healthcare teamwork

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Teamwork as an Essential Component of High-Reliability Organizations David P. Baker, Rachel Day, and Eduardo Salas Organizations are increasingly becoming dynamic and unstable. This evolution has given rise to greater reliance on teams and increased complexity in terms of team composition, skills required, and degree of risk involved. Highreliability organizations (HROs) are those that exist in such hazardous environments where the consequences of errors are high, but the occurrence of error is extremely low. In this article, we argue that teamwork is an essential component of achieving high reliability particularly in health care organizations. We describe the fundamental characteristics of teams, review strategies in team training, demonstrate the criticality of teamwork in HROs and finally, identify specific challenges the health care community must address to improve teamwork and enhance reliability. Key Words. High-reliability organization, teams, teamwork, health care, patient safety, training A healthy 38-year-old woman was admitted to a major medical center to deliver her first child. Although she was a low-risk patient with only mildly elevated blood pressure, her admission ended tragically when she underwent an emergency cesarean after a failed forceps delivery. Once inside the abdominal cavity, the uterus was found to have ruptured, and the placenta was in the abdomen. She delivered a stillborn fetus. After an unsuccessful attempt to repair her uterus, she received a full hysterectomy, underwent blood transfusions, and endured endless complications resulting in a 3-week hospital stay, including 18 days in intensive care. What went wrong? According to root cause analyses, lack of teamwork played a significant role. Specifically, communication was poor; there was a lack of mutual performance cross-monitoring, inadequate conflict resolution, poor situational awareness, and work overload. A major response to the tragedy was the initiation of team training at the medical center (Sachs 2005). r Health Research and Educational Trust DOI: 10.1111/j.1475-6773.2006.00566.x 1576 Safety is a fundamental patient right, though not a certainty (Knox and Simpson 2004). When patients arrive at a health care organization, they expect to leave that institution in equal or better health. Patients and their families do not expect physicians, nurses, and other hospital staff to make mistakes, or worse yet cover up as opposed to communicate errors. The publication of To Err Is Human by the Institution of Medicine (IOM) highlighted the fact that the delivery of care is not error free. The report concluded that medical errors cause up to 98,000 deaths annually. The IOM report brought national focus to this important issue and has since spawned significant research on the causes of medical errors and the effectiveness of different strategies for making health care a more reliable system (Kohn, Corrigan, and Donaldson 1999). The IOM issued a number of recommendations designed to move health care institutions toward high reliability. HROs are institutions that operate in complex, hazardous environments making few mistakes (i.e., medical errors) over long periods of time. Recommendations related to voluntary error reporting, systems changes, safety systems design, and standard for health care professionals were presented in To Err Is Human. The IOM also pointed toward the need for enhanced teamwork. Historically physicians, nurses, and other health care professionals have functioned as discrete parts. The IOM recommended that interdisciplinary team training programs be established, based on sound principles of team management, to improve coordination and communication among health care staff (Kohn et al. 1999). The Agency for Healthcare Research and Quality (AHRQ) is the lead federal agency in supporting and implementing the recommendations of the IOM in its effort to reduce medical error and improve patient safety. As part of this agenda, AHRQ established the HRO network to support patient safety leaders by providing them with a forum for learning about promising practices and identifying new and innovative ways to implement research findings. AHRQ’s goal is to create high-reliability health care organizations. In support of that goal, AHRQ will launch Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) during 2006 and distribute this team training curriculum to members of the HRO network (Alonso et al. 2006). Address correspondence to Rachel Day, Ph.D., American Institutes for Research, 1000 Thomas Jefferson Street, NW, Washington, DC 20007. David P. Baker, Ph.D., is with the American Institutes for Research, NW, Washington, DC. Eduardo Salas, Ph.D., is with the Department of Psychology and Institute for Simulation and Training, University of Central Florida, Orlando, FL. Essential Component of High-Reliability Organizations 1577 The purpose of this paper then is to demonstrate that teamwork is an important component of HROs. While moving health care toward teambased work will not automatically result in high reliability, there are many parallels between teams and HROs (Knox and Simpson 2004; Wilson et al. 2005). To justify our argument, we