NotesImprovementteams-week6.pdf

IMPROVEMENT TEAMS

U. S. Department of Health and Human Services

Health Resources and Services Administration

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Contents

IMPROVEMENT TEAMS ……………………………………………………………………………………………. 1

Part 1: Introduction ………………………………………………………………………………………………….. 1

Prerequisites ……………………………………………………………………………………………………………. 1

Part 2: The Power of Teams ……………………………………………………………………………………… 1

Part 3: Selecting Members for a Team ………………………………………………………………………. 2

System Leadership …………………………………………………………………………………………………… 3

Clinical Technical Expertise ……………………………………………………………………………………… 3

Day-to-Day Leadership …………………………………………………………………………………………….. 3

Part 4: Defining Roles and Responsibilities………………………………………………………………… 5

Orient the Team to the Work …………………………………………………………………………………….. 6

Guide the Work ……………………………………………………………………………………………………….. 7

Part 5: Stages of Team Growth …………………………………………………………………………………. 7

Stage 1: Forming …………………………………………………………………………………………………….. 7

Stage 2: Storming ……………………………………………………………………………………………………. 7

Stage 3: Norming ……………………………………………………………………………………………………. 7

Stage 4: Performing ………………………………………………………………………………………………… 8

Part 6: Tips from Successful Teams …………………………………………………………………………… 8

Set Ground Rules …………………………………………………………………………………………………….. 8

Establish an Effective Team Meeting Process ……………………………………………………………… 9

Tools to Support the Team ………………………………………………………………………………………. 13

Part 7: Supporting Information ………………………………………………………………………………. 13

References …………………………………………………………………………………………………………….. 13

Resources and Related Reading ……………………………………………………………………………….. 13

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IMPROVEMENT TEAMS The goals of this module are to provide an overview of the characteristics and benefits of an improvement team for quality improvement (QI) work, the functioning roles and responsibilities of the various team members, and the stages of growth as a team evolves into a cohesive entity with a single focus. The module also provides strategies, tools, and additional resources that experienced QI teams use to become effective and successful in achieving their aims. Part 1: Introduction Improvement work within an organization is typically coordinated through an improvement team, also known as a quality improvement (QI) team. The effectiveness of the QI process often depends on the ability of the improvement team members to work well together, and especially with the rest of the health system. This module describes:

• The importance of an improvement team in QI projects • How to choose effective members for a QI team • Roles and responsibilities of an improvement team’s members • Tips from successful improvement teams

Prerequisites

The purpose of a QI plan is to describe the targeted quality improvement activities for an organization. Often, quality improvement activities are distributed across multiple QI projects. These QI projects should have a clearly defined aim statement [link to glossary] The aim statement should specify resource constraints, reporting frequency, and pertinent ground rules for completing the project. The work of the QI project is accomplished by a team of individuals, which is the QI team. In order for a QI team to be successful, there must be clear objectives to guide its activities, explicit support from its leadership, and the resources necessary to complete the project. Additional information on QI plans can be found in the Developing and Implementing a QI Plan module. Part 2: The Power of Teams For a QI project to succeed, an organization must use the knowledge, skills, experiences, and perspectives of a wide range of people. A QI project requires problem solving, multiple decisions, and effective solutions that involve complex systems. A comprehensive multidisciplinary approach by a QI team is preferred over individual decision makers, especially when:

• A task is complex • Creativity is necessary • The path to improvement is unclear • Efficient use of resources are required • Cooperation is essential to implementation

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• Team members have a stake in the outcome • The process involved is cross-functional • No one individual has sufficient knowledge to solve the problem

An effective improvement team is flexible enough to respond to the ongoing challenges of QI work. Even though a team may assume many roles, this module describes a QI team that is focused on improvement using clinical quality measures. Part 3: Selecting Members for a Team Thoughtful attention toward selecting members for a QI team is critical to successful improvement. While there is not a specific “how-to” guide for QI team selection, there are some worthy guiding principles to consider. An ideal QI team member:

1. Represents any discipline and ideally works directly with the system targeted for improvement

2. Is willing to learn from other team members 3. Is willing to maintain open communication with staff, leadership, and consumers 4. Is willing to assume individual responsibility that contributes to the team’s success 5. Commits to the success of the improvement project

One strategy is to consider the attributes of an individual who is identified as a potential candidate for the QI team. Leaders of successful QI teams suggest that an organization should seek individuals who have the following attributes:

• Respected by a broad range of staff • Team players • Excellent listeners • Good communicators • Proven problem solvers • Frustrated with the current situation and ready for change • Creative and able to offer solutions • Flexible–demonstrated by their willingness to change and accept new technology • Proficient in the areas and systems focused for improvement

If an organization has many individuals who are eligible and willing to serve on a QI team, the leader may use a chart, such as the one in Table 3.1, to compare potential candidates.1 This chart has been used with simple check boxes or with a Likert scale rating of 1 to 5 for each characteristic, with 1 defined as strongly disagree that the characteristic represents the person being evaluated and 5 equaling strongly agree.

