Administrative Article
Improving Palliative Care Team Meetings: Structure, Inclusion, and ‘‘Team Care’’
American Journal of Hospice & Palliative Medicine® 1-9 ª The Author(s) 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049909115577049 ajhpm.sagepub.com
Caitlin W. Brennan, PhD, APRN1,2, Brittany Kelly, BA2, Lara Michal Skarf, MD2, Rotem Tellem, MD2, Kathleen M. Dunn, LICSW2, and Sheila Poswolsky, APRN2
Abstract Increasing demands on palliative care teams point to the need for continuous improvement to ensure teams are working collaboratively and efficiently. This quality improvement initiative focused on improving interprofessional team meeting efficiency and subsequently patient care. Meeting start and end times improved from a mean of approximately 9 and 6 minutes late in the baseline period, respectively, to a mean of 4.4 minutes late (start time) and ending early in our sustainability phase. Mean team satisfaction improved from 2.4 to 4.5 on a 5-point Likert-type scale. The improvement initiative clarified communication about patients’ plans of care, thus positively impacting team members’ ability to articulate goals to other professionals, patients, and families. We propose several recommendations in the form of a team meeting ‘‘toolkit.’’ Keywords palliative care, interprofessional, team meeting, quality improvement, model for improvement, efficiency
Introduction Interprofessional team meetings routinely occur in health care settings in order to exchange information and make decisions about the plan of care for patients and families. Team meetings are particularly vital in palliative care, which relies heavily on the expertise of multiple professionals collaborating to provide patient-centered care focused on individuals’ physical, psychosocial, emotional, and spiritual needs.1 Other writers have suggested that in the young field of palliative care, team meetings have been emphasized as a means of providing both interprofessional care and emotional and professional support for palliative care staff.2 Successful interprofessional teamwork is an integral part of palliative care. One challenge faced by interprofessional teams is that in traditional medical models, physicians often assume a leadership role, which can lead to an unbalanced focus on medical history and excessive use of terminology unfamiliar to some disciplines present for care discussions. This approach can hinder team collaboration and at times cause miscommunication among team members.3 Rock4 summarized from previous research that there is evidence that poor leadership and communication issues can result in increased mortality and length of stay. One study conducted in Australia specifically investigated communication among various members of a prototypical palliative care team and found that each discipline reported challenges with role boundaries and suggested that interdisciplinary team training programs may improve communication and team functioning.3 Improved interprofessional
communication can drastically reduce errors and inadvertent harm to patients.5 Leonard et al5 gathered knowledge of the culture at Kaiser Permanente Healthcare and subsequently analyzed 2455 sentinel events. Their findings indicated that the primary root cause in 70% of the events was communication failure, and 75% of the patients involved in these events died. Building upon past research, our palliative care team aimed to improve interprofessional communication and team care in an efficient and timely manner during our weekly meetings. Our palliative care team includes members from chaplaincy, medicine, nursing, nutrition, pharmacy, social work, speech pathology, and research. Several team members work at multiple campuses. Our weekly team meeting is the only time when all team members are present to discuss active palliative care consults, clarify questions, share expertise, and formulate a plan of care for our patients. One reported challenge encountered by our palliative care team was difficulty keeping interprofessional team members updated on patients’ current symptom management needs, goals, and care plans. As is
1
National Institutes of Health Clinical Center Nursing Department, Research and Practice Development Section, Bethesda, MD, USA 2 Veterans Affairs Boston Healthcare System, Jamaica Plain, MA, USA Corresponding Author: Caitlin W. Brennan, PhD, APRN, Research and Practice Development Section, Nursing Department, National Institutes of Health Clinical Center, 10 Center Drive, Suite 2B, Room 08, Bethesda, MD 20892, USA. Email: [email protected]
Downloaded from ajh.sagepub.com at SUNY HEALTH SCIENCE CENTER on April 17, 2015
American Journal of Hospice & Palliative Medicine®
2 reported by others, most members see each other infrequently and expend a significant amount of time and energy keeping other providers updated.6 Our practice has been to spend 1 hour each week discussing active patients and an additional 30 minutes completing continuing education activities and addressing various ‘‘housekeeping’’ items, such as announcements, division of responsibilities for team activities, and planning a biannual memorial service. Finally, we devote time during meetings on a bimonthly basis for ‘‘Remembrance,’’ during which a chaplain leads the group in a session aimed to honor and remember Veterans who recently died in our care. This time is beneficial to address our own grief and bereavement, which is crucial for clinicians who provide end-of-life care. Several aspects of our team meetings were problematic, namely, that our meetings often started and ended approximately 15 to 20 minutes late. As a result, we were often unable to discuss all of our patients, which led to an additional meeting to discuss patients not covered during team meeting. Time spent discussing patients routinely ran late, reducing the amount of time we spent conducting Remembrance, addressing housekeeping items, and completing continuing education activities. These inefficiencies were consistent sources of frustration for our team and led to the decision to embark on a quality improvement (QI) initiative centered on improving the efficiency of our weekly team meeting. The complexity of the current health care system, coupled with growing demand for palliative care teams’ input in the care of patients with advanced illnesses, requires teams to adopt efficient practices and processes that maximize effective communication in order to provide high-quality, safe, and timely care to patients and families. Palliative care teams, as well as other interprofessional teams, may find the process described in this article useful for adding structure to their time together, ensuring opportunities for all attendees to participate, and for incorporating various ‘‘team care’’ activities into their time together, as described in the Results and Discussion sections.
Purpose The purpose of this QI initiative was to improve the efficiency of our interprofessional team meeting to better utilize our time together and promote the well-being of our patients and ourselves. In particular, we aimed to improve communication across the various specialties within our team and ensure that all professionals in attendance could ask questions and provide insight and feedback regarding our patient census.
Methods We used the Model for Improvement to guide our work.7 We created a ‘‘current state’’ process map of our meetings and identified areas of waste and inefficiency. Next, we conducted a voluntary stakeholder survey of all team members. Team members returned surveys anonymously or via e-mail. We then discussed the stakeholder results as a team and planned several interventions for changing our meeting structure and processes.
We conducted numerous ‘‘plan, do, study, act’’ (PDSA) cycles to implement interventions and evaluate continued challenges and improvements, including using ‘‘rapid evaluations’’ at the close of each weekly meeting. The results of our stakeholder surveys and our weekly rapid evaluations guided each PDSA cycle. After 12 weeks, we discussed the results as a team and collectively decided how to proceed. After 16 weeks, we conducted a stakeholder postsurvey. Our outcome measures included start and end times of our meeting and satisfaction questions included in the stakeholder surveys. The project was deemed nonresearch by our institution’s Administrative Officer of Health Services Research & Development and required review by our institution’s Privacy Officer to ensure all data were deidentified and survey respondents’ privacy was protected. The privacy officer deemed the project ‘‘deidentified.’’ Institutional review board review was not required.
Results Presurvey Of 17 team members, 14 (82%) completed the stakeholder presurvey. Results revealed a clear lack of consensus about the goal of the meeting with responses varying from no clear goal to the goal being to discuss the entire patient census, to only discuss difficult cases and to conduct team activities. Several challenges centered on a lack of structure, poor time keeping (late start and end time and rushing at the end of the meeting to finish discussing all of our patients), and no formal process for ensuring that all team members had an opportunity to provide input. There was concern among team members that the meetings were too ‘‘physician centric’’ or ‘‘nurse practitioner centric.’’ Physicians and nurse practitioners tended to talk most of the time and focused on the medical history of the patient, leaving little time to discuss broader palliative care issues and the psychosocial, nutritional, and spiritual needs of patients. When asked ‘‘How satisfied are you with the current structure of the palliative care interprofessional meeting?’’, mean team satisfaction was 2.43 on a 5-point Likert-type scale, with 5 indicating extremely satisfied. Mean favorability of changing the structure of team meetings was 4.57, with 5 indicating highly in favor of change. Comments included a request that providers limit commentary about the patient’s medical history and hospital course if it does not provide helpful insights into the patient’s palliative care needs. Of note, our team reported a high readiness for change during our presurvey. This is an important feature to assess before initiating PDSA cycles, as additional work may need to be done seeking stakeholder buy-in and support prior to starting rapid tests of change.
