Michigan Nursing Career Guide

Facilitating Inter-Professional Team Meetings – Established Team

Outline of content July 29, 2015

Pre-Requisite: Complete and be thoroughly familiar with the content of the Interprofessional Collaboration and Education Module of the Michigan Nursing Career Guide.

Objectives:

To understand the role of the team Facilitator in relation to the other team members.
To know the basic skills required to be an effective Facilitator.
To be familiar with techniques that can be used to respond to frequently encountered situations.
To be able to help improve the performance of an inter-professional team.

What is an Inter-Professional Team?

D’Amour and Oandasan (2005) defined interprofessionality as “the process by which professionals reflect on and develop ways of practicing that provides an integrated and cohesive answer to the needs of the client/family/population… [I]t involves continuous interaction and knowledge sharing between professionals, organized to solve or explore a variety of education and care issues all while seeking to optimize the patient’s participation.” (D’Amour, D. & Oandasan, I. (2005). Interprofessionality as the field of interprofessional practice and interprofessional education: An emerging concept. Journal of Interprofessional Care, 19 (Supplement 1), 8-20.)
An inter-professional team is made up of representatives of two or more health professions who, together, develop and implement a single, shared intervention plan to effectively address the health conditions of their shared patients.
The team should, ideally, include all of the professionals who will provide or who can inform the care of the patient.
A typical team may include a Physician, an RN, a Social Worker, and a Medical Assistant. Larger teams may include a Nurse Practitioner or PA, a Pharmacist, additional RN’s or Social Workers, and a Dentist. Other specialists may be invited to regularly meet with the team to consult on complex cases.

Why have an Inter-Professional Team?
As noted in the Michigan Nursing Career Guide, inter-professional practice can:
Improve safety.
Reduce hospital admissions and readmissions.
Improve access.
For people with chronic health conditions, increase their involvement and their ability to self-manage.

Introduction: The Role of the Facilitator and other Team Members
The Facilitator is much like that of the coach of a sports team. The Facilitator’s job is to provide feedback and guidance as needed to optimize the performance of the inter-professional team. Therefore, the Facilitator guides the team, but is not the team leader or even a member of the team. The team has implicitly given the Facilitator the authority to provide feedback and direction during and outside of their meetings. Mutual respect and trust is necessary to do this effectively. It is recommended that the Facilitator not be a direct supervisor of any of the professionals so that team members do not confuse feedback with corrective action.
The Discussion Leader is the professional who directs the meeting as it considers a specific patient. He or she is the Leader of the team during that time. In general, the Discussion Leader should be the person who best knows the patient’s current status. This is often the person who saw the patient last and may as likely be a Medical Assistant as a Physician or Nurse. It is expected that everyone on the team will, at one time or another, be a Discussion Leader. This supports the key team characteristic of Shared Leadership. The Discussion Leader is responsible for completion of the meeting or huddle script (see sample script in Item 9) for that patient.
Supervision may be provided by a Team Supervisor who has direct authority over evaluating and directing all the members of the team. But more commonly, each profession will have its own Supervisor. There is an important distinction between facilitation and supervision. The Facilitator coaches, but the Supervisor is the one who can formally evaluate and discipline. It is very important that the Supervisor(s) understand and support the participation of their staff on the inter-professional team and take seriously the feedback from the Facilitator regarding their performance.

Knowledge Review (1)
What do I do if the physician insists that she will lead all discussions?
Defer to her.
Remind her of the key characteristic of shared leadership.
Ask her to participate using the Discussion Leader model for one month and then review the team’s effectiveness with the team.
What do I do if a team member never contributes to the team discussion?
Meet with him outside of the meeting to find out if there is a reason for his reticence.
Ask him to lead the discussion the next time one of his patients comes up.
Report this to his supervisor and suggest that she counsel him regarding his performance.
Both a and b.
All of a, b, and c.

Key Characteristics of a Facilitator

An effective Facilitator has working knowledge of the ability to teach these key characteristics of a high performing inter-professional team (see the Interprofessional Collaboration and Education Module of the Michigan Nursing Career Guide.

o Common purpose

o Effective communication

o Shared leadership

o Shared decision making

o Cohesion

o Mutual respect and trust

o An evaluation process

 The Facilitator has the respect and trust of all of the team members.

 The facilitator fully understands and continuously reinforces the purpose of the team.

o The organization should have a written “Purpose Statement” that defines what the team is to accomplish for its patients.

o An example written for an established team that serves people with multiple chronic conditions is:

“To help a person manage their health conditions so that those conditions aren’t obstacles to how they want to lead their life.”

 The Facilitator has a firm grasp of the common vocabulary.

o Different professions frequently find that they use different words to describe the same thing or the same word to mean different things. Does the team serve ‘patients’ or ‘clients’ or ‘consumers’ or something else? Is it a ‘record’ or a ‘chart’ or ‘file’?

o The team should have a written glossary of the words and terms they have agreed to use in common.

 The Facilitator must have the confidence to provide immediate feedback, either as reinforcement or as correction, to every team member regardless of their profession or organizational status.

