CrossCross--Functional Team Functional Team Processes Processes

and Patient Outcomesand Patient OutcomesJeff AlexanderJeff Alexander

Richard Lichtenstein Richard Lichtenstein Kimberly Jinnett Kimberly Jinnett Rebecca Wells Rebecca Wells James Zazzali James Zazzali

Dawei LiuDawei Liu

Why Cross Functional Teams?Why Cross Functional Teams?

synthesize and apply knowledge synthesize and apply knowledge from a variety of disciplines from a variety of disciplines Health problems have become more Health problems have become more complex with chronic illnesscomplex with chronic illnessMedical training has become more Medical training has become more specializedspecializedimproving the performance of CFTs improving the performance of CFTs ––IOMIOM

CFTsCFTs-- the normative modelthe normative model

individuals from different disciplines who individuals from different disciplines who have varied backgrounds and interpretive have varied backgrounds and interpretive schemes for analyzing problems schemes for analyzing problems Relationships among CFT members are Relationships among CFT members are intended to be nonintended to be non--hierarchical hierarchical all members contribute their knowledge all members contribute their knowledge according to situational demands rather according to situational demands rather than traditional organizational roles than traditional organizational roles

CFTsCFTs-- the evidencethe evidence

more creative solutions more creative solutions better quality decisions better quality decisions increased organizational increased organizational effectivenesseffectivenesslower turnover rateslower turnover ratesgreater opportunities for learning greater opportunities for learning and professional growth and professional growth greater sense of empowerment greater sense of empowerment

CFTsCFTs-- the evidencethe evidence

randomized control trials to assess randomized control trials to assess team performance team performance limited understanding of team limited understanding of team process process quasiquasi--experimental studies of CFT experimental studies of CFT are crossare cross--sectional and focused on sectional and focused on structurestructureNo objective measures of team No objective measures of team performance performance

Team ProcessesTeam Processes

Normative versus the empiricalNormative versus the empiricalTeam embeddednessTeam embeddednessStatus distinctions among Status distinctions among professional groupsprofessional groups

CFTs in Mental HealthCFTs in Mental Health

mainstay of psychiatric care for mainstay of psychiatric care for seriously mentally illseriously mentally illinclude physicians, nurses (RNs and include physicians, nurses (RNs and LPNs), social workers, psychologists, LPNs), social workers, psychologists, and pharmacists. and pharmacists. Therapists (occupational, Therapists (occupational, recreational), dieticians, and recreational), dieticians, and chaplains participate on a more chaplains participate on a more selective basis selective basis

Participation and Team Functioning Participation and Team Functioning

ParticipationParticipation: extent to which staff : extent to which staff members members ““engage jointly with engage jointly with othersothers”” in making patient care in making patient care decisions decisions Team Functioning:Team Functioning: inputs from inputs from interdependent members are jointly interdependent members are jointly integrated so that the work of the integrated so that the work of the team flows seamlessly. team flows seamlessly.

Sample and DataSample and Data

patient sample: consisted of 1,638 patient sample: consisted of 1,638 seriously mentally ill patientsseriously mentally ill patientsOrganization sample:40 units that Organization sample:40 units that cared exclusively for the mentally ill cared exclusively for the mentally ill in 16 Veterans Affairs hospitalsin 16 Veterans Affairs hospitals40 patient care teams embedded in 40 patient care teams embedded in 40 units40 units

Team CharacteristicsTeam Characteristicsaverage team: average team: 9.5 members, (range 2 9.5 members, (range 2 –– 38) 38) modal team staff :modal team staff :1 physician, 1 physician, 1 social worker, 1 social worker, 3 registered 3 registered nurses (RNs), nurses (RNs), 1 licensed practical nurse (LPN), 1 licensed practical nurse (LPN), 2 2 nursesnurses’’ aides, aides, 1 1 recreational therapist. recreational therapist.

DataData

selfself--administered survey to direct administered survey to direct patient care providers patient care providers –– 3 waves3 wavesshorter survey of unit directors data shorter survey of unit directors data on unit level characteristicson unit level characteristics-- 3 waves3 wavesPatient data collected by trained Patient data collected by trained clinicians at regular intervals using a clinicians at regular intervals using a standard instrumentstandard instrument-- 1 to 14 waves1 to 14 wavesAdministrative data on staffing for Administrative data on staffing for each sample unit each sample unit

MeasuresMeasures--team levelteam level

Team ParticipationTeam Participation-- 7 item scale based on 7 item scale based on an aggregation of individual team an aggregation of individual team membersmembers’’ participation on each team. participation on each team. Team FunctioningTeam Functioning-- 8 item scale 8 item scale aggregated from individual assessments of aggregated from individual assessments of how well the treatment team was how well the treatment team was functioning in coordination, cohesion, and functioning in coordination, cohesion, and perceived performance perceived performance Patient cohort functioning, team sizePatient cohort functioning, team size

Measure Scale Items 1) Team Participation a) I frequently contribute information

b) I frequently interpret information c) I can comfortably disagree with others d) I feel free to participate actively e) I usually propose alternatives f) I usually evaluate alternatives g) I frequently participate in making decisions

2) Team Functioning a) Overall, our team has done its work well this last month b) In general, our patients receive high quality of care. c) Members of our team depend on each other to do our jobs d) We clearly are a team of people with a shared task – not a collection of individuals who have their own particular jobs to do. e) In general members of our team would agree that we have worked well as a team this past month. f) Overall, the difference patient-related jobs and activities that everyone does on this team fit together very well.