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Table 3.1: QI Team Selection Chart 1= strongly disagree (this characteristic does not represent this individual) 2= disagree 3= neutral, 4= agree 5= strongly agree.)

Desired Characteristics Candidate’s initials Respected Team player Listener Communicator Problem solver Frustrated with current system Creative and innovative Open to change List area of skill/proficiency TOTAL SCORE Each QI team is unique, melding together the insights and experiences of its individual members. It is important to ensure that the QI team includes members with complementary skills. The Institute for Healthcare Improvement recommends three different types of expertise within an organization are included: 1) system leadership, 2) technical expertise, and 3) day-to-day leadership. 2 There may be one or more individuals on the team with each expertise, or one individual may have expertise in more than one area, but all three areas should be represented in order to drive improvement successfully. System Leadership

An improvement team needs a leader with authority in the organization to institute a suggested change and to overcome barriers that may inhibit its implementation. The team's system leader understands both the implications of the proposed change for various parts of the system and the remote consequences the change might trigger. It is important that the system leader has authority over all of the areas affected by the change. This person should also be authorized to allocate the time and resources the team needs to achieve its aim. 2 Clinical Technical Expertise

A clinical technical expert knows the subject intimately and understands the processes of care. An expert on improvement methods can provide additional technical support by helping the team determine what to measure, assisting in design of simple, effective measurement tools, and providing guidance on collection, interpretation, and display of data. 2 Day-to-Day Leadership

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A day-to-day leader is the driver of the project, overseeing data collection and ensuring that tests are implemented. This person should understand the details of the system and the various effects of making change(s) in the system. The day-to-day leader also needs to work effectively with the physician champion(s). 2 Increasingly, the value of having consumers on a QI team is recognized. Consumers need training to participate in a meaningful way, but they can provide unparalleled insights into the impact of current processes and proposed changes. Those considering inclusion of a consumer on their QI team should learn from experienced improvement teams. A few resources for consideration are listed below:

• A Guide to Consumer Involvement • The Two Dimensions of Quality • The Partnership for Healthcare Excellence • New Health Partnerships • Improving Quality Health Care: The Role of Consumer Engagement • Families USA • How to Effectively Present Health Care Performance Data To Consumers • Maximizing Consumer Understanding of Public Comparative Quality Reports: Effective

Use of Explanatory Information • How to Maximize Public Awareness and Use of Comparative Quality Reports Through

Effective Promotion and Dissemination Strategies Recruiting members for a team that have the right mix of expertise can be challenging–especially in small organizations. Fortunately, many of the clinical technical expertise skills, such as, QI tools, measurement tools, and data collection and display can be learned. An organization that is committed to QI should invest in the necessary training to ensure the team is adequately prepared. Most experienced QI leaders start with volunteers and then assess any gaps in the team’s expertise and then recruit specific individuals who can best round out the team.

Note: Successful teams have learned the importance of keeping the team tight. Typically a team has five to seven members at the most. Team members should represent each area and employee affected by the improvement project. If the project cuts across departments, so should the team membership. For QI, consider selecting someone from finance to provide an organization-wide perspective. Contributors can also add value outside of the team as consultants or experts as the project develops.

Before a QI team’s membership is finalized, ensure there is buy-in from its leadership. It is critical to the success of the project that leadership assumes responsibility for the team entrusted to execute the QI project. Additional resources for assisting an organization with training or ongoing support of improvement teams are listed in Table 3.2:

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Table 3.2: Additional Support Resources for Improvement Teams

Name of Tool or Resource Description Training-of-Trainers (TOT) Program

The TOT Program is designed for individuals with a strong experiential background in quality management; it provides participants exposure to adult learning theories and other available training resources. Graduates of TOT plan engaging and effective workshops, while linking them with QI experts and peers facing similar challenges.

NQC Quality Academy: Using Teams to Improve Quality

Creating a team-oriented environment begins at the top. Each person in an organization performs a unique function, and this module shows how to integrate these disciplines, so everyone is working towards a common goal.

The Team Handbook The Team Handbook facilitates team building and covers the following topics: • Learn how to establish teams • Understand team roles and responsibilities • Use teams to resolve problems and learn together • Learn how to deal with conflicts

This handbook is helpful for both leaders and team members and offers many strategies for helping teams work well together.

