bjectives1. Analyze collaborative leadership behaviors in real-life situations.2. Examine the meaning of collaborative cultures.3. Employ positive communication and productive, interprofessional dia-logue to facilitate team function.4. Identify boundary-spanning activities that support collaborative cultures.5. Understand the dynamics of successful interprofessional healthcare teams.Every organization has its own unique spoken and unspoken rules that define the culture. Culture is often simply stated as, “the way we work around here.” Cultures are formed and change through a variety of envi-ronmental events, leadership, and experiences. Dramatic and sometimes traumatic events impact the way cultures operate much the same way that the environment impacts personality in individuals. The way lead-ers respond to these events also shapes the culture. Edgar Schein (1986) defined culture using the following three levels:1. Artifacts: These are the things you can easily see on the surface. How people behave is an artifact of culture.Facilitating a Collaborative Culture137
CHAPTER 8 Espoused values: These are the stated goals, philosophies, and values of an organization or group. Vision, mission, and val-ues statements published on webpages, on posters, or in team charters are examples of espoused values.3. Basic assumptions and values: These are the unconscious workings that underlie the core behaviors of a group. Shifting from a primarily hierarchical, disciplinary-centered culture to a more relationship- and patient-centered, collaborative culture is one of the primary challenges for healthcare systems.Team cultures that value and actively seek each member’s contribu-tion can only inspire collaboration, commitment, and active engagement in the achievement of common goals (Wheatley, 2005, 2006; Whitney, Trosten-Bloom, & Radu, 2010). Successful team leadership is, at its heart, an affirmation of the need for human beings to contribute and collaborate in a positive manner. Affirmative cultures are created and sustained through positive, rather than negative, dialogues and groups that demonstrate a higher ratio of positive language tend to be more open to new ideas, more creative, and more productive. As feelings of self-efficacy emerge and grow, so does the perceived range of choices and possibility for action (Frederickson, 2003, 2009).REFLECTION: Cultural Cues ■What are some of the artifacts of your organization/team? ■What are the espoused values of your organization/team? ■If a friend was joining your organization/team and he wanted to know how to succeed, what would you tell him about the unspoken values and assumptions of your organization/team?Like a pebble dropped into a pond, acts of affirmative leadership begin with the self and radiate out to impact other individuals, groups, organizations, and local and global communities. The result is the distri-bution of leadership behaviors beyond the designated leader and a facili-tation of a culture of possibilities—a collective willingness to try new things and a more equal sharing of responsibility for goals and outcomes. Not surprisingly, this concept is associated not only with best practices in interprofessional healthcare teams, but also in a wide range of highly profitable business endeavors (Anchor, 2012; Briskin, Erickson, Ott, & Callanan, 2009; Fox, 2012; Institute of Medicine, 2001, 2002, 2003; Pew 138 | Chapter 8 Facilitating a Collaborative Culture rofessions Commission, 1998; Spreitzer & Porath, 2012; WHO, 2006; Zolno, 2007).Creating and maintaining a collaborative culture is an important aspect of a professional orientation—no matter what the discipline or position in the organization. Members of high-performing teams per-ceive their work environment as having high levels of flexibility, respon-sibility, standards, rewards, clarity, and team commitment. They feel that new ideas are welcomed, their expertise is trusted, accountability and excellence are the norm, expectations are clear, and there is a com-monality of purpose (Spreier, Fontaine, & Malloy, 2006). The designated leader of the team sets the tone by modeling collaborative behaviors but also actively coaches team members by learning to listen, learning to ask powerful questions, and creating a safe environment based on trust and confidentiality (McKee, Tilin & Mason, 2009).Leaders facilitate the team’s capacity to adapt by encouraging diverse perspectives. Members who take a leadership stance do so by practicing a professional assertiveness that allows them to offer their unique professional perspective while maintaining an active curiosity and actively soliciting the same from other team members. Opportuni-ties for frequent, productive dialogue between team members facilitate the development of a common sense of purpose, which enables them to strategically leverage their unique professional and personal contri-butions. Interprofessional dialogue, at its most productive, is the art of thinking together and embracing different points of view (Isaacs, 1999).Wheatley (2005) offers some provocative questions that can guide dialogue and help a healthcare team to define a unique, interprofessional culture that is strengthened by the diversity of its disciplinary parts. The