1. Successful MDTs: What Are They
Successful MDTs: What Are They? A Patient’s Journey through the QEH Stroke Team
Cilla Williams
Stroke Physiotherapist
Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust
My name is Cilla Williams and I’ve been working on the Stroke Unit at the Queen Elizabeth Hospital in King’s Lynn for over 16 months. Prior to that I worked for over 8 years at two hospitals in Derby, rotating across different neurological departments including the Acute Stroke Unit and the Stroke Rehabilitation Unit.
Today I’m going to focus on the QEH Stroke Team and the improvements in team working that we have made over the last year in particular. We will explore:
the stroke pathway at QEH
consider relevant research and what constitutes good team work
look at how this relates to service performance, and the patient’s experience

2. Who are we?
28 bed (+ 1 thrombolysis bed) stroke unit, combining acute stroke and stroke rehabilitation
545 strokes per year
Ward manager – Sister Diane Benefer
Consultants – Raj Shekhar, James Phillips, Umesh Rai
Stroke OT/PT Team Lead - Anne-Marie Hurst
QEH Stroke AHPs cover entire stroke pathway (successful bid in 2008)
Let me tell you a little bit about the stroke service at the QEH.
Our Stroke OT/PT Team Leader Anne- Marie is on maternity leave at the moment, which is why I’m here presenting in her absence. The names on this slide are only a few of many key leaders in our stroke service, and their leadership is one reason why we have developed a strong service. We have some very experienced and skilled leaders within our clinical team who have been able to drive forward positive changes.
One unique aspect of our current service is that the entire stroke pathway (inpatient and community) is covered by our allied health professionals (PT, OT, Clinical Psychology, Speech & Language Therapy, Dietetics). This is a feature that is currently under review, but as you can imagine it fully enhances the continuity of care for stroke patients in West Norfolk. We have a specialist Community Stroke Team, but this team does not fully meet all of the ESD criteria, which is again something that we are working towards.
Hospital serves an area of approx 750 square miles and people (west Norfolk, parts of Breckland, North East Cambridgeshire, South Lincolnshire)

3. What is teamworking in Stroke?
A coordinated multidisciplinary team that meets at least once a week for the interchange of information about individual patients (RCP, 2012)
Staff should have specialist expertise in stroke and rehabilitation (RCP, 2012)
Stroke units should have multi-disciplinary notes (Clarke, 2010)
Is that it??!!!
We are all aware of the national targets for stroke care in the UK. But what do these guidelines state about teamwork?
Is that it? We all know that there is more to good teamwork than this.

4. What is real teamworking in Stroke?
Current measures of teamworking in stroke are inadequate
Location of staff, frequency of team contact, team size, management structure, defined team membership and shared goal planning are key determinants of teamworking practice
(Baxter & Brumfitt, 2008a)
So what is real teamworking in stroke? Baxter & Brumfitt reviewed current measures of teamwork in stroke and found them to be inadequate. They found that location of staff, frequency of team contact, team size, mgt structure and shared goal planning are more relevant measures.

5. The inpatient journey – an overview
Patient and Carer
Discussed at 8.45am board round
Assessment and treatment by MDT
Feedback to board round
Commence discharge planning
So lets go on to look at the stroke patient’s journey at the QEH see how this compares to Baxter & Brumfitt’s recommended measures.
The inpatient stroke team meet daily Monday to Friday at 8.45 in the day room on the ward to hold the board round. This is one of the most significant features of our service, and will be explained in more detail in a moment. Following board round, and the discussion of new patients, the MDT complete their assessments and commence their treatment programmes. This will include goal setting, and explaining the service to patients and their carers. All the information gained will then be discussed at board round the following day. Alongside this, we all know that discharge planning commences at day one, so provisional/expected length of stay and discharge destinations will be discussed
As you can see, the patient is at the heart of this process. Even if the patient is not physically present at these discussions, it is their wellbeing which is constantly leading the discussions/decisions made.
Let’s look at board round in a bit more detail.

