1
|
Connell NB, Zupanc SN, Lorenz KA, Bhatnagar S, Fereydooni S, Gamboa RC, Ganesh A, Satija A, Singh N, Spruijt O, Giannitrapani KF. Facilitators of palliative care quality improvement team cohesion: Lessons from a seven-site implementation project in India. Health Care Manage Rev 2023; 48:219-228. [PMID: 37158411 DOI: 10.1097/hmr.0000000000000368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
BACKGROUND The Palliative Care: Promoting Access and Improvement of the Cancer Experience (PC-PAICE) initiative is a team-based, palliative care (PC) quality improvement (QI) project working to promote high-quality PC in India. As a PC QI initiative, PC-PAICE implementation relied upon building interdisciplinary teams, providing the ideal context for understanding facilitators of team cohesion that compelled clinical, organizational, and administrative team members to work together. There is an opportunity to leverage the intersection between QI implementation and organizational theory to inform and improve implementation science. PURPOSE As a subaim of a larger implementation evaluation, we aimed to identify facilitators of team cohesion within QI implementation context. METHODOLOGY A quota sampling approach captured the perspectives of 44 stakeholders across three strata (organizational leaders, clinical leaders, and clinical team members) from all seven sites through a semistructured interview guide informed by the Consolidated Framework for Implementation Research (CFIR). We used a combination of inductive and deductive approaches informed by organizational theory to identify facilitators. RESULT We identified three facilitators of PC team cohesion: (a) balancing formalization and flexibility around team roles, (b) establishing widespread awareness of the QI project, and (c) prioritizing a nonhierarchical organizational culture. PRACTICE IMPLICATIONS Leveraging CFIR to analyze PC-PAICE stakeholder interviews created a data set conducive to understanding complex multisite implementation. Layering role and team theory to our implementation analysis helped us identify facilitators of team cohesion across levels within the team (bounded team), beyond the team (teaming), and surrounding the team (culture). These insights demonstrate the value of team and role theories in implementation evaluation efforts.
Collapse
|
2
|
Sasnal M, Lorenz KA, McCaa M, Wu A, Morris AM, Schenker Y, Shreve ST, Giannitrapani KF. "It's Not Us Versus Them": Building Cross-Disciplinary Relationships in the Perioperative Period. J Pain Symptom Manage 2023; 65:263-272. [PMID: 36646332 DOI: 10.1016/j.jpainsymman.2022.12.140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 12/20/2022] [Accepted: 12/26/2022] [Indexed: 01/15/2023]
Abstract
CONTEXT Palliative care (PC) interventions improve quality outcomes for surgical patients, yet they are underutilized in the perioperative period. Developing cross-disciplinary provider relationships increases PC consults. However, the attributes of collaborative relationships and how they evolve are unclear. OBJECTIVES To identify perceptions of PC providers and surgeons on how collaborative cross-disciplinary relationships are built and maintained in the perioperative period. METHODS This cross-sectional multiphase qualitative study included 23 semistructured interviews with 10 PC teams (20 providers) and 13 surgeons at geographically distributed Veteran Health Administration (VHA) sites. An analytic approach relied on team-based thematic analysis with a dual review (Krippendorf α above 0.8). RESULTS Respondents defined successful collaborative work relationships between PC and surgeons as having the following features: 1) mutual trust; 2) mutual respect; 3) perceived usefulness; 4) shared clinical objectives; 5) effective communication; and 6) organizational enablers. In addition, the analysis elucidated a framework of six strategies for developing collaborative relationships between PC and surgical teams in the perioperative period: 1) being present, available, and responsive; 2) understanding roles; 3) establishing communication; 4) recognizing an intermediary and connecting role of supporting team members; 5) working as a team; and 6) building on previous experiences. CONCLUSION The study informs future interventions to improve the quality of care for seriously ill patients by better-involving PC in the perioperative period. Future work will extend this approach to incorporate the perspectives of patients on their providers' collaboration and how it impacts patient-related outcomes at the intersection of PC and surgery.
Collapse
Affiliation(s)
- Marzena Sasnal
- Stanford Medicine, Surgery Policy Improvement Research & Education Center (M.S., A.M.M.), Stanford California, USA
| | - Karl A Lorenz
- VA Quality Improvement Resource Center for Palliative Care (K.A.L., M.M., K.F.G.), Menlo Park, California, USA; Stanford Medicine, Primary Care and Population Health (K.A.L., K.F.G.), Stanford, California, USA
| | - Matthew McCaa
- VA Quality Improvement Resource Center for Palliative Care (K.A.L., M.M., K.F.G.), Menlo Park, California, USA
| | - Adela Wu
- Department of Neurosurgery, Stanford Medicine (A.W.), Stanford, California, USA
| | - Arden M Morris
- Stanford Medicine, Surgery Policy Improvement Research & Education Center (M.S., A.M.M.), Stanford California, USA
| | - Yael Schenker
- Section of Palliative Care and Medical Ethics, Palliative Research Center (PaRC), University of Pittsburgh (Y.S.), Pittsburgh, Pennsylvania, USA
| | - Scott T Shreve
- United States Department of Veterans Affairs, VA Palliative Care (S.T.S.), Lebanon, Pennsylvania, USA
| | - Karleen F Giannitrapani
- VA Quality Improvement Resource Center for Palliative Care (K.A.L., M.M., K.F.G.), Menlo Park, California, USA; Stanford Medicine, Primary Care and Population Health (K.A.L., K.F.G.), Stanford, California, USA.
