Apraxia

In New Jersey, physical therapists (PTs) serve children in more than 60 schools, spanning two school districts. They travel and work alone, often not encountering another PT all day long. Yet, continuity of care and morale are high. Further west, PTs span a 120-mile radius around Grand Forks, ND, to bring city-based care to rural settings. Driving alone for hours a day, they connect primarily by cell phone. Yet they don't feel isolated, and patient care is top-level. The key to the success of these programs-and of others in a variety of settings nationwide-is extraordinary teamwork.

Over the past few months, PT has explored the dynamics of the clinical environment with articles discussing motivational factors for physical therapists (PTs), how different personality types may (or may not) work well together, and motivating and managing the generations.1-3 This month we explore the factors that go into building teams whose effectiveness improves patient care while enhancing individual PT performance.

School Systems

The University of Medicine and Dentistry of New Jersey (UMDNJ) Newark Therapy Services assigns PTs and occupational therapists (OTs) to more than 60 New Jersey schools. "Our monthly teambuilding meetings began as quality circles to improve patient documentation and continuity of care," reports Sandra Kaplan, PT, PhD, associate professor and assistant director, Doctoral Programs in Physical Therapy. "We use quality circles organized around common caseloads and schools to help PTs connect with others from our practice, develop a sense of teamwork if they are treating the same child or dealing with staff from the same schools, and help orient new staff who join our faculty practice."

The geographic-based circles meet monthly to address the challenges inherent in traveling to serve multiple schools, intervention approaches for specific students, and reporting of students' progress to teachers. The meetings proved to be so popular that in 2004 the PTs chose to add topic-based circles to their schedules as well. Kaplan explains, "PTs and OTs now also meet to discuss specific conditions, such as autism, or to analyze testing materials and evaluation tools, or to discuss and coordinate their unique roles in treating students." These discussions have helped to streamline documentation, reduce redundancy, and make better use of new and part-time PTs.

Their relationships with school system teachers has vastly improved as well, Kaplan notes. "When we first introduced UMDNJ's services to these school districts, multiple agencies were providing therapists. There was a great need for communication between the PTs and the teachers from whose classes students were being pulled for treatment. While teachers were resistant to us at first, they are now a part of the team serving these children. Our PTs regularly report progress to them, and their input is welcomed."

A sure sign that the system is working is its growth. Now in its seventh year, the UMDNJ program employs approximately 40 PTs and OTs. Kaplan reports that she now is approached by PTs who have heard of their program and want to join it. "And we have had therapists leave the program, only to ask to return after finding that other programs serving schools lack our team component," she says. "They miss the meetings and the sense of belonging to a team."

Rural Settings

A sense of belonging also keeps attrition rates low among health care professionals providing outreach rehabilitation services (ORS) for Altru Health System in Grand Forks, ND. In a situation in which the geographic challenges could cause PTs to seek work elsewhere, the opposite has proved true. "The team aspect of our services has moved beyond multidisciplinary to interdependent," says Brad Wehe, PT, manager of outreach rehabilitation services for Altru. Although the PTs may travel and work separately, Wehe says, "they know they have a strong team behind them to address any and all patient, time, and even weather situations."

Altru's ORS, created 15 years ago, currently has 42 PTs, OTs, and speech therapists on its outreach team, serving 23 rural facilities. "Our primary mission is to design satellite therapy centers throughout the region," Wehe explains. "Our centers, which we base in existing rural facilities, serve pediatric to geriatric populations and provide the complete range of rehabilitation programs.

"Everything we do-education, presentation, communications-is team-based," Wehe says. "No one person ever approaches a facility or addresses a patient situation alone. We generally send five, six, or seven team members to serve a given site." He notes that team building within each facility begins with his team giving a joint presentation to the facility's doctors, nurses, therapists, activities directors, and staff members. "Our initiatives are all team-based and team-directed."

Wehe's definition of a "team" is flexible and changes based on patient needs. "We have PT teams, OT teams, and outreach teams," he explains, "and we construct specific teams to serve a specific situation. We don't ask, 'How do we provide x hours of physical therapy to this region?' but instead ask, 'How do we provide top-level cardio rehab to this facility 100 miles away from our base?'"

