TEAM BUILDING RESOURCE GUIDE FOR ONTARIO. PRIMARY HEALTH CARE TEAMS Module 3: Clarifying January Roles 2009 & Expectations

Transcription

1 TEAM BUILDING RESOURCE GUIDE FOR ONTARIO PRIMARY HEALTH CARE TEAMS Module 3: Clarifying January Roles 2009 & Expectations Amended December 2010 Revised December 2012 Revised December 2012

2 Purpose of the Guide This guide is designed to help you and your team better understand your processes and to help you find ways of strengthening team-based care in your primary health care (PHC) organization. The guide is divided into ten standalone modules. Each module contains background information and theory related to the topic (Part A). Some modules (i.e., 3, 4, 7, and 10) also contain companion tools and resources to address the topic (Part B). The modules are not sequential. Choose the module that addresses a specific challenge you have identified and use the tools that are most applicable to your situation. The Introduction module contains background information about interdisciplinary teams, interprofessional care and other types of teams. The Introduction module also includes acknowledgements and key references. It is recommended that before beginning any of the suggested activities, both the facilitator or group leader and the participants take the time to review the whole module. This will help to ensure that the facilitator and all participants have the information necessary to fully engage in all discussions. Each PHC organization should decide who will be responsible for overseeing team development and addressing any problems that arise. This usually falls to the existing leadership or a newly-established quality improvement team/leadership team. From time to time you may also involve an external consultant to facilitate team building activities, although external facilitation is not required to use these modules. Visit our website at for the complete set of modules including: Introduction Module 1: What Is an Effective Team? Module 2: Building a Team Module 3: Clarifying Roles and Expectations Module 4: Making the Most of Meetings Module 5: Evaluating Team Performance Module 6: Understanding Change Module 7: Enhancing Collaboration Module 8: Improving Communication Module 9: Leadership and Decision-Making Module 10: Conflict Management Primary health care (PHC) organization refers to a group of providers, allied health professionals and other staff, etc. within a FHT, CHC, NPLC or other practice model with multiple providers. A number of teams may function within one organization. In the case of solo-provider practice models, organization may refer to an individual provider and staff. 2

3 Clarifying Roles and Expectations Part A Each profession has unique values, beliefs, attitudes, customs and behaviours. These different cultural attributes provide a starting point for effective collaboration. These shared characteristics ensure that each member of a team understands the role, scope of practice, and experience of other professionals in the team. This is crucial, as teamwork in a primary health care setting, by definition, involves considerable overlap in competencies. Knowing where there are overlapping skill-sets on your team make it much easier to resolve conflicts related to role differentiation and boundaries. Failure to establish clear roles or to take advantage of the varying skills of team members can lead to frustration, conflict and inefficiency. Indeed, failure in this regard can leave a team mired in the storming phase, unable to experience optimal performance or develop into a truly efficient, high-functioning team. There are some latent turf issues that can affect teamwork if they are not recognized and either accommodated or resolved. These turf issues relate to autonomy, accountability and identity: Autonomy reflects the desire for each profession within a team to define itself, set its own criteria for practice and professionalism, and maintain influence over its area of expertise. Loss of autonomy may lead to undesired changes in modes of practice and loss of potential earnings. Accountability refers to the evaluation and assessment of standards of care. Professionals both define how they want to practice and how they are accountable to others in their profession according to these standards. Collaboration introduces performance evaluation by team members from other professions. To some individuals, this can represent an invasion of their professional domain. One s identity as an individual practitioner derives from the identity of the profession as a whole. If interprofessional collaboration blurs the boundaries that define the roles of the various professions, it may have an impact upon the professional identity of individual providers. Identifying, acknowledging, and accommodating these issues can foster trust among team members, which in turn will lead to a willingness to look at how these issues can be resolved one by one - sometimes with different solutions for each discipline. 3

