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Managers Questioning How They Work to Improve Inter-Professional Collaboration and Clinical Governance Print E-mail
The Quarterly 2012

This article was written by Dr. Susan Keam, derived from material presented by Dr David Greenfield on Thursday the 13th of October 2011 at the Great Healthcare Challenge.

Interprofessional collaboration (IPC), a fluid mix of interprofessional learning (IPL) or education (IPE) and interprofessional practice (IPP), is advocated as being a driver to improve health care and address patient safety issues. To assess whether improved IPC improves patient healthcare, over a 4-year period, we ran a project in which a group of health service managers with responsibility for clinical governance used an existing professional meeting as an opportunity to consult with staff on managing quality and safety, risk and performance in these services. In this forum, managers were able to "look down" on their services and ask questions such as "are we doing things the right way and could we do them better?" and "are we sharing knowledge effectively so that it makes a difference?"


The significance of IPC

Factors contributing to sentinel events in Australian hospitals 2004-2005

Figure 1. Factors contributing to sentinel events in Australian hospitals 2004 – 2005
click image to enlarge



If we look at the factors contributing to sentinel events (figure 1), just under 90% of the issues relate to communication, teamwork and interprofessional collaboration. Only 6% are due to equipment problems and 7% are due to the work environment.

The Project

We investigated how an established senior managers' meeting could be improved to enhance IPC and clinical governance. Within the context of the project, the meeting provided the opportunity for the group to ask questions such as "Am I doing it the right way?", "Could I do it better?", "What do my colleagues think?" and then stop and think about the answers.

The overall project aim was to see whether improving IPP and IPL through improving various interprofessional factors, such as communication, trust and collaboration (see figure 2), leads to improved patient care, patient safety and health professional wellbeing.



Research framework:

Project aim: To enhance teamwork, collaboration, and the sharing of ideas, knowledge and practice

Method: A large research team was drawn from a number of institutions, with seven studies conducted in parallel over 4 years. These studies comprised the following:
  • Study 1: literature review (year 1)
  • Study 2: IPL and IPP data collection tools (year 1)
  • Study 3: baseline audit of IPL and IPP activities (year 1) [identify the leadership, collaboration and teamwork activities that were present and the extent to which they worked well]. Project initiatives to improve these activities arose from the audit.
  • Study 4: collection and dissemination of IPP and IPL materials and training of stakeholders (years 2-4)
  • Study 5: modification of tertiary and professional curricula and learning structures (putting ideas and initiatives into practice) (years 2-4)
  • Study 6: mapping of emergent successes and failures (year 1 at 6 months, then annually thereafter)
  • Study 7: measuring of progress in IPL and IPP (at 9 months in each study year)
  • Studies 3-7 covered four domains: tertiary providers, professional bodies, streams of care and teams. Outcomes from studies 6 and 7 following each review stage (ideas generated by the staff in the health service) were fed back into studies 4 and 5 until the end of the project.
Purpose of the initiatives: Ideas were generated by ACT Health staff following participation in the 'audit' activities. UNSW research team offered to work with individuals/ teams on projects which had an interprofessional focus. Their purpose was to guide and promote practice change to enhance IPC.

Of the 111 initiatives proposed, 42 were rejected because they were only concepts. Of the 69 activities initiated during the project, 28 were completed by project end, and 41 were ongoing. Initiatives ranged across the health service and university interface, health services, universities and professional associations (see table below).


Focus of initiative Progress outcome
  Concept only Completed Progressing Total
At the boundary between health and university domains 3 - 1 4
Within the health service 33 26 29 88
- Acute services 3 6 1 10
- Sub-acute services 3 6 4 13
- Community health 16 8 1 25
- Mental health 3 4 4 11
- Across divisions 8 2 19 29
Within universities 3 2 9 14
Within professional associations 3 - 2 5
Total 42 28 41 111


Examples of the initiatives included:
  • Developing an interprofessional pediatrics' induction pathway
  • Enhancing interprofessional teamwork in palliative care
  • Improving interprofessional recovery planning in mental health care
  • Integrating IPL into a new simulation centre
  • Evaluating doctor-nurse collaboration in Corrections Health
  • Evaluating the role of the Aboriginal Health Worker in health care teams
  • Curriculum map of IPL activities across four tertiary education providers
  • Evaluating IPL in university clinics
  • Analysis of IPL themes in 3rd-year medical students' reflective journals
A review of the literature found that quality improvement is most effectively achieved by combining the skills of both managers and frontline clinicians. However, engaging and maintaining the focus of staff on improvement initiatives is challenging, and it is important to get the right people interested and engaged in an open and transparent way, especially those at the bottom of the workforce heap.

Investigations into quality improvement programs have shifted focus from appreciating how improvement initiatives manifest to investigating the determinants of their effectiveness. There is also a need for greater understanding of the impact of the social context, that is, the interpersonal, team and organisational factors, and strategies that engage staff.

Research process

The Action Research cycle (Plan, Action, Observe, and Reflect) was followed.