6. Board round

7. Board round 30 minute MDT meeting held in day room, 5 days per week
Exceptional multi-professional attendance – doctors (including consultants), specialist stroke nurses, physiotherapists, occupational therapists, speech & language therapists, stroke coordinator sister, dietician, social worker, clinical psychologist, Stroke Association Coordinator
Week to view documentation
“I don’t think decisions are made above your head, they involve you” (Patient Experience Survey 2012)
The vast majority of each profession is represented daily. Prior to holding a daily board round, the stroke unit used to hold more separate handovers and then hold a weekly MDT, lasting approximately hours. A weekly MDT can no longer be justified with the high volumes and turnovers of patients using our service. We cannot wait a week for important issues to be discussed. Therefore although the primary idea of board round is a quick summary of the key actions to be completed that day, there is also the time (and the relevant professionals present) to discuss more complex issues in more detail.
The actions are documented in a week to view proforma so we can ensure they are completed by the allocated professional in a timely manner.
The presence of the specialist stroke nurse not only helps with the information about new patients who were admitted the day before, but as they will potentially be admitting new patients to the ward that day, it helps with bed management as they can discuss who could be outlied if this was needed.
As previously mentioned, the patient may not be physically present, but the team interactions with the patient the previous day will be fed into the next day’s boardround, and the discussions at that day’s boardround can be fed back to the patient.
About discharge planning: “I don’t think decisions are made above your head, they involve you” (Patient Experience Survey 2012)
The board round format is going to be rolled out across the Trust.
Discuss jonah??
If a patient and their carers were to be physically present during the round, it could be considerably time consuming (Monaghan et al 2005) looked at this in a 25 bed stroke unit and found it involved 4.5 hours for each team member involved (also involved new paperwork).
Value of sharing knowledge – ‘putting each part of the jigsaw together’, enhancing clinical problem solving (Baxter & Brumfitt, 2008b)

8. A typical day – joint working
So after we have prioritised our working day after board round, we start the real work! This is our therapy gym, where patients will spend a great deal of time.
Joint working is vital for effective and efficient MDTs. Due to the complete integration of the PTs and OTs, joint working is the norm rather than the exception. We have generic OT/PT therapy assistants which really helps with patient rehabilitation. I have worked in stroke team where the therapy assistants are either PT or OT, or they have a shared role which is half time OT and half time PT. So we had to plan our therapy based on what role the assistant was in at that time, and the PTs and the OTs would fight over their allocated time. But at QEH each patient is allocated their own physio, OT and therapy assistant, making the planning of therapy much easier. All of the PTs, OTs and therapy assistants work in their own subteams to help divide the caseload.
A further layer of team work is added with the nursing staff, clinical psychologists and speech and language therapists. For example I assisted the nursing assistants with the showering of a gentleman with reduced postural control and bilateral leg weakness following a spinal stroke.
All of the allied health professionals on the stroke unit share an office and a therapy gym. The size of this shared space provides an excellent location for joint working.

9. A typical day – joint working
Patient with midbrain infarct, presenting with reduced postural control, aphasia, ptsosis, visual disturbance, dysphagia
Tilt table session in stroke therapy gym with PT and Therapy Assistant (dual OT/PT), as well as…….
SLT
Orthoptist
One such example is a gentleman who had experienced a midbrain infarct, presenting with reduced postural control, aphasia, ptosis, visual disturbance (bilateral divergance) and dysphagia. The physios used a tilt table to allow the patient to experience some pressure bearing and gravity. The speech and language therapist joined the session to explore the patient’s communication further, and the orthoptist/opthalmologist also attended to complete her initial assessment of the patient. She explained to us his visual deficits and how we could assist his vision in therapy.
This was an extremely useful session not only for the patient, as his needs were being addressed in such a organised and holistic manner, but also from a staff perspective. Joint working facilitates appreciation and understanding of different professions, and a sharing of knowledge and skills – my knowledge of visual deficits is poor, and this gentleman had complex visual needs that I did not previously understand. The learning gained from that joint session benefitted the patient’s future therapy sessions immensely.
Therefore the patient gained not only in that one session, but in his future sessions too.
This helps to make the patient’s journey seamless.

10. A typical day –opportunistic dialogue
Unplanned, problem orientated interaction between team members unconstrained by location, time, or team member status (Clarke, 2010)
Occurs on the ward, in the day room, in the therapy gym, in the therapy office
Close proximity to Wheelchair Services, Social Services departments
Not only with staff members but also patient and carers
In his recent paper on teamwork in stroke units, David Clarke from the University of Leeds observed the practices of teams on two stroke units in northern England, and identified the importance of informal conversations between team members which he termed ‘opportunistic dialogue’. He described this as being ….
Although this appears such a simple, innate and automatic process which we might overlook when evaluating our team work, like Clarke, I believe this is a fundamental component of good team working.
2) These shared spaces have been shown to allow increased joint working (Borrill et al 2003, in Clarke, 2010). Opportunistic dialogue allows team members to recognise their inter-dependence in patient’s achieving their rehabilitation goals.
3) Our close proximity to other departments means we can meet with team members face to face rather than over the phone. I have valued working at a smaller hospital where so many aspects of the service are close to hand.
4) I don’t think opportunistic dialogue should be constrained to just communication between health professionals – I believe it greatly applies to communication with patient’s and their carers too. As we have such a large gym, carers are often invited to join therapy sessions. Or we will often catch up with them during visiting time to give them an update on how someone is progressing. All these small interactions could be easily dismissed, but their significance is great.
This helps to make the patient’s journey seamless