4 Three Steps to Clarifying Roles & Scope of Practice There are three steps to clarifying roles and each role s scope of practice. These are: Step 1 - As a group, clarify the scope of practice of each member and resolve misperceptions about the roles of other providers This is a crucial component of team development, as team members learn about each others skills, interests and scope of practice. It has two related components: 1. Learning about each others roles 2. Identifying and correcting misperceptions individuals may have about what their team members will do for the team. Step 2 - Learn about the skills, experiences, and potential of all team members Step 2 is focused on acquiring an understanding of the knowledge, skills and potential of your team members as representatives of their professions and as individuals (based on their experiences and expertise). Develop a provider inventory by listing specific activities or tasks associated with caring for your practice population, and identifying which provider has the necessary knowledge and skills to deliver on these activities or tasks. This inventory becomes the basis for making decisions about who does what in Step 3. Step 3 - Divide up the tasks of the team among all members When looking at this inventory and thinking about the fit between skills and tasks, consider all the tasks the team faces. These include not only specific clinical roles such as starting insulin, monitoring blood pressure or providing health teaching, but also team and system roles. Team roles are those that facilitate team efficiency, such as organizing or running working groups, and leading particular team processes. System roles relate to tasks that cut across all disciplines such as looking after the Chronic Disease Management registries, linking with community agencies, and program development. Part B of this module contains the following exercises and activities, which address the themes we have already discussed Appreciating the Scope of Practice of All Team Members Understanding Roles: The Talking Wall Learning About the Scope of Practice of All Team Members The Case Discussion Learning About the Skills and Potential of All Team Members 4

5 Clarifying Roles and Expectations Part B Activity Appreciating the Scope of Practice of All Team Members The Interprofessional Perception Scale Preparation: Review Part A, Module 3 Time Required: minutes Materials: Handouts Pens, markers Flipchart This activity requires the following handouts: Before the Talking Wall: Interprofessional Perception Scale After the Talking Wall: Interprofessional Perception Scale This activity is a crucial component of team development and is important for helping team members learn about each other s skills, interest, and scope of practice. It has two related components: 1. Learning about each other s roles 2. Identifying and correcting misperceptions individuals may have about what their team members do for the team as a whole. Steps: 1. Ask each team member to complete Before the Talking Wall: Interprofessional Perception Scale (this scale may be found on the following page). This should be done individually and without people sharing their results with their team. 2. Conduct the Talking Wall exercise (or other scope-of-practice exercises) with the group (see Activity 3.2). 3. Ask each team member to complete After the Talking Wall: Interprofessional Perception Scale. Address how people s impressions have changed. Afterwards, the team should get together and discuss what they have learned and how their perceptions may have changed. This scale can be used in conjunction with the Talking Wall exercise (see Activity 3.2 for instructions on how to conduct the Talking Wall ) 5

6 Activity 3.1: Appreciating the Scope of Practice of All Team Members Before the Talking Wall: Interprofessional Perception Scale 1 What is your opinion of persons in other professions? (Fill in column blanks with professions other than your own.) Persons in this profession: Very Untrue Very True Very Untrue Very True 1. Are competent Have very little autonomy Understand the capabilities of your profession Are very concerned with the welfare of the patient/client Sometimes encroach on your professional territory Are highly ethical Expect too much of your profession Have a higher status than your profession Are very defensive about their professional prerogatives Trust your professional judgment Seldom ask your professional advice Fully utilize the capabilities of your profession Do not cooperate well with your profession Are well trained Have good relations with your profession Mariano, C., et al. (1999). Modified from Ducarris, A. and Golin, K. (1979). The Interdisciplinary Health Care Team: A Handbook. MD: Aspen Publishing Co 6

7 Activity 3.1: Appreciating the Scope of Practice of All Team Members After the Talking Wall: Interprofessional Perception Scale 2 What is your opinion of persons in other professions? (Fill in column blanks with professions other than your own.) Persons in this profession: Very Untrue Very True Very Untrue Very True 1. Are competent Have very little autonomy Understand the capabilities of your profession Are highly concerned with the welfare of the patient/client Sometimes encroach on your professional territory Are highly ethical Expect too much of your profession Have a higher status than your profession Are very defensive about their professional prerogatives Trust your professional judgment Seldom ask your professional advice Fully utilize the capabilities of your profession Do not cooperate well with your profession Are well trained Have good relations with your profession Mariano, C., et al. (1999). Modified from Ducarris, A. and Golin, K. (1979). The Interdisciplinary Health Care Team: A Handbook. MD: Aspen Publishing Co 7