questions are: ■Who are we? ■What matters? ■What do people talk about and where do they spend their energy? ■What topics generate the most energy—positive or negative? ■What issues do people talk about most? ■What stories do they tell over and over? ■Is it possible to develop a sense of shared purpose without deny-ing our diversity? ■Are there ways that we develop a shared sense of what is signifi-cant without forcing people to accept someone else’s viewpoint?The interprofessional healthcare team is, at its best, a community of practice—a community of practice that is sustained by ongoing and Facilitating a Collaborative Culture | 139 amples of Boundary-Spanning Activities That Support a Collaborative CultureProblem Solving: Can we get together to design a tool to evaluate the effectiveness of our caregiver training program?Requests for Information: Where can I find the appropriate reimbursement codes for this diagnosis?Seeking Experience: Has anyone dealt with a person who is a bilateral amputee with dementia?Reusing Assets: I have a protocol that I have used with caregivers of persons with dementia. I can help you adapt it for use on your unit.Coordination and Synergy: Can we collaborate on our patient education process and save time and resources?Documentation Projects: What are some examples of best practices? What went right? How can we make that the norm?Visits: Can we sit in on your in-service program? We think we may have similar needs.Mapping Knowledge and Identifying Gaps: What information are we lacking for patients with left ventricular assist devices? We provide excellent cardiac rehabilitation, but this is a new patient group for us. What other individuals/groups should we connect with?Data from Wenger, E. (2006). Communities of practice: A brief introduction. Retrieved from http://www.ewenger.com/theoryproductive dialogue and continuous learning. Wenger (2006) describes a community of practice as “a group of people who share a concern or pas-sion for something they do and learn how to do it better as they interact regularly” (p. 1). There are three distinguishing features of a community of practice. They are shared interest; engagement in information-sharing activities; and a development of shared resources such as experience, stories, and strategies for problem solving that facilitate the learning of all participants—a shared practice. The conceptualization of the inter-professional healthcare team as a community of practice brings into high relief the basic values of patient- and relationship-centered practice that defines a collaborative interdisciplinary culture. Wenger (2006) notes a variety of activities that can help to span disciplinary boundaries and facilitate the development of a community of practice and a culture of collaboration. The examples in Table 8-1 show how these activities can be used to support a collaborative interprofessional culture.140 | Chapter 8 Facilitating a Collaborative Culture tures are often studied by listening to the collective stories told by the members of the organization. It is the tone of the day-to-day interactions that gives us an insight into the web of values and behaviors that comprise a culture. The following stories provide real-world per-spectives about how people experience the cultures of their workplaces. Although each of their stories is unique, there are common themes that that include: trust, open communication, empowerment, and patient-centered care.A Technology-Enhanced Community of Practice†Interprofessional education (IPE) focuses on collaborative practice, whereby students who learn together are able to create a knowledge-rich environment that shares the characteristics of a community of practice—common interest, community, and practice (Wenger, 1998). While students and educators see the value of IPE in clinical learn-ing environments, many are challenged with competing schedules and course demands. Technology affords students learning environments that are easy to use, real-time, and collaborative, despite any logistical and scheduling barriers that may develop along the way. Technology can be used to develop the structured environments needed for students to develop the knowledge, skills, and attitudes of collaborative practice (Ho, et al, 2010).We conducted an action research study at one urban health sci-ence school to explore ways technology could be used to enhance IPE in a clinical service, allowing more students to collaborate and develop collaborative competency. The study was designed to use tools such as Google Docs and Google Hangouts for collaboration during clinical rounding on a patient care unit. Previous attempts to engage students and clinical faculty from a number of disciplines were not sustainable because of time and geographical constraints. Technology provided opportunities for students and faculty from multiple disciplines to tran-scend limitations imposed by logistics. With the use of Google Docs, nursing, pharmacy, medicine, and physical therapy students were able to join together to collaborate on a patient plan of care, which was later presented at bedside to the patient and surgeon. Members of the team collaborated on Google Docs throughout the day to add input or seek clarification