presentatie svin deneckere 28/01/2014

28/01/2014

Doctoral thesis in Biomedical Sciences, KU Leuven

Promoter: 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

28/01/2014

MAKING TEAMS WORK

OUTLINE

Growing need for teamwork in healthcare

How could care pathways improve teamwork?

Setting of the PhD-study

Objectives, research questions and included studies

Study results

General discussion and recommendations

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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.

http://books.nap.edu/catalog.php?record_id=9728

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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

liv

es l

os

t p

er

year

DANGEROUS

(> 1/1000)

REGULATED ULTRA-SAFE

(< 1/100K)

Bungee Jumping

Mountain

Climbing

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 preventable

Joint 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)


MAKING TEAMS WORK

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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). Monitor Zorggerelateerde Schade 2011/2012.

Dossieronderzoek in Nederlandse Ziekenhuizen. Amsterdam, NIVEL en EMGO+ Instituut.

Van Den Bos J., Rustagi K., Gray T., Halford M., Ziemkiewicz E., Shreve J. (2011) The $17.1 Billion Problem: The Annual Cost Of

Measurable Medical Errors. Health Affairs, 30, 4:596-603.

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Potential

Problem

Acc

iden

t

Problems with

legal procedures

Incomplete

Procedures Unclear roles

and tasks

Workload

Unclear

accountability

Inadequate

training

Divertion due to

other problems Inappropriate

maintenance Unstable

technology

Conflicts in Goals

System problems call for system solutions

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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 trained

Regular team conflicts: task /relation / process conflicts

Pseudo-teams in healthcare


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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). Patient safety,

satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the

United States. British Medical Journal, 344, e1717.

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MAKING TEAMS WORK

OUTLINE





Study results


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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

28/01/2014

Team training interventions: Crew Resource Management

‘Ferrari pit stops saves lives’ Prof. Martin Elliot

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Structured Communication Protocols: SBAR-Survey/Briefing

Adapted by Kaiser Permanente from a communication tool that

was adapted from the US Navy

An effective and efficient way to communicate important

information;

A simple way to help standardize communication

Allows parties to have common expectations related to what is to

be communicated and how the communication is structured.

S=Situation (a concise statement of the problem)

B=Background (pertinent and brief information related to the

situation)

A=Assessment (analysis and considerations of options —

what you found/think)

R=Recommendation (action requested/recommended — what

you want)

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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 Medicine 2010; 8:31.

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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. Social Science & Medicine; 75(2):264-268.

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MAKING TEAMS WORK

OUTLINE





Study results


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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 Portugal

Three 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

http://www.e-p-a.org/





28/01/2014

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

28/01/2014

Included studies

RQ1:

Team indicators

RQ2:

Impact of CPs on teamwork

RQ3:

CP conditions

Study 1 Study 2 Study 3 Study 4

Delphi-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

M

ETH

OD

S

SA

MPL

E

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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. Medical Care 2012; In Press.


sample

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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. Medical Care; 51(1):99 107.

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Job Demand Control model van Karasek

“Wie tegen problemen oploopt in zijn werk (dus regelbehoefte heeft),

moet die zelf kunnen oplossen (regelcapaciteit)”

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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.

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MAKING TEAMS WORK

OUTLINE





Study results


28/01/2014

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 setting

CPs 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 processes

Deregularization on professional boundaries

Training 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 structures

Support care innovation and care process organization

Transparency of quality which leads to collective ambition

for change

MAKING TEAMS WORK

28/01/2014 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.

________________

dr. Svin Deneckere

Doctoral thesis in Biomedical Sciences Department of Public Health, KU Leuven

Leuven, 2012

“Talent wins games, but teamwork and intelligence wins

championships.”

(Michael Jordan)

presentatie svin deneckere 28/01/2014

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