Quality in Health Care

Teams make up the building blocks of health care and every team—from the executive to the coal face—is composed of diVerent professionals, ideally possessing a variety of skills necessary to produce safe and eVective care. We are constantly reminded of the value of diversity within teams, but the reality is that working together from a variety of perspectives is sometimes diYcult to achieve. The paper by Jenkins et al in this issue of Quality in Health Care shows, for example, that, unless roles are well defined and understood, responsibility for giving diVerent types of information to patients could easily result in overload to the patient, diVerences in messages, and gaps in certain areas. The diYculties of multidisciplinary teamwork are also apparent in diVering attitudes towards the way to bring about a good outcome, and even what actually constitutes a good outcome. For example, in teams caring for patients with stroke there are a number of “ideal outcomes” from the various stakeholders and staV involved—complete mobility is desired by the patient, physical immobility but good mental ability by the carer, compliance with the regime is required from some health workers, and (I have heard say) death from the contracts manager. Just as feedback from the cancer team audit would be helpful in producing better communication in the future, so discussing diVerent approaches to care and diVering ideas of best outcome will also keep the team on what is inevitably a wavy line along the best practice meridian. What makes healthcare teams so diVerent from those in other types of organisation is that team members have differing allegiances, not only to the team but also to their professional groups. For example, if a member of the nursing staV abuses a patient on a psychiatric ward, who has ultimate authority to deal with this—the nursing line manager or the consultant psychiatrist who is seen by some as the team leader? In commercial organisations such questions would be easily answered, but history and professionalism play their part in making questions of authority and responsibility in the health service team much more complex. Reinforcement of the supra-goal— patient safety—can help to push people beyond professional barriers, but clarity about authority and accountability in health care teams is long overdue. There is another warning to heed against complacency in terms of teams: in these days of constant measurement and the drive towards reporting of poor care, we need to look beyond the data laid before us. A study by Edmondson on medication errors in nursing teams showed that poor teams produced fewer errors; however, poor teams had authoritarian team leaders and so the likely explanation for this surprising finding is that data were being manipulated in poor teams and shown honestly in good open communicating teams. Clearly, teams need to be rewarded for their reporting systems and use of feedback rather than for the data alone. These are not issues to dodge, but neither do they make good multidisciplinary teamwork an impossible task to achieve. Such teams are the reality that we work in and, although rarely captured in data, their diversity does actually help patient care. It is possible that this happens because of the increasing findings which show that members of good teams are significantly less stressed than others. Moreover, in a study of house oYcers, those who appreciated that they were part of a multidisciplinary team (as opposed to simply being bottom of a medical hierarchy) had far lower stress levels than those who did not, probably because they were able to learn from the diversity of skills that surrounded them and could look further than their medical colleagues for support. Since we know that lower stress means better patient care, it is also likely (as well as common sense) that better teams produce better care through having more cheerful staV, probably through their greater sense of participation and support. Somewhere in this equation lies the issue of suYcient resources—suYcient to allow time for good communication within the team and with the patient. So multidisciplinary teams are likely to be better for everyone, but to keep them working well needs skill as well as recognition that this is always a long term task requiring constant attention and adjustment. Good team leaders are essential for maintaining patient safety and the sooner we get them the training and support they need for this task, the better the quality of care is likely to be.