HIVQUAL Workbook – Guide for Quality Improvement in HIV Care

The HIVQUAL Workbook is a step-by-step, self-learning guide intended to give HIV providers a clear roadmap for making QI a reality in ambulatory care settings. Materials provided are adaptable to facilities, whether or not they participate in HIVQUAL, and are applicable to all HIV programs, regardless of caseload, geographic location or the service delivery model used.

A Team Approach to Quality Improvement

This is a helpful book to assist in team development and highlights successful strategies teams have used to make organizational improvements.

Quality Function Deployment and Lean-Six Sigma Applications in Public Health

The purpose of this book is to introduce the concepts embedded in quality function deployment (QFD) and Lean-Six Sigma to help public health professionals implement QI within their agencies. The tools and techniques of QFD and Lean-Six Sigma are designed to augment a robust PDCA or PDSA problem-solving process—not replace it.

American Society for Quality

This is a Web site devoted to QI including specific information on the value and use of teams in QI.

Quality Improvement & Risk Management Training Module 5: What Works Really Works

Module 5 provides training to further enhance the team’s role in QI.

Part 4: Defining Roles and Responsibilities Within a QI team, members often organize themselves to effectively accomplish the work by defining specific roles. Multiple roles may be fulfilled by one person, and some roles may be rotated among team members. The following is a list of key team roles:

• Team Leader fully understands the processes targeted for improvement and the breadth of the project in order to effectively lead team meetings.

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• Team Facilitator assists the team leader in planning meetings and developing agendas. The Team Facilitator tends to the meeting process by ensuring the participation of all team members, monitoring the agenda, and keeping track of time.

• Team Members agree to contribute their knowledge and insights to QI project. They agree to support suggested improvements in their areas of the organization to facilitate buy-in for changes that result in improvement. For clinical performance improvement work, having a physician or provider champion on the team is important. The champion should have a good working relationship with colleagues and the day-to-day leader(s), and be interested in driving change in the system. A physician/provider who is an opinion leader in the organization makes an effective champion.

This chart in Table 4.1 further illustrates roles and responsibilities for QI team members:3

Table 4.1: Roles and Responsibilities for Team Members

Each team member may have a different communication and social style. These differing styles serve to move the team forward when the interaction is constructive and all members are focused on a common goal. At times, there may be less harmony, and a team needs guidance to use its diversity to an advantage. There are many resources available that describe successful strategies in managing team dynamics. [link to resources section at the end of this module] In successful QI teams, members are flexible, embrace diverse ideas, constructively leverage conflict, and contribute to the teams’ achievements of completing their QI projects. Orient the Team to the Work

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With the new team formed, it is critical to align expectations for the work to be performed. Building a sense of “team” and generating enthusiasm for the work are also important from the beginning. The team leader is responsible for these tasks, and often a QI Project Launch meeting is held. Critical elements of the launch meeting include:

1. Introduce the members and identify team roles. 2. Clarify why improvement is necessary and define the aim for improvement, which is

outlined in the QI Project documentation. 3. Provide general ground rules about how the team will function, such as, meeting times,

expectations for punctuality and participation, record keeping, and accountability of the team and its members.

Guide the Work

The work of the team is to design, manage, and monitor performance improvement activities to achieve the aim of the QI Project. This work is more specifically detailed in the Performance Management and Measurement module. The team leader must orchestrate this work and ensure that the system changes, suggested by the team and tested by staff, result in the desired improvement. A well-functioning team directly correlates to a successful completion of the project. There are many available resources regarding team building, team dynamics, and overcoming challenges in teamwork. Part 5: Stages of Team Growth According to The Team Handbook, teams go through fairly predictable stages of growth as they learn to work effectively together.4 The following subsections briefly describe each stage. Stage 1: Forming

At this stage, team members are exploring the boundaries of acceptable group behavior and are trying to establish their positions and status within the team. While being somewhat excited about the opportunity to be on a team, they may be suspicious and anxious about the job ahead. It is normal at this stage to see little progress, as the team may complain about the task and have lofty, abstract discussions, which cause some members to become impatient. Stage 2: Storming

At this stage, team members realize the task is different and more difficult than first imagined. Some may become impatient with the lack of progress and begin to assert their ideas, resisting the need to collaborate. Some simply withdraw as discussions become contentious and argumentative. They are beginning to understand one another and realize how the different communication and social styles are affecting them. Storming takes on many different forms, but it almost always occurs before progress can begin. Stage 3: Norming