begin by providing an overview of teams, teamwork, and strategies for promoting team effectiveness. Much has been written about these topics in domains where high reliability is critical because the consequences of error are great (e.g., the military, commercial aviation, and air traffic control) (Salas and Cannon-Bowers 2000; Davies 2001; Baker et al. 2003; Salas, Sims, and Klein 2004). Later in this document, we describe the key characteristics of HROs. The concept of HROs has been around for more than 20 years, but has only recently begun to take hold in health care with the publication of To Err Is Human and AHRQ’s patient safety agenda. In this section, we compare the fundamental features of teamwork and the critical characteristics of HROs and demonstrate how these characteristics are interwoven as well as how and why the HRO environment demands teamwork. Finally, although the science of teamwork has been around for over 30 years, it is only recently that this concept has begun to take hold in health care. In the last section we present a series of challenges researchers and practitioners need to address to advance the health care community’s understanding of team performance and instantiate these practices as part of health care’s quest to achieved high reliability. TEAMS, TEAMWORK, AND TRAINING Teams and Teamwork There is a general consensus in the research literature that a team consists of two or more individuals, who have specific roles, perform interdependent tasks, are adaptable, and share a common goal (Salas et al. 1992). To work effectively together, team members must possess specific knowledge, skills, and attitudes (KSAs), such as the skill in monitoring each other’s performance, knowledge of their own and teammate’s task responsibilities, and a positive disposition toward working in a team. Such KSAs comprise teamwork (Cannon-Bowers et al. 1995; Sims, Salas, and Burke 2004). Based on its definition alone, it is easy to see how teamwork is critical for the delivery of health care. Physicians, nurses, pharmacists, technicians, and other health professionals must coordinate their activities to deliver safe and efficient patient care. As specified in our definition of a team, health care 1578 HSR: Health Services Research 41:4, Part II (August 2006) workers perform interdependent tasks (e.g., a surgeon cannot operate until a patient is anesthetized) while functioning in specific roles (e.g., surgeon, surgical assistant, anesthesiologist) and sharing the common goal of safe care. However, despite the importance of teamwork in health care, most clinical units continue to function as discrete and separate collections of professionals (Knox and Simpson 2004). This is partially due to the fact that members of these teams are rarely trained together; furthermore, they often come from separate disciplines and diverse educational programs. Given the interdisciplinary nature of the work and the necessity of cooperation among the workers who perform it, teamwork is critical for ensuring patient safety. Teams make fewer mistakes than do individuals, especially when each team member knows his or her responsibilities, as well as those of other team members (Smith-Jentsch, Salas, and Baker 1996; Volpe et al. 1996; Sims et al. 2004). However, simply installing a team structure does not automatically ensure it will operate effectively. Teamwork is not an automatic consequence of co-locating people together and depends on a willingness to cooperate for a shared goal. Teamwork does not require that team members work together on a permanent basis. Teamwork is sustained by a commitment to a shared set of team KSAs rather than permanent assignments that carry over from day to day (Morey et al. 2002). Critical Components of Teamwork Extensive research on teamwork during the past 20 years (McIntyre, Salas, and Glickman 1989; Howard et al. 1992; Helmreich and Foushee 1993; Holzman et al. 1995) suggests that teamwork is defined by a set of interrelated KSAs that facilitate coordinated, adaptive performance (Cannon-Bowers et al. 1995; Salas, Bowers, and Cannon-Bowers 1995; Baker et al. 2003). Teamwork is distinct from taskwork (e.g., surgical skill) but both are required for teams to be effective in complex environments (Morgan et al. 1986). Furthermore, in health care, knowledge and skill at the task are not enough. Teamwork depends on each team member being able to anticipate the needs of others; adjust to each other’s actions, and have a shared understanding of how a procedure should happen (e.g., knowing the steps in an appendectomy). Recently, researchers have begun to identify skills that define team performance in health care. This line of research began with the work of Gaba et al. (2001) who developed Anesthesia Crisis Resource Management (ACRM). ACRM was designed to help anesthesiologists effectively manage crises by working in multidisciplinary teams that include physicians, nurses, Essential Component of High-Reliability Organizations 1579 technicians, and other medical professionals (Howard et al. 1992; Gaba et al. 1998, 2001). ACRM uses patient simulators to provide training in specific technical and generic teamwork skills. The simulated anesthesia environment consists of a real operating room