8 Activity Understanding Roles & the Talking Wall 3,4 Preparation: Review Part A, Module 3 Activity Time Required: minutes Materials: Handouts Pens, markers Flipchart This activity requires the following handouts for participants: No handouts or worksheets are required for this learning activity. Goal: Learn about team members roles by identifying and resolving any misperceptions team members may have about other providers. The Talking Wall exercise will allow participants to explore their conceptions and misconceptions of the roles and responsibilities of other health care professions. Steps: 1. Divide participants into subgroups of 4 to 6 people. In smaller teams, this can be done in a single group. 2. For each sub-group, attach a flipchart sheet to the wall for each profession represented in the subgroup. The name of the profession is to be indicated on each flipchart sheet using a black marker. 3. Using black markers, participants write their perceptions of the roles and responsibilities of each of the professions on the respective sheets, with the exception of their own. 4. Only new items are added to the lists to avoid duplication. 5. Once the lists are complete, participants are to examine their own professions lists and use a red pen to delete misconceptions, correct inaccuracies and add missing items. 6. Have each group discuss their flipchart list with the other groups, highlighting where there were misconceptions and how these were resolved within the group. 7. Have each group compile their misconceptions into a single list. Identify the most common misconceptions that appear on groups lists. 3 Parsell, G and Bligh, J 1998 Educational Principles Underpinning Successful Shared Learning Medical Teacher Volume 20, No. 6, p London UK: Informa Healthcare 4 Association of Ontario Health Centres (2007). Building Better Teams: A Toolkit for Strengthening Teamwork in Community Health Centres Association of Ontario Health Centres Toronto 8

9 Activity 3.3: Learning about the Scope of Practice of All Team Members Preparation: Review Part A, Module 3 Activity Time Required: 60 minutes Materials: Handouts Pens This activity requires the following handouts for participants: Participant Worksheet Interprofessional Separate & Shared Functions I Interprofessional Separate & Shared Functions II *The following activity was adopted from Jones & Way and has been revised by the authors for this module.* Goal: Learn about the roles of each team member by identifying both shared and separate functions with reference to comprehensive primary health care services. Steps: 1. Complete the Interprofessional Separate & Shared Functions I and II. 2. Once a list of the roles that each team member can potentially play has been developed, team members should discuss in more detail each role at a follow-up team meeting. Team members can be identified either by role (as in the sample sheet) or by name. 3. Distribute the following worksheet sheet and ask the team: Is the distribution of roles that team members came up with a surprise? If so, which parts (this may lead into a discussion about the scope of practice of different roles I didn t realize that a dietician was able to )? Where are the major areas of overlap? What are the implications for the distribution of roles within the team? 5 Jones, L. Way, D. (2006) Collaborative Practice Learning Guide. Developed for Supporting Interdisciplinary Practice: the Family Physician/Nurse Practitioner Educational and Mentoring Program. Ontario Ministry of Health Long-Term Care Primary Health Care Transition Fund Grant # G

10 Activity 3.3: Learning About the Scope of Practice of All Team Members 6 Each PHC organization is engaged in delivering comprehensive primary health care. One way to learn about the scope of practice of various provider groups within an organization is by referring to the services that comprise PHC, using the World Health Organizations five domains of primary care (health promotion, disease prevention, curative care, rehabilitative care, and supportive care). The Separate and Shared Functions Table (below) lists these domains and the activities/responsibilities that fall under each. The table is not meant to identify which profession is best suited or most competent to perform a given activity. Rather it demonstrates which profession can contribute to that care domain and where functions overlap. Separate or unique contributions may be a result of different professional approaches to the same activity. There is the risk that shared or overlapping functions may result in competition and turf protection. Instead, any overlap should be viewed positively. A diverse team of professionals with unique functions increases the breadth of service, while overlapping functions increase the depth of service. For example, with more than one provider engaged in acute minor illness care, access is increased, more patients/clients can be seen with similar concerns, and patients/clients have their choice of provider. Function is defined as having requisite knowledge and skill (based on formal educational preparation), as well as the scope of practice (i.e., legislated authority to make and implement decisions related to the activity). Questions to be discussed after completing the Interprofessional Separate & Shared Functions I and II 1. Did you find the allocation of roles surprising? If so, identify the surprises: 2. Where are the major areas of overlap in roles on your team? 3. What are the implications for who should be doing what in your organization? 6 Jones, L. Way, D. (2006) Collaborative Practice Learning Guide. Developed for Supporting Interdisciplinary Practice: the Family Physician/Nurse Practitioner Educational and Mentoring Program. Ontario Ministry of Health Long-Term Care Primary Health Care Transition Fund Grant # G