Plan, Do, Study, Act Cycles After analyzing our current state process map, areas of waste and inefficiency, and our stakeholder presurvey results, we identified several interventions for improving our team meeting. We decided as a group that moving our start time from
Downloaded from ajh.sagepub.com at SUNY HEALTH SCIENCE CENTER on April 17, 2015
Brennan et al
3
8:30 AM to 9:00 AM. would assist with starting on time. We created a document with meeting objectives and ‘‘etiquette’’ and adopted a shortened version of the 7-step meeting process,8 including a structured, timed agenda (Table 1).
Meeting Objectives Two team members attended the oral presentation ‘‘Model for Running a Palliative Care Interdisciplinary Team Case Conference’’ at the 2012 Annual Assembly of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association.9 The presentation included specific steps for structuring a clinical case conference. We discussed as a team what the objective of our time together should be—to discuss our entire census or to focus on one or two complex cases, as in the Meyerson et al’s presentation.9 Given that our team meeting is the only time each week our entire team convenes, we decided our meeting objective would be to prioritize complex cases and seek input from each other about goals and plans of care for these patients. Then, if time allowed, we would discuss our remaining census. Next, we iteratively conducted several PDSA cycles. PDSA #1 included adopting a shortened version of the 7step meeting process and using templates to guide the discussion. Our shortened version of the 7-step meeting process included assigning roles of facilitator and timekeeper for each meeting, clarifying the meeting objective, using a structured and timed agenda, soliciting team participation, and evaluating the meeting (Table 2). We also added a few minutes at the beginning of the meeting for ‘‘reflection,’’ in which a team member volunteers to read a poem or excerpt from The Book of Awakening: Having the Life You Want by Being Present to the Life You Have.10 Next, we discuss announcements, bereavement cards that need to be signed, and division of bereavement telephone calls to families of Veterans who have died in the past week. Then, the meeting facilitator asks each member of the team which patients they would like to discuss. This method ensured all members had the opportunity to communicate current/pressing issues for complex patients on our census list. Prior to beginning the patient discussion, we determined how much time we had for each patient and used a timer to provide a 1-minute warning chime to prompt team members to finish the discussion and move to the next patient. This ensures that we do not run out of time for patients at the end of the meeting. We also created a ‘‘parking lot’’ for topics that came up during our discussion that we did not have time to address during our meeting. Examples include how to effectively have a DNR/DNI (Do Not Resuscitate/Do Not Intubate) discussion, preparing patients with head and neck cancer for the challenges of symptom management, body image, and side effects of medical procedures as well as housekeeping items, such as updates on new policies. Putting these topics in the parking lot provides a mechanism for tabling issues at that moment rather than detracting from the goal of the meeting. Returning to these items at a later date also guarantees we can devote sufficient
Table 1. Meeting Agenda and Templates for Patient Prioritization and Discussion. Palliative Care Interprofessional Team Meeting Thursdays, 9-10:30 AM Medicine Service Conference Room (1B-119) Meeting Agenda 1. 9-9:05 AM Meeting set-up a. [Only if new person is joining us: go around table and read objectives, team meeting etiquette] b. Discuss/assign roles (facilitator, timekeeper) c. Call pharmacist to join via phone 2. 9:05-9:10 AM ‘‘House-keeping’’ a. Announcements/upcoming absences/travel b. Divide up bereavement calls 3. 9:10-9:14 AM Reflection 4. 9:14-9:15 AM Patient Prioritization: Each member has the opportunity to: a. Name patients they would like to discuss (potential, active, discharged, or deceased) b. Name patients they think do not need to be discussed c. ‘‘Pass’’ (eg, if new to service and don’t know any patients) 5. 9:15-9:55 AM Patient Discussion: Our timekeeper will divide our time among the patients we would like to discuss. Next, the person presenting the patient (which can be anyone) has 1 minute to state: a. Name b. Age c. Main diagnosis d. Date and reason for admission e. Date and reason for palliative care consult f. One main palliative care issue from their perspective g. You will hear a chime when the 1 minute has lapsed. After the chime, we will move around the table and others can briefly add to the patient discussion from their discipline’s perspective. People can ‘‘pass’’ if they don’t know the patient or have nothing to add. Please keep your comments brief so that everyone has a chance to talk. Once we have gone around the table, the presenter can provide additional information if needed. You will hear a second chime indicating 1 minute is left before moving to the next patient. Please use the second chime to wrap-up your comments and help the facilitator move to the next patient. 6. 9:55-10 AM Rapid Evaluation or make plan for the day 7. 10-10:30 AM Team Care a. Remembrance (first and second Thursdays) b. Staff meeting for core members (third Thursday): Move to room 118 c. Presentations/memorial service planning/parking lot discussions (fourth and fifth Thursday)
time to address them in a broader context, rather than a caseby-case basis and allows for preparation if the topic requires it. PDSA #2 included limiting the opening statement for each patient to 1 minute. Using a timer with alarm capabilities, we decided to use 2 chimes. The first chime alarms after 1 minute to signal the end of the brief case presentation. This serves as a cue to the individual presenting the case to move the discussion around the table. This prompt ensures the presenter does not dominate the conversation and signals others to provide
Downloaded from ajh.sagepub.com at SUNY HEALTH SCIENCE CENTER on April 17, 2015
American Journal of Hospice & Palliative Medicine®
4 Table 2. Meeting Objectives, ‘‘Etiquette,’’ and Rapid Evaluation. Meeting Objectives 1. Run the list of palliative care patients 2. Gain insight from all disciplines in attendance 3. Communicate in an interprofessional manner to guide Veteran and family plan of care a. Includes ‘‘housekeeping’’ communication related to bereavement calls, announcements, etc. 4. Conduct ‘‘team care’’ activities a. Remembrance b. Presentations (clinical and/or team-building focus) c. Staff meetings for core members Meeting Etiquette 1. Start and end on time 2. No rank in the room 3. This is a safe zone 4. Everyone participates, nobody dominates 5. Everyone has a place at the table 6. Speak freely, listen attentively 7. Be an active listener 8. Listen as an ally 9. Stay on track 10. Keep an open mind 11. Agree only if it makes sense to do so 12. Maintain confidentially 13. Give freely of your experience 14. Maintain each other’s self esteem 15. Turn beepers to vibrate 16. Use cell phones/check emails only when absolutely necessary, step outside room to do so Rapid Evaluation 1. What worked well? 2. What did not work well? 3. What could be improved for next meeting? 4. Items to put in the ‘‘parking lot’’ to discuss at next meeting?
input. This strategy provided a structural cue to new attendees, such as trainees, to limit the patient summary in order to focus more on team discussion. In doing this, the team responded to survey responses that reviewing a case too thoroughly was not useful to all participants and shortened the time devoted to other patient discussion. This PDSA cycle also helped to ensure that discussion would not be limited to medical issues. The second chime alarms when there is 1 minute left in the discussion of the patient. This serves as a cue for the team to finish the discussion and for the facilitator to move to the next patient. PDSA #s 3 to 8 included making adjustments to the agenda and trialing moving deliberately around the table during the discussion, starting with the presenter, instead of a more ‘‘free form’’ discussion, in order to be certain each person had an opportunity to contribute. We also encouraged the facilitator to give cues and interrupt to keep the discussion on track. During a later PDSA cycle, we decided to read the objectives and etiquette only when a new person joins, in order to save time. We devoted time to discussing barriers to starting on time and how to rotate the facilitator and timekeeper roles. We decided that encouraging the facilitator and timekeeper to sit next to
each other to ‘‘colead’’ the meeting would be a less intimidating way for people to participate in each role.