of information. Students not physically at bedside were able to join the group through Google Hangouts.Students stated that the experience was invaluable, and the faculty noted that the information exchange and collaboration of the students A Technology-Enhanced Community of Practice | 141 for higher-order thinking and clinical reasoning. When asked about meaningful knowledge exchange, students felt that the technol-ogy enhanced their collaboration and how they functioned on a health-care team.An important subtheme from knowledge exchange was the aware-ness of patient safety during team exchanges. ■“I think the aspirin dose that my guy was on was real high . . . I brought it up to the team when they rounded and they didn’t know why he was on such a high dose. So that question was definitely meaningful.” —Nursing studentStudents liked the collaborative tool Google Docs because it pro-vided a platform for collaboration among team members in real time despite physical barriers. ■“With a Google Docs you could be anywhere and still get the information relayed.”—Pharmacy student ■“It was kind of everyone coming together and doing everything at the same time . . . with the Google Docs you share it all with mul-tiple people and we were all able to see it and provide input to it.” —Physical therapy studentIn this case, technology provided a communication tool that allowed students to see themselves as important members of an inter-professional community of practice.†Kathryn M. Shaffer, EdD, RN, MSN, CNE, Assistant Professor, Director of Clini-cal Education and Faculty Development, Jefferson College of Nursing, Philadel-phia, PAThe 12-Lead EKG†An interprofessional team is one that incorporates all of the disciplines and professions required to move toward a patient’s goals. An inter-professional team is like a 12-lead electrocardiogram (EKG). Much like a 12-lead EKG gives you 12 views of the heart, you get many different views of a case.When I reflect on successful interprofessional teams that I have been a part of, the relationships and the time that we spent building relationships was key. It happened first of all with an understanding and consensus of what the patient had to accomplish. As a physical therapist, I do not have goals. There are no physical therapy (PT) goals; 142 | Chapter 8 Facilitating a Collaborative Culture nt has goals. I ask myself these questions: “What can I as a PT contribute to the patient’s goals?” “How are others on the team looking at the goals?” In this ongoing conversation, you learn the perspectives of the other team members, and roles become clear. As a team you can answer the ongoing question, “Who on the team can best address the issues that are important to this patient?” Each team is unique to the set-ting or to an individual patient’s needs. It is not enough to say, “I know what occupational therapy (OT) is.” The question is, “What is the role of OT in this particular patient’s care?” The more I know about how you practice as a profession, the better teammates we can be.Formal team meetings contributed to the success of the team. But they were only one part of the success. The most productive interac-tions occurred when I was cotreating with someone, or I would ask for advice. You can leverage the expertise of your colleagues and generate creative solutions to problems.As a leader, you really don’t achieve anything on your own. You need to take care of relationships so you can take care of business. As both a team member as well as a leader, developing and maintaining relation-ships is day-to-day work that ultimately makes you successful.I received a physical therapy consult for a 68-year-old woman who was admitted to the hospital from home. The chart said that she was independent at home but had recently experienced a change in her mental status. It was the end of the day and the physicians were planning for her discharge that day. One might question the need for a physical therapy consult for a patient with mental status changes, but in this facility, a PT consult was standard procedure prior to dis-charge. The referral indicated that the patient was medically stable. I went to the patient’s room and met the patient, her family, and the resident and medical student who were managing the case. Her daugh-ter was crying. In a conversation away from the patient, the daughter said emphatically, “Mom cannot go home!” The daughter reported that her mother could not go home because she had started to fall as a result of her rapidly deteriorating mental status. The daughter could not continue to care for her mother. She had two small children, was working full time, and was recently divorced. She would come home and find her mom on the floor! As I assessed the patient, I demon-strated and explained to the resident and medical student. Her balance was horrific! She was clearly not safe! The decision was made that she could not go home. She was a clear fall risk. I admit that I also made an assumption about the patient’s level of function based on the refer-ral information. I went to the room thinking that PT would not be The 12-Lead EKG | 143 d and found that this patient clearly needed an aggressive PT program. I was able to convey that to the physician. Working together (and in consultation with the attending physician), the resident, the daughter, and I were able to stop an unsafe discharge. In this case, an intelligent conversation between disciplines led to a positive patient outcome. As I reflect on this case, I feel that it was successful because I introduced myself to the resident, was clear about what I had to offer as a physical therapist, and engaged the physician and the family (most importantly, the daughter) into an interprofessional conversation that focused on the needs of the patient.