Teamwork and Patient Care in Health Services

Office of Health Care ManagementDublin

19th September 2003

Professor Michael WestProfessor Michael WestAston Business SchoolAston Business School

Attracting and retainingAttracting and retainingInformation overloadInformation overloadCooperative working Cooperative working

Involvement Involvement Building trust Building trust

Innovation and changeInnovation and changeLeadershipLeadership

Job Satisfaction and Stress in Britain

!! In the ten years of the 1990s, job satisfaction In the ten years of the 1990s, job satisfaction of workers fell and stress increasedof workers fell and stress increased

!! Levels of satisfaction fell particularly in the Levels of satisfaction fell particularly in the public sector (but generally higher levels of public sector (but generally higher levels of satisfaction). satisfaction).

!! People in smaller organisations and women People in smaller organisations and women are more satisfied with their jobs.are more satisfied with their jobs.

www.oswald.co.ukwww.oswald.co.uk

Research Question

What is the link between people What is the link between people management practices and patient management practices and patient care in hospitals?care in hospitals?

Interviews and questionnaires: 61 trusts

TrainingTraining

Appraisal: % in formal teams

Controls: size & health profile; Controls: size & health profile; number of doctors; mortalitynumber of doctors; mortality

Research Methods

Methods

!! size of training budget size of training budget !! spend over statutory requirements spend over statutory requirements !! access to tailored, formal training policy for each access to tailored, formal training policy for each

occupational group occupational group !! percentages of each occupational group having 3 percentages of each occupational group having 3

days formal offdays formal off--thethe--job training in previous year job training in previous year !! frequency of training needs analysis for each frequency of training needs analysis for each

occupational group occupational group !! percentages doing percentages doing NVQsNVQs

TrainingTraining

Methods

!! priority attached to appraisalpriority attached to appraisal!! % of staff in each group received % of staff in each group received

appraisals in last yearappraisals in last year!! frequencyfrequency!! % of appraisers receiving training% of appraisers receiving training!! methods used to evaluate appraisals and methods used to evaluate appraisals and

systems of appraisalsystems of appraisal

Appraisal:

Methods

!! hospital sizehospital size!! number of doctors per bednumber of doctors per bed!! local health profile from Health Authority local health profile from Health Authority

data:data:–– deaths (all causes) 15deaths (all causes) 15--64 standardised64 standardised–– deaths from cancerdeaths from cancer–– deaths from circulatory diseasedeaths from circulatory disease–– emergency reemergency re--admissionsadmissions–– emergency admissionsemergency admissions

Controls: size & health profile; Controls: size & health profile; number of doctors; mortalitynumber of doctors; mortality

Methods

!! Does the team have clear overall objectives?Does the team have clear overall objectives?!! Do team members have to work interdependently Do team members have to work interdependently

to achieve these objectives?to achieve these objectives?!! Do team members have clear roles within the Do team members have clear roles within the

team?team?!! Do others in the organization see the team as a Do others in the organization see the team as a

team?team?

Percentage of staff working in formal Percentage of staff working in formal teamsteams

ResultsHR accounts HR accounts for 33% of hospitalfor 33% of hospital

variance in mortalityvariance in mortality

1. Appraisal

2. Training2. Training

3. Staff in formal teams

7.5

8.0

8.5

9.0

9.5

10.0

10.5

11.0

low moderate high

% d

eath

s af

ter a

dmis

sion

for h

ip fr

actu

res

Sophistication of appraisal system

92949698

100102104106108

<40% 40-59% 60-79% 80-99% 100%

Mea

n m

orta

lity

inde

x

%staff working in teams

Implications

!! A significant improvement in appraisal is A significant improvement in appraisal is associated with a reduction of 12.3% of associated with a reduction of 12.3% of the number of deaths after hip fracture the number of deaths after hip fracture

!! 25% more staff working in teams is 25% more staff working in teams is associated with 275 fewer deaths per associated with 275 fewer deaths per 100,000 following emergency surgery or 100,000 following emergency surgery or 7.1% of the total number of deaths 7.1% of the total number of deaths following emergency surgery following emergency surgery

Additional Control Variables

GP Facilities per 100,000

NHS facilities per 100, 000NHS facilities per 100, 000

Income

Prior mortality 72%Prior mortality 72%

Doctors/Doctors/100 beds100 bedsNo controlsNo controls

significantsignificant

HR directorHR directorVotingVoting

HRM overallHRM overall

Case studiesCase studiessupportsupport Implications …Implications …

Change inChange inmortalitymortality

Results …

AppraisalAppraisal

A Comparison of GHQ-12 Findings from the BHPS1 and the NHS Sample

SourceSource StatusStatus Sample SizeSample Size Percent Percent CaseCase

BHPSBHPS EmployedEmployed 5,0015,001 17.8%17.8%NHSNHS EmployedEmployed 11,29111,291 26.8%26.8%

1. British Household Panel Survey, 3rd Wave data, 19931. British Household Panel Survey, 3rd Wave data, 1993--19941994

0

5

10

15

20

25

30

35

Not in a team Pseudo team Work in a team

%

Team working and stress

Benefits due to:

Buffered from organisation

Social support

Role clarity

Humans in groups

Clear shared Clear shared objectivesobjectives

Support for innovationSupport for innovation

Participation Participation

Emphasis on quality of patient Emphasis on quality of patient carecare

Health Care Team Effectiveness

3.43.63.8

44.24.4

Exte

rnal

R

atin

gs o

f Ef

fect

iven

ess

<3.2 3.2 - 3.4 3.4 - 3.6 3.6 - 3.8 >3.8

PHC Team Functioning

Similar findings in CMH teams

Health Care Team Effectiveness

11.5

22.5

33.5

External Ratings of Innovation

<3.2 3.2 - 3.4 3.4 - 3.6 3.6 - 3.8 >3.8

PHC Team Functioning

Similar findings in CMH teams

Health Care Team Innovation

0.51.52.53.54.55.5

Innovationin Quality of

Care

5 7 8 9 10 11 12

Professional Diversity

Health Care Team Effectiveness

!! Within health care, those working in Within health care, those working in well functioning teams are more well functioning teams are more likely to stay working in their settings likely to stay working in their settings than those working in poorly than those working in poorly functioning teamsfunctioning teams

Retention and turnoverRetention and turnover

Why Team-based Working?

PerformancePerformance Involvement

Change andChange andinnovationinnovationWell-being

CooperationCooperationacrossacrossteamsteams

AutonomyAutonomyandand

responsibilityresponsibility

The tasks The tasks for teamsfor teams

BuildingBuildingteamteam

organizationsorganizations

Failures of team-based working

How to promote effectiveness and

innovation in teams ...

1. Select people with diverse experience and knowledge to

form the team

2. A team task and one that challenges the team

3. Clear leadership

4. Dance together constantly to pass the 20

second test

5. Encourage constructive conflict and dissent –agreeing to disagree

6. Regularly check that the team is functioning well

(role of leadership)

7. Value errors and problems

8. Emphasise team creativity not just

productivity … and stop work.

Reflexivity and Team EffectivenessReflexivity and Team Effectiveness

!! Teams will be more effective and Teams will be more effective and innovative to the extent that they reflect innovative to the extent that they reflect upon their objectives, strategies, upon their objectives, strategies, processes and environments and adapt processes and environments and adapt these aspects of their task worlds these aspects of their task worlds accordingly.accordingly.

9. Bonding and bridging –inter-team relationships

Train to work in teams

Knowledge, skills and attitudes for customer teamwork

•• KSAs for teamwork:KSAs for teamwork: communicationcommunication

•• KSAs for teamwork:KSAs for teamwork: goal setting and performance goal setting and performance managementmanagement

•• KSAs for teamwork:KSAs for teamwork: planning and coplanning and co--ordinationordination

•• KSAs for teamwork:KSAs for teamwork: collaborative problemcollaborative problem--solvingsolving

•• KSAs for teamwork:KSAs for teamwork: conflict resolution conflict resolution

Audit of organisational structures and culture

Audit of business environment

Identification of types and locations of teams

Implementation of support systems

Implementation of team management and leadership systems

Implementation of team based working

Evaluation and maintenance systems

Introducing team-based working

Organizational Supports for TeamsOrganizational Supports for Teams

!! Setting clear objectives for teams and theSetting clear objectives for teams and the

organization with a primary focus on patient careorganization with a primary focus on patient care

!! Communication and information systemsCommunication and information systems

!! Education and training systemsEducation and training systems

!! Feedback systemsFeedback systems

!! Liaison and integrationLiaison and integration

!! Process assistanceProcess assistance

!! Recruitment, appraisal and selection policies.Recruitment, appraisal and selection policies.

Team-organizational Relationships

!! Negotiate versus comply with Negotiate versus comply with organizational demandsorganizational demands

!! Challenge versus accept organizational Challenge versus accept organizational limitationslimitations

!! Challenge versus accept organizational Challenge versus accept organizational incompetenceincompetence

!! Communicate independence versus Communicate independence versus dependencedependence

!! Rely appropriately versus heavily on Rely appropriately versus heavily on organizational directionorganizational direction

Revolutionary Teams!! Have a clear visionHave a clear vision!! Form small team of committed colleaguesForm small team of committed colleagues!! Develop a clear, consistent and coherent Develop a clear, consistent and coherent

message linked to patient caremessage linked to patient care!! Repeat, repeat, repeat the messageRepeat, repeat, repeat the message!! Listen openly to the views of othersListen openly to the views of others!! Be persistent whatever the obstacleBe persistent whatever the obstacle!! Ensure participationEnsure participation!! Be prepared for conflictBe prepared for conflict

Rwanda

Race

FootballViolence

MiddleEast

Customers?

BosniaKashmir

NorthernIreland

IntergroupPrejudice

The Human Pathology

What words?What words?

Who are they?Who are they?

Their threat?Their threat?Feelings?Feelings?

Your Out Groups

Circle of Trust

open

Comm

altruism

Sharedfate

+conflict

respect

risk

values

LeadershipKindness

Courage

Identity

Externalrelationships

Reflexivity

Relationships

Optimism

Vision