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This is the stage team members begin to accept the individuality of each person, trust the ground rules to maintain equality in the process, and realize competitiveness must yield to cooperation. They look forward to the contribution of others on the team, and a sense of team spirit and dedication to a common goal unfolds. With this shift in team energy, they start to make significant progress. Stage 4: Performing

Team members now have insights into personal and group processes in this stage. They recognize, and even anticipate, how they can each contribute to the mission. They quickly identify and resolve interpersonal communication problems and develop a synergy that enables rapid progress. Evidence about the characteristics of successful teams can be gleaned from understanding the pitfalls associated with failure. In the Risk of Quality Team Project Failure Index (RTFI), the following characteristics can be extrapolated as correlating with success or failure of the team:

1. Training regarding teamwork, quality methods, and problem solving sequences 2. Facilitation skills 3. Measurable objectives 4. Visible senior leadership support 5. Regular meetings at minimum monthly 6. High percentage of team member attendance at every meeting 7. Small tests of change that can be successfully implemented in a short time 8. Disciplined to follow change methodology

Regardless of the strategies employed, leading a QI team requires a balance of cheerleader and task master. Knowing team dynamics, understanding differing proclivity to change, and bringing the best out in individuals all contribute to a successful QI team. Part 6: Tips from Successful Teams In addition to the prerequisites previously mentioned, successful teams emphasize the importance of an organized infrastructure to support the work. This section discusses tools that facilitate ground rules for meetings and effective meeting processes, including use of agendas and discipline for documenting the work. Set Ground Rules

Ground rules are a code of conduct for meetings. This is particularly important for Quality Improvement Teams as members should participate equally, regardless of the hierarchical role they may have in the delivery of care. Putting these rules on the table in the beginning facilitates the team dynamics by making the expected behavior explicit. Typically, ground rules are

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discussed and agreed to early on at an initial meeting of the team. Again, there are no required ground rules, but these are examples of those that teams often adopt:5

• Start the meeting on time • Have a prepared agenda with an objective and expected outcomes • End the meeting on time • Parking lot discussion items that don’t relate to this meeting’s objective • Complete action items as committed • One person speaks at a time • All team members are equals • Leave rank at the door • Address conflict by dealing with the issue not the person • Turn of cell phones / pagers • Notify the team in advance if you will be absent • Listen actively • Be a participant, not a lurker • What’s said in the room, stays in the room. • Have fun, but not at the expense of someone else’s feelings. • Be present, both physically and mentally

Establish an Effective Team Meeting Process Having a well-defined meeting process helps the entire team focus on the important meeting tasks. Steps to an Effective Team Meeting 1. Provide an effective environment for the meeting. Team members should be in a room or

area that is conducive to good communication. They should be seated at a table or in an open-ended circle with a flipchart at one end where all team members can easily see each other and the flipchart. Make sure there is an adequate supply of markers for writing on the flipchart. If the flipchart paper is not self-adhesive, have tape available so that the filled flipchart paper can be hung on a wall where it continues to be easily seen by everyone. This process of keeping all of the information visual to everyone is an important part of empowering the entire team.

2. Clarify the purpose and objectives of the meeting. Make sure that all team members are in

agreement. 3. Determine who will be the timekeeper and recorder and review at what time intervals the

timekeeper should give feedback based on the ground rules.

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4. Review the prior meeting’s action list. This provides team accountability for between-meeting assignments and brings relevant information to the current agenda.

5. Review the meeting agenda in detail and make sure that all team members understand and

agree with the agenda and its time frames. If there is disagreement, the team leader should try to get a consensus agreement from the team on how the agenda should be changed.

6. Work through the agenda items within the time allotted to each. If time runs out on any item,

the team must follow the ground rules to agree on how to proceed. 7. Review the meeting record by reviewing the flipchart information recorded during the

meeting. Decide which charts or information should be included in the meeting record and which should be discarded.

8. Develop the items that should be included on the next meeting agenda and determine what

assignments should be given to prepare for the next meeting. 9. Evaluate the meeting by asking what the team did well and what the team could do

differently to improve the meeting process. This is an important step. Any improvement opportunities should be noted in the meeting record and incorporated into the next meeting.

Meeting Agenda In order to have an effective team meeting, the team leader should develop a meeting agenda that uses the above steps. Every team member should have a copy of the meeting agenda and agree with its content. It is very important that the meeting agenda include the time that each agenda item will begin. The team leader estimates the amount of time for each topic when preparing the agenda. The ability to estimate the time improves with practice. Using the ground rules, the team members should agree to adjust the time whenever necessary to accomplish their goals. The team leader can develop a template in Word or Excel for the meeting agenda based on the following sample:

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Meeting Agenda

Team Name: ____________________________________________________

Meeting Date _________________________ Time: ___________________

Location: ____________________________________________________

Team Members: ____________________________________________________

____________________________________________

Content Start Time 1. Clarify Purpose and Objectives 9:00 a.m.