†Mary Sinnot, PT, DPT, Associate Professor, Director, Doctor of Physical Therapy Program, College of Public Health, Temple University, Philadelphia, PAJust in Time Communication†On a well-functioning interprofessional team, the boundaries of the disciplines dissolve, and everyone works together for the benefit of the patient. Effective teams require the flow of communication among and between the disciplines. It is about creating a total picture of the patient. It requires that all team members be patient centered and holistic.I feel that one key to the development and functioning of interpro-fessional teams lies in empowerment by the leadership. The leadership empowers the team by giving them the tools, training, and an under-standing of what patient-centered care looks like. Leadership then mod-els effective teamwork on a day-by-day basis in multiple circumstances.A key blockage to effective interprofessional communication is day-to-day busyness. It creeps in. When staff are up to their eyeballs with discipline-specific tasks that they must attend to, communication becomes the most vulnerable to being compromised. For example, if a patient is exhibiting medical complications and the nurses are monitor-ing vital functions and medication levels and only communicating with the attending physician, then the opportunity to communicate what is happening with that patient to the rest of the team may be lost. The disciplines can then easily retreat into their silos. It is precisely at these crucial times when the patient’s care is the most complicated that inter-professional communication is key.Communication and teamwork techniques need ongoing training. Without well-planned training, the team does not work well and there is a tendency for professionals to revert back into previously learned modes of communication that are less effective and may compromise 144 | Chapter 8 Facilitating a Collaborative Culture nctioning. If, for example, the physical therapist only reports on the patient’s transfer status but doesn’t mention that the patient told them during the session that their spouse just lost their job necessitat-ing a social work consult, the progress of the whole team being able to address the identified need can be delayed and treatment and care can be adversely affected. If team members are encouraged to speak up, it becomes the team standard and the culture of the team. New members absorb this culture informally (by seeing it modeled) and formally (by attending training sessions) and it becomes self-perpetuating.When new employees are brought aboard, they are oriented to our standards and expectations of teamwork and communication through an 8-hour workshop. If staffing allows for all new staff to be together, we break it up into sets of sessions that each focus on specific commu-nication techniques and teamwork principles. Staff participates in active sessions where they learn specific communication strategies involving various other disciplines, to see everyday issues from other perspectives. It gets staff up to speed with what we expect. It also empowers them to advocate for their patients and to speak up to other healthcare provid-ers. We incorporate examples from our own unit to demonstrate the benefits of good teamwork and communication as well as the problems that can occur when communication and teamwork are lacking. We also reinforce that their input is highly valued.We have developed an interprofessional communication system here that grew out of our teamwork and communication classes called Report Doc. All professionals for the shift-to-shift handoff use it. We now know everything about the patient from the perspectives of mul-tiple disciplines, such as how they did in therapy, if there was a change in their diet (because they passed their swallow study), or perhaps a change in the amount of pain medicine that they require. For example, if the psychologist has determined that a particular patient does best if they are presented with only two choices per task, they would note this and team members could incorporate this strategy into their treat-ment sessions. Or, if PT notes that the patient’s ability to transfer has improved and they now require only minimal assistance, nursing uses this information to assign staff for the next shift. This reporting system also has a column for anticipated needs and factors to watch for. Each team member is able to see the to-do list of his or her colleagues and again, communication is enhanced.