11. A typical day –opportunistic dialogue
Suddick & De Souza (2006) completed a qualitative study of 5 PTs and 5 OTs at three different neurological healthcare teams – they highlighted the importance of the environment (open plan office), and ‘informal liaisons’, and social events.

12. A typical day… Comprehensively trained staff
Electronic nursing handover updated by all of the team
Six day PT & OT Stroke service
Early inpatient contact with Stroke Association Information, Advice and Support Coordinator
So far I have described some of the key contributors' as to what makes our QEH Stroke Team so effective. We have talked about strong leaders and individuals within the team, the daily board round, joint working, shared space, and opportunistic dialogue. But there are other factors which play a part…
Staff training programmes, which takes various forms…
The nursing staff receive a comprehensive training package involving 163 competencies. The training involves past service users and their carers.
The rotational PT/OT staff receive a comprehensive induction within their first two weeks of arriving in the stroke team, covering everything from national stroke standards to postural control and stroke classification.
Last year I organised a study day for the nursing assistants ‘The 24 hour approach to Rehabilitation’ to emphasise their important contributions.
Skilled, experienced staff enhances the patient’s journey through the stroke service.
All of the team update the electronic nursing handover to add another layer to the methods of communication used on the ward
The PT & OT service runs across 6 days. One OT, one PT and one therapy assistant work on a Sunday to assess new patients, facilitate discharges where possible, and provide extra rehabilitation sessions if time allows. This not only impacts on length of stay, but eases the burden for busy Monday mornings.
One very valued part of our MDT are our Stroke Association Colleagues. They also have a base in our therapy office, and can start to make links with patients and their families as early as needed. Their role continues as the patient moves into the community setting.
The staff having the tools to do the job is vital. It makes the patient’s journey seamless.

13. Discharge Planning Dedicated Stroke Coordinators (1 WTE)
Discharge Planning Assistant (0.5 WTE)
Formal meeting with patient and carer if required
Community Stroke Team
Comprehensive therapy discharge summary
So we have talked through a lot of the typical inpatient experience on the QEH stroke unit. We have seen how their rehabilitation is discussed and progressed during the daily board round, how they will experience joint working, and how they and their carer will have regular informal conversations with staff. We mentioned at the beginning of the presentation how discharge planning starts on day one, and I would like to tell you more about this part of the team.
We have two Stroke Coordinator Sisters (Sharon and Esther) who make up 1 WTE. They play a vital role in the discharge planning, especially for our more complex patients. They will organise the completion of the DST checklist, nursing needs assessment, and the full continuing care assessment if indicated. This is unique to our service as they are specialised in stroke. Although they are not always counted in the nursing numbers, they can still assist in the care of particular patients where needed – for example, not only will they rely on the feedback from the rest of the team when completing the continuing care paperwork, they can also be ‘hands on’ with the patient themselves, and build up a rapport with the carers. This is much better than an ‘outsider’ coming in and leading the Continuing care meeting.
We also have a discharge planning assistant, who works closely not only with Sharon and Esther, but also with the therapy staff. This can save a great deal of time for therapy staff, freeing them up for hands-on work.
As well as the informal opportunistic dialogue described with patients and carers, a more formal MDT meeting can be arranged if required at any time.
And as the patient’s discharge date approaches, if they have a West Norfolk GP they can receive their first appointments with the Community Therapists and meet those staff who will be continuing their rehab (as we are all based in the same office). This again helps to make the patient’s journey seamless.
Upon discharge, a comprehensive therapy discharge summary is created, and this is something that will be progressed to form the Joint Health and Social Care Plan.

