Pulling the Team Together: Diabetic Foot Infection

General

In starting a quality improvement (QI) project, you should realize that in many cases resistance will come from both complexity inherent in the system and the ingrained hierarchical culture. A strong, well-led team is perhaps the most effective strategy to address these barriers.

Team Leader

There is a science to leadership for the improvement and effective management of resources. Initial steps include knowing who, how, and when to ask for resources. Strong leaders endeavor to know the skills, abilities, and strengths of team members. Tasks should be distributed accordingly. The team leader should help the team identify the overarching goal. Keep the team focused on the overall goal and build consensus between team members and between various stakeholders (see Reliable Interventions).

Establish Team Rules

IDENTIFY AIMS: Identify the overarching role of the DFI QI team. Define this as precisely as possible. Write it down! Gain consensus among all team members.

ESTABLISH ROLES: Identify various content areas for team members. Clear, well-defined roles will allow individuals to “take ownership” of a portion of the QI project.

SET TASKS: Identify as clearly as possible who will do what by when.

BUILD RAPPORT: This can often be accomplished by establishing certain ground rules:

1. Ensure that the discussion environment is open and safe — consider all ideas fairly; avoid ad hominem attacks (address the problems not the people).
2. Be inclusive — value all potential contributors including diverse views.
3. Seek consensus — find a solution acceptable enough that all members can support it and no member opposes it. Be aware in particular that consensus is not the same as a unanimous vote (consensus may not represent everyone’s first priorities), nor is it a majority vote (when only those in the majority get something they are happy with, with those in the minority possibly getting something they don’t want at all, not what consensus is all about). The keys to achieving consensus include discussion with good communication and willingness to compromise.

At your very first team meeting, the team rules need to be established and everyone needs to explicitly agree to them. The facilitator is usually given the task of gaining consensus on and enforcing the team rules.

Use the team rules below as a starting point. The team should modify the rules as needed, then officially record and acknowledge them.

To some, these rules may appear a bit preachy. The key principle that must be adhere to is this: everyone on the team must be encouraged to speak up, and their views must be respected. Traditional concepts of rank have to go out the window. A unit clerk should feel comfortable telling the lead physician, “I don’t think that will work because of [reason]. Why don’t we try it this way?”

In addition to these rules, it should be made very clear that potential members should notify the leader quickly if they cannot devote the requisite time and effort so suitable replacements can be found. Timely minutes as well as a quick turnaround for comments/corrections should be the rule.

Task assignment: Team Facilitator

Team Ground Rules . . .

• All team members and opinions are equal.
• Team members will speak freely and in turn.
• We will listen attentively to others.
• Each must be heard.
• No one may dominate.
• Problems will be discussed, analyzed, or attacked (not people).
• All agreements are kept unless renegotiated.
• Once we agree, we will speak with “one voice” (especially after leaving the meeting).
• Honesty before cohesiveness.
• Consensus versus democracy: we each get our say, not our way.
• Silence equals agreement.
• Members will attend regularly.

Meetings will start and end on time.

For a print out version of Team Ground Rules click here.

Quality Improvement Champion

The QI champion, who may or may not be a physician, should be someone with QI experience. The QI champion plays the pivotal role in ensuring that the team functions constructively and that the project stays on track. This role requires project management skills and at times may call for the ability to balance team dynamics or introduce appropriate QI tools. Mastery of the topic literature is not required; rather, a general understanding and acceptance of quality improvement methodology are needed. The QI champion need not be an expert on QI tools at the outset but should have a readiness to acquire new tools and a talent for moving projects forward. Often the QI champion simply helps the team keep systems errors as the focus rather than individuals. For smaller-scale projects, the team QI champion could be the same person as a team leader, but for more ambitious projects or for projects involving buy-in from disparate physician and nursing groups, a separate champion is strongly recommended.