Outcomes Start and end times. Figures 1 and 2 are statistical process control charts, graphing the number of minutes we started and ended late each week.11 Meeting start time improved from a mean of approximately 9 minutes late to a mean of 6.5 minutes late (Figure 1). We experienced a 10-week period between July and September 2012 during which we improved our mean start time from 9 minutes late to 5 minutes late. We improved our meeting end time from a mean of approximately 6 minutes late to a mean of 0 minutes late (Figure 2). Statistical significance is not calculated in the traditional sense with statistical process control charts. Rather, data are presented over time and a set of rules are applied to identify whether, in this case, our interventions caused a decrease in the number of minutes our meetings started and ended late.11 These rules allow for identification of ‘‘special cause’’ or ‘‘common cause’’ variation in the data. Special cause indicates a ‘‘signal’’ and that the process itself has changed, whereas common cause indicates ‘‘noise’’ or random variation that cannot be attributed to a specific cause. For start time, a special cause signal is reflected in greater than or equal to 8 successive values falling on the same side of the centerline (starting July 12, 2012). For end time, the control limits were reset starting July 26, 2012 and show graphically that we ended early or only a few minutes late after initiating improvement efforts. Thus, the change in meeting start and end times can be attributed to our series of PDSAs. Stakeholder postsurvey. One student, 1 fellow, and a rotating physician were no longer a part of the team during postsurvey period and thus, total team members decreased from 17 to 14. Of 14 team members, 12 (86%) responded to the postsurvey. Mean team satisfaction improved from 2.4 in our presurvey to 4.5 in our postsurvey. Team members were asked ‘‘To what degree did our changes meet our overall objective of improving our team meeting?’’ and the mean response was 5 or ‘‘very much.’’ Team members were also asked to comment on which aspects of team meeting are better and which are worse after implementing our team meeting changes (Table 3). Team members reported that tasks and responsibilities are more evenly distributed and that there is better morale, an improved sense of teamwork, and a feeling of being more centered as a group. Team members responded positively to the fact that we altered our meeting processes as a group and took into consideration elements each member considered desirable or essential. Respondents commented that being more efficient with our time provides the ability to target the discussion to the most important aspects of each case. Team members responded that we have created better intrateam communication and awareness of resources and roles. Team members were asked to comment on how they think our team meeting improvements are impacting patient care.
Downloaded from ajh.sagepub.com at SUNY HEALTH SCIENCE CENTER on April 17, 2015
Brennan et al
5
Baseline period 20 18
Improvement efforts initiated
16
Minutes Late
14 12 10 8 6 4 2
11.29.12
12.27.12
1.24.13
11.29.12
12.27.12
1.24.13
10.11.12
9.13.12
8.16.12
7.19.12
6.21.12
5.24.12
4.26.12
3.29.12
3.1.12
2.2.12
1.5.12
0
Date Figure 1. Meeting start time.
Baseline period 20
Improvement efforts initiated
Facilitator unexpectedly absent
15
High census; team decided to stay late to discuss patients
5
-10
10.11.12
9.13.12
8.16.12
7.19.12
6.21.12
5.24.12
4.26.12
3.29.12
-5
3.1.12
0
2.2.12
Minutes Late
10
Date
Figure 2. Meeting end time.
Respondents reported that a formal mechanism of including all members in the meeting discussion resulted in a more cohesive, interprofessional overview of our patients and allowed all disciplines the opportunity to raise questions and concerns in a timely manner. Team members commented that our team meeting improvements created a better understanding of the ‘‘big
picture’’ for each patient, not only in terms of the prognosis and treatment plan but also related to the patient’s interests and values. This provides the team with a better understanding of our patients and, as a result, an improved ability to care for them. Team members reported that our improvements have clarified communication about the plan of care for patients, positively
Downloaded from ajh.sagepub.com at SUNY HEALTH SCIENCE CENTER on April 17, 2015
American Journal of Hospice & Palliative Medicine®
6 Table 3. Survey Results.
‘‘How satisfied are you with the current structure of the palliative care interprofessional meeting?’’ Answer choices included 1 ¼ not at all satisfied; 2 ¼ somewhat satisfied; 3 ¼ quite satisfied; 4 ¼ very satisfied; and 5 ¼ extremely satisfied Presurvey
Postsurvey
2.43
4.5
‘‘Since we changed our team meeting format, what aspects are better and what aspects are worse?’’ Answer choices included 1 ¼ worse; 2 ¼ somewhat worse; 3 ¼ no change; 4 ¼ somewhat better; and 5 ¼ better Aspect
Mean Postsurvey Score
Timeliness (eg, starting/ending on time, use of time during meeting, etc)
5
Focus of discussion (eg, discussing information most pertinent to palliative care consult, not getting side-tracked, etc)
4.6
Efficiency (eg, pacing of discussion, not repeating the plan for late-comers, not using meeting time for discussions that can be handled outside of team meeting, etc)
4.7
Organization/structure of the meeting (eg, clear understanding of what we hope to accomplish in the meeting, deliberate planning, and execution of how we will spend our time together, etc)
4.8
Clarification of meeting objectives (eg, clear, shared understanding of our meeting objectives)
4.8
Inclusion (level of participation of various professionals present at the meeting)
4.8
impacting their ability to articulate the plan to other health care professionals, patients, and families.
Discussion Our palliative care team meeting QI initiative can be summarized into 3 core elements for interprofessional team meetings, namely, structure, inclusion, and team care.
topics may not be as relevant or fresh in our minds when we find time to address them during future sessions. Another challenge is that the parking lot list is quite long and people may find it less useful if we do not address the topics we place in the parking lot. Prioritizing topics and scheduling them in a way that meets the needs of each member of the team is an ongoing challenge.
Inclusion Structure Changing our meeting start time from 8:30 AM to 9:00 AM, along with applying a shortened version of the 7-step meeting process, resulted in improvement in our meeting start time. One disadvantage of a later start time is that team members have more opportunities to be called into clinical issues before team meeting and it is challenging to break away from patient care. This remains the biggest barrier to starting on time. We made a marked and sustained improvement in our end time. We consistently end on time or early because we use our time efficiently during the meeting. Prioritizing patients, using a timer, and putting topics/ideas in the parking lot have all collectively impacted our ability to end on time. While in the past, interesting and important topics related to the care of palliative care patients often became a distraction from the main discussion, these topics now go in the parking lot, and we use the last 30 minutes of the fourth and fifth Thursday of the month to choose one of these topics to discuss. We discuss the topic as a group or invite a team member or guest to give a formal presentation. However, waiting to discuss topics that are relevant to patients for whom we are currently caring means that the
Improved structure led directly to improved inclusion. Although team members reported in the presurvey that not all members had an opportunity to participate in the discussion, respondents in the postsurvey reported an increase in participation from all professions and increased team cohesion. Of note, all team members are included in the structure of the meeting. For PDSA cycles 1 to 6, the first author facilitated and assisted with timekeeping, in order to help model the roles for the group and to maintain consistency while the process was being piloted. During the initial phase of the QI initiative, this consistency was beneficial. We discussed collaboratively that the facilitator role and structure of the meeting cannot be dependent on one person. Starting with PDSA #7 to the present date, team members rotate the roles of timekeeper and facilitator in each meeting. All team members have participated in at least one of the roles at least one time. The team distributes a sign-up sheet every month to help facilitate the rotation of roles. Team members voluntarily fill in if a facilitator or timekeeper is unexpectedly absent. Two practices of inclusion we deliberately avoided during our intervention phases were waiting for others to arrive to start
Downloaded from ajh.sagepub.com at SUNY HEALTH SCIENCE CENTER on April 17, 2015
Brennan et al
7
18
16
Delay due to urgent patient care issue
14
Minutes Late
12
10
8
6
4
2
03/27/14
02/27/14
01/30/14
01/02/14
12/05/13
10/31/13
10/03/13
09/05/13
08/08/13
07/11/13
06/06/13
05/09/13
04/11/13
0
Figure 3. Meeting start time (sustainability phase).
the meeting and repeating content when a team member arrived late. This required a change in culture, which we were able to accomplish by discussing this plan and seeking all members’ input and buy-in before implementing it. All members have accepted and implement these rules when they serve in the facilitator or timekeeper role. This shift in culture has been an important driver of our ability to start and end on time.
preferred to use a kitchen timer. This team member was open to trying something more aligned with his comfort level, rather than learning to use a smartphone to keep time or opting out of the role altogether. Finally, our team vacillates between going around the table to elicit input from each member and a more free form process for the discussion. In this way, we are experimenting with the balance between structure and allowing the discussion to take its natural course.