14. In the community Monthly MDTs and interdisciplinary MDT training
Stroke Association
Communication Group
Advice/support
Prevention
Long term support groups
Very briefly – once the patient has left hospital the excellent MDT working continues. The variety of professionals at the monthly community MDT continues to be exceptional like the inpatient board round.
The role of the Stroke Association is expanded within the community and includes…

15. What do others say?
“They demonstrate true interdisciplinary working” Liz Bennett, Anglia Stroke Network Lead
The integrated physiotherapy and occupational therapy services “reduces duplication and increases effectiveness and efficiency of service delivery” Caroline Hayden-Wright, Rehabilitation Services Review, October 2012
So I’m obviously biased when flying the flag for our team. But what do those outside of the service say about the QEH Stroke Team?
Liz Bennett uses the term interdisciplinary working – this is what we should be aiming to achieve within our teams (it will improve outcomes far greater than team members working in isolation) (Suddick & De Souza, 2006)

16. What do our patients say?
“My family and I wish to express our gratitude and admiration for this team of talented health care professionals” Patient AS, September 2012
“Seems to be a well practised unit”
“Absolutely brilliant” [about QEH Stroke Unit]
Patient Experience Survey 2012
Patient AS also said “the excellent level of care I have received both as an inpatient and during my recovery at home”, “the weekend service really kick started my recovery”
The patient experience survey completed in 2012 highlighted the importance of joint sessions with carers.

17. The results?
QEH Stroke Team achieved a total organisational score of 89.1 in the SSNAP 2012 (national average 73.3)
And in terms of the hard data, what does that say about our team working?
Sentinel Stroke NationalAudit Programme (SSNAP): Acute organisational audit report
We were in the upper quartile.
Domain 1) Acute care organisation 100%,
2) care 80%,
3) specialist roles 100%,
4) inter-disciplinary services 65%,
5) TIA service 100%,
6) training & research 80.4%,
7) team meetings 100%,
8) communication with pts & carers 87.5%.

18. For the future… Service user participation in service development
Restructuring our community service
6 month reviews
The QEH Stroke Team is evolving constantly. We are not the perfect service just yet – here’s what we are working on to enhance our team working even more…
We hold monthly stroke steering group meetings which are again very well attended by all of the professionals mentioned previously. We would like to involve service users with these meetings.
As mentioned earlier, although we meet some of the criteria for ESD, we do not have a fully fledged ESD, so this is something that needs to be established.
We do not yet have a system in place for formal 6 monthly reviews.

19. Conclusion
Effective team work is complex and requires frequent contacts at a variety of levels, not only between professions but with patients and their carers
Successful interdisciplinary working is vital in stroke but national guidelines do not go far enough when describing what makes teams most effective
The QEH Stroke Team demonstrates a range of qualities of effective team work including co-location, good leadership, skilled staff, joint working and opportunistic dialogue
The patient and their carer will be physically or virtually present at every stage of the pathway
A daily, organised, well-attended boardround can have a significant impact on your service.
Staff feel supported by teamwork (Baxter & Brumfitt, 2008b)
Make the time for regular communication – formally and informally.
The patient is at the core of every stage of their journey through the stroke service, and it is our job to ensure that journey is seamless.

20. Any questions? ?

21. References
Baxter, S. K. & Brumfitt, S. M. (2008a) Once a week is not enough: evaluating current measures of teamworking in stroke. Journal of Evaluation in Clinical Practice, 14,
Baxter, S. K. & Brumfitt, S. M. (2008b) Benefits and losses: a qualitative study exploring healthcare staff perceptions of teamworking. Quality Safety Health Care, 17,
Clarke, D. J. (2010) Achieving teamwork in stroke units: The contribution of opportunistic dialogue. Journal of Interprofessional Care, 24 (3),
Enefer, C. & Scantlebury, K. (2012) Patient Experience: Patient Satisfaction Interviews (West Raynham Stroke Unit), QEH Audit Dept.
Hayden-Wright, C. (2012) Review Rehabilitation Services Queen Elizabeth Hospital King’s Lynn.

22. References (continued)
Monaghan, J., Channell, K., McDowell, D. & Sharma, A. K. (2005) Improving patient and carer communication, multidisciplinary team working and goal-setting in stroke rehabilitation. Clinical Rehabilitation, 19, RCP (2012) National Clinical Guideline for Stroke, 4th Edition, London, Royal College of Physicians. RCP (2o12) Sentinel Stroke National Audit Programme (SSNAP) Acute organisational audit report, London, Royal College of Physicians. Suddick, K. M. & De Souza, L .(2006) Therapist’s experiences and perceptions of teamwork in neurological rehabilitation: reasoning behind the team approach, structure and composition of the team and teamworking processes. Physiotherapy Research International, 11 (2),