2. Select Timekeeper and Recorder (Review Roles) 9:05 a.m.

Timekeeper: _____________________________________

Recorder: _____________________________________

3. Review Prior Action List

4. Review Agenda 9:08 a.m.

5. Work through the Agenda Item(s) .

A. ____________________________________________

B. ____________________________________________

C. ____________________________________________

D. ____________________________________________

E. ____________________________________________

6. Review Key Activities, Information, and Decisions 9:40 a.m.

7. Plan Next Meeting Agenda 9:45 a.m.

8. Evaluate the Meeting 9:55 a.m. 9. Adjourn 10:00 a.m.

Figure 5.1: Sample Meeting Agenda Meeting Outcomes/Actions Creating a record of the outcomes and actions from each meeting is a vital part of the team communication process. Unlike keeping detailed minutes of a meeting, the following form identifies three key components of this record:

1. The key activities and decisions reached.

2. Actions needed before the next meeting.

3. Improvements to be embraced during the next meeting. The easiest way to prepare a record is for the team leader to make notes on his or her agenda related to each outcome, action needed, and improvement. Some of the information can also be

Set start time for each item

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collected from the items recorded on the flipchart by the recorder during the meeting. The following model works well for a record. The record should be distributed to each team member within several days after the meeting, so that team members are reminded to follow-through on the action items.

PROJECT TEAM MEETING RECORD PROJECT: ___________________________________________________ DATE: ___________________________ LOCATION: ______________________________ Meeting Outcomes/Decisions Reached: 1. 2. 3. 4. 5. Actions Needed:

WHAT WHO WHEN

Improvements for Next Meeting:

Figure 5.2: Sample Meeting Record Form Special Issues Even with clear guidance and an organized approach, difficulties may arise within a QI team that has a negative impact on the work. There are several resources available that provide insights into common situations within a team, although discussion is beyond the scope of this module. The number of successful QI teams is a testament that leadership support, a clear focus, and the tools to perform the work, enable most teams to overcome their challenges and achieve their aims.

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Tools to Support the Team

Tool Description

Team Building This Web site compiles important concepts on motivation and team building. Effectively Managing Team Conflict

Successful managers can effectively manage conflict. This ability is considered a core competency and required for leaders who want to grow and advance their organizations.

Teampedia Teampedia is a collaborative encyclopedia of free-team building activities, icebreakers, teamwork resources, and tools for teams that can be edited.

SWOT Analysis Template This template is for guiding the team’s analysis of its strengths, weaknesses, opportunities, and threats (SWOT).

An effective team includes members with diverse thinking styles, approaches, experience and knowledge. Diversity can support creativity through various viewpoints. When people with varying viewpoints, experiences, skills, and opinions are tasked with a project or challenge, their combined efforts can far surpass what an individual can achieve. Part 7: Supporting Information References

1. Institute for Healthcare Improvement (IHI) website

http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/HowToImprove/formingtheteam.htm

2. HIV QualWorkbook, Guide for Quality Improvement in HIV Care New York State Department of Health AIDS Institute; Health Resources and Services Administration HIV/AIDS Bureau; page 95.

3. Scholtes, Peter R. and other contributors, The Team Handbook., Third Edition Madison, WI: Joiner Associates, Inc. 2003

4. As the Team Doc; Setting Team Ground Rules: http://www.askteamdoc.com/index.php/2007/08/26/setting-team-ground-rules/#ixzz0roHkBMMy

Resources and Related Reading

1. Susan M. Heathfiel. Twelve Tips for Team Building: How to Build Successful Work Teams (Available: http://humanresources.about.com/od/involvementteams/a/twelve_tip_team.htm

2. Reinertsen JL, Gosfield AG, Rupp W, Whittington JW. Engaging Physicians in a Shared Quality Agenda. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2007. (Available on www.IHI.org)

3. National Quality Center http://nationalqualitycenter.org/ 4. Prochaska JO et al. In Search of How People Change. American Psychologist 1992 Sept;

1102-1114

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5. M Leonard, S Graham, D Bonacum 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. doi: 10.1136/qshc.2004.010033

6. Heifetz, Ronald A., Linsky, Marty Leadership on the Line Harvard Business School Press, Boston, MA 2002.

7. The Team Handbook, Third Edition 8. Establishing A Quality Improvement Team 9. The Quality Improvement Handbook: Team Guide to Tools and Techniques