Multidisciplinary Teams: Complicated Pressure Ulcers

by Joseph Li, MD
Adapted from the Diabetic Foot Infection Multidisciplinary Teams section by Chayan Chakraborti, MD

Role

The role of the Improvement Team is to develop a local system to optimize care of patients with pressure ulcers. Some areas can be improved through standardization and incorporation of specific practices into routine care delivery. Why is routine important? Across a population of patients, one of the most common sources of suboptimal care is provider inconsistency. For several reasons providers inevitably vary care inappropriately, whether compared with each other or with themselves. In fact, a graph that depicts improved system performance over time almost always shows progressive narrowing of the range of performance data points.

By its very nature, managing pressure ulcers requires a multidisciplinary team. Given the morbidity and potential chronic debilitation that patients with pressure ulcers face, shepherding them through the complexities of the health care system also involves wound specialists, nurses, physical therapists, nutritionists, and others.

Complexity

Complex process problems need multidisciplinary solutions. Within the hospital, on a daily basis hospitalists are dealing with system failures, and are in a prime position to observe process errors. Identifying performance gaps and improving quality deliver better patient care at lower costs with potential rewards for both patients and providers.

Much of the change necessary for improvement depends on culture, which can be a frequent challenge to assembling an effective QI team. Perhaps the most critical culture change is that the administrative personnel and senior medical staff are aware that pressure ulcers are a significant problem at your institution. Next in importance is obtaining buy-in from workplace personnel in order to demonstrate that the institution is receptive to change. Finally, local experts must be available to identify which research should be translated into practice.

Characteristics of good teams

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

For a more detailed description of team members, roles, and establishing ground rules, please refer to First Steps: Build a Team and Establish Team Rules.

Effective team behaviors and dynamics

Studies of health care teams have demonstrated certain behaviors that can lead to more effective teams.^1–4

Team Behaviors and Dynamics

The leadership role

QI needs leadership; we cannot affect the most important measures of systemwide quality performance without strong, capable physician leadership willing to be accountable for aligning resources with improvement activities. There is a science to leadership for improvement and effective management of resources. Initial steps include knowing who, how, and when to ask for resources. Strong leaders also endeavor to know the skills and abilities of team members and distribute tasks accordingly. Finally, the team leader is responsible for keeping the focus on the team’s objective.

Team functions

Aside from specific, self-defined goals, the multidisciplinary QI team asks what, where, and how.

• What will make the system more effective? Helpful strategies include brainstorming, multivoting and nominal group techniques, and affinity grouping.
  
• Dissect and understand the processes — where do we start?

Where are the processes that can be improved? Where are the processes with the greatest improvement impact?

1. Ishikawa, or “fishbone,” cause-and-effect diagrams.
   
2. Tally sheets.
   
3. Pareto charts — see QI Primer slides 43–46.
   
4. Flow charts (conceptual flow, decision flow) — see QI Primer slides 48–49.
   
5. Run charts – see QI Primer slides 51–53.

How can the changes (at least) maintain, or enhance, workplace efficiency? How can changes be blended into the flow of clinical care? How do we take into consideration variables such as staffing, training, supplies, physical layout, information flow, and educational materials?

Be aware that more than one team may be involved. The first is the team responsible for identifying systems problems and developing interventions. The second team is the team responsible for implementation. These teams can separate (i.e., a QI team for the hospital rolls out a new protocol for obtaining blood cultures that will be implemented by individual ward personnel), share members (overlap — some QI team members are also ward personnel), or even be identical (the ward personnel identified the problem and developed and implemented a solution).

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, Salas E, Barach P. 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.