Team Care Our team highly values setting aside time for morning reflection, Remembrance, staff meeting, and continuing education and parking lot discussions. In the past, patient discussions routinely ran longer than the allotted time and took away time and momentum from team care. Because of our improvement efforts, we have consistently been able to use the last 30 minutes of our time together for team care, which respondents reported helps with team building and unity. We regularly review items in the parking lot to assist with scheduling presentations and continuing education opportunities.
Adaptability Although our team is committed to structure, we are also flexible with adapting various aspects of our team meeting to fit our needs. For example, we might adjust the agenda as needed, such as skipping reading the morning reflection if we have started the meeting late. We are open to new changes and ideas in order to fit individuals’ needs. For example, typically the timekeeper uses a smartphone for initiating the chimes during the discussion. However, one team member
Sustainability In the year following our improvement initiative, we sustained our improvements and maintained the structure of the meetings without any changes. As shown in Figures 3 and 4, we consistently start our meeting on time (mean start time of 4.44 minutes late) and end on time or early (mean end time of 5.58 minutes early). Of note, special cause signals occurred between May 2nd and July 11th, 2013, during which time there were more than eight successive values above the center line and one value above the upper control limit. This special cause variation is attributed to turnover of staff (during this period the first author took another position and the last author retired). No other special cause variation occurred in Figure 3 and none occurred in Figure 4. Currently, adherence to the new structure is maintained even in the presence of exterior pressures such as personnel changes, patient care obligations, and a high census of patients. Several other improvements have been extended from our initial improvement work focused on restructuring our team meeting. For example, our practice had been to prepare a list
Downloaded from ajh.sagepub.com at SUNY HEALTH SCIENCE CENTER on April 17, 2015
American Journal of Hospice & Palliative Medicine®
8
20 15 10
0
03/27/14
02/27/14
01/30/14
01/02/14
12/05/13
10/31/13
10/03/13
09/05/13
08/08/13
07/11/13
06/06/13
-15
05/09/13
-5 -10
04/11/13
Minutes Late
5
-20 -25 -30 -35
Figure 4. Meeting end time (sustainability phase). Table 4. Summary of Quality Improvement Tools Applied to Team Meeting. Stakeholder pre- and post-surveys Readiness for change Satisfaction How do our team meeting processes affect patient care? Current state process map Small tests of change (PDSA cycles) 7-Step Meeting Process Structured Agenda Clear Meeting Objectives and Etiquette Roles (timekeeper, facilitator) & Rotation of roles Rapid Evaluation & What worked well? & What did not work well? & What could be improved for next meeting? & Items to put in the ‘‘parking lot’’ to discuss at next meeting? Timer and Chime Parking Lot Outcome measure: meeting start and end times
to determine whether the topic was suitable for our monthly education session following team meeting or whether a separate meeting needed to be scheduled. Currently, all parking lot topics are either scheduled to be discussed or complete. Another major change was the introduction of a new palliative care administrative assistant to the team who leads the administrative work in the service, including scheduling outpatient appointments and tracking the patients cared for by the service, including deaths. As a permanent participant in the team meetings, the administrative assistant updates the signout sheet and education session schedule and sends a team meeting report via e-mail to all participants after each meeting. Adding an administrative assistant has improved coordinating the role sign-up process, planning and scheduling educational seminars, ensuring continuity of care for patients going off inpatient service and being followed in our outpatient clinic, and communicating pertinent administrative information to the entire team.
Limitations
Abbreviation: PDSA, plan, do, study, act.
of active patients for sole use in team meeting, which was created by one or two team members who were the only people able to create or access it. Instead, we have created a new active sign-out list that is accessible by all team meeting participants and is updated regularly by all team members during their regular work. The list includes all of the patients who died each week. For active patients, the list contains medical and psychosocial information, goals, and a tentative plan of care, which is a major improvement from the old list that featured names only. Adding the parking lot to our team meeting processes helped ensure that topics of discussion and ideas for education or a guest presentation did not derail our patient discussions or get lost to follow-up. During our sustainability phase, we asked each team member to anonymously prioritize the list of topics by urgency and importance. We used this prioritization
A limitation of our data collection procedures was the use of team member approximations of start and end times in lieu of real-time data collection during the baseline period. It is challenging to decipher the influence of timekeeper error in recording the start and end times. This is particularly the case for start times, given that conversations at the beginning of the meeting can be distracting. In addition, being too structured in a team meeting can limit the free and open exchange of ideas. Striking the balance between structure and free discussion is something our team continues to address.
Recommendations We recommend using our team meeting improvements as a ‘‘toolkit’’ for interprofessional team meetings. Additional data that identify and measure ways in which team meeting improvements directly affect patient care are needed. Adoption of this
Downloaded from ajh.sagepub.com at SUNY HEALTH SCIENCE CENTER on April 17, 2015
Brennan et al
9
type of toolkit can be used in future research that investigates the relationships among improved interprofessional team meeting structure, communication, and burnout rates in the palliative care discipline. A summary of the tools we applied to our QI initiative are provided in Table 4. Author’s Note This work was conducted at the VA Boston Healthcare System. Dr. Brennan was supported by the VA National Quality Scholars Program.
Acknowledgments The authors would like to thank Fr James Diemand; Maya Dietz; Peter Engel, MD; Douglas Falls, MDiv; Melissa Franklin, MS, CCC-SLP, Sarah Grudberg, MD; Christina Harris, MS, CCC-SLP; Matthew Mendlik, MD, PhD; Natalie Noto, PharmD; Marci Salow, PharmD; Allie Richards, MS, CF-SLP; James Rudolph, MD; Makayla Schuchardt, MS, RD; and numerous rotating fellows, residents, and students for their participation, input, and support for this project. The authors would also like to acknowledge and thank Mary Dolansky, PhD, RN, for her guidance and mentorship and her ideas for ‘‘team etiquette’’ and ‘‘parking lot’’ and Mark Splaine, MD, MS, and the Veterans Affairs Quality Scholars program for mentorship and expertise in statistical process control charting.
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
References 1. Arber A. Team meetings in specialist palliative care: Asking questions as a strategy within interprofessional interaction. Qual Health Res. 2008;18(10):1323-1335.
2. Junger S, Pestinger M, Elsner F, Krumm N, Radbruch L. Criteria for successful multiprofessional cooperation in palliative care teams. Palliat Med. 2007;21(4):347-354. 3. O’Connor M, Fisher C. Exploring the dynamics of interdisciplinary palliative care teams in providing psychosocial care: ‘‘Everybody thinks that everybody can do it and they can’t’’. J Palliat Med. 2011;14(2):191-196. 4. Rock W. Interdisciplinary teamwork in palliative care and hospice settings. Am J Hosp Palliat Care. 2003;20(5):331-333. 5. Leonard M, Graham S, Bonacum D. The human factor: The critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care. 2004;13(suppl 1):i85-i90. 6. Street A, Blackford J. Communication issues for the interdisciplinary community palliative care team. J Clin Nurs. 2001; 10(5):643-650. 7. Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd ed. San Francisco: Jossey-Bass Publishers; 2009. 8. Hyer K, Flaherty E, Fairchild S, et al. Geriatric Interdisciplinary Team Training: The GITT Kit. 2nd ed. New York: John A. Hartford Foundation, Inc; 2003. 9. Meyerson EM, Chai E, Horton JR. Model for running a palliative care interdisciplinary team case conference [abstract]. J Pain Symptom Manage. 2012;43(2):330. Web site. http://www. jpsmjournal.com/article/S0885-3924(11)00602-6/abstract. Accessed March 6, 2015. doi:http://dx.doi.org/10.1016/j.jpainsymman.2011.12.031. 10. Nepo M. The Book of Awakening: Having the Life You Want by Being Present to the Life You Have. San Fancisco, CA: Conari Press; 2000. 11. Carey R. Improving Healthcare with Control Charts: Basic and Advanced SPC Methods and Case Studies. Milwaukee, WI: American Society for Quality; 2003.
Downloaded from ajh.sagepub.com at SUNY HEALTH SCIENCE CENTER on April 17, 2015
Improving Palliative Care Team Meetings: Structure, Inclusion, and ‘‘Team Care’’
American Journal of Hospice & Palliative Medicine® 1-9 ª The Author(s) 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049909115577049 ajhpm.sagepub.com
Caitlin W. Brennan, PhD, APRN1,2, Brittany Kelly, BA2, Lara Michal Skarf, MD2, Rotem Tellem, MD2, Kathleen M. Dunn, LICSW2, and Sheila Poswolsky, APRN2
Abstract Increasing demands on palliative care teams point to the need for continuous improvement to ensure teams are working collaboratively and efficiently. This quality improvement initiative focused on improving interprofessional team meeting efficiency and subsequently patient care. Meeting start and end times improved from a mean of approximately 9 and 6 minutes late in the baseline period, respectively, to a mean of 4.4 minutes late (start time) and ending early in our sustainability phase. Mean team satisfaction improved from 2.4 to 4.5 on a 5-point Likert-type scale. The improvement initiative clarified communication about patients’ plans of care, thus positively impacting team members’ ability to articulate goals to other professionals, patients, and families. We propose several recommendations in the form of a team meeting ‘‘toolkit.’’ Keywords palliative care, interprofessional, team meeting, quality improvement, model for improvement, efficiency
Introduction Interprofessional team meetings routinely occur in health care settings in order to exchange information and make decisions about the plan of care for patients and families. Team meetings are particularly vital in palliative care, which relies heavily on the expertise of multiple professionals collaborating to provide patient-centered care focused on individuals’ physical, psychosocial, emotional, and spiritual needs.1 Other writers have suggested that in the young field of palliative care, team meetings have been emphasized as a means of providing both interprofessional care and emotional and professional support for palliative care staff.2 Successful interprofessional teamwork is an integral part of palliative care. One challenge faced by interprofessional teams is that in traditional medical models, physicians often assume a leadership role, which can lead to an unbalanced focus on medical history and excessive use of terminology unfamiliar to some disciplines present for care discussions. This approach can hinder team collaboration and at times cause miscommunication among team members.3 Rock4 summarized from previous research that there is evidence that poor leadership and communication issues can result in increased mortality and length of stay. One study conducted in Australia specifically investigated communication among various members of a prototypical palliative care team and found that each discipline reported challenges with role boundaries and suggested that interdisciplinary team training programs may improve communication and team functioning.3 Improved interprofessional
communication can drastically reduce errors and inadvertent harm to patients.5 Leonard et al5 gathered knowledge of the culture at Kaiser Permanente Healthcare and subsequently analyzed 2455 sentinel events. Their findings indicated that the primary root cause in 70% of the events was communication failure, and 75% of the patients involved in these events died. Building upon past research, our palliative care team aimed to improve interprofessional communication and team care in an efficient and timely manner during our weekly meetings. Our palliative care team includes members from chaplaincy, medicine, nursing, nutrition, pharmacy, social work, speech pathology, and research. Several team members work at multiple campuses. Our weekly team meeting is the only time when all team members are present to discuss active palliative care consults, clarify questions, share expertise, and formulate a plan of care for our patients. One reported challenge encountered by our palliative care team was difficulty keeping interprofessional team members updated on patients’ current symptom management needs, goals, and care plans. As is
1
National Institutes of Health Clinical Center Nursing Department, Research and Practice Development Section, Bethesda, MD, USA 2 Veterans Affairs Boston Healthcare System, Jamaica Plain, MA, USA Corresponding Author: Caitlin W. Brennan, PhD, APRN, Research and Practice Development Section, Nursing Department, National Institutes of Health Clinical Center, 10 Center Drive, Suite 2B, Room 08, Bethesda, MD 20892, USA. Email: [email protected]
Downloaded from ajh.sagepub.com at SUNY HEALTH SCIENCE CENTER on April 17, 2015
American Journal of Hospice & Palliative Medicine®
2 reported by others, most members see each other infrequently and expend a significant amount of time and energy keeping other providers updated.6 Our practice has been to spend 1 hour each week discussing active patients and an additional 30 minutes completing continuing education activities and addressing various ‘‘housekeeping’’ items, such as announcements, division of responsibilities for team activities, and planning a biannual memorial service. Finally, we devote time during meetings on a bimonthly basis for ‘‘Remembrance,’’ during which a chaplain leads the group in a session aimed to honor and remember Veterans who recently died in our care. This time is beneficial to address our own grief and bereavement, which is crucial for clinicians who provide end-of-life care. Several aspects of our team meetings were problematic, namely, that our meetings often started and ended approximately 15 to 20 minutes late. As a result, we were often unable to discuss all of our patients, which led to an additional meeting to discuss patients not covered during team meeting. Time spent discussing patients routinely ran late, reducing the amount of time we spent conducting Remembrance, addressing housekeeping items, and completing continuing education activities. These inefficiencies were consistent sources of frustration for our team and led to the decision to embark on a quality improvement (QI) initiative centered on improving the efficiency of our weekly team meeting. The complexity of the current health care system, coupled with growing demand for palliative care teams’ input in the care of patients with advanced illnesses, requires teams to adopt efficient practices and processes that maximize effective communication in order to provide high-quality, safe, and timely care to patients and families. Palliative care teams, as well as other interprofessional teams, may find the process described in this article useful for adding structure to their time together, ensuring opportunities for all attendees to participate, and for incorporating various ‘‘team care’’ activities into their time together, as described in the Results and Discussion sections.
Purpose The purpose of this QI initiative was to improve the efficiency of our interprofessional team meeting to better utilize our time together and promote the well-being of our patients and ourselves. In particular, we aimed to improve communication across the various specialties within our team and ensure that all professionals in attendance could ask questions and provide insight and feedback regarding our patient census.
Methods We used the Model for Improvement to guide our work.7 We created a ‘‘current state’’ process map of our meetings and identified areas of waste and inefficiency. Next, we conducted a voluntary stakeholder survey of all team members. Team members returned surveys anonymously or via e-mail. We then discussed the stakeholder results as a team and planned several interventions for changing our meeting structure and processes.
We conducted numerous ‘‘plan, do, study, act’’ (PDSA) cycles to implement interventions and evaluate continued challenges and improvements, including using ‘‘rapid evaluations’’ at the close of each weekly meeting. The results of our stakeholder surveys and our weekly rapid evaluations guided each PDSA cycle. After 12 weeks, we discussed the results as a team and collectively decided how to proceed. After 16 weeks, we conducted a stakeholder postsurvey. Our outcome measures included start and end times of our meeting and satisfaction questions included in the stakeholder surveys. The project was deemed nonresearch by our institution’s Administrative Officer of Health Services Research & Development and required review by our institution’s Privacy Officer to ensure all data were deidentified and survey respondents’ privacy was protected. The privacy officer deemed the project ‘‘deidentified.’’ Institutional review board review was not required.
Results Presurvey Of 17 team members, 14 (82%) completed the stakeholder presurvey. Results revealed a clear lack of consensus about the goal of the meeting with responses varying from no clear goal to the goal being to discuss the entire patient census, to only discuss difficult cases and to conduct team activities. Several challenges centered on a lack of structure, poor time keeping (late start and end time and rushing at the end of the meeting to finish discussing all of our patients), and no formal process for ensuring that all team members had an opportunity to provide input. There was concern among team members that the meetings were too ‘‘physician centric’’ or ‘‘nurse practitioner centric.’’ Physicians and nurse practitioners tended to talk most of the time and focused on the medical history of the patient, leaving little time to discuss broader palliative care issues and the psychosocial, nutritional, and spiritual needs of patients. When asked ‘‘How satisfied are you with the current structure of the palliative care interprofessional meeting?’’, mean team satisfaction was 2.43 on a 5-point Likert-type scale, with 5 indicating extremely satisfied. Mean favorability of changing the structure of team meetings was 4.57, with 5 indicating highly in favor of change. Comments included a request that providers limit commentary about the patient’s medical history and hospital course if it does not provide helpful insights into the patient’s palliative care needs. Of note, our team reported a high readiness for change during our presurvey. This is an important feature to assess before initiating PDSA cycles, as additional work may need to be done seeking stakeholder buy-in and support prior to starting rapid tests of change.
