In our last session, we discussed the importance of teamwork in healthcare, and reviewed the five key conditions required for effective teamwork. One of the most important conditions, is creating an effective team is structure. A useful analogy is an egg. What happens if the shell of the egg, the structure, is too thick? In other words, too much structure. The chick is unable to break out of the shell. Teams with rigid rules, lack a sense of autonomy, are discouraged from innovating, and demonstrate low job satisfaction. We'll talk more about job satisfaction in our next session. What happens if the shell of the egg is too thin? In other words, insufficient structure. The shell easily breaks. Killing the chick, before it has developed sufficiently to hatch. Without any guiding rules, or individual performance expectations, the team will be incapable of achieving its goals. As we discuss in our session on Toyota, TPS builds team structure, by creating very specific performance protocols, for each member of the work team. It also establishes interdependence, by carefully defining its customer supplier relationships. And finally, it encourages continual performance improvement, by asking all employees to make suggestions on how every process can be made more efficient and effective. Can this structure be used to create effective, interprofessional teams in healthcare? The answer is yes. And as I discussed in the introduction to session two, Virginian Mason Medical Center in Seattle, Washington has implemented TPS with remarkable success. It was recently designated the hospital of the decade, by the rating organization, Leap Frog. But what happened when I tried to use TPS, at the University of Florida Health Center? A common response was, patients are not cars, and this response has been evident throughout the country. And I wondered, could TPS be taught in some other way? How could I tap into our caregivers past experiences, to improve teamwork? As I thought about this challenge, I realized that nearly all of us have played or observed team sports, and therefore, have an extensive understanding of teamwork. Could the principles of highly successful athletic teams be adapted to interprofessional medical teams? As you can see, I am dressed differently today. I am wearing my good luck Florida Gator shirt. I always wear it when I attend University of Florida athletic events. In case you didn't know, the mascot of our school is the alligator. I also usually wear a blue and orange baseball hat, but today I thought everyone would like to see this rowdy reptile hat. And also, I wanted to show you how they do the gator chomp to cheer their team on. And usually they yell, gator bait, as they use the gator chomp. I will take my rowdy reptile hat off for now, cuz I don't want to look too silly. And by the way, in the background, you will see our football stadium. We call it the Swamp. Because during many games, it is hot and humid and filled with Gator fans who often yell at the opposing players, Gator Bait. Because our school has won multiple championships in team sports, including American football, European football, basketball, volleyball and baseball, I asked our coaches how they achieved such remarkable team performances. Just like Toyota, they follow three fundamental principles. First, playbooks. Every member of the team memorizes their role on the team, and practices these roles over and over, resulting in a highly coordinated effort. There is no ambiguity. As we discussed earlier, too often in healthcare, the team members do not fully understand their roles and as a consequent, work is either duplicated, or never performed. In our model, the patient is the team owner or athletic director. The senior physician, is the coach caring for the patients through the other members of the team. And the Senior Resident is the Quarterback, because he or she creates the daily game plan, and distributes the work to the interns. And the interns are the Running Backs directly carrying the ball, by ordering all tests and treatments for the team's patients. The Nurses are the offensive line, emphasizing their critical importance to daily care. Without the offensive line effectively blocking, the Running Backs can not gain yardage. And finally, the Case Manager and the pharmacist are assistant coaches assisting the coach and other team members, in creating discharge plans and administering the proper medications. In championship athletic teams, everyone knows exactly what they should be doing, because they are all following detailed protocols, just like Toyota. The second principle, know who is passing and who is receiving. Players practice passing and receiving over and over again. The passer needs to understand where to place the ball, so the receiver doesn't mishandle the pass. This requires stable relationships and understanding of each players preferences. At Toyota, these are called stable customer supplier relationships. As we discussed earlier, these relationships are often poorly understood in healthcare. The third principle is game films. After each game, the coaches review the game films and point out what went well, and what could be improved. Players learn from their successes and failures, and everyone understands that these reviews are intended to improve each teammate's performance. Game films are analogous to Toyota's expectation, that all workers make suggestions for improvement based on a scientific analysis of their work processes. Of course, every member of an athletic team must master certain fundamental skills, like blocking and tackling in American football. Or kicking and heading the ball in European football. In healthcare these fundamentals include succinct and accurate communication. There are two highly efficient communication protocols, that all caregivers should master. Your problem based SOAP followed by Disposition, is very important. Subjective. What complaints does the patient have related to his problem? For example, in a patient with pneumonia, the presentation should include how much sputum is he continuing to cough up. Objective. What abnormal physical findings are found, and what laboratory and imaging studies are abnormal? For example, in a patient with pneumonia, does he have fever, an elevated pulse, or low blood pressure? Are there wet sounds, called rales, heard in the area of the pneumonia? Is his peripheral blood white count elevated, a marker of continued inflammation? And what were the results of the sputum gram stain and culture? As well as his pneumonia urine antigen test? And does the chest x-ray show a change in the large, opaque density caused by his pneumonia? Next assessment. How is the patient doing? Is the patient improving, staying the same or getting better? Plan. What diagnostic test and treatment do you plan to order today? For a pneumonia patient, do you want to reduce the number of antibiotics? And finally, disposition. Do you think the patient will be able to go home? And will he require any special home equipment? When something unexpectedly goes wrong, SBAR is the preferred communication. And this tool is described on our gator rounds website, listed on your course page. Another important fundamental, is using the huddle formation when rounding. Everyone stands in an even circle. This encourages all members of the team to speak, rather than a hierarchical or power gradient that we showed in the last set of slides. The power structure is flattened, creating a zone of safety, where everyone feels comfortable sharing their ideas, including the patient and the nurse. As will be seen in the video, the team will huddle around the bedside of the patient who is designated the team owner. Notice how everyone on the team participates in the management decisions. Also how care is modified by the patient's input. The active participation of all team members, took only three and a half minutes. >> Mr. Johns, good morning. >> Good morning. >> How are you, do you remember me? I'm Dr. Sathlic, and this is Dr. Holland, Dr. Bellanos, and Dr. Gatey. And this is the case manager Michelle Lewis and the pharmacist Annie Snyder, and you know your nurse, Vicky. We wanted to present at the bedside and discuss your case, is that okay? >> Sure, that'd be fine. >> Great. All right, so as you know Mr. Jones is our 59 year old protein chemist, who has chronic obstructive lung disease. And who was admitted to the hospital for pneumonia. Subjectively, he has felt better over the last 24 hours. His sputum production has decreased, and now he only has scant white sputum production. Objectively, his temperature is 37.2, pulse is 70, respiratory rate of 16, blood pressure 130 over 80. On his physical exam today, his lung examination only reveals scattered rales in the left lower lung field. And his E to A changes have now resolved. His white blood cell count has decreased from 14,000 with 90% PMNs to 9,000 with 70% PMNs. His chest x-ray two days ago, demonstrated a stable left lower lobe infiltrate. And his sputum gram stain revealed gram positive lancet shaped diplococci. However, his culture only grew normal throat flora. His urine antigen though, was positive for strep pneumonia. So for my assessment, Mr. Jones' pneumococcal pneumonia is subtly improving. And my plan, we can discontinue his IV Ceftriaxone, and continue him on his Erythromycin alone. And in terms of disposition if he continues to improve, I think that he could be discharged to home tomorrow. >> Great. Mr. Jones can I take a quick listen to you here? Let me listen to your heart first. Okay, can you sit forward for me? Take big breaths through your mouth. Okay say e. >> e >> e >> e >> All right. >> So I agree, why don't we also give him an Incentive spirometer. You know, help increase his breathing capacity. Vicky do you have any concerns for us today? >> No, he's been ambulating in the hall without significant shortness of breath. He's eating all his meals, I think a discharge in the morning would be okay. >> Is he gonna need home oxygen? I noticed his stats have been a little bit low. >> He does have chronic hypoxia with exertion because of his COPD, so he will need home oxygen. >> Okay, I can get that set up at home. >> Great, great. So, Mr. Jones, do you have any questions at this point? >> Everything seems okay. The Erythromycin, when I take it, makes me a little bit nauseous. Is there anything else I could get? >> So, we could actually give amoxicillin, which would effectively treat the pneumococcus. >> That should work. >> Great. >> I would recommend amoxicillin 875 milligrams, twice a day, for five more days. And based on his response to the ceftriaxone and adrenal function. >> So ordering amoxicillin, 875 mg PO, twice per day for five days? >> His insurance covers that. >> Great. So, Mr. Jones, our plan is, switch you to oral amoxicillin today and discharge you tomorrow for another four days of antibiotics after that. Now just to be sure you understand our plan, could you repeat back the plan for you? >> I'm gonna be on amoxicillin for five days, and then I'll probably go home tomorrow, and I'll have oxygen at home. >> Exactly. Really good to see you today, and keep up the great work on healing. >> What happens when this athletic model for teamwork is followed? We compared a control group, they rounded the same old way forming working groups like the ones described by our business students, in the first session. And an experimental group who were trained to adopt our athletic principles and fundamentals. Care was more efficient, rounds were 16 minutes shorter then the control group, and were consistently completed in less than two hours. As a consequence patients in the experimental group had a 20% shorter average hospital stay. Care was of higher quality, patients in the experimental group were at 30% less likely to be readmitted to the hospital within 30 days. This is considered a failure of the original care plan. Nurses in the experimental group, were more likely to feel respected by physicians and also felt that physicians were more responsive to their requests. Physicians in the experimental group, residents, interns and senior physicians, grade the rounds as more efficient than the control group, and they were more highly satisfied with work rounds. A similar rounding system could be implemented in virtually any hospital, and the local team mascot could be used to create team spirit. For example, Yale University could implement bulldog rounds, after their mascot, the bulldog. Hospitals in New England could implement patriot rounds, emulating the New England Patriot professional football team. And hospitals in Manchester, England could institute Manchester United rounds, after their championship football team. When healthcare teams are structured using athletic principles, effective teamwork, efficient higher quality care, can be more easily achieved. One final question. Don't patients deserve the same high quality systems as our athletic teams? Thank you.