Outpatient Clinics

A smaller facility. Isolation can be a factor even within a sprawling urban area. As director of physical therapy services for one of five outpatient clinics operated by the PT-owned Greater Therapy Center serving the Dallas metroplex area, Mike Connors, PT, MPT, works alone, with the help of two college students as support staff. Having recently moved to the new position from one in a busy hospital setting, Connors concedes that "it certainly is a new dynamic."

However, he notes that "I can't say that I miss the hospital setting. We are still a team, even though we are scattered throughout the corporation's facilities." Just like the PTs in rural settings, Connors keeps in daily touch with colleagues by phone and e-mail. "If I encounter obstacles with treatment, I can pick up the phone and ask, 'How can I adapt this procedure or try something new?' My immediate boss, a PT, provides important support."

Connors notes that PTs by nature always are working as a part of a team, even in solo settings. "You consult with a physician regarding each patient. The doctor is always a part of the team, as is the patient. The patients are the core of any team-the reason we're here."

He also notes that, as PTs move from one job setting to another, "you still have your peer network of close associates, developed over the years, that you call on to exchange ideas. Our local APTA chapter meetings offer a chance to network and to develop new relationships with people."

A neurologic team. Clinicians combined their talents to form an interdisciplinary team in an outpatient satellite facility of Danbury Hospital in Danbury, CT, in order to provide optimum care for neurologic patients. The team includes family members, doctors, nurses, PTs, OTs, and speech therapists, as well as a representative of the states Bureau of Rehabilitation Services when financial issues are a factor in rehabilitation and patient care.

"The team began to form in the outpatient facility among a group of therapists who had a special interest in neurologic patients and understood the many issues that need to be addressed regarding their care," reports Darlene Klosen, PT, senior physical therapist at the facility. "This patient population is so complex, it was important to make sure that everyone providing care was in agreement regarding evaluation, treatment, and the patient's short-term and long-term goals."

Klosen offers an example of the team's approach to treatment of a patient following a middle cerebral artery stroke. The patient was aphasie as well as apraxic, Klosen notes, with moderate hemiplegie deficits. The team first conducted a family meeting to educate the family regarding realistic long-term goals. The patient was referred for physical therapy, occupational therapy, and speech therapy. In this case, the speech therapist offered guidance on how to communicate with the patient throughout treatment. The PT and OT then brainstormed on ways to work through the patient's severe apraxia. "Our team sessions are productive and increase efficiency of care because we gain knowledge through each other, so we are not each trying to address a challenge that our colleague already may have resolved," Klosen says.

Key factors in the team's effectiveness are confidence and respect, she notes: "We are each comfortable with our own skills, and we have tremendous respect for each others' skills."

Large Hospital Settings

Teamwork is serving to empower PTs within today's larger medical systems nationwide. "We feel that we as a team can make better decisions than as separate islands within the system, or as individuals," says Jose Kottoor, PT, MS, director of physical therapy/occupational therapy in the Department of Physical Medicine and Rehabilitation (PMR) of the University of Michigan Health System (UMHC). The system includes an 800-bed acute care hospital and several outpatient satellite programs. Kottoor conducts team meetings among the 186 therapists and support staff, both on-site in the PMR department and at each of their satellite facilities.

When Kottoor became director of physical therapy/occupational therapy 3 years ago, he noticed that the same issues were being discussed in his meetings with the 10 PT and OT supervisors he oversaw. He decided to combine the PT/OT meetings and led their discussions based on the hospital systems abiding principle of "Patients and Families First."

"This common value and vision has made it easier for us to work around issues, to develop strategic plans," he reports. In the combined meetings, PT and OT supervisors rapidly built up trust regarding each team's perspectives and professionalism, and "now we feel comfortable discussing both physical therapy and occupational therapy issues around the same table." In fact, all issues now are faced first from a team perspective.

"Our people feel empowered. I can throw ideas out to them, and say, 'You make the decision,'" he says. A recent case in point was the need to combine PT/OT outpatient support staff to ensure 11-hour coverage in the outpatient area. "The supervisors began discussing moving people, and we soon saw it wasn't working. We decided to ask the staff themselves-the ones who would be most affected by this change. We set the parameters-that we need diis many people working these hours-and asked them to develop a schedule. After a few days, they came back with a schedule that was appropriate for everyone."

Rapid review process. Carol Ramsey, PT, reports on the effectiveness of teamwork when performing rapid cycle reviews (RCRs) at North Colorado Medical Center (NCMC) in Greeley, Colorado, a large acute care hospital where she recently served as director of inpatient and outpatient rehabilitation. "We developed a quality improvement RCR team to refocus staff in both our 20-bed rehabilitation unit and a 20-bed, in-house skilled nursing facility, and to address issues facing bodi units."

She describes the challenges facing the review team: "We needed to look at the PT, OT, and speech language pathology staff, and how they integrated with the nursing staff to form a clinical team. The second problem was the lack of teamwork between the clinical team and the medical records, coding, and billing departments. The challenge also included holding the teams together during the months it would take to recruit and train a new director. Staff wanted to take time to review, analyze, and restructure before bringing in a new supervisor."

The RCR entailed a 4-step process of "Plan, Do, Study, Act," according to Ramsey. "When you identify a problem and need to develop a solution fairly quickly, this system allows you to implement what you think might work, then rapidly review it, before it becomes institutionalized. It offers the chance for a 'quick fix' while you continue to analyze the situation." Ramsey offers an example: "Our facility operates 12-hour nursing shifts, ending at 7:00 am. Our therapists began their shifts at 8:00 am. Between 7:00 and 7:30 am, the nurses were in transitional staff meetings. However, mis was a crucial time for scheduling physical therapy, occupational therapy, or speech therapy sessions for the entire day. We were experiencing communication and scheduling breakdowns as a result.

"We brought representatives from all of the disciplines together to brainstorm. During the RCR process, we decided that our OTs might begin their shifts at 6:30 am, and report to nursing at that time. We implemented the schedule change immediately, then reviewed it in a few weeks. We found that this scheduling change eliminated the conflict with the nursing shift change and simplified staff transition times. As a part of the review, we also changed our reporting system back from tape recordings to the old-fashioned written word. The nurses then could read the prior shift's notes as needed, which also eased stress."

Bringing teams together across disciplines resolved billing and coding issues as well, Ramsey reports. "The billing and coding departments were perceived by the clinical staff as being rigid in their rules. Our clinicians understandably put patient care first, and couldn't understand, for example, why billing personnel were requesting a patients chart just 24 hours after admission. They resented having the chart taken away." Ramsey decided to bridge the gap between the teams.

"We brought a billing representative together with our staff to explain how important specific documentation of patient treatment was to reimbursement. Our clinicians began to see that timely reporting of, for example, the use of supplies helped ensure those supplies were included in future budget allocations." With the billing personnel's guidance, staff learned how the budget cycle worked and the best times to request supplies-or to seek continuing education funds.

Ramsey also invited a coding staff member to the hospital floor twice a week. Sitting with the staff reviewing patient records helped her to understand patient flow. When she heard staff discussing a patient, she could coach them on factors that affected coding, and show how coding also was very important for reimbursement.

Teamwork in Hiring. Paul McKoy,PT,MS,GCS, reports how teamwork plays a role even in the hiring process at Marianjoy Rehabilitation Services in Darien, IL, where he serves as senior physical therapist. "After the appropriate manager conducts an initial interview with a prospective PT or other team member, we invite the candidate back for an informal team interview," he says.

All staff are invited to participate in the second interview. "The team can include nurses, therapists, the receptionist, the office coordinator, even the van driver," he notes. "The meeting is low-key and relaxed. We'll ask questions such as why the candidate decided to enter the profession. What are they used to in terms of caseload? What is their experience with working as a team member with other disciplines?" Following the , interview, the team meets again to discuss their impressions.

The result is a "closeknit" team, and a low attrition rate: "The process has helped us sustain our team in terms of the personalities that come into our setting and that fit well with us."

Factors That Make It Work

As those interviewed for this article described their teambuilding initiatives, a few key factors emerged as essential to making the process work. Among them:

Communication. "Communication is key to any team, any system working effectively," says Ramsey. "Bringing people together who don't normally communicate to a great extent is fundamental to the team building and problem-solving process."

"The biggest problem with turf battles is lack of information," says Mary Chown, PT, senior director, therapy services at The Institute for Rehabilitation and Research in Houston. She recounts how she had to take over the cardiac rehabilitation unit with nursing personnel in a small hospital. "The nurses were afraid I would change their procedures right away. Instead, I took my time and learned about the nursing discipline, asked questions, and learned what they needed." The point, she says, is "the team must have openness and the ability to give and take and learn from each other. Once you understand what the other practice areas are doing, defensiveness melts away."