†Sue Carol Verrillo, RN, MSN, CRRN, Nurse Manager, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MDJust in Time Communication | 145 esearch Community of Practice†In the development of my research projects, I started reaching out to people in engineering to help me understand complex databases. I reached out to mathematicians to help me understand computational models. I brought in a biomechanist who had a better understanding of mechanics of motion. I brought my skills as a neuroscientist and my clinical point of view to the project. By assembling a team, we were able to ask more complicated questions and focus on researching a question that would have broad, practical implications.A collaborative culture is also facilitated by organized social events, such as speed dating for researchers, that are designed to get research-ers talking in a more informal way. During speed dating, pairs of par-ticipants speak for 4 minutes and are then moved on to the next table. These activities give participants an opportunity to know each other in a more relaxed environment and learn about the variety of research interests and networking possibilities in their community of practice.Recently, I was part of an exciting interprofessional project. I secured a grant to support undergraduate students’ research. I had six students from different majors ranging from computer science to kinesi-ology to psychology. I shared the grant with a faculty member from com-puter science. The research mentors in the project were also a diverse group—computer science, neuroscience, etc. We developed five projects that provided the students opportunities to utilize their special skills. For example, the computer science students developed the data collec-tion programs that we needed. The psychology and kinesiology students collected data using the programs developed by the computer science students. I feel that much of the success of the project was due to the collaborative atmosphere that we created. Both my coinvestigator and I are very enthusiastic people and understood what we were trying to accomplish. He had the role of supporting the technology in the labora-tory so that I could focus on the science. I know that I depended on his technological skills. We engaged in respectful sharing. We had weekly lab meetings where we shared both progress and engaged in group prob-lem solving as a team. At the conclusion of the grant, students were required to reflect on the experience. One student wrote, “Everybody should have this experience. It was the best experience of my education.”When I reflect on what makes a team successful, four factors come to mind: equanimity, open communication, common interests, and opportunities for personal development. The contribution of each mem-ber on the team is respected. Many times, I was a member of a team 146 | Chapter 8 Facilitating a Collaborative Culture made up of clearly senior and junior members. This did not mean that the senior members had the final say. The communication was characterized by intellectual sharing and openness. There was an ongoing process of learning. We were all learning at the same time and from each other.†Emily Keshner, PT, PhD, Professor & Chair, Department of Physical Therapy, Director of Research Strategy, College of Public Health, Temple University, Phila-delphia, PAHow Do You Spell Successful Collaboration? R-E-S-P-E-C-T†At Austill’s Rehabilitation Services, Inc., our goal is to provide high-quality, cost-effective services. Our therapists are at the core of our business. We have three constituencies—our therapists, our agency contracts, and the clients that we treat. If the therapists are happy, then everyone wins. Each year we poll our therapists to get an idea of what is working for them and what is not. We are interested and concerned about the therapists, their lives, and their ability to care for their fami-lies. For example, a therapist may want to start working later in the day to accommodate a child’s school schedule. We strive to facilitate all therapists working their ideal jobs. We empower our staff. While this strategy may seem soft to some, it has been very successful for us. We have a very low staff turnover and an extremely satisfied customer base. Austill’s is growing and thriving!We are committed to getting to know each of our therapists at a per-sonal level. We are committed to having the right match of our employ-ees. In order to demonstrate that they are a fit for Austill’s, a prospective staff member must be able to clearly articulate what he or she is looking for in a position—what makes him or her happy? In addition, candi-dates need to be friendly, self-assured, independent, and professional. At the foundation, they must respect themselves and the value of their profession.I value personal relationships. This value is central to the mission and success of Austill’s. It is reflected in all of my team and group expe-riences. If you get to know people at a deeper level, it opens new chan-nels of communication.I strive to create a positive climate and empowering atmosphere. I love people and I listen to my heart. I use an open communication style and give people permission to say what they want, and I listen. I hire How Do You Spell Successful Collaboration? R-E-S-P-E-C-T | 147 s who are also positive, respectful, good listeners, collaborative, and goal directed.As a leader I believe in getting people together. I look for common-alities