Logic of assessment: from ruling out to ruling in Focus of efforts: from acute episodes to quality of life Locus of Responsibility: from executive to collaborative Pace of Action Focus of attention: from task to process Interprofessional stereotypes Decision making expectations: from executive to consensus Beliefs about professional independence: from autonomy to interdependence

Barriers to teamwork: Though we practice together until recently we trained apart (from Cleary & Howell, 2003)

A framework for examining teamwork Management Teams Ad hoc Inter-agency Shared Care Teams Continuing care and Rehabilitation teams TYPES OF TEAMS Acute Care Teams Specialized Geriatric Services Teams Primary Care Teams CustomerFocusedOutcomes InternalFocusedOutcomes OUTCOMES OF TEAMWORK FinancialFocusedOutcomes InnovationFocused Outcomes Communication&ConflictManagement Team Member Skills & Strengths CustomerNeeds &InterteamIssues PerceivedSupport fromOrganization DecisionsAuthorityAccount-bility Clarity/Coherenceof Goals Roles &Inter-dependence THE DIMENSIONS OF TEAMWORK

History of Teamwork in Health Care The Original Team - Romantic Era (circa 1900) General Practitioner

History of Teamwork in Health Care Classic Sequential Teamwork and the Specialist Era (circa 1920) Specialist Specialist Nurse Nurse

History of Teamwork in Health Care Sequential Multi-Professional Practice Teams(circa 1930) Specialist Psychology Social Work Rehab Nurse

History of Teamwork in Health Care Dynamic Multi-Professional Team (circa 1960)from a cadre of professionals Nurse Social Work OT Physio Physician Pharmacy SLP Psychology Nutrition Recreation Dentist

History of Teamwork in Health Care Dynamic Multi-Professional Team (circa 1960)a team is convened around the needs of a particular patient Social Work Nurse OT Physician SLP Psychology

History of Teamwork in Health Care Dynamic Inter-Professional Team (circa 1985)from a cadre of professionals Nurse Social Work OT Physio Physician Pharmacy SLP Psychology Nutrition Recreation Dentist

History of Teamwork in Health Care Dynamic Inter-Professional Team (circa 1985)A team is convened around the needs of a particular patient Core skills Core skills Nurse Physician Social Work Pharmacy Core Skills Core skills

Independent practice Guided by professional standards Professions report to depts. Leadership by rank or profession Rigid role boundaries Conflict attributed to individuals Little attention to team process Interdependent practice guided by professional & team standards Discussion & collaboration Leadership by skill or primary issue Flexible role boundaries Conflict is a team responsibility Routine attention to team process issues Multiprofessional Interprofessional

Myths about Teamwork • There are no leaders on teams; everyone is equal • If we just work together, we will eventually become a high performance team • Everyone is accountable for everything on teams • Teams take a long time to get up and running • All team decisions must be made by consensus • Conflict must be worked out for a team to be productive • On the best teams, everyone likes everyone else • The most important work takes place in team meetings • Confrontation means conflict

Just putting people together to work in teams doesn’t necessarily produce effective interprofessional teamwork

Some of the things a team can do to maximize performance Develop expertise to facilitate interprofessional practice Annually monitor and reflect on team culture Balance attention to task and process functions Develop clear goals and monitor outcomes Understand the dynamic nature of team development Recruit or develop the right mix of skills Value professional and personal diversity

The Dimensions of Teamwork Annual Survey • Customer and inter-team issues • Team member strengths and skills • Communication and conflict management • Roles and interdependence • Clarity of team goals • Decision-making and leadership • Perceived organizational support

Quarterly review of informal team role performance Task Roles Initiating/energizing Information/opinion giving Information seeking Reality Testing Coordinating Orienting Technician Maintenance Roles Harmonizing Gate keeping Encouraging Following Acclimatizing Individual roles Blocking/aggression Out of field Digressing Recognition seeking

Routinely reflect on the stage of team development

Value one another's diverse personal styles I get pretty excited and energetic and tend to let my thoughts and feelings show I stay cool, calm and collected and tend to keep my thoughts and feelings to myself C 4 3 2 1 0 1 2 3 4 E When new things come I prefer to wait, watch, ask questions and hear all sides before reacting I get into new things quickly, make up my mind fast and hate to wait. J 4 3 2 1 0 1 2 3 4 S

Value one another's diverse personal styles Use the ratings to plot your place on the “So Simple” grid. The results can be amusing even insightful. Remember we are not rating whether someone is good or bad. We are trying to better understand difference. React quickly and hate to wait J DRIVERSprefer to move ahead calmly, watching results, staying organized and asking “what’s next” ENTHUSIASTS like to jump into new things, sets everyone on fire by “just doing it” and asking “Why not?”. 4 3 2 Stay cool calm and collected Let feelings and emotions show 1 C 4 3 2 1 0 1 2 3 4 E 1 ANALYSTS like to hear the details, see facts and figures and asks “How is this going to work?” HARMONISTS like to give everyone the opportunity to express themselves and their opinions often asking “how is everyone feeling?” 2 3 4 S Wait, watch, hear all sides

To summarize It has taken us more than 100 years to get to this point of recognizing interprofessional interdependence The provincial interprofessional care blueprint is removing barriers Frailty and chronic disease demand high quality interprofessional practice Effective teamwork doesn’t just happen it needs ongoing care and tending Teamwork can enhanced by a few strategic interventions GiiC provide family health teams and community health centres with several useful tools GiiC has embedded interprofessional thinking within each geriatric topic GiiC provides a consultant to help you to facilitate your team

Inter-professional practice in health care