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 and Flows (Ryan 1996) 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 # of Articles Decades Patient safety is linked to the quality of collaboration s40s50s60s70s80s90s00s Estimate Teamwork Articles in the Journal of Orthopsychiatry by Decade Since the Journal Began in 1930

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 Why Interprofessional Practice? Why Now?

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 Current Initiatives in Interprofessional Care

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 Decisions Authority Account- bility Roles & Inter- dependence Communication & Conflict Management Team Member Skills & Strengths Clarity/ Coherence of Goals Perceived Support from Organization THE DIMENSIONS OF TEAMWORK OUTCOMES OF TEAMWORK Customer Needs & Interteam Issues Customer Focused Outcomes Internal Focused Outcomes Financial Focused Outcomes Innovation Focused Outcomes Ad hoc Inter-agency Shared Care Teams Acute Care Teams Continuing care and Rehabilitation teams Specialized Geriatric Services Teams Management Teams TYPES OF TEAMS Primary Care Teams

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 Nurse

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

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

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

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

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 Core skills Social Work Physician Pharmacy Nurse

Multiprofessional Interprofessional 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

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

StageLeader Behaviour and Informal Style Team Member Behaviour and Informal Roles Emotional Climate and Team Ritual The Teams Style of Humour Stage 1: Forming The leader seeks to control and direct Dependency seeking characterizes team member behaviour. Refreshments reduce anxiety Leaders joke to soften control Member joke about the team and about patients Stage 2: Storming The leader tries to convince the team. Team members resist. Scapegoating is evident Clowning reduces tension Conflict emerge often in response to minor issues which take on broader symbolic meanings. Humour is often barbed and personal, interspersed with the clowns buffoonery. Stage 3: Norming Leadership exercised by coalitions of members based on Perceptions of competence Members are colleagues who are able to defer to a each other’s relevant experience. Members provide mutual support. Parties express solidarity. Team symbols emerge Sharing of team deprecating humor. Self-disparaging jokes. In-jokes emphasize membership Stage 4: Performing Authority exercised by a coalitions depending on skills and emergent needs Members find opportunities for interdependence and resist earlier activities such as scapegoat and clowning Members have pride in the teams accomplishments. Team meetings become constructive and enjoyable. Team legends emerge and team anniversaries celebrated. The team laughs at itself but explains its in-jokes to new or non-members. It enjoys it's own funny stories and myths. Humour typically at the expense of the team but without loss of task orientation. Routinely reflect on the stage of team development

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

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. C E J S DRIVERS prefer 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?”. 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?” Stay cool calm and collected Let feelings and emotions show React quickly and hate to wait Wait, watch, hear all sides Value one another's diverse personal styles

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