Effective Team Work in Quality Patient Care

INTRODUCTION

Establishing a relationship between leading effective teams and the delivery of quality patient care is a complex topic to review and requires investigation at multiple levels. In the instance, the definition of a team and what makes it effective needs to be considered. Secondly, we need to establish how leadership impacts on effective teams and subsequently links to quality patient care. This paper will look to explore the links between leading real teams and delivering quality patient care and what supports are required for the future to support development of leaders working in healthcare.

DEFINING QUALITY CARE

Prior to understanding the relationship between leading effective teams and quality patient care we first need to understand what quality care is. Opinions of quality care is widely discussed in literature and can be different depending on who is reviewing it. Quality viewed through the lens of patient will be much different to a Chief Executive Officer who may believe it is measured through reduced hospitalisations and costs (Borrill et al., 2000). Quality patient care has been well researched in literature and over the years there has been wide discussion regarding difficulties in establishing a clear definition (Crow et al., 2002). The Institute of Medicine (2001)  have created six aims of quality care which largely covers the variety of definitions in the literature and are: safe, effective, patient centred, timely, efficient, and equitable. The Institute of Medicine has subsequently supported six dimensions of patient centred care as developed by the Picker Institute as being: respectful to patients’ values, preferences, and expressed needs; coordinated and integrated; provide information, communication, and education; ensure physical comfort; provide emotional support; and involve family and friends (Tzelepis et al., 2015). Tzelepis et al. (2015) reported the best way to measure patient centeredness is via patient evaluation with examples including patient satisfaction and patient evaluation. Crow et al. (2002) recognised the value in ensuring patient feedback is included as an outcome in patient care however highlighted that patient satisfaction is multidimensional and as it is subjective can be difficult to measure. For the purpose of this paper quality patient care is referred to as patient centred care that is measured through patient evaluation.

EFFECTIVE TEAMS

In the same way quality care is difficult to define in literature so is defining leading effective teams. In this instance it is crucial to have an understanding of what a team is and what makes it effective. A common definition of a team in literature is:

A group of people who have clear shared objectives, who need to work interdependently to achieve these objectives and who are able to regularly take time to review the way in the which the team is working to achieve those objectives (Markiewicz and West, 2011).

Richardson (2010) subsequently proposed the theory that for a team be ‘real’ they should meet six key criteria to be classified as team. These have been identified as: interdependence, having shared objectives, autonomy, reflexivity, boundedness, and having specified roles. Underlying all of these it was recognised that effective communication was required. Not only do these share similarities of Markiewicz and West (2011) but also of other literature in the area of defining teams (Babiker et al., 2014; Buttigieg et al., 2011; Mickan, 2005; West and Borrill, 2005; West et al., 2015).  Past NHS staff surveys indicate that approximately 90% of people feel they work in teams, however in reality often they do not work in teams as per Richardson’s (2010) criteria, but rather work in pseudo teams (West and Lyubovnikova, 2012). I have seen this first hand when working through the Anderson Team Journey (NHS Leadership Academy, 2018) and realising that services I manage fit more into pseudo teams and could be structured differently to establish real teams with potential to work more effectively.

The effectiveness of team working has been argued over time in the literature and lacks a reliable definition due to the complexity around team work, the stakeholders, and differing goals (Borrill et al., 2000; Mickan, 2005). The input-process-output model theorised by Hackman (1987) is widely referred to in literature. It suggests three stages for effective team work being; inputs such as composition of the team, clarity of roles, and organisational support; processes such as objectives, reflexivity, and communication; outputs such as patient satisfaction, innovation and error rates (West and Borrill, 2005; West and Lyubovnikova, 2013). Ilgen et al., (2005) recognised the importance of feedback for effective team work and how outputs from one cycle and influence the inputs of a future cycle. From this the input-mediation-output-input (IMOI) model was developed (Ilgen et al., 2005). Literature suggests that teams need to go through stages to be effective with the Tuckman and Jensen (1977) popularly cited. Their model is comprised of five stages of forming, storming, norming, performing, and adjourning (Bonebright, 2010). Over the years the theory has been criticised due to its simplicity and that it does not reflect the dynamic and complex nature of team working in order to achieve goals. Despite this criticism the theory continues to be used throughout literature. Measuring the effectiveness of team is complex, however ensuring the right people, skills, and processes are established is essential for effective teams.

Despite the vast amount of literature defining an effective team it is recognised in literature that a positive relationship exists between effective team working and quality patient care. Both Borrill et al. (2004) and (West et al., 2011) identified a positive link between effective team work and patient satisfaction through evelaution of both staff surveys and patient satisfaction results. Further literature reviews have been undertaken over the years that also support the positive relationship between effcitive team work and quality patient care through patient satisfaction (Babiker et al., 2014; Markiewicz and West, 2011; Mickan, 2005;  West and Borrill, 2005)  Whilst establishing a positive relationship between effective teams and quality patient care is well documented it is interesting to note that these studies that share common attributes of team do not necessarily identify the need for leadership.

Whilst much of the literature that support a positive relationship between effective teams and quality patient care other arguments need to be recognised. A study by Purdy Nancy et al. (2010) found little significance between team working and patient satisfaction. However, the definition of team working within this study was not set against the previously discussed criteria. The role of leader was not discussed in this study however, a recommendation was suggesting a leader could be beneficial in sharing information and providing feedback. It could be hypothesied that if leadership were present and supporting the team to identify objective, be reflexive and then the team could be more effective and therefore impact on patient satisfaction may have been significant. (SOMEHOW LINK THIS WITH A SUMMARY OF NOT MUCH EVIDENCE)

LEADERSHIP

There have been other literature that has been able to show a distint link between leadership, patient saitisfaction and team working.