Plan, Do, Study, Act Cycles After analyzing our current state process map, areas of waste and inefficiency, and our stakeholder presurvey results, we identified several interventions for improving our team meeting. We decided as a group that moving our start time from
Downloaded from ajh.sagepub.com at SUNY HEALTH SCIENCE CENTER on April 17, 2015
Brennan et al
3
8:30 AM to 9:00 AM. would assist with starting on time. We created a document with meeting objectives and ‘‘etiquette’’ and adopted a shortened version of the 7-step meeting process,8 including a structured, timed agenda (Table 1).
Meeting Objectives Two team members attended the oral presentation ‘‘Model for Running a Palliative Care Interdisciplinary Team Case Conference’’ at the 2012 Annual Assembly of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association.9 The presentation included specific steps for structuring a clinical case conference. We discussed as a team what the objective of our time together should be—to discuss our entire census or to focus on one or two complex cases, as in the Meyerson et al’s presentation.9 Given that our team meeting is the only time each week our entire team convenes, we decided our meeting objective would be to prioritize complex cases and seek input from each other about goals and plans of care for these patients. Then, if time allowed, we would discuss our remaining census. Next, we iteratively conducted several PDSA cycles. PDSA #1 included adopting a shortened version of the 7step meeting process and using templates to guide the discussion. Our shortened version of the 7-step meeting process included assigning roles of facilitator and timekeeper for each meeting, clarifying the meeting objective, using a structured and timed agenda, soliciting team participation, and evaluating the meeting (Table 2). We also added a few minutes at the beginning of the meeting for ‘‘reflection,’’ in which a team member volunteers to read a poem or excerpt from The Book of Awakening: Having the Life You Want by Being Present to the Life You Have.10 Next, we discuss announcements, bereavement cards that need to be signed, and division of bereavement telephone calls to families of Veterans who have died in the past week. Then, the meeting facilitator asks each member of the team which patients they would like to discuss. This method ensured all members had the opportunity to communicate current/pressing issues for complex patients on our census list. Prior to beginning the patient discussion, we determined how much time we had for each patient and used a timer to provide a 1-minute warning chime to prompt team members to finish the discussion and move to the next patient. This ensures that we do not run out of time for patients at the end of the meeting. We also created a ‘‘parking lot’’ for topics that came up during our discussion that we did not have time to address during our meeting. Examples include how to effectively have a DNR/DNI (Do Not Resuscitate/Do Not Intubate) discussion, preparing patients with head and neck cancer for the challenges of symptom management, body image, and side effects of medical procedures as well as housekeeping items, such as updates on new policies. Putting these topics in the parking lot provides a mechanism for tabling issues at that moment rather than detracting from the goal of the meeting. Returning to these items at a later date also guarantees we can devote sufficient
Table 1. Meeting Agenda and Templates for Patient Prioritization and Discussion. Palliative Care Interprofessional Team Meeting Thursdays, 9-10:30 AM Medicine Service Conference Room (1B-119) Meeting Agenda 1. 9-9:05 AM Meeting set-up a. [Only if new person is joining us: go around table and read objectives, team meeting etiquette] b. Discuss/assign roles (facilitator, timekeeper) c. Call pharmacist to join via phone 2. 9:05-9:10 AM ‘‘House-keeping’’ a. Announcements/upcoming absences/travel b. Divide up bereavement calls 3. 9:10-9:14 AM Reflection 4. 9:14-9:15 AM Patient Prioritization: Each member has the opportunity to: a. Name patients they would like to discuss (potential, active, discharged, or deceased) b. Name patients they think do not need to be discussed c. ‘‘Pass’’ (eg, if new to service and don’t know any patients) 5. 9:15-9:55 AM Patient Discussion: Our timekeeper will divide our time among the patients we would like to discuss. Next, the person presenting the patient (which can be anyone) has 1 minute to state: a. Name b. Age c. Main diagnosis d. Date and reason for admission e. Date and reason for palliative care consult f. One main palliative care issue from their perspective g. You will hear a chime when the 1 minute has lapsed. After the chime, we will move around the table and others can briefly add to the patient discussion from their discipline’s perspective. People can ‘‘pass’’ if they don’t know the patient or have nothing to add. Please keep your comments brief so that everyone has a chance to talk. Once we have gone around the table, the presenter can provide additional information if needed. You will hear a second chime indicating 1 minute is left before moving to the next patient. Please use the second chime to wrap-up your comments and help the facilitator move to the next patient. 6. 9:55-10 AM Rapid Evaluation or make plan for the day 7. 10-10:30 AM Team Care a. Remembrance (first and second Thursdays) b. Staff meeting for core members (third Thursday): Move to room 118 c. Presentations/memorial service planning/parking lot discussions (fourth and fifth Thursday)
time to address them in a broader context, rather than a caseby-case basis and allows for preparation if the topic requires it. PDSA #2 included limiting the opening statement for each patient to 1 minute. Using a timer with alarm capabilities, we decided to use 2 chimes. The first chime alarms after 1 minute to signal the end of the brief case presentation. This serves as a cue to the individual presenting the case to move the discussion around the table. This prompt ensures the presenter does not dominate the conversation and signals others to provide
Downloaded from ajh.sagepub.com at SUNY HEALTH SCIENCE CENTER on April 17, 2015
American Journal of Hospice & Palliative Medicine®
4 Table 2. Meeting Objectives, ‘‘Etiquette,’’ and Rapid Evaluation. Meeting Objectives 1. Run the list of palliative care patients 2. Gain insight from all disciplines in attendance 3. Communicate in an interprofessional manner to guide Veteran and family plan of care a. Includes ‘‘housekeeping’’ communication related to bereavement calls, announcements, etc. 4. Conduct ‘‘team care’’ activities a. Remembrance b. Presentations (clinical and/or team-building focus) c. Staff meetings for core members Meeting Etiquette 1. Start and end on time 2. No rank in the room 3. This is a safe zone 4. Everyone participates, nobody dominates 5. Everyone has a place at the table 6. Speak freely, listen attentively 7. Be an active listener 8. Listen as an ally 9. Stay on track 10. Keep an open mind 11. Agree only if it makes sense to do so 12. Maintain confidentially 13. Give freely of your experience 14. Maintain each other’s self esteem 15. Turn beepers to vibrate 16. Use cell phones/check emails only when absolutely necessary, step outside room to do so Rapid Evaluation 1. What worked well? 2. What did not work well? 3. What could be improved for next meeting? 4. Items to put in the ‘‘parking lot’’ to discuss at next meeting?
input. This strategy provided a structural cue to new attendees, such as trainees, to limit the patient summary in order to focus more on team discussion. In doing this, the team responded to survey responses that reviewing a case too thoroughly was not useful to all participants and shortened the time devoted to other patient discussion. This PDSA cycle also helped to ensure that discussion would not be limited to medical issues. The second chime alarms when there is 1 minute left in the discussion of the patient. This serves as a cue for the team to finish the discussion and for the facilitator to move to the next patient. PDSA #s 3 to 8 included making adjustments to the agenda and trialing moving deliberately around the table during the discussion, starting with the presenter, instead of a more ‘‘free form’’ discussion, in order to be certain each person had an opportunity to contribute. We also encouraged the facilitator to give cues and interrupt to keep the discussion on track. During a later PDSA cycle, we decided to read the objectives and etiquette only when a new person joins, in order to save time. We devoted time to discussing barriers to starting on time and how to rotate the facilitator and timekeeper roles. We decided that encouraging the facilitator and timekeeper to sit next to
each other to ‘‘colead’’ the meeting would be a less intimidating way for people to participate in each role.