and I work diligently to create an atmosphere where collaboration and consensus are the norms. The following story is another example of how respect, collaboration, and consensus yielded successful outcomes. I was a member of an interprofessional group that represented reha-bilitation services in home care for the Joint Commission (formerly the Joint Commission on the Accreditation of Health Care Organizations, or JCAHO). The members of the group represented the American Occu-pational Therapy Association (AOTA), the American Physical Therapy Association (APTA), the American Speech and Hearing Association (ASHA), and three therapeutic recreation associations. There were 18 group members in total. I was the team leader and the only one who had a voice and a vote at the Joint Commission meeting. It was impor-tant that I went to the Joint Commission meeting with a clear idea of the ideas and feelings of each of the associations that I represented. We would meet as a group the night before the Joint Commission meeting to discuss the issues and achieve consensus. Before the meeting, I dis-tributed an agenda. Each of the group members worked with their dis-ciplinary associations and constituents to be sure that they accurately represented the issues. We would meet and work through the issues until we achieved 100% consensus and were able to speak with one voice. I feel that this process worked because each of the members of the group respected each other. We listened to each other—actively listened—and each member came to the meeting prepared. The day after the reha-bilitation meeting, I joined nursing, medicine, and a number of other professions (there were 30 representatives in total) for a full-day Joint Commission meeting. I was the only voice for rehabilitation in home care at the table. As a team, we successfully lobbied for rehabilitation in home care. I feel that we were successful because each of the group members came prepared, respected each other, listened, and were committed to achieving consensus. We worked as a team. We understood that we were more powerful as a group than each of us would be individually. When I am a member or the leader of a successful team, I get excited! Build-ing consensus by mobilizing a diversity of viewpoints can be both chal-lenging and great fun! Setting a goal and seeing that goal met is thrilling.†Rebecca Austill-Clausen, MS, OTR/L, FAOTA, Founder, Austill’s Rehabilitation Services, Inc., Exton, PA148 | Chapter 8 Facilitating a Collaborative Culture mation Technology: A Tool for Collaboration†A culture of collaboration is a fundamental element for the sustainable integration of health information technology (HIT) and health care. Making decisions about HIT should not be a top-down, isolated process but a collaborative process that takes into account the perspectives of information technology (IT) and clinical leadership, interprofessional healthcare team members, and patients. The digital infrastructure of a health system must be informed by the goals of the system and the needs of the stakeholders in that system. This is what is meant by the intentional design of HIT systems. If the overarching goal of the health system is to provide interprofessional, patient-, and family-focused care that is evidence based, the HIT tools must be designed to support those goals. Software and hardware has to support the usability of the elec-tronic health record (EHR) system, interprofessional care planning, and evidence-based clinical documentation tools. For instance, evidence-based clinical practice guidelines; interprofessional care plans, evalu-ations, and assessments; and the patient’s history must be designed so they support the individual needs of the professions, the integrated needs of the interprofessional team, and the unique needs of the patient, and are accessible by all members of the team. Having work stations that are readily available on each unit for all professions to use enhances real-time documentation and improves team communication. This enables everyone to have immediate access to the information that is needed to care for the patient.Since most members of the healthcare team provide and retrieve information at each juncture of the process of care, there are many opportunities to reinforce interprofessional collaboration when HIT is designed to support those processes. For instance, using a common tool for history taking can facilitate the sharing of patient information, improving collaboration, and reducing duplication. Developing an inter-professional plan of care is an opportunity for the integration of ser-vices and shared decision-making. Assessments and interventions can serve to clarify the unique contributions of each discipline, scopes of practice, role boundaries, and role overlap. Contextually relevant and intentionally designed HIT has the potential to become a “collective consciousness” for the interprofessional healthcare team, a vehicle that can support timely and consistent communication and collaboration among healthcare providers and healthcare consumers. The following is an example of this type of collaboration.Health Information Technology: A Tool for Collaboration | 149
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