Kaplan notes how improved communication between therapists and teachers has helped student performance. "Our treatment situation is unique in that improving, say, a child's sitting position can improve his or her handwriting. Many areas of student achievement can be affected directly by physical therapy. As we reached out to the teachers and increased their understanding of how physical therapy affects a child's ability to learn and to function in the classroom, the teachers became far more enthusiastic about releasing them for therapy."

As is noted above, though, communication need not be "face-to-face" either among health care professionals or between health care providers, patients, clients, and others. Telehealth-defined by the federal Office for the Advancement of Telehealth as "the use of electronic information and telecommunications technologies to supportlong-distance clinical health care, patient and professional health-related education, public health, and health administration"-is promoting communication among all these parties.4 [See "Enhancing Patient Care With Telehealth" beginning on page 64 of this issue.]

Focus on the patient. Focusing all discussions on improving patient care is key to encouraging disciplines, departments, and staff members to work smoothly together. "Make it clear that the job of each staff member is to provide the best care possible, and that you are there as supervisor to help them do the best job they can," advises Chown.

Kottoor explains how patient care is fundamental to any discussion at UMHS. "Sometimes during a discussion, a staff member will ask, 'Is this putting patients and families first?' When we realize a proposed initiative may not be effective at putting the patient first, we change the initiative."

"We're not here to build an empire," Wehe notes. "We're here to serve patients in the most effective way possible. That means that each team member will brainstorm for the best solution to meet a patient's needs and respect each other team member's contributions."

Maintaining individuality. While Kottoor stresses team involvement and problem-solving, he meets one-on-one with staff members as well. "There always are going to be individual questions and issues," he says. "When I travel to our satellite facilities, I schedule individual meetings, especially with the newer clinicians. I tap into the educational resources of the system, connect them with people who can address their unique questions."

Chown notes how important individual mentoring can be when friction occurs in a team environment. "If someone is labeled a 'troublemaker,' for example, you may find that that person is an excellent therapist but simply doesn't follow the mainstream. It may be that he or she never had mentoring to show them how to channel their energy." Chown gains the individual's trust, then offers suggestions to help him understand others' perceptions.

Group events, recognition. "Therapists are social animals," notes Chown. "They enjoy being a part of a bigger group. That sense of belonging matters to them." She describes a Competency Fair held at TIRR, where each discipline chose a high-risk area of treatment-patient transfers, wheelchair safety-and taught the competency to other team members.

Interviewees also stressed the importance of in-services, continuing education sessions, and even the occasional group lunch. All those interviewed noted that holiday and seasonal functions play a part in bringing team members together. Kottoor holds a yearly retreat for the 10 supervisors he oversees, to "relax, brainstorm, and plan for the upcoming year."

Recognition is an important aspect of group dynamics as well, according to these managers. Kottoor's team began an internal newsletter for staff to report achievements, research in process, and educational initiatives. Ramsey reports how sharing the fact that staff were achieving a higher "going-home rate" and better stroke rehabilitation outcomes than their regional and national competitors greatly improved team spirit in the rehabilitation unit at NCMC.

More Is Better

Kottoor may speak for all PTs who thrive in team environments as he describes the effectiveness of his own team: "With all of the current changes in health care, reduced reimbursement, and the challenges of acute care, we feel we can gain a lot more from each other's insights. We have 150 years of management experience in our supervisory group," he notes. "That's certainly better than any one persons perspective."

References

1 Coyne C. Motivational factors for PTs and PTAs. PTMagazine of Physical Thempy. 2004; 12(10):46-51.

2 Coyne C. Understanding FF, PTA, & patient personality types. PT-MagazineofPhysicalTherapy. 2004;! 2(4) :46-53.

3 Fowler K. Motivating & managing the generations. PTMagazine of Physical Therapy. 2004;12(3):34-40.

4 Office for the Advancement of Telehealth, Health Resources and Service Administration, US Department of Health and Human Services. Available at http://telchealt.h- hrsa.gov/welcome.htm. Accessed April 7, 2005.

Claire Coyne is o freelance writer.

Copyright American Physical Therapy Association Jun 2005
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