11 Activity 3.3: Learning about the Scope of Practice of All Team Members Interprofessional Separate and Shared Functions I 7 Primary Health Care Activities Health Promotion Outreach activity (community program development/ presentations) Promote self-efficacy/self-care Attention to the determinants of health Attention to lifestyle factors Nutrition Exercise Habits (drugs, alcohol, smoking) Function FP NP RN SW PT OT RD PH RPN AS Other Disease Prevention Comprehensive health history Complete physical exam Laboratory/diagnostic evaluation Primary prevention Secondary prevention Tertiary prevention Curative (Acute Conditions) Triage Symptom-directed history Symptom-directed exam Acute episodic minor illness dx/tx Minor injury dx/tx Acute major complex illness dx/tx Major injury Medications Administering Prescribing Dispensing Monitor drug therapeutic and side effects, interactions FP = Family Physician, NP = Nurse Practitioner, RN = Registered Nurse, RPN = Registered Practical Nurse, SW = Social Worker, PT = Physiotherapist, OT = Occupational Therapist, RD = Registered Dietician, PH = Pharmacist, AS = Administrative Staff 7 Jones, L. Way, D. (2006) Collaborative Practice Learning Guide. Developed for Supporting Interdisciplinary Practice: the Family Physician/Nurse Practitioner Educational and Mentoring Program. Ontario Ministry of Health Long-Term Care Primary Health Care Transition Fund Grant # G

12 Activity 3.3: Learning about the Scope of Practice of All Team Members Interprofessional Separate & Shared Functions II 8 Primary Health Care Activities Rehabilitative (Chronic Conditions) Initial diagnosis and treatment Treatment adjustment unstable chronic condition Monitoring stable chronic condition Hx /physical data collection Laboratory /diagnostic evaluation Medications Medication renewal Administering Prescribing Dispensing Monitor drug therapeutic and side effects, interactions Function FP NP RN SW PT OT RD PH RPN AS Other Supportive Education Disease processes and treatment Disease prevention and health promotion Advocacy Counseling Stress management crisis intervention Adaptation to illness Mental health therapeutic counseling Mental health supportive counseling Service coordination Consult/refer team members Referral community resources Referral medical specialists Referral hospital admission Administrative supports Program planning and co-ordination Program monitoring and evaluation; quality improvement FP = Family Physician, NP = Nurse Practitioner, RN = Registered Nurse, RPN = Registered Practical Nurse, SW = Social Worker, PT = Physiotherapist, OT = Occupational Therapist, RD = Registered Dietician, PH = Pharmacist, AS = Administrative Staff 8 Jones, L. Way, D. (2006) Collaborative Practice Learning Guide. Developed for Supporting Interdisciplinary Practice: the Family Physician/Nurse Practitioner Educational and Mentoring Program. Ontario Ministry of Health Long-Term Care Primary Health Care Transition Fund Grant # G

13 Activity 3.4 Case Study Discussion Preparation: Review Part A, Module 3 Activity Time Required: 60 minutes Materials: Handouts Pens This activity requires the following handout for participants: Participant Worksheet Goal: To learn about each team members scope of practice through a case study discussion. Steps: 1. The group should discuss a case study, either real or fictional. Sample case: Mr. Brown is a 78-year-old widower, now living on his own after the death of his wife nine months ago. He has Type 2 diabetes, which has been poorly controlled for the last two years, and his blood pressure was 148/92 seven months ago, when it was last measured. He has been unable to get to the clinic during the last four months because he becomes increasingly out of breath when walking. He has two married children: a son who lives in town and a daughter who lives in another province. His daughter has called the office to say that her father seems a bit more confused when she talks to him over the phone. 2. After the case has been presented and before having a general discussion, ask each team member: o What extra information would you require at this point in time? o What is the priority with this case? o What could you be doing that might be unique to your discipline? 3. In your discussion, focus on: identifying potential contributions each team member can make, where there may be areas of overlap in the division of roles, and how tasks are going to be divided. 13