with standard equipment and situations requiring actual performance of clinical interventions. A life-like mannequin with appropriate breath and heart sounds permits team members to perform clinical procedures such as endotracheal intubation and infusion of intravenous drugs. Scenarios presented include overdose of inhalation anesthetic, cardiac arrest, and complete power failure (Holzman et al. 1995). The team skills trained in this simulated environment include making inquiries and assertions, communicating, giving and receiving feedback, exerting leadership, maintaining a positive group climate, and reevaluating actions. In addition to anesthesia, a number of researchers have recently begun to identify the KSA requirements of teamwork in other health disciplines. For example, Healey, Undre, and Vincent (2004) have developed the Observational Assessment for Teamwork in Surgery (OTAS) to assess cooperation, leadership, coordination, awareness, and communication in surgical teams (Healeyet al. 2004). Thomas, Sexton, and Helmreich (2004) developed 10 behavioral markers for teamwork in neonatal resuscitation teams and Flin and Maron (2004) have identified nontechnical skill requirements for teams in acute medicine. These studies encapsulate the core KSA requirements for physicians, nurses, and other health care professionals to function effectively in a wide variety of health care teams. Although different researchers use different terminology to define these KSA requirements (e.g., Thomas et al. 2004) identify one of their behavioral markers as ‘‘Information Sharing,’’ while others identify a requirement for ‘‘Communication’’ (Leonard and Tarrant 2001; Flin and Maron 2004; Healey et al. 2004), we argue, much as have Salas and colleagues, that these generic KSAs can be clustered into eight broad competencies of teamwork (Sims et al. 2004). These competencies must be possessed by health care professionals so they can perform (1) in the variety of teams of which they are part and (2) a variety tasks requiring coordination in day-to-day practice. Table 1 presents each KSA, its definition, and behavioral examples. Characteristics of Effective Teams Teams whose members possess a shared commitment to the KSAs presented in Table 1 have been shown to out perform teams whose members do not possess these attributes (Smith-Jentsch et al. 1996; Leonard and Tarrant 2001; 1580 HSR: Health Services Research 41:4, Part II (August 2006) Table 1: Team KSA Competencies and Outcomes Teamwork Definition Behavioral Examples Team leadership (Cannon-Bowers et al. 1995; Sims et al. 2004; Barach and Weingart 2004) Ability to direct and coordinate the activities of other team members, assess team performance, assign tasks, develop team KSAs, motivate team members, plan and organize, and establish a positive atmosphere Facilitate team problem solving Provide performance expectations and acceptable interaction patterns Synchronize and combine individual team member contributions Seek and evaluate information that impacts team functioning Clarify team member roles Engage in preparatory meetings and feedback sessions with the team Mutual performance monitoring (a.k.a., situation monitoring) (McIntyre and Salas 1995) The ability to develop common understandings of the team environment and apply appropriate task strategies in order to accurately monitor teammate performance Identifying mistakes and lapses in other team members actions Providing feedback regarding team member actions in order to facilitate self-correction Backup behavior (a.k.a., mutual support) (McIntyre and Salas 1995; Porter et al. 2003) Ability to anticipate other team member’s needs through accurate knowledge about their responsibilities Recognition by potential backup providers that there is a workload distribution problem in their team The ability to shift workload among members to achieve balance during high periods of workload or pressure Shifting of work responsibilities to under-utilized team members Completion of the whole task or parts of tasks by other team members Adaptability (Cannon-Bowers et al. 1995; Kozlowski et al. 1999; Klein and Pierce 2001) Ability to adjust strategies based on information gathered from the environment through the use of compensatory behavior and reallocation of intrateam resources. Altering a course of action or team repertoire in response to changing conditions (internal or external) Identify cues that a change has occurred, assign meaning to that change, and develop a new plan to deal with the changes Identify opportunities for improvement and innovation for habitual or routine practices Remain vigilant to changes in the internal and external environment of the team continued Essential Component of High-Reliability Organizations 1581 Table 1: Continued Teamwork Definition Behavioral Examples Shared mental models (Klimoski and Mohammed 1994; Mathieu et al. 2000; Stout, Cannon-Bowers, and Salas, 1996) An organizing knowledge structure of the relationships between the task the team is engaged in and how the team members will interact Anticipating and predicting each other’s needs Identify changes in the team, task, or teammates, and implicitly adjusting strategies as needed Communication (McIntyre and Salas 1995) Exchange of