| |
Collapse
|
3
|
Garcia R, Brown-Johnson C, Teuteberg W, Seevaratnam B, Giannitrapani K. The Team-Based Serious Illness Care Program, A Qualitative Evaluation of Implementation and Teaming. J Pain Symptom Manage 2023; 65:521-531. [PMID: 36764413 DOI: 10.1016/j.jpainsymman.2023.01.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 01/23/2023] [Accepted: 01/26/2023] [Indexed: 02/11/2023]
Abstract
CONTEXT Earlier and more frequent serious illness conversations with patients allow clinical teams to better align care with patients' goals and values. Nonphysician clinicians often have unique perspectives and understanding of patients' wishes and are thus well-positioned to support conversations with seriously ill patients. The Team-based Serious Illness Care Program (SICP) at Stanford aimed to involve all care team members to support and conduct serious illness conversations with patients and their caregivers and families. OBJECTIVES We conducted interviews with clinicians to understand how care teams implement team-based approaches to conduct serious illness conversations and navigate resulting team complexity. METHODS We used a rapid qualitative approach to analyze semistructured interviews of clinicians and administrative stakeholders in two team-based SICP implementation groups (i.e., inpatient oncology and hospital medicine) (n = 25). Analysis was informed by frameworks/theory: cross-disciplinary role agreement, team formation and functioning, and organizational theory. RESULTS Implementing team-based SICP was feasible. Theme 1 centered on how teams formed and managed to come to an agreement: teams with rapidly changing staffing/responsibilities prioritized communication, whereas teams with consistent staffing/responsibilities primarily relied on protocols. Theme 2 demonstrated that leaders and managers at multiple levels could support implementation. Theme 3 explored strengths and opportunities. Positively, team-based SICP distributed work burden, timed conversations in alignment with patient needs, and added unique value from nonphysician team members. Role ambiguity and conflict were attributed to miscommunication and ethical conflicts. CONCLUSION Team-based serious illness communication is viable and valuable, with a range of successful workflow and leadership approaches.
Collapse
Affiliation(s)
- Raquel Garcia
- Duke School of Medicine, Durham (R.G., K.G.), North Carolina, USA
| | - Cati Brown-Johnson
- Stanford University School of Medicine (C.B-J., W.T., B.S., K.G.), Stanford, California, USA
| | - Winifred Teuteberg
- Stanford University School of Medicine (C.B-J., W.T., B.S., K.G.), Stanford, California, USA
| | - Briththa Seevaratnam
- Stanford University School of Medicine (C.B-J., W.T., B.S., K.G.), Stanford, California, USA.
| | - Karleen Giannitrapani
- Stanford University School of Medicine (C.B-J., W.T., B.S., K.G.), Stanford, California, USA.
| |
Collapse
|
4
|
Ma JE, Haverfield M, Lorenz KA, Bekelman DB, Brown-Johnson C, Lo N, Foglia MB, Lowery JS, Walling AM, Giannitrapani KF. Exploring expanded interdisciplinary roles in goals of care conversations in a national goals of care initiative: A qualitative approach. Palliat Med 2021; 35:1542-1552. [PMID: 34080488 DOI: 10.1177/02692163211020473] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The United States Veterans Health Administration National Center for Ethics in Health Care implemented the Life-Sustaining Treatment Decisions Initiative throughout the Veterans Health Administration health care system in 2017. This policy encourages goals of care conversations, referring to conversations about patient's treatment and end-of-life wishes for life-sustaining treatments, among Veterans with serious illnesses. A key component of the initiative is expanding interdisciplinary provider roles in having goals of care conversations. AIM Use organizational role theory to explore medical center experiences with expanding interdisciplinary roles in the implementation of a goals of care initiative. DESIGN A qualitative thematic analysis of semi-structured interviews. SETTING/PARTICIPANTS Initial participants were recruited using purposive sampling of local medical center champions. Snowball sampling identified additional participants. Participants included thirty-one interdisciplinary providers from 12 geographically diverse initiative pilot and spread medical centers. RESULTS Five themes were identified. Expanding provider roles in goals of care conversations (1) involves organizational culture change; (2) is influenced by medical center leadership; (3) is supported by provider role readiness; (4) benefits from cross-disciplinary role agreement; and (5) can "overwhelm" providers. CONCLUSIONS Organizational role theory is a helpful framework for exploring interdisciplinary roles in a goals of care initiative. Support and recognition of provider role expansion in goals of care conversations was important for the adoption of a goals of care initiative. Actionable strategies, including multi-level leadership support and the use of interdisciplinary champions, facilitate role change and have potential to strengthen uptake of a goals of care initiative.
Collapse
Affiliation(s)
- Jessica E Ma
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health System, Durham, NC, USA
| | - Marie Haverfield
- Department of Communication Studies, San José State University, San José, CA, USA.,Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - Karl A Lorenz
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - David B Bekelman
- Division of General Internal Medicine, University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora, CO, USA.,Center of Innovation for Veteran-Centered and Value Driven Care and Department of Medicine, Rocky Mountain Regional VA Medical Center, Aurora, CO, USA
| | - Cati Brown-Johnson
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Natalie Lo
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA
| | - Mary Beth Foglia
- Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, WA, USA.,National Center for Ethics in Health Care, Veterans Health Administration, Washington, DC, USA
| | - Jill S Lowery
- National Center for Ethics in Health Care, Veterans Health Administration, Washington, DC, USA.,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Anne M Walling
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, West Los Angeles, CA, USA.,David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Karleen F Giannitrapani
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| |
Collapse
|