Outcomes Start and end times. Figures 1 and 2 are statistical process control charts, graphing the number of minutes we started and ended late each week.11 Meeting start time improved from a mean of approximately 9 minutes late to a mean of 6.5 minutes late (Figure 1). We experienced a 10-week period between July and September 2012 during which we improved our mean start time from 9 minutes late to 5 minutes late. We improved our meeting end time from a mean of approximately 6 minutes late to a mean of 0 minutes late (Figure 2). Statistical significance is not calculated in the traditional sense with statistical process control charts. Rather, data are presented over time and a set of rules are applied to identify whether, in this case, our interventions caused a decrease in the number of minutes our meetings started and ended late.11 These rules allow for identification of ‘‘special cause’’ or ‘‘common cause’’ variation in the data. Special cause indicates a ‘‘signal’’ and that the process itself has changed, whereas common cause indicates ‘‘noise’’ or random variation that cannot be attributed to a specific cause. For start time, a special cause signal is reflected in greater than or equal to 8 successive values falling on the same side of the centerline (starting July 12, 2012). For end time, the control limits were reset starting July 26, 2012 and show graphically that we ended early or only a few minutes late after initiating improvement efforts. Thus, the change in meeting start and end times can be attributed to our series of PDSAs. Stakeholder postsurvey. One student, 1 fellow, and a rotating physician were no longer a part of the team during postsurvey period and thus, total team members decreased from 17 to 14. Of 14 team members, 12 (86%) responded to the postsurvey. Mean team satisfaction improved from 2.4 in our presurvey to 4.5 in our postsurvey. Team members were asked ‘‘To what degree did our changes meet our overall objective of improving our team meeting?’’ and the mean response was 5 or ‘‘very much.’’ Team members were also asked to comment on which aspects of team meeting are better and which are worse after implementing our team meeting changes (Table 3). Team members reported that tasks and responsibilities are more evenly distributed and that there is better morale, an improved sense of teamwork, and a feeling of being more centered as a group. Team members responded positively to the fact that we altered our meeting processes as a group and took into consideration elements each member considered desirable or essential. Respondents commented that being more efficient with our time provides the ability to target the discussion to the most important aspects of each case. Team members responded that we have created better intrateam communication and awareness of resources and roles. Team members were asked to comment on how they think our team meeting improvements are impacting patient care.
Downloaded from ajh.sagepub.com at SUNY HEALTH SCIENCE CENTER on April 17, 2015
Brennan et al
5
Baseline period 20 18
Improvement efforts initiated
16
Minutes Late
14 12 10 8 6 4 2
11.29.12
12.27.12
1.24.13
11.29.12
12.27.12
1.24.13
10.11.12
9.13.12
8.16.12
7.19.12
6.21.12
5.24.12
4.26.12
3.29.12
3.1.12
2.2.12
1.5.12
0
Date Figure 1. Meeting start time.
Baseline period 20
Improvement efforts initiated
Facilitator unexpectedly absent
15
High census; team decided to stay late to discuss patients
5
-10
10.11.12
9.13.12
8.16.12
7.19.12
6.21.12
5.24.12
4.26.12
3.29.12
-5
3.1.12
0
2.2.12
Minutes Late
10
Date
Figure 2. Meeting end time.
Respondents reported that a formal mechanism of including all members in the meeting discussion resulted in a more cohesive, interprofessional overview of our patients and allowed all disciplines the opportunity to raise questions and concerns in a timely manner. Team members commented that our team meeting improvements created a better understanding of the ‘‘big
picture’’ for each patient, not only in terms of the prognosis and treatment plan but also related to the patient’s interests and values. This provides the team with a better understanding of our patients and, as a result, an improved ability to care for them. Team members reported that our improvements have clarified communication about the plan of care for patients, positively
Downloaded from ajh.sagepub.com at SUNY HEALTH SCIENCE CENTER on April 17, 2015
American Journal of Hospice & Palliative Medicine®
6 Table 3. Survey Results.
‘‘How satisfied are you with the current structure of the palliative care interprofessional meeting?’’ Answer choices included 1 ¼ not at all satisfied; 2 ¼ somewhat satisfied; 3 ¼ quite satisfied; 4 ¼ very satisfied; and 5 ¼ extremely satisfied Presurvey
Postsurvey
2.43
4.5
‘‘Since we changed our team meeting format, what aspects are better and what aspects are worse?’’ Answer choices included 1 ¼ worse; 2 ¼ somewhat worse; 3 ¼ no change; 4 ¼ somewhat better; and 5 ¼ better Aspect
Mean Postsurvey Score
Timeliness (eg, starting/ending on time, use of time during meeting, etc)
5
Focus of discussion (eg, discussing information most pertinent to palliative care consult, not getting side-tracked, etc)
4.6
Efficiency (eg, pacing of discussion, not repeating the plan for late-comers, not using meeting time for discussions that can be handled outside of team meeting, etc)
4.7
Organization/structure of the meeting (eg, clear understanding of what we hope to accomplish in the meeting, deliberate planning, and execution of how we will spend our time together, etc)
4.8
Clarification of meeting objectives (eg, clear, shared understanding of our meeting objectives)
4.8
Inclusion (level of participation of various professionals present at the meeting)
4.8
impacting their ability to articulate the plan to other health care professionals, patients, and families.
Discussion Our palliative care team meeting QI initiative can be summarized into 3 core elements for interprofessional team meetings, namely, structure, inclusion, and team care.
topics may not be as relevant or fresh in our minds when we find time to address them during future sessions. Another challenge is that the parking lot list is quite long and people may find it less useful if we do not address the topics we place in the parking lot. Prioritizing topics and scheduling them in a way that meets the needs of each member of the team is an ongoing challenge.
Inclusion Structure Changing our meeting start time from 8:30 AM to 9:00 AM, along with applying a shortened version of the 7-step meeting process, resulted in improvement in our meeting start time. One disadvantage of a later start time is that team members have more opportunities to be called into clinical issues before team meeting and it is challenging to break away from patient care. This remains the biggest barrier to starting on time. We made a marked and sustained improvement in our end time. We consistently end on time or early because we use our time efficiently during the meeting. Prioritizing patients, using a timer, and putting topics/ideas in the parking lot have all collectively impacted our ability to end on time. While in the past, interesting and important topics related to the care of palliative care patients often became a distraction from the main discussion, these topics now go in the parking lot, and we use the last 30 minutes of the fourth and fifth Thursday of the month to choose one of these topics to discuss. We discuss the topic as a group or invite a team member or guest to give a formal presentation. However, waiting to discuss topics that are relevant to patients for whom we are currently caring means that the
Improved structure led directly to improved inclusion. Although team members reported in the presurvey that not all members had an opportunity to participate in the discussion, respondents in the postsurvey reported an increase in participation from all professions and increased team cohesion. Of note, all team members are included in the structure of the meeting. For PDSA cycles 1 to 6, the first author facilitated and assisted with timekeeping, in order to help model the roles for the group and to maintain consistency while the process was being piloted. During the initial phase of the QI initiative, this consistency was beneficial. We discussed collaboratively that the facilitator role and structure of the meeting cannot be dependent on one person. Starting with PDSA #7 to the present date, team members rotate the roles of timekeeper and facilitator in each meeting. All team members have participated in at least one of the roles at least one time. The team distributes a sign-up sheet every month to help facilitate the rotation of roles. Team members voluntarily fill in if a facilitator or timekeeper is unexpectedly absent. Two practices of inclusion we deliberately avoided during our intervention phases were waiting for others to arrive to start
Downloaded from ajh.sagepub.com at SUNY HEALTH SCIENCE CENTER on April 17, 2015
Brennan et al
7
18
16
Delay due to urgent patient care issue
14
Minutes Late
12
10
8
6
4
2
03/27/14
02/27/14
01/30/14
01/02/14
12/05/13
10/31/13
10/03/13
09/05/13
08/08/13
07/11/13
06/06/13
05/09/13
04/11/13
0
Figure 3. Meeting start time (sustainability phase).
the meeting and repeating content when a team member arrived late. This required a change in culture, which we were able to accomplish by discussing this plan and seeking all members’ input and buy-in before implementing it. All members have accepted and implement these rules when they serve in the facilitator or timekeeper role. This shift in culture has been an important driver of our ability to start and end on time.
preferred to use a kitchen timer. This team member was open to trying something more aligned with his comfort level, rather than learning to use a smartphone to keep time or opting out of the role altogether. Finally, our team vacillates between going around the table to elicit input from each member and a more free form process for the discussion. In this way, we are experimenting with the balance between structure and allowing the discussion to take its natural course.