Content Experts

Although the team leader ensures the cooperation and functioning of the team and the QI champion focuses attention on systems processes, content experts can provide invaluable assistance in obtaining buy-in and local treatment guidelines. Some suggestions include:

• ID: Infectious disease physicians may provide location-specific advice in antibiotic selection and could facilitate the construction of DFI protocols. They may be able to communicate more effectively with lab personnel to expedite specificity and sensitivity testing and to disseminate local antibiograms and resistance patterns.
• pharmacy: Enlisting the aid of pharmacists at your institution is one of the most important moves to make in forming your team. This will help ensure that your team is up to date with local antibiograms and maintains antibiotic stewardship.
• endocrine: An endocrinologist or a glycemic control team will be helpful in improving glycemic control. Please refer to the SHM Glycemic Control Resource Room for more information.
• surgery: Some surgical fields such as vascular surgery or orthopedics may have pathways in place to address the level of amputation. Podiatry can often expedite debridement when infections are confined to the foot.
• vascular services: Often revascularization of the lower limb is needed to permit adequate tissue healing. Engaging the vascular studies lab and/or vascular surgery department may help to evaluate the need for vascular bypass surgery or stent placement. 

Content experts may be helpful for reviewing and summarizing the relevant literature, including its applicability to your institution and patient population. These individuals may be more aware of the metrics available to assess the success of your QI project. They will be invaluable in reviewing and formulating order sets, protocols, and educational materials and will lend authority to the team’s recommendations and interventions.

Process Owners

Recognize that certain people on the front lines already are “experts” in the things that they do. Obtaining buy-in from these individuals will help to ensure that work-flow disruption is minimized and that new changes/improvement steps are well accepted. Generally, process owners should come from each service (pharmacy, nursing, etc.) and geographic area (medical, surgical, ICU, etc.).

IT/HIS Experts

From performance tracking to actual QI interventions, the contributions of information technology or health information system experts will be pivotal. Enlist those who can report ICD-9 code frequencies at discharge, can perform data entry, can set up reports from the electronic clinical data warehouse and radiology, and can be a liaison with medical records. In other words, these experts can provide you and your team with data.

Effective Team Behaviors and Dynamics

Studies of health care teams have demonstrated certain behaviors that can lead to more effective teams.1–4 How team members interact with one another is critical, and teams should strive to remove authority gradients. Because the perspective of every team member is potentially critical, every perspective must be heard. To do this, team members must be comfortable expressing their viewpoints. Try to pick people who have reputations for being collaborators. It is up to the leader and facilitator to enforce constructive team dynamics.

Although meetings with the whole team are invaluable, they can occasionally become impractical or impossible to schedule. Team “huddles,” where part of the team meets briefly to advance action items, can be very effective for overall progress.

Team Behaviors and Dynamics:

1. Effective leadership.
2. Team members monitor each other’s performance and provide con­struc­tive feedback.
3. Redistribute tasks as a particular situation demands using accurate knowl­edge of team members’ individual skills.
4. Ability to adapt to changing circumstances.
5. Clearly identified and agreed-upon goals and objectives.
6. Trust between team members.
7. “Closing the loop” with communication — for example, calling to say a fax is being sent à sending fax à verifying that the fax was received.
8. Ensuring that all team members are “on the same page.”

1. Pizzi L, Goldfarb N, Nash D. Crew resource management and its applications in medicine. In: Making health care safer: a critical analysis of patient safety practices. Evidence Report/Technology Assessment: AHRQ Publication 01- E058. 2001;43:501–509.
2. Morey JC, Simon R, Jay GD, et al. Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the MedTeams project. Health Serv Res. 2002;37:1553–1581.
3. Baker DP, Gustafson S, Beaubien JM, et al. Advances in patient safety: medical team training programs in health care. Washington, DC: American Institute for Research; 2004.
4. Wilson KA, Burke CS, Priest HA, Salas E. Promoting health care safety through training high reliability teams. Qual Saf Health Care. 2005;14:303–309.