Plan: To identify whether the managers meeting was effective, feedback was sought from colleagues. A 28-question survey that used a Leichardt scale of 1-5 (where 1 =unhappy and 5 = happy) was developed to examine:
  • Efficiency
  • Accountability
  • Value of the meeting
  • Participation
  • IPC
  • Improvements to enhance governance


Examples of Survey Questions
A1 The Continuing Care Allied Health Managers meeting is an effective forum that meets my needs.
A2 I believe that I have a good understanding of the purpose of the meeting.
A3 The decision making process of the meeting is open and transparent.
A4 In the meeting I have an opportunity to express my opinions and be heard.
A5 The meeting is a consultative forum.
A6 The meeting has a democratic decision making process.
A7 The meeting is a friendly, non confrontational yet confidential environment in which to raise and discuss sensitive issues.
A8 The meeting provides the opportunity to hear different viewpoints which are respected.
A9 The meeting facilitates communication of updates relating to the organisation's policies and initiatives


Action:
Following a pilot study to check the validity of the questions, the formal survey was sent by email from the researcher in July 2010.

Observe:
Descriptive and thematic analysis (common themes were identified from survey results)

Reflect:
The outcomes were presented to the manager running the meetings, who in turn took the results to the wider group. The managers identified that the process had started them talking to each other about the way they did things. It allowed them to voice their uncertainties and questions in a way that felt comfortable, an environment that wasn’t present previously (prior to the project, voicing these questions equated to saying that they didn’t know what they were doing).

After reflection and discussion, the managers asked that the survey be repeated 6 months later to see if survey scores improved.

Repeat cycle:
Plan:
Re-do survey

Reflection activity with managers

Action:
The survey was re-administered in February 2011

Observe:
Comparison of 2010 and 2011 results

Reflect:
Team Reflection Activity (looks at the results with the managers and talk about the implications of them)

Research Outcomes:
Positive responses were reported across all 28 items surveyed.

Scores improved for 25 of the 28 items across the two surveys.

Improvements were identified in organisational and collective accountability domains.

The meetings provided an avenue for talking about governance, trust and accountability with one another, how they could do their jobs as managers better, and a safe environment for voicing uncertainty.

Organisational improvements:
  • Revising agenda to incorporate participants’ interests and professional needs;
  • When making decisions, promoting consistency across different professional services;
  • A need to build in time to reflect on issues in the meeting (don’t have a packed, hurried agenda); and,
  • Decision making to be more open and inclusive.
Collective accountability improvements:
  • To promote a collaborative team environment (this led to an increased value from the meeting);
  • To contribute to a positive learning environment (less task-focused; learning from each other);
  • Improving individual organisation of services; and,
  • Encouraging participation, leadership and support for each other.
How did this study improve patient care?
The success of the action research activity prompted at least four participants, all of whom were managers of services, to replicate it with their respective teams, cascading the effect through the organisation. This demonstrates that the activity has had a positive effect on professional health wellbeing, which was one of the aims of the overall IPC project. It is too early to establish if the IPC project has had a measurable effect on patient-centred care and patient safety. Attempting to establish these outcomes is the focus of other studies.


Conclusion

The 'Great Healthcare Challenge' is in identifying and implementing similar leadership strategies and interprofessional forums that enable shared governance to be enacted, and collaborative problem-solving to be addressed. This simple activity was valued highly because it enabled those processes to be there and enabled trust and support between managers.

Research Team
  • Professor Jeffrey Braithwaite
  • A/ Professor Ruth Foxwell
  • A/ Professor Marc Budge
  • Ms Elisabeth Renton
  • Dr Joanne Travaglia
  • Ms Judy Stone
  • Professor Bill Runicman
  • Dr Rosalie Boyce
  • Ms Karen Murphy
  • Dr Peter Nugus
  • Ms Robyn Clay-Williams
  • Ms Rebecca Vanderheide
  • Professor Johanna Westbrook
  • Professor Timothy Devinney
  • Dr Mary-Ann Ryall
  • Dr David Greenfield
  • Ms Tania Lawlis

Research funded by the Australian Research Council Linkage funding scheme (project number LP0775514)

Research Partners
  • Professor Johanna Westbrook
  • Australian Government: Australian Research Council
  • The University of New South Wales
  • ACT Health
  • Australian Catholic University ACU National
  • University of Canberra
  • The Australian National University
  • Canberra Institute of Technology
  • Australian Patient Safety Foundation
  • The University of Queensland
  • The University of Sydney

David Greenfield; Peter Nugus and Jeffrey Braithwaite
Centre for Clinical Governance Research in Health, Australian Institute of Health Innovation

Contact details:
David Greenfield, PhD, Senior Research Fellow
Centre for Clinical Governance Research in Health, Australian Institute of Health Innovation
Faculty of Medicine, University of New South Wales
Email: This e-mail address is being protected from spambots. You need JavaScript enabled to view it ; Web: http://www.aihi.unsw.edu.au/