6. Knowledge Review (2)

 What do I do if there is no purpose statement?

a. Take time at the next team meeting to develop one.

b. Alert the administrator responsible for the team and ask her to agree to a deadline to provide one .

c. Provide the team with a statement and ask them to discuss and vote on it at a special meeting.

d. Set a special meeting of the team to develop one.

 What do I do if one of the team members has been openly disrespectful to you in the recent past?

a. Meet with the person outside of the team meeting, remind her of the key characteristics of a team and ask her to keep any personal issues away from team operations.

b. Alert the administrator of the team and ask to be replaced because of a potential problem of respect and trust.

c. Ask the person’s supervisor to replace her on the team.

d. Inform the team of the potential of a problem and ask them to be alert for a recurrence and to assist the Discussion Leader to stick to the script.

7. Preparation for the Meeting

 Assure that the meeting space is reserved.

 Assure that all team members know when and where the meeting will be and that they are expected to be on time.

 Assure that all team members know which patients will be on the agenda and that they are expected to have reviewed their records before the meeting.

8. During the Meeting – Patient-Focused Care

 In general, the person who has last seen the patient should lead the discussion. They have the most up-to-date knowledge. If that person isn’t present, the person with the most familiarity with the patient should lead.

ROLE of the FACILITATOR: If the most appropriate leader for the discussion of that patient doesn’t self-identify, quickly ask the question, “Who saw him or her most recently?” and then reinforce the expectation that that person will lead the discussion.

 The discussion leader should follow the script established by the team for efficient communication. A sample script follows. The script should assure that the discussion efficiently focuses on new information that’s relevant to the coming encounter and on reaching a consensus on the intervention plan.

ROLE of the FACILITATOR: If the discussion becomes inefficient, ask the team how the discussion is helping to achieve the purpose of the team for that patient. Prompt the discussion leader to follow the script.

 Every discussion regarding a patient should end with a clearly stated intervention plan. Who will do what when?

ROLE of the FACILITATOR: It is important not only that there be a stated plan, but that every team member understands his or her role in implementing it. If the discussion leader doesn’t ask for confirmations, prompt him or her by asking “Is everyone sure of what they will do the next time they see this patient?”

 If there are emergent situations not on the agenda, there needs to be time to discuss them.

ROLE of the FACILITATOR: Time keeping is essential, whether emergent situations will be discussed first (risking not finishing the agenda), or last (risking not getting to them). Decide whether they will come before or after those on the agenda and remind the team of the importance of brevity and precision in their contributions.

9. Sample meeting or huddle script

Unless this is a patient who has not been seen before, team members should have reviewed the record prior to the meeting so that they have at least a general familiarity with the patients being discussed at the meeting.
The discussion should focus on relevant changes that have occurred since the last visit and on what will be done during the upcoming visit.
For each patient:
The Discussion Leader should state the person’s name, sex, and age so everyone is clear about who is being considered
For each health condition or presenting problem the Discussion Leader should either provide or solicit information from the team members about the following. Current knowledge about anything that has changed is especially important.
Status (Has there been a recent change in how well the condition is controlled?)
Stage of change (Is the person in “action” regarding this condition? Has there been a recent change?)
Current medications (Have there been any changes?)
Current intervention plan (Have there been any changes in response to treatment?)
What do the team members need to do today? The interventions need to be clearly defined. Every team member who will see the patient needs to know what these are and needs to be prepared to either provide them or reinforce them so that the entire visit is seamless and consistent.
It then needs to be clear who will be responsible for entering the results of the discussion into the health record.

During the meeting – Team Performance

If you let it go, you are saying it is ok. A highly effective team exhibits the key characteristics during all of its interactions.

ROLE of the FACILITATOR

It is important for the Facilitator to provide immediate feedback, both reinforcing and corrective, during the meeting. People learn by doing, and they learn to do well when they receive constructive guidance as they perform.
Failure to provide corrective feedback signals to the team that what happened was ok. Providing immediate correction creates an opportunity for the team to practice good performance.

Common Purpose. The team should have a clearly written statement of purpose and should assure that all of their activity is consistent with it.

ROLE of the FACILITATOR: If the discussion strays from, or is in conflict with, the purpose, ask the question “How is this discussion helping to achieve the team’s purpose?” It is not ok for team members to put the team’s purpose “into my own words” or to otherwise paraphrase it. If necessary, ask the team to restate the purpose and to do so verbatim.

Effective Communication: The team should have a common vocabulary.

ROLE of the FACILITATOR: If someone doesn’t use the common vocabulary, ask them to restate their comment using it. If there is a new instance of differing terminology, make a note of it for resolution by the team later.

Shared leadership and decision making: Every member of the team has something to contribute, or that profession wouldn’t be on the team. Every intervention is important to the patient, or it wouldn’t be performed.

ROLE of the FACILITATOR: If a team member has not contributed to the discussion of a patient, prompt the discussion leader by asking him or her “Do we have what we need to know from everyone?” If someone hasn’t confirmed their role in the intervention plan, prompt the discussion leader in a similar manner.

Cohesion and mutual respect: Every team member must be treated as an equal by every other member. There may be disagreements, but there may not be disrespect.

