Challenges in Linking Team Effectiveness and Health Outcomes Research

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Challenges in Linking Team Effectiveness and
Health Outcomes Research

• G. Ross Baker, Ph.D.
• Deborah Tregunno, Ph.D.
• Madelyn Law, M.A.
• University of Toronto
• Academy Health Conference
• June 9, 2004

Supported in part by a grant from the Connaught
Foundation Contributions from work by L.
Lemieux-Charles, M. Murray and D. Irvine Doran
are gratefully acknowledged
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The Impact of Teams on Outcomes

• The importance of teamwork to high quality
  patient care is frequently asserted
• But much of the teamwork literature is
  exhortatory, prescriptive and anecdotal
• There is a considerable research literature
  examining health care team effectiveness
• But much of that literature does not examine the
  impact of teams on patient care outcomes
• There is a growing literature on patient care
  outcomes
• But few articles that study teams and team
  characteristics as determinants of these outcomes
• More research is needed that incorporates valid
  and reliable measures of team attributes and
  clinical outcomes

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The Healthcare Team Paradox

• While many see improved teamwork as a critical
  strategy for creating better quality healthcare
  there are few studies that demonstrate what team
  aspects contribute to quality care, or what
  interventions will improve team performance
• Why is that?
• What are some useful steps to bridge this divide?

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Criteria for Healthcare Teamwork

• Multiple health disciplines are involved in the
  care of the same patients
• The disciplines encompass a diversity of
  dissimilar knowledge and skills required by the
  patients
• The plan of care reflects an integrated set of
  goals shared by the providers of care
• Team members share information and coordinate
  their services through a systematic communication
  process

Schmitt, Farrell and Heinemann, 1988
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Problems in Healthcare Teamwork

• Failure to appreciate the value of different
  roles
• Power differentials inhibit communications
• Professional autonomy concerns limit roles of
  some team members
• Professional roles limit participation in
  decision making
• Conflict and conflict avoidance limit team
  effectiveness
• Frequent staff changes complicate team learning
  and development
• Effective team work may be compromised by a
  predominance of less experienced workers

Adapted from Opie, 1997
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Three Types of Workgroups

• Task forces
• Temporary groups that are assigned projects (and
  deadlines)
• Crews
• Short terms groups composed of specialized
  personnel assembled in modular fashion from a
  larger pool
• Members fill slots until their shift or
  assigned time is up
• Teams
• Work groups whose lifetime spans many projects
  and is typically open ended
• Strong need to become cohesive and require tools
  for communication, coordination and conflict
  resolution
• Team building exercises are most often focused
  on the member network at this level

Arrow, McGrath and Bendahl, 2000
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Lemieux-Charles,et al 2004
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Three Types of Healthcare Team Studies

• Studies of team structure, work processes and
  team processes (what makes teams effective?)
• Studies of interventions that change team
  structures (how did new clinical roles or skills
  influence performance?)
• Studies of how teams worked to improve quality of
  care (how did new team skills or team focused
  interventions improve outcomes?)

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Team Effectiveness Studies

• Studies of the relationship of team composition,
  team task, team processes and team psycho-social
  traits
• Teams studied in range of different settings
• Varying instruments used to gather data with
  little overlap
• Richard Hackmans model of team effectiveness
  used in several studies, but complexity of model
  limits focus to partial testing

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Lemieux-Charles,et al 2004
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Team Effectiveness Studies

• Example Gibson 2001
• Methods Multi-center study of relationship of
  goal setting training, self and group efficacy
  and individual and team effectiveness in 71 teams
  of 187 nurses
• Findings While self-efficacy was found to be
  related to individual effectiveness, and training
  raised self efficacy scores, the training did not
  affect team effectiveness
• This study does not examine impact of team
  variables on objective outcomes, e.g., clinical
  status

Gibson, CG, J. Org Behavior, 2001
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Team Intervention Studies

• Studies that evaluate the impact of
  interdisciplinary teams on clinical outcomes
• RCT designs common
• Outcome measures are reliable, valid but linked
  to specific populations
• Limited measures of team or psychosocial factors
• Unclear whether team performance improved or
  whether addition of new skills was key (e.g.,
  physician on home care team)