14 Activity 3.4 Case Study Sample Case: Mr. Brown is a 78-year-old widower, now living on his own after the death of his wife nine months ago. He has Type 2 diabetes, which has been poorly controlled for the last two years, and his blood pressure was 148/92 seven months ago, when it was last measured. He has been unable to get to the clinic during the last four months because he becomes increasingly out of breath when walking. He has two married children: a son who lives in town and a daughter who lives in another province. His daughter has called the office to say that her father seems a bit more confused when she talks to him over the phone. What extra information about the case would you require at this point in time? What is the priority with this case? What could you be doing for this case that might be unique to your discipline? Further Discussion: Identify potential contributions each team member can make to the patient/client s care plan: Identify where there may be areas of overlap in role division: How would you divide the respective tasks?

15 Activity 3.5 Discovering the Skills of Each Team Member Preparation: Review Part A, Module 3 Time Required: 60 minutes Materials: Handouts Pens This activity requires the following handouts for participants: Participant Worksheet Individual Provider Inventory Sheet Collective Provider Inventory Sheet *This activity was adopted from Jones & Way (2006) 9 and has been revised by the authors for this module. Goal: To learn about the knowledge, skills and interests of each team member to inform key decisions regarding service delivery. Developing a provider inventory involves listing the tasks in the delivery of specific service and identifying which provider has the knowledge, skills and interest to deliver that service. This list will help the team make decisions about the division of roles. Steps: 1. Develop an Individual Provider Inventory Ask participants to complete the Individual Provider Inventory (either before or during the team session). Ask them to answer the following questions: 1. What is your knowledge base and what specific skills (competencies) do you have related to your profession? 2. How would you contribute if you were starting in a new position? (i.e., what are you able to do, as a result of your position, skills, and scope of practice?) 3. What tasks would you do you prefer to complete (i.e., would like especially to learn) or are you not interested in? (i.e., what do you want to do?) Remind participants that the list of common activities developed by the team is by no means complete! 9 Jones, L. Way, D. (2006) Collaborative Practice Learning Guide. Developed for Supporting Interdisciplinary Practice: the Family Physician/Nurse Practitioner Educational and Mentoring Program. Ontario Ministry of Health Long-Term Care Primary Health Care Transition Fund Grant # G

16 2. Develop a Collective Provider Inventory Ask participants to share their completed Individual Provider Inventory Complete the list of activities on the Collective Provider Inventory form Beside each activity mark the initials of each team member who has expressed an interest in or the ability to complete that activity Review the collective list for separate and shared functions and preferences Discuss how best to use the provider resources you have and identify what resources you need Begin to complete Part II of the Collective Provider Inventory form - Decisions Regarding Service Provision: Exercise Instructions 16

17 Activity 3.5 Discovering the Skills of Each Team Member Individual Provider Clinical Inventory 10 Each provider not only brings their professional knowledge and skills, but also their own combination of experiences and interests to the practice setting. At the practice level, acquiring a better understanding and appreciation of the collective knowledge and skills that are available to you as a provider group involves taking inventory. Developing a provider inventory involves listing the tasks in the delivery of specific service and identifying which provider has the knowledge, skills and interest to deliver that service. This list will help the team make decisions about the division of roles. Completing your inventory requires that you answer the following questions: 1. What knowledge and skills have you acquired through your initial and on-going education? i.e., what can you do? 2. What services do you currently provide or will provide if you start in a new position? i.e., what may you do based on your position and scope of practice? 3. What services do you prefer to provide? What have you acquired expertise doing? What would you like to learn? i.e., what do you want to do? This exercise allows your team to begin a list of common activities associated with primary health care (clinical activities, procedures, administrative tasks). However, it is by no means complete! The list does not include acute episodic and chronic disease conditions. Add specific disease conditions if, for example, your practice has an especially large population of diabetics and/or you have a special interest or expertise in diabetes management. Beside each activity, add a checkmark if you have the competency, if you are or will be contributing, or if you have a preference for this activity. 10 Jones, L. Way, D. (2006) Collaborative Practice Learning Guide. Developed for Supporting Interdisciplinary Practice: the Family Physician/Nurse Practitioner Educational and Mentoring Program. Ontario Ministry of Health Long-Term Care Primary Health Care Transition Fund Grant # G

18 Individual Provider Inventory ACTIVITY COMPETENCY I have the knowledge and skills CONTRIBUTION I am or will be performing this activity. PREFERENCE I especially want to do this, have the expertise, or want to learn how to do this. Clinical Functions Patient/client scheduling Referral appointments Chart filing Lab results review Prenatal care > 32 weeks Manage labour and delivery Well infant care Well child care Adolescent health exams Women s health exams Male health exams Seniors health exams Lifestyle counseling (e.g., exercise, nutrition) Mental health counseling: individual Mental health counseling: couple Mental health counseling: family Crisis intervention Family planning Pregnancy options counseling Addictions assessment and counseling Minor surgery (e.g., mole removal) Suturing Venipuncture IUD insertion Wound care Team Functions 18

19 System Functions 19

20 Collective Provider Clinical Inventory 11 The purpose of this team exercise is to develop an inventory by asking team members to: 1. Share their Individual Provider Inventory. 2. Develop an inventory of the activities performed at your practice setting. 3. Identify all team members who have the necessary professional competencies and an interest in the performance of those activities. Exercise Instructions Part I: Inventory Complete the list of activities by asking team members to review their individual forms and add any other activities that might have been missed. Record providers initials in the appropriate columns beside each activity in order to identify providers who: Have the knowledge and skills to do each activity Are interested in or will be performing each activity Especially want to do, have expertise to do, want to learn or prefer not to do each activity Review the lists for separate and shared functions and preferences. Use the list and discuss how to best use the provider resources you have and identify what resources you need. Are there necessary activities that all or no one prefers to do? Does one provider have the needed expertise? Or does no one have the appropriate knowledge and skills required? Part II: Decisions Regarding Service Provision Enter team decisions regarding the provision of each service. Examples In one practice, both the FP and NP have the knowledge and skills and they love to work with youths. Therefore, the decision is made to share the care for this population through a teen clinic. The clinic s RN has taken additional courses as a diabetic educator so patients/clients are referred to her. The public health nurses in the community run a breastfeeding clinic, so new moms are referred there. No one in the clinic has the expertise for addictions counselling. Therefore, the decision is made to hire an addictions counsellor on a part-time basis. 11 Jones, L. Way, D. (2006) Collaborative Practice Learning Guide. Developed for Supporting Interdisciplinary Practice: the Family Physician/Nurse Practitioner Educational and Mentoring Program. Ontario Ministry of Health Long-Term Care Primary Health Care Transition Fund Grant # G

21 Collective Provider Inventory ACTIVITY COMPETENCY Initials of team members who have the knowledge and skills. CONTRIBUTION Initials of team members who are or will be performing this activity. PREFERENCE Initials of team members who especially want to do this or have the expertise. Clinical Functions Patient/client scheduling Referral appointments Chart filing Lab results review Prenatal care > 32 weeks Manage labour and delivery Well infant care Well child care Adolescent health exams Women s health exams Male health exams Seniors health exams Lifestyle counseling (e.g., exercise, nutrition) Mental health counseling: individual Mental health counseling: couple Mental health counseling: family Crisis intervention Family planning Pregnancy options counseling Addictions assessment and counseling Minor surgery (e.g., mole removal) Suturing Venipuncture IUD insertion Wound care Team Functions 21

22 System Functions 22

23 Part II: Decisions Regarding Service Provision 23

24 References Association of Ontario Health Centres (2007). Building Better Teams: A Toolkit for Strengthening Teamwork in Community Health Centres Association of Ontario Health Centres Toronto Jones, L. Way, D. (2006) Collaborative Practice Learning Guide. Developed for Supporting Interdisciplinary Practice: the Family Physician/Nurse Practitioner Educational and Mentoring Program. Ontario Ministry of Health Long-Term Care Primary Health Care Transition Fund Grant # G Mariano, C., et al. (1999). Modified from Ducarris, A. and Golin, K. (1979). The Interdisciplinary Health Care Team: A Handbook. MD: Aspen Publishing Co Parsell, G and Bligh, J 1998 Educational Principles Underpinning Successful Shared Learning Medical Teacher Volume 20, No. 6, p London UK: Informa Healthcare 24