MeasuresMeasures-- Patient LevelPatient Level

Basic Activities of Daily Living Scale Basic Activities of Daily Living Scale (ADL)(ADL)Prior Inpatient DaysPrior Inpatient DaysAgeAgeDiagnosisDiagnosis--Dementia & alcoholDementia & alcohol--related disorders; schizoaffective related disorders; schizoaffective disorders & schizophrenia; bipolar & disorders & schizophrenia; bipolar & major depression. major depression.

MeasuresMeasures-- TimeTime

Repeated assessments of ADLRepeated assessments of ADL--cumulative, repeated measure of cumulative, repeated measure of elapsed time (in days) from program elapsed time (in days) from program entry to each subsequent ADL entry to each subsequent ADL assessmentassessment

AnalysisAnalysis

three levels of analysis: time (level 1), three levels of analysis: time (level 1), individual (level 2), and team (level 3)individual (level 2), and team (level 3)Multilevel statistical methods account for Multilevel statistical methods account for nested structure of the data (Proc Mixed in nested structure of the data (Proc Mixed in SAS)SAS)takes account of the level of the outcome takes account of the level of the outcome variable at program entry, change in variable at program entry, change in outcome status over time, and nesting of outcome status over time, and nesting of clients within treatment teams. clients within treatment teams.

ResultsResults

intraclass correlation (ICC) intraclass correlation (ICC) 37% time level 37% time level 42% individual level 42% individual level 21% team level. 21% team level.

Final Estimation of Fixed Effects of Team Participation on ADL Fixed effect Coefficient S.E. INTRCEPT 0.946 ** (0.408) GAF -0.006 ** (0.003) Team SIZE -0.002 ns (0.003) Team Participation. -0.156 ** (0.063) InptDAYS 0.001 *** (0.0001) Age 0.005 *** (0.001) Dementia 0.176 *** (0.058) Bipolar 0.075 ** (0.027) Time -0.000 ns (0.0003) GAF x Time -2.80E-6 ns (2.49E-6) SIZE x Time -8.87E-7 ns (2.71E-6) Team Part. x Time -0.00012 ** (0.000059) Inpt.DAYS x Time -1.55E-7 *** ( 9.337E-7) AGE x Time 9.17E-6 ns (1.113E-7) Dementia x Time 0.000015 ns (0.000066) Bipolar x Time -0.0001 *** (0.000031) _____________________________________________________________________________ **=p<.05, ***=p<.01; schizophrenia is the reference condition for dementia and bipolar ______________________________________________________________________________ Final estimation of variance components: Random Effect Variance Component INTRCPT1 0.2851 TIME slope 0.000262 level-1 0.07984 INTRCPT1/INTRCPT2 0.1472 TIME/INTRCPT2 0.000127

Final Estimation of Fixed Effects of Team Functioning on ADL Fixed effect Coefficient S.E. INTERCEPT 0.692 ** (0.310) GAF -0.006 ** (0.003) Team SIZE -0.002 ns (0.003) Team Functioning. -0.122 ** (0.049) InptDAYS 0.001 *** (0.0001) Age 0.005 *** (0.001) Dementia 0.178 *** (0.058) Bipolar 0.073 ** (0.027) Time -0.000 ns (0.0003) GAF x Time -1.67E-6 ns (2.678E-6) SIZE x Time 1.966E-6 ns (3.008E-6) Team Fct x Time 0.000016 ns (0.000051) Inpt.DAYS x Time -1.59E-7 *** (9.337E-7 ) AGE x Time 9.122E-6 ns (1.113E-7 ) Dementia x Time 0.00000999 ns (0.000066) Bipolar x Time -0.0001 *** (0.000031) _____________________________________________________________________________ **=p<.05, ***=p<.01; schizophrenia is the reference condition for dementia and bipolar Final estimation of variance components: Random Effect Variance Component INTRCPT1, 0.2851 TIME slope 0.000262 level-1 0.07984 INTRCPT1/INTRCPT2 0.1454 TIME/INTRCPT2 0.000145

0

0.5

11.5

2

2.5

3

entry 1 year 5 years

ADL

impa

irmen

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low participationhigh participation

ImplicationsImplications

importance of the relationship importance of the relationship between treatment between treatment teamteam processes processes and patient functional status and patient functional status team design and evaluation must team design and evaluation must take into consideration the difference take into consideration the difference between team functioning and team between team functioning and team performance performance other outcomes other outcomes