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Lemieux-Charles,et al 2004
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Team Intervention Studies

• Example Evans 2001 study of stroke units versus
  stroke team care
• Methods 267 patients with moderately severe
  ischemic stroke were randomly allocated to stroke
  units or general medical units with stroke team
  support
• Mortality, other health outcome and resource use
  assessed at 3 and 12 months
• Findings Vary by stroke subtypes
• Stroke unit mortality lower for patients with
  large vessel infarcts, but not for those with
  lacunar strokes
• Resource use is lower for patients with lacunar
  strokes on general medical units with stroke
  teams
• No assessment of team variables that might
  account for some of the differences in
  performance.

Evans, Harraf, Donaldson, et al. Stroke, 2002
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Quality Improvement Team Studies

• Studies of quality improvement teams and other
  teams focused on improving quality of care
• Most studies focus on team measures
• Outcome variables are perceptions of impact or
  project activity
• Goldberg RCT looks at performance outcomes
• Complex analytical models

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Lemieux-Charles,et al 2004
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Quality Improvement Studies

• Example Lemieux-Charles 2002 study of how
  quality improvement practices contribute to team
  effectiveness
• Methods 506 team members of 97 quality
  improvement teams in 11 Ontario hospitals
  competed surveys about their work on QI teams
• Findings Quality improvement practices had a
  direct impact on team effectiveness (as judged by
  team members, but not by external assessors)
• Norms and process strategies mediated the impact
  of QI on team effectiveness
• Organizational context had a direct effect on QI
  practices and team processes
• No measures of specific clinical outcomes

Lemieux-Charles, Murray, Baker, et al., J. Org
Behavior, 2002
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Key Methods Issues In Qualitative Studies of Teams

• Team research requires complex analytical models
• Analyses are often multi-level
• Assessing interventions requires longitudinal
  data
• Valid and reliable instruments are not available
  for many constructs
• Where measures are available, they are often not
  used or other measures not directly relevant are
  used
• Measures of team require pooling data from team
  members
• Weighting team membership
• Increasing numbers needed when team is the unit
  of analysis
• Sample sizes limit analyses

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Key Research Questions

• What are the key components of team
  effectiveness?
• How does team effectiveness influence treatment
  outcomes, patient satisfaction with care and
  costs?
• What interventions improve team effectiveness?
• What organizational supports improve team
  effectiveness and the relationship between
  effectiveness and outcomes?
• What instruments provide valid and reliable
  measures of team effectiveness?

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Some Useful Measurement Tools

• Caregiver Interaction Questionnaire (Shortell, et
  al.,1994)
• Leadership, communication, coordination and
  problem-solving/conflict management
• Group Interaction Scale (Watson Michaelson,
  1988)
• Measures 5 dimensions of group interaction
• Team Climate Inventory (Anderson West, 1998)
• Measures 4 factors linked to work group climate
  for innovation
• Operating Room Management Attitudes Questionnaire
  (Schaefer Helmreich, 1993)
• OR staff attitudes toward teamwork and safety,
  stress, hierarchy, teamwork and error

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Useful Measures, contd

• Relational coordination (Gittell, 2000)
• Four communications dimensions including request,
  timely accurate and problem solving and 3
  relationship dimensions
• Coordination (Young, 1998 Alt-White, et al.,
  1983)
• Measures 2 approaches to coordination,
  programming and feedback
• Collaborative Practice (Weiss Davis, 1985)
• Measures of collaboration between nurses and
  physicians
• Quality in Action (Baker and Murray)
• Five dimensions of culture related to improving
  care
• Improvement orientation
• Teamwork orientation
• Patient focus
• Mission and goals
• Management style

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Conclusions

• While high quality care requires effective teams,
  there is little current research uses measures of
  team behavior and culture in evaluating clinical
  interventions or quality improvements
• Identifying the types of constructs and measures
  of these constructs that can be used in health
  services research will help to bridge the gap
  between team effectiveness research and clinical
  or quality improvement studies

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• For copy of papers and bibliography
• ross.baker_at_utoronto.ca