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

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

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?

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

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

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

Lemieux-Charles,et al 2004

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?)

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 Hackman’s model of team effectiveness used in several studies, but complexity of model limits focus to partial testing

Lemieux-Charles,et al 2004

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

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)

Lemieux-Charles,et al 2004

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

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

Lemieux-Charles,et al 2004

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 Key: teams are a critical component of quality improvement, but what practices used by teams contribute to their effectiveness? Are teams adhereing to QI practices more effective than those that do not? Lemieux-Charles, Murray, Baker, et al., J. Org Behavior, 2002

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

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?

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

Useful Measures, cont’d 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

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

For copy of papers and bibliography ross.baker@utoronto.ca