Team Care Our team highly values setting aside time for morning reflection, Remembrance, staff meeting, and continuing education and parking lot discussions. In the past, patient discussions routinely ran longer than the allotted time and took away time and momentum from team care. Because of our improvement efforts, we have consistently been able to use the last 30 minutes of our time together for team care, which respondents reported helps with team building and unity. We regularly review items in the parking lot to assist with scheduling presentations and continuing education opportunities.
Adaptability Although our team is committed to structure, we are also flexible with adapting various aspects of our team meeting to fit our needs. For example, we might adjust the agenda as needed, such as skipping reading the morning reflection if we have started the meeting late. We are open to new changes and ideas in order to fit individuals’ needs. For example, typically the timekeeper uses a smartphone for initiating the chimes during the discussion. However, one team member
Sustainability In the year following our improvement initiative, we sustained our improvements and maintained the structure of the meetings without any changes. As shown in Figures 3 and 4, we consistently start our meeting on time (mean start time of 4.44 minutes late) and end on time or early (mean end time of 5.58 minutes early). Of note, special cause signals occurred between May 2nd and July 11th, 2013, during which time there were more than eight successive values above the center line and one value above the upper control limit. This special cause variation is attributed to turnover of staff (during this period the first author took another position and the last author retired). No other special cause variation occurred in Figure 3 and none occurred in Figure 4. Currently, adherence to the new structure is maintained even in the presence of exterior pressures such as personnel changes, patient care obligations, and a high census of patients. Several other improvements have been extended from our initial improvement work focused on restructuring our team meeting. For example, our practice had been to prepare a list
Downloaded from ajh.sagepub.com at SUNY HEALTH SCIENCE CENTER on April 17, 2015
American Journal of Hospice & Palliative Medicine®
8
20 15 10
0
03/27/14
02/27/14
01/30/14
01/02/14
12/05/13
10/31/13
10/03/13
09/05/13
08/08/13
07/11/13
06/06/13
-15
05/09/13
-5 -10
04/11/13
Minutes Late
5
-20 -25 -30 -35
Figure 4. Meeting end time (sustainability phase). Table 4. Summary of Quality Improvement Tools Applied to Team Meeting. Stakeholder pre- and post-surveys Readiness for change Satisfaction How do our team meeting processes affect patient care? Current state process map Small tests of change (PDSA cycles) 7-Step Meeting Process Structured Agenda Clear Meeting Objectives and Etiquette Roles (timekeeper, facilitator) & Rotation of roles Rapid Evaluation & What worked well? & What did not work well? & What could be improved for next meeting? & Items to put in the ‘‘parking lot’’ to discuss at next meeting? Timer and Chime Parking Lot Outcome measure: meeting start and end times
to determine whether the topic was suitable for our monthly education session following team meeting or whether a separate meeting needed to be scheduled. Currently, all parking lot topics are either scheduled to be discussed or complete. Another major change was the introduction of a new palliative care administrative assistant to the team who leads the administrative work in the service, including scheduling outpatient appointments and tracking the patients cared for by the service, including deaths. As a permanent participant in the team meetings, the administrative assistant updates the signout sheet and education session schedule and sends a team meeting report via e-mail to all participants after each meeting. Adding an administrative assistant has improved coordinating the role sign-up process, planning and scheduling educational seminars, ensuring continuity of care for patients going off inpatient service and being followed in our outpatient clinic, and communicating pertinent administrative information to the entire team.
Limitations
Abbreviation: PDSA, plan, do, study, act.
of active patients for sole use in team meeting, which was created by one or two team members who were the only people able to create or access it. Instead, we have created a new active sign-out list that is accessible by all team meeting participants and is updated regularly by all team members during their regular work. The list includes all of the patients who died each week. For active patients, the list contains medical and psychosocial information, goals, and a tentative plan of care, which is a major improvement from the old list that featured names only. Adding the parking lot to our team meeting processes helped ensure that topics of discussion and ideas for education or a guest presentation did not derail our patient discussions or get lost to follow-up. During our sustainability phase, we asked each team member to anonymously prioritize the list of topics by urgency and importance. We used this prioritization
A limitation of our data collection procedures was the use of team member approximations of start and end times in lieu of real-time data collection during the baseline period. It is challenging to decipher the influence of timekeeper error in recording the start and end times. This is particularly the case for start times, given that conversations at the beginning of the meeting can be distracting. In addition, being too structured in a team meeting can limit the free and open exchange of ideas. Striking the balance between structure and free discussion is something our team continues to address.
Recommendations We recommend using our team meeting improvements as a ‘‘toolkit’’ for interprofessional team meetings. Additional data that identify and measure ways in which team meeting improvements directly affect patient care are needed. Adoption of this
Downloaded from ajh.sagepub.com at SUNY HEALTH SCIENCE CENTER on April 17, 2015
Brennan et al
9
type of toolkit can be used in future research that investigates the relationships among improved interprofessional team meeting structure, communication, and burnout rates in the palliative care discipline. A summary of the tools we applied to our QI initiative are provided in Table 4. Author’s Note This work was conducted at the VA Boston Healthcare System. Dr. Brennan was supported by the VA National Quality Scholars Program.
Acknowledgments The authors would like to thank Fr James Diemand; Maya Dietz; Peter Engel, MD; Douglas Falls, MDiv; Melissa Franklin, MS, CCC-SLP, Sarah Grudberg, MD; Christina Harris, MS, CCC-SLP; Matthew Mendlik, MD, PhD; Natalie Noto, PharmD; Marci Salow, PharmD; Allie Richards, MS, CF-SLP; James Rudolph, MD; Makayla Schuchardt, MS, RD; and numerous rotating fellows, residents, and students for their participation, input, and support for this project. The authors would also like to acknowledge and thank Mary Dolansky, PhD, RN, for her guidance and mentorship and her ideas for ‘‘team etiquette’’ and ‘‘parking lot’’ and Mark Splaine, MD, MS, and the Veterans Affairs Quality Scholars program for mentorship and expertise in statistical process control charting.
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
References 1. Arber A. Team meetings in specialist palliative care: Asking questions as a strategy within interprofessional interaction. Qual Health Res. 2008;18(10):1323-1335.
2. Junger S, Pestinger M, Elsner F, Krumm N, Radbruch L. Criteria for successful multiprofessional cooperation in palliative care teams. Palliat Med. 2007;21(4):347-354. 3. O’Connor M, Fisher C. Exploring the dynamics of interdisciplinary palliative care teams in providing psychosocial care: ‘‘Everybody thinks that everybody can do it and they can’t’’. J Palliat Med. 2011;14(2):191-196. 4. Rock W. Interdisciplinary teamwork in palliative care and hospice settings. Am J Hosp Palliat Care. 2003;20(5):331-333. 5. Leonard M, Graham S, Bonacum D. The human factor: The critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care. 2004;13(suppl 1):i85-i90. 6. Street A, Blackford J. Communication issues for the interdisciplinary community palliative care team. J Clin Nurs. 2001; 10(5):643-650. 7. Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd ed. San Francisco: Jossey-Bass Publishers; 2009. 8. Hyer K, Flaherty E, Fairchild S, et al. Geriatric Interdisciplinary Team Training: The GITT Kit. 2nd ed. New York: John A. Hartford Foundation, Inc; 2003. 9. Meyerson EM, Chai E, Horton JR. Model for running a palliative care interdisciplinary team case conference [abstract]. J Pain Symptom Manage. 2012;43(2):330. Web site. http://www. jpsmjournal.com/article/S0885-3924(11)00602-6/abstract. Accessed March 6, 2015. doi:http://dx.doi.org/10.1016/j.jpainsymman.2011.12.031. 10. Nepo M. The Book of Awakening: Having the Life You Want by Being Present to the Life You Have. San Fancisco, CA: Conari Press; 2000. 11. Carey R. Improving Healthcare with Control Charts: Basic and Advanced SPC Methods and Case Studies. Milwaukee, WI: American Society for Quality; 2003.
Downloaded from ajh.sagepub.com at SUNY HEALTH SCIENCE CENTER on April 17, 2015