ROLE of the FACILITATOR: Disrespectful comments are not to be tolerated. Appropriately and sensitively ask the originator of the comment to restate what they said in a more positive way. If the response is inappropriate or the behavior repeated, report the situation to the supervisor for resolution outside of the team meeting.

Evaluation: There may be disagreements about a patient’s condition or recommended interventions.

ROLE of the FACILITATOR: Call for evidence supporting each position. If the team can’t reach consensus based on a preponderance of the evidence, then there are, in effect, competing hypotheses to be tested. Ask the team to develop a plan to decide which to try first, what evidence will be gathered, and the criteria to be used to decide.

Knowledge review (3)

What do I do if a team member comes to the meeting after two patients have already been discussed?
Take the time to recap the cases.
Continue the meeting uninterrupted.
Meet with the person after the meeting to remind him that he needs to review the new information and intervention plan.
Both a and c.
Both b and c.

What do I do if a team member begins to recap, in detail, his last meeting with the patient?
Ask the individual how this information is helping to achieve the team’s purpose.
Ask the Discussion Leader how many more patients are to be reviewed in the time left.
Ask the team what parts of the information presented is helpful in achieving the team’s purpose.
Any of a, b, or c.
Either a or b.
Either b or c.

What do I do if a team member doesn’t respond to the Discussion Leader’s request to the team to confirm their roles in implementing the plan?
Ask the person if she is ok.
Prompt the Discussion Leader to ask again if everyone is clear about their role in implementing the intervention plan.
Ask the individual to explain her role.
Any of the above.

What do I do if two team members argue about what to do next, they ask the others to take sides?
Ask the two parties to clearly state what they believe the plan should be.
Ask the team to list the potential risks if one plan is followed rather than the other.
Ask the team which of the two alternatives will be tested first, for how long and to specify what evidence will be collected and what criteria will be used to decide whether to continue or switch.
All of the above.
Both b and c.

Summary

The Facilitator is the coach. He or she has the job of forming and sustaining a high performing team. Keep these things in mind:

Everything the team does should help it achieve its patient-centered-purpose.
Everyone on the team is responsible for everything regarding patient care.
A patient meeting with one team member should be like meeting with the entire team.
If you let it go, you are saying it is ok.

Answer key
Item 4 question 1
(c) Ask her to try the model. Physicians have been trained in empirical methods and may well be willing to test a hypothesis. This may not work if the physician is solidly of the opinion that a physician assumes legal liability and so must retain control. If the physician is not willing to try the model, it will be necessary to alert the administrator responsible for the team. The same approach should be used with any professional on the team. (a) is saying it is alright for the team to not have the key characteristic of shared leadership and perhaps shared decision making. (b) is likely to be perceived as confrontational and may become a test of authority rather than a test of a model of care
Item 4, question 2
(d)Take the time to find out if there is a correctible reason for non-participation. The person may be deferential for reasons of training, license, or culture. The person may believe that everything that needs to have been said has already been said and doesn’t want to be repetitive. It is also important to reinforce the characteristic of shared leadership and the Discussion Leader model is an effective way to do that. It also can help to assure that the person’s knowledge about the patient is shared. (c) is an overreaction unless the non-participation persists and is clearly due to unwillingness.
Item 6, question 1
(b) definition of the purpose of the team is the responsibility of the organization’s management. They have created and funded the team to accomplish something for the people served. They need to clearly define what that is so that the team is given clear direction and so that the effectiveness of the team can be evaluated.
Item 6 question 2
(a) this could be a serious problem and needs to be addressed. But it is a problem for the two professionals to resolve. Performance on the team by all parties, including the Facilitator, need to reinforce the key characteristics. (b) and (c) are premature. Team members have, or should have, been selected because of the positive qualities and skills that they can bring to the team. It is their obligation to provide high quality, effective inter-professional care. Supervisors should be brought in only if the problem is recurrent and irreconcilable. At that time both Supervisors, as well as the administrator responsible for the team should be involved in any decision to change personnel. Option (d) has the undesirable potential to make a personal rift a team rift.
Item 12, question 1
(e)the key characteristic of mutual respect includes respect for everyone’s time. If the person knew about the location and time of the meeting, he has an obligation to the team and its patients to be there. He also has the obligation to be an effective provider, and so must be fully informed about his shared patients. The team should prepare a written record that he can consult to be prepared when he meets the patients.
Item 12, question 2
(f) these approaches have a good chance of success in addressing what could be a difficult situation. Until the team has thoroughly practiced efficient communication, it’s likely that there will be more discussion than is needed to review and plan for all of the patients on the agenda. (b) reminds the entire team that there is much work and little time. (c) invites the team to critically consider what information is essential and what is superfluous to achieving the team’s purpose for the patient. (a) may be seen as essentially an invitation to shut up, which might have an immediate effect but doesn’t help the individual or team to learn efficiency.

Efficient communication is effective communication and is, therefore, one of the key characteristics. If this hasn’t been adequately addressed in the training of the team, the Facilitator should call it to the attention of the administrator responsible for team so that additional practice, for all of the team, can be scheduled.