The characteristics of an effective team have long been documented in literature and continue to build on what has been defined as the criteria to be an effective team. West et al. (2015) have recognised that the role of leaders is to support and facilitate an environment where effective team working can occur. Babiker et al (2014) similarly suggested that leaders are required to facilitate, coach and coordinate the team for effectiveness. This supports earlier work by Herron (1999) where it was identified that the leader has a role in ensuring the team dynamic remains positive as this can impact on the effectiveness of a team and subsequently patient satisfaction.

Studies such as Markiewicz and West (2011) have  acknowledged that leadership can be complicated in teams and that for leadership to be effective clarity around the role of the team leader is required. West et al. (2003) identified that having poor clarity around the leadership role could impact on the team processes such as having objectives set , role clarity and effective communication. From the studies discussed in this paper these processes are paramount in effective teams that have shown positive impact on patient satisfaction.

West (2005) reported that effective and clear team leadership is needed to provide quality patient care. Whilst others such as (Markiewicz and West, 2011) have suggested that leadership is essential for any team wanting to reach is maximal potential and leadership is required for mentorship and facilitation. It has also been recognised that there is a difference between team leadership and supervision.

There are vast amount of literature supporting both positive relations between leadership and effective team work as well as effective team work and quality patient care. What is difficult to ascertain a direct link between leading effective team and quality patient care. However, reading the literature together it is possible to establish a link that supports a positive relationship between leading effective teams and quality patient care.

The effectiveness of leadership in teams has been argued in literature with (West et al., 2015) suggesting that there is a link between leadership and quality patient care that includes patient satisfaction.  Mickan (2005) reported a link between team working and delivering effective health care including improved patient satisfaction. Whilst the study supported the criteria of team it did not identify leadership as a core requirement. Similarly, Borrill et al. (2004) was able to prove a strong link between team working and patient satisfaction without the use of leadership. These studies could suggest that quality patient care can be achieved through a collaboration of people with diverse skills that are formed within the defined criteria of a team without needing a defined leader.

Alternatively, it could be argued that a team does not require just one leader. The Clinical Teams Programme developed by the Royal College of Nursing (Benson and Cunningham, 2006) supports the theory that leadership can be shared amongst a team and come from more than one person depending on skill set and diversity of the team (West, 2012; West and Borrill, 2005). The focus of the Clinical Teams Programme was improving team working. It required all members of the team to engage in the process but was facilitated by members of the team who had attended training and acted as leaders and facilitators. For shared leadership to be successful then the role of the leader and team members need to recognised and clarified (West et al., 2003). The Anderson Team Journey identified role clarity as weakness in a team I manage. Following a discussion with the team not only were role clarified but staff actively volunteered to lead on project for the team based on experience and interest.

This complex the role of leading effective healthcare teams is evident. It is therefore not surprising that there has been a trend over recent years for the  National Health Service (NHS) to focus on developing leaders for the future. Kings Fund, NHSI, Nusiing Matters etc have identified that NHS is lacking effective leaders and is now focussing on training. This has been a core recommendation following the Midstaffordshire report.  The strong message by the NHS across multiple domains (GMC, Kings Fund, NHS Academy, Nrsing ) to develop leaders is suggestive alone that leadership is core in delivering quality patient care. This is only backed up by reports such as the Francis report –

To develop leaders that are going to be effective the training needs to meet the requirements of the future leaders. It is recognised that clinicians who step into leadership roles are often not provided with the appropriate training and therefore require support to develop into these roles (Shepherd, 2011; West et al., 2015). Pilling and Slattery (2004) reported the difficulties that clinicians often face stepping into leadership roles with most only having competency based training for entry level professional requirements (i.e. physiotherapy or nursing). For leaders to be effective they need to be developed into the roles with appropriate training.

West et al. (2015) has suggested the National Health Service needs to prioritise developing leaders at all levels that are patient centred. (West, 2012) reported that leadership training should also be bespoke as different people will require different supports based on their background. Training has emerged in many formats and include internal training as well as external post graduate training including the Elizabeth Garrett Anderson Programme (REFERENCE) in supporting the development of patient-centred leaders. At present the outcomes of many of these programmes do not appear to have been evaluated against quality patient care. Benson and Cunningham (2006) were able to report that the Clinical Teams Programme is an example of how effective leadership was able to deliver improved quality patient care across many domains including patient satisfaction. Evaluating current and future leadership programmes against quality patient care should be a priority moving forward.

Due to the complex nature of the topic a direct link between leading effective teams and quality patient care is not well established, however a positive relationship is able to be established if literature is reviewed across multiple….. . It is recognised that leadershiop is required for effective team working and it is also evident that an effective team improved quality patient care. What is lacking in research is the direct link between leadership and quality patient care and should be the next steps. Research in the future needs to be more focussed around leadership in clinical teams and how this can directly impact on quality patient care. The NHS is currently focussed on developing appropriate leaders for the future across all areas including clinical leaders through a variety of programmes. Moving forward it would be beneficial to study the impact these courses are having on quality patient care.

Team

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