information between a sender and a receiver irrespective of the medium Following up with team members to ensure message was received Acknowledging that a message was received Clarifying with the sender of the message that the message received is the same as the intended message sent Team/collective orientation (Driskell and Salas 1992; Shamir 1990; Wagner 1995) Propensity to take other’s behavior into account during group interaction and the belief in the importance of team goal’s over individual member’s goals Taking into account alternative solutions provided by teammates and appraising that input to determine what is most correct Increased task involvement, information sharing, strategizing, and participatory goal setting Mutual trust (Bandow 2001; Webber 2002) The shared belief that team members will perform their roles and protect the interests of their teammates Information sharing Willingness to admit mistakes and accept feedback 1582 HSR: Health Services Research 41:4, Part II (August 2006) Salas et al. 2001; O’Shea et al. 2003). One important fact to note about these KSAs is that they are all individual as opposed to team-level competencies. In other words, team members bring these KSAs to each team task they engage in; the competencies are not unique to the task or the team. When team members work together on a more permanent basis, these competencies are refined over time (they are tailored within the team) and some additional competencies emerge (e.g., knowledge of teammate characteristics). Regardless of whether a team has consistent membership or not, when team members possess the KSAs in Table 1 they are able to perform as a highly reliable and efficient system. Table 2 presents a list of characteristics of effective teams that make them reliable and efficient. These characteristics are similar to the properties that embody HROs, which we describe in the next Table 2: Characteristics of Effective Teams Team Knowledge, Skills, and Attitudes Characteristics of Effective Teams (Salas, Sims, and Klein 2004) Team leadership Have a clear common purpose Team member roles are clear but not overly rigid Involve the right people in decisions Conduct effective meetings Establish and revise team goals and plans Team members believe the leaders care about them Distribute and assign work thoughtfully Backup behavior Compensate for each other Manage conflict well-team members confront each other effectively Regularly provide feedback to each other, both individually and as a team (‘‘debrief’’) ‘‘Deal’’ with poor performers Are self-correcting Mutual performance monitoring Effectively ‘‘span’’ boundaries with stakeholders outside the team Members understand each others’ roles and how they fit together Examine and adjust the team’s physical workplace Periodically diagnose team ‘‘effectiveness,’’ including its results Communication Communicate often ‘‘enough’’ Adaptability Members anticipate each other Reallocate functions Recognize and adjust their strategy under stress Consciously integrate new team members. Shared mental models Coordinate without the need to communicate overtly Mutual trust Trust other team members’ ‘‘intentions’’ Team orientation Select team members who value teamwork Strongly believe in the team’s collective ability to succeed Essential Component of High-Reliability Organizations 1583 section. However, before our review of HROs, we describe the mechanisms by which effective team performance can be achieved. How to Promote Teamwork There are three basic strategies by which effective teamwork can be achieved. First, specific individuals, who have the correct KSAs, can be selected to participate in a team or to perform team-based work (Klimoski and Mohammed 1994). This strategy requires precise measurement of individual-level team competencies and a correct balancing of task-oriented and team-oriented KSAs among team members. Second, teamwork can be enhanced by modifying tasks, workflow, or structure (Campion, Medsker, and Higgs 1993; Campion, Papper, and Medsker 1996). In other words, one can examine the environmental conditions in which team-based work occurs and reengineer these conditions accordingly. Finally, individual team member competencies can be developed through training (Cannon-Bowers et al. 1995, 1989; Cannon-Bowers and Salas 1997; Leonard, Graham, and Bonacum 2004). Team training has been the most widely applied strategy to improve team performance. Team training is defined as applying a set of instructional strategies that rely on well-tested tools (e.g., simulators, lectures, videos) (Salas et al. 1999; Salas, Rhodenizer, and Bowers 2000). Effective team training reflects general principles of learning theory, presents information about requisite team behaviors, affords team members the opportunity to practice the skills they are learning, and provides remedial feedback. A great deal of research has been devoted to the most effective strategies and techniques for training specific team KSAs. A comprehensive review of this research has presented an extensive collection of principles and guidelines concerning the design and delivery of team training. For example, guidelines exist for assertiveness training (Smith-Jentsch et al. 1996), cross-training (Volpe et al. 1996), stress management training (Driskell and Johnston 1998), and team self-correction (Smith-Jentsch et al. 1998). Team training programs have been an essential component of the airline industry’s efforts to achieve high reliability. For over 30 years, crew resource management (CRM) has been a critical part of most airlines’ efforts to improve their margin of safety. Recent research suggests that CRM training results in heightened safety-related attitudes; improved communication, coordination, and decision-making behaviors; and enhanced error-management skills (Wiener, Kanki, and Helmreich 1993; Helmreich and Merritt 1998). CRM 1584 HSR: Health Services Research 41:4, Part II (August 2006) training has also demonstrated consistently positive results across a wide range of team structures, including pilot crews, maintenance crews, dispatch crews, and air traffic control teams (Helmreich and Foushee 1993; Oser et al. 2001; Smith-Jentsch et al. 2001). Interestingly, CRM’s effect on the ultimate criterion——a reduction in the number of accidents——has yet to be empirically established (Salas et al. 2001). However, accidents represent a poor criterion methodologically because they exhibit an extremely low base rate (Helmreich and Foushee 1993). Thus, researchers have relied on surrogate measures——like improvements in teamrelated knowledge and skills, behavioral demonstrations of CRM skills on simulated flights, instructor evaluations of trained versus untrained crews, and changes in an organization’s safety culture——to demonstrate the effectiveness of CRM training (Helmreich and Foushee 1993; Hansberger, Holt, and Boehm-Davis 1999; Ikomi et al. 1999; Incalcaterra and Holt 1999; Holt, Boehm-Davis, and Hansberger 2001). Similar to the airline industry, some type of formal team training is now a major component of training in most branches of the United States Armed Forces. For example, all branches of the Armed Forces give their aircrews a military version of CRM, ranging from Fighter Resource Management (FRM) for single-seat fighter pilots to CRM training for the large crews that staff transport and patrol aircraft (Spiker et al. 1998). In addition, many sailors, soldiers, airmen, and marines receive team training. For example, the Navy, having tested several team-training approaches (Serfaty, Entin, and Johnston 1998), has adopted an approach called Team Dimensional Training (TDT), which resulted from the TADMUS program (Cannon-Bowers and Salas 1998). TDT addresses team-related knowledge and skills, provides practice in briefing and debriefing, and trains trainers and team leaders to evaluate and critique team skills (Tannenbaum, Smith-Jentsch, and Behson 1998). TEAMS AND HROS The characteristics of HROs dictate that teamwork is an essential component of such organizations. HROs will not achieve high reliability unless its members are able to effectively and efficiently coordinate their activities. In the previous section, we have spent considerable time clarifying what we mean by ‘‘teams’’ and ‘‘teamwork.’’ In this section we define the concept of high Essential Component of High-Reliability Organizations 1585 reliability, review the key characteristics of HROs, and demonstrate why teamwork is so critical in such organizations. HROs are defined by their potential for causing failures that lead to catastrophic consequences. If the potential is high (thousands of dramatic failures), but the actual number of failures is low, the organization is an HRO (Roberts 1990a). For example, a nuclear power plant failure could result in horrific consequences for its surrounding community, although such failures are extremely rare. The same can be said for many U.S. hospitals——there are thousands of opportunities for major accidents everyday. Although the IOM estimated that 98,000 preventable deaths occur per year, the actual occurrence of medical error resulting in deaths is extremely low (Kohn et al. 1999). HROs are those organizations that function in hazardous, fast-paced, and highly complex technological systems essentially error-free for long periods of time (Roberts 1990a, b). Roberts and Rousseau (1989) identified eight characteristics of HROs: (1) hypercomplexity, (2) tightly coupled, (3) extreme hierarchical differentiation, (4) many decision makers working in complex communication networks, (5) high degree of accountability, (6) frequent, immediate feedback regarding decisions, (7) compressed time factors, and (8) synchronized outcomes (Roberts and Rousseau 1989). Below we review each of these characteristics, demonstrate how teamwork is an essential component of effective performance in such organizations, and provide a health care example, where appropriate. Hypercomplexity is defined as an extreme variety of components, systems, and levels, each having their own standard procedures, training routines, and command hierarchy (Roberts and Rousseau 1989). Based on its definition alone, successful performance in hypercomplex environments relies upon multiteam systems and teamwork is an essential component of such environments. For example, Roberts and Rousseau describe aircraft carrier operations is indicative of hypercomplexity. Pilots, air traffic controllers, dispatchers, ground crews, and many others must work collectively to launch and recover aircraft. These interdependent teams (e.g., air traffic control team, aircrews, maintenance teams, etc.), must coordinate their activities and effi- ciently monitor each other’s performance. Similarly, the delivery of health care occurs in a hypercomplex environment that is dependent on multiteam systems. Even though health care workers have historically operated in distinct silos and have been trained in separate professions and possess distinct expertise, these individual must coordinate to deliver safe care. At the most basic level, physicians must 1586 HSR: Health Services Research 41:4, Part II (August 2006) accurately communicate treatment information to the nurse based, in part, on information the nurse presents to the physician regarding the patient’s condition. Orders are written on the basis of this discussion and the physician’s examination of the patient. These orders are distributed to the pharmacy, X-ray, labs, physical therapy, etc., so that other health care professionals can collect additional information to provide insight regarding the patients or initiate treatment. Tight coupling is defined as reciprocal interdependence across many units and levels. Tight coupling relates to task interdependence, which is the defining characteristic of teams. That is, tasks performed by one member of the team are dependent on tasks performed by other members of the team and the performance of these tasks must be coordinated among team members for effective team performance (delivery of safe care). For example, in health care an emergency C-section is a tightly coupled event that involves several different members of the labor and delivery team. The nurse handling the case is typically the first to observe fetal distress and must communicate this information to the attending physician. The doctor must decide if a C-section is necessary based upon the information the nurse provides and review of information collected from the fetal heart rate monitor. If the attending decides to operate, appropriate staff must be notified (anesthesiologist, neonatologist, or pediatrician), and the patient must be moved to surgery. Before making the initial incision, the patient must be properly anesthetized and the staff should be briefed as to the status of the patient and the baby. This process, which involves a series of interdependent steps, can take place in a matter of minutes depending on the history of the case and the level of fetal distress observed. For such a sequence to run smoothly, teams must use effective communication and have a shared understanding of the mother’s and baby’s condition. The Joint Commission ( JCAHO) reported that ineffective communication resulted in 70 percent of all preventable errors involving death or serious injury from 1995 to 2003 ( JCAHO 2004). Extreme hierarchical differentiation is defined as an organizational structure in which levels and roles are clearly differentiated. This characteristic is also true of most health care teams. Physicians tend to be at the top of this hierarchy with the case or treatment resulting from their directions. Therefore, a great deal of coordination is necessary to keep physicians, nurses, and technicians working together as a cohesive unit. Unfortunately hierarchy often makes it more difficult for medical teams to achieve this level of coordination and cohesiveness. In fact, research suggests that the extreme hierarchical difference between physicians and nurses in particular can contribute to Essential Component of High-Reliability Organizations 1587 dysfunctional communication yielding less than optimal patient care (Keenan, Cooke and Hillis, 1998; Knox and Simpson 2004). Although most medical teams are hierarchical, high-reliability teams trained in teamwork exhibit characteristics such as assertiveness and mutual trust, which reduce the negative effects of hierarchy. Mutual trust, an essential teamwork KSA, involves a shared belief that team members will protect and support the interests of their team (Sims et al. 2004). Team members with mutual trust are willing to admit to mistakes and accept and appreciate feedback (Bandow 2001; Webber 2002). This allows team members to firmly assert their concerns even to a higher-ranking team member without fear of reprisal. Another key characteristic of HROs is that they contain many decision makers working in complex communication networks (Roberts and Rousseau 1989). This characteristic personifies most health care teams. First, team members continually need to make important decisions concerning patient care (e.g., start an IV, induce labor, administer narcotics, admit patient). Consequences of these decisions clearly have implications on the ultimate well being and safety of patients. As most teams in health care are comprised of four to six unique individuals, however, decisions are not always unanimous. Second, as different team members are trained separately in their respective professions (e.g., medical school and nursing school), they have learned to communicate differently and have varying styles of conveying information depending on their role. Fortunately, new and emerging techniques like the Situation Background Assessment Recommendation (SBAR) strategy have been used in health care to overcome such communication difficulties with positive results (Leonard et al. 2004). This particular strategy facilitates clear and concise communication among members of health care teams by providing an easy-to-remember acronym used for framing critical conversations. A high degree of accountability in HROs is characterized by the severe consequences that can result from errors (Roberts and Rousseau 1989). Although serve consequences may be characteristic of all teams (e.g., project teams), in health care, the consequence of a mistake can often be death the patient. Preventable medical errors that result in loss of human life eternally affect the patient’s family, the staff that tended to the patient, the community, and the hospital’s reputation. However, even small mistakes resulting in patient harm yield grave consequences, yet not all medical team members are held equally accountable when errors do occur. More often then not, it is the physician in charge of the patient’s care that gets the brunt of the blame for any mistakes made. Malpractice lawsuits or the possibility of losing one’s license 1588 HSR: Health Services Research 41:4, Part II (August 2006) are very real outcomes that add to pressures felt by already stressed physicians. Consequences may also be present for the hospital such as loss of accreditation, and negative media attention. HROs are also characterized by ‘‘immediate feedback’’ resulting from their decisions; the plane crashes; there is a nuclear disaster; the patient is injured (Roberts and Rousseau 1989). In other words, there is an identifiable, measurable outcome associated with HRO performance. Such outcomes are typically an indicator of poor team and/or system processes within the HRO. For example, in aviation 60–80 percent of all accidents are attributed to human error as opposed to anything technically wrong with the aircraft. Similarly, the IOM report points to human error as a major contributor in patient deaths (Foushee 1984; Kohn et al. 1999). Immediate feedback is also a characteristic of effective team performance. Team members must monitor each other and provide each other feedback to maximize team functioning. However, feedback here focuses on team process and its improvement rather than solely on team outcomes. To ensure that feedback occurs, team members must be trained to deliver timely, behavioral, and specific feedback to one another (using such strategies as TDT). The ability to monitor each other’s performance and effectively provide feedback to other team members is a critical facet of achieving higher reliability in health care and elsewhere. Major HRO activities often occur under compressed time, as in the case of naval flight operations where aircraft are launched and recovered in 48–60- second intervals (Roberts and Rousseau 1989). Somewhat different than the other characteristics, the extent to which this variable is related to team performance is a function on the environment in which the team operates as opposed to the team itself. Some teams operate under compressed time while others do not. The same is true of health care, with a slightly different twist. Routine procedures like childbirth can quickly become a stressful, time compressed situation should a problem arise with the mother or baby. In such cases, teams need to be able to quickly adapt. Team members may have to be quickly added and integrated into the team and task——anesthesiologist, emergency response team——or existing members may have to take on new roles—— OB-GYN converts from coaching the mother through a normal delivery to conducting an emergency C-section. The last characteristic of HROs is that critical outcomes occur simultaneously (Roberts and Rousseau 1989). As discussed earlier, team members work together on interdependent tasks. This is what separates teams from groups or individuals working in isolation. Interdependency creates the need for Essential Component of High-Reliability Organizations 1589 synchronization of activities and outcomes. For instance, when delivering a baby, each member of a labor and delivery team is actively engaged in different aspects of the process yet their actions are synchronized. As can be seen from the description above, the HRO environment demands teamwork. Teamwork, or the KSAs that comprise it (refer to Table 1), are critical for successful performance in organizations that are hypercomplex, tightly coupled, hierarchical, time compressed, and rely upon synchronized outcomes (Sims et al. 2004). Aviation, the military, and now health care acknowledge the criticality of teamwork in achieving high reliability despite data that show a direct relation between team training and the ultimate criterion, a reduction in errors (e.g., accidents, deaths, etc.) (Salas et al. 2001). However, the science of teamwork and team training is still evolving, particularly in health care. The IOM report did much to stimulate research on health care teams, but much of this early work relied upon direct transitions from the commercial airlines to health care. Despite the work of Gaba and colleagues, it is only within the last 3 years that the science of health care teams has really begun to emerge and take hold (Baker et al. 2003). As a result, a number of questions remain that health care must address to have a firm understanding of teamwork and its relation to patient safety and high reliability. Direct transitions from aviation without additional study are insufficient. In the next section, we outline a series challenges the health care community must address to better understand health care team performance, how to maximize this performance, and ultimately improve patient safety. CHALLENGES Throughout this paper we focused on three basic themes. First, the delivery of health care, by its nature, requires that organizations providing such services act as HROs. Patients expect error-free care (Knox and Simpson 2004). Second, teamwork is an essential component of HROs. Although not the sole determinant of high reliability, HROs are typically comprised of teams embedded in multiteam systems and effective teamwork is critical for success in environments that demand high reliability (Wilson et al. 2005). Finally, the easiest way of improving teamwork is through training. Team training has been effectively implemented in the commercial airlines and the military with positive results (Salas et al. 2001). Such training programs are now emerging in health care with potentially similar benefits (Baker, Beaubien, and Holtzman 2003). 1590 HSR: Health Services Research 41:4, Part II (August 2006) Nonetheless, teamwork in health care is an emerging science. To move this science forward so that findings can be transitioned and implemented, we recommend that health researchers, quality improvement specialists, regulatory bodies, and others seek to address the following challenges. Challenge 1: A Theoretical Model of Team Performance in Health Care Should Be Developed To date, research has not developed a comprehensive model of team performance in medical settings; consequently, existing and emerging team training programs are not grounded in a scientific understanding of what comprises effective teamwork in health care (Baker et al. 2003, 2003). In our review of the team literature, we recommend the teamwork framework advocated by Salas and colleagues and this framework serves as the foundation for AHRQ’s TeamSTEPPS training program. However, the Salas model needs to be tested in health care to determine (1) the relations among predictors of performance (team KSAs) and (2) the relations between predictors (KSAs) and outcome criteria (e.g., quality of care, error management, effi- ciency, etc.). Challenge 2: Proven Instructional Strategies Should Be the Basis for Team-Training Programs in Health Care Team training is the most practiced strategy for enhancing team performance and improving team outcomes. Most HROs provide some form of team training and the science of team training has developed and validated numerous training strategies. Through a variety of formats and objectives, these strategies extend beyond CRM training. However, health care seems to be focused on adapting CRM programs derived directly from aviation (Baker et al. 2003) and not implementing other strategies which have been shown to be effective and may by more appropriate (i.e., team dimensional training). Therefore, we challenge health care to (1) move beyond CRM and look to other validated methods, (2) use these strategies wherever possible as the foundation for team training programs, and (3) test and refine these strategies to ensure that they effectively generalize to health care teams. It is only through implementation, testing, and refinement that health care will be able to understand and demonstrate how to enhance teamwork. Essential Component of High-Reliability Organizations 1591 Challenge 3: Team-Training Strategies Must Be Further Adapted to Specific Health Care Needs Similar to our previous recommendation, we are convinced that no single model of team training, like CRM, can be applied across all health care services and contexts when attempting to achieve high reliability. For purposes of this discussion, we define a ‘‘service’’ as a medical specialty or subspecialty, such as emergency medicine, general or family medicine, intensive care, general surgery, obstetrics, etc. Medical services differ dramatically across a variety of criteria: size, purpose, duration, redundancy of expertise, decision time, and consequence of error, to name but a few. In addition, services operate in a number of diverse contexts. As an example, emergency medicine providers function in hospital emergency departments, in emergency-response mobile units, and on battlefields. Similarly, urban and rural providers operate in independent or multipractitioner offices, as well as in community walk-in clinics. Neither the competencies that impel successful teamwork nor an optimal team-training strategy can be expected to generalize across all these contexts. And, of course, not all members within the same team will necessarily need the same KSAs. Therefore, in addition to the core competency taxonomy, the science of teamwork in health care must seek to develop service-specific taxonomies. These putative taxonomies would not be redundant with the generic, core competency taxonomy. Rather, a specific taxonomy would denote the specific KSA requirements that are central to teