Question

State Donor Services (SDS) centrally manages the state’s organ procurement and donation process. There had been a trend of declining organ availability for transplant, despite efforts to increase awareness and success in registering donors through the Division of Motor Vehicles. To help solve the problem, SDS approached State University Hospital (SUH), one of the biggest sources of and utilizers of donated organs through its renowned organ transplant programs. Initial exploration of the problem quickly indicated a consistent demand for organs, but organ donations at SUH were down, matching the pattern seen by SDS.

Chris Carter, the new administrator for SUH’s emergency department, was asked to build a team to solve this problem for SUH. The hospital’s Chief Operating Officer (COO) told Chris that this was a top priority because of the high visibility of the transplant programs, the revenues it brought to the institution, and the fact that the Chairman of Surgery had just threatened to leave the institution if SUH “didn’t fix this problem it had obviously created.” The COO gave Chris 2 weeks to get a team together and develop a solution, which Chris would present at SUH’s monthly Executive Committee meeting. Chris asked the COO for advice regarding whom to have on the team, and the COO referred him to the Chief Nursing Officer (CNO).

Chris went immediately to the CNO, but the first available meeting time she had was in 3 days. In the meantime, Chris gathered as much information as possible. On the third day, the CNO’s secretary called to cancel the meeting but suggested that he talk with the Nursing Division Director for Medicine. She met with Chris that afternoon, and together, they formulated a list of people they thought would be able to address the issue. SUH was a functionally structured organization, so they built a team with nursing directors from each of the transplant services and the emergency department, the Director of Patient Care Services, a clerk, a physician from the emergency room, and the State Medical Examiner—whose office was located at SUH and who was responsible for autopsies—as well as a clerk from his office.

The earliest possible meeting time for this group was in 3 weeks—well beyond the COO’s deadline. Nonetheless, Chris set up a meeting with as many team members as possible and met with the others individually. The team would be able to meet only once or perhaps twice given the aggressive deadline and members’ schedules.

Fearing the approaching deadline and wanting to waste no time, Chris got right to business when the group met. He told the group his goals and invited an open discussion of each team member’s experiences with organ procurement. It quickly became evident that several members of the team were too new or too junior to be helpful, with some of Chris’s invitees having asked more junior colleagues to be a part of the team in their stead. The Medical Examiner immediately called into question the validity of the group and the authority by which he had been called to this meeting. When Chris told him this was a high-priority project for the COO and CNO—stating only their names and not their titles—the Medical Examiner indignantly replied that he had never heard of these people and that this was a waste of his time. When Chris clarified their titles, the Medical Examiner became less vocal, but remained indignant. He had been focused on solving a problem of declining autopsies, which placed SUH at risk of violating a state regulation. He was angry to have been diverted from this pressing problem and felt that Chris’s group would draw organizational focus and energies away from his own needs. His resentment spread to others in the group, which, coupled with their inexperience and a lack of appropriate representation, rendered the meeting—and the group—effectively useless.

In an effort to avoid a public display of this disaster, Chris reported his lack of success to the COO prior to the Executive Committee meeting. The COO realized the impossibility of the goals he had set for Chris. He extended the deadline 3 months and also utilized his own authority by agreeing to attend the next team meeting. These two key factors allowed Chris to rebuild a more knowledgeable, representative, and experienced team.

Ultimately, the organ donation problem was traced to a series of new federal regulations and SUH’s fragmented approach to processing end-of-life paperwork. In summary, each operational unit had established its own processes for responding to the regulatory requirements, none of which were integrated with the other operational units, thus creating hours of work for the clinical staff, most of whom gave up trying to secure organ donations. Interestingly, the Medical Examiner’s problem of a declining autopsy rate was also a result of this same disjointed method of paperwork processing.

The events at SUH illustrate multiple violations of building a successful, high-performing team. The situation was improved, however, as senior management became more involved, setting an appropriate timeline, changing membership, and conveying the importance of the team to the organization. As team composition and size were restructured to include the appropriate participants, senior management also granted the team visible and legitimate authority to undertake its tasks, and an environment of psychological safety was created where open communication was encouraged and individual team members could contribute with no risk of rebuke by others.

Teams are pervasive in health care and used for virtually every activity carried out in health care organizations, including clinical and management-focused activities. While our knowledge of evidence-based practices continues to grow, implementation of these practices has been uneven and fragmented. The recent development of the field of implementation science, introduced in Chapter 3, has sought to address the challenges of putting evidence into practice (Nilsen, 2015). While there is an array of obstacles to implementation, the application of medical knowledge to clinical service delivery is limited by the effectiveness and efficiency of teams charged with putting that knowledge into practice. Similarly, as new management techniques and technologies are developed, including QI methods, successful use of these approaches is dependent upon appropriately staffed, well-functioning teams. Clearly, we have moved well beyond the era of the autonomous heroic clinician (or manager, for that matter). It is not a stretch to state that behind every successful clinician or manager is a high-functioning team (or teams). And given what we know about the effectiveness of teams in most organizations, it can safely be said that the performance of virtually all clinicians and managers could be markedly improved by improvements in team effectiveness.

Teams also play a critical role in improving the performance of health care systems, whether a medical group practice, a hospital inpatient unit, a long-term care facility, or local public health departments. While effective patient care certainly requires that physicians and others possess current clinical knowledge, patient outcomes often depend upon how well patient-care teams work—whether team members understand and agree on patient-care goals, how members communicate with each other, and the effectiveness of team leadership. In sum, teams are the building blocks of health care organizations and are absolutely essential to implementing plans, caring for populations and individual patients, and identifying and successfully solving quality problems. Teams are not an option but a necessity. As such, it makes great sense to examine these building blocks and see how they can be strengthened.

In this chapter, the concept of team is applied very broadly, and shares characteristics with the concept of microsystems (Nelson et al., 2002), which are also discussed in greater detail, with specific application to patient safety, in Chapter 9. A microsystem is one of several subsystems of a larger system that is integral to system performance. This perspective, drawn from systems theory, is not a new concept but clearly helps us understand how the human body, an automobile, or an organization, operates. When examining the performance of any system, it is essential to examine (among other factors) the effectiveness of each component subsystem (e.g., the respiratory system), how these subsystems work together (e.g., the nature and adequacy of coordination between a hospital pharmacy and an inpatient unit), and the adequacy of information about system and subsystem performance (e.g., the extent to which the driver of an automobile is provided with information about the automobile’s performance).

According to this view, a health system is composed of many subsystems. In patient care, these may be referred to as clinical microsystems or frontline systems, referring to teams charged with meeting the needs of the patient population. It is these smaller microsystems that actually provide those services that result in positive patient outcomes, provider and patient safety, system efficiency, and patient satisfaction. And as is true with any large system, the effectiveness of any large health care system can be no better than the microsystems of which it is composed (Nelson et al., 2002).

Using the terminology of the microsystem, it is apparent how a microsystem is in fact one type of team, as defined by Nelson et al. (2002):

A clinical microsystem is a small group of people who work together on a regular basis to provide care to discrete subpopulations of patients. It has clinical and business aims, linked processes, and a shared information environment, and it produces performance outcomes. Microsystems evolve over time and are often embedded in larger organizations. They are complex adaptive systems, and as such they must do the primary work associated with core aims, meet the needs of internal staff, and maintain themselves over time as clinical units. (p. 474)

This definition may be slightly altered to apply to all other types of teams in health care. The key concepts in relation to teams are as follows:

• ■   People work together toward specific goals.

• ■   They use multiple interconnected processes.

• ■   They produce performance outcomes.

• ■   They have access to information about the team’s performance.

In addition, teams must adapt to changing circumstances, ensure the satisfaction of team members, and maintain and improve their performance over time.

In this chapter, we bring together several traditions of research on teams. We demonstrate how our knowledge of teams informs our understanding of team performance and the important role of teams in QI efforts.

Most of the research on team effectiveness has been carried out in relatively permanent teams with stable membership and opportunities for face-to-face interactions. However, many teams in health care and other sectors exist for only a short period of time, perhaps as short as a nursing shift. Because QI teams typically draw from multiple parts of an organization, these teams may exist for a limited period of time. These types of teams must organize themselves rapidly, and may not have the luxury of going through extended stages of team development. In this chapter, attention is given to traditional as well as temporary teams. Simply put, today’s teams do not always fit into traditional team structures and processes, and we need to account for these variations when discussing health care teams.

QUESTION.

Why did the approach fail? What was done to correct the situation. Please keep in mind the content of the chapter...the importance of Teams in CQI success.

Answer 1

Quality improvement process have an important role for improving the health of the population. The quality process can be improved by enhancing patient experiences and outcomes, and reducing the cost of care, and to improving provider experience.

Many organizations are actively involved in improving quality. An effective team work is verymuch needed for the continuous quality improvement.

The principles underlying the every procedure like giving comprehensive care after initial assessment have been derived from models of continuous quality improvement (CQI).

The ineffective application of team work leads to the failure of continuous quality improvement. So an active role of the practice team and the application of a clearly structured, stepwise problem-solving method is needed to develop and implement the improvement plans. The measures for CQI success are;

Facilitators are needed to coach and train the team. An outreach educational effort also needed.

Then monthly meeting for the entire team is necessasry to update the working aspects and for the further improvement of quality. In that the weak aspects of the team's practice management are discussed then,help is provided with the selection of suitable topics for improvement and the team is guided through the quality improvement cycle.Quality improvement cycle includes measurement and description of the present situation, identification of potential barriers, determination and implementation of change and improvement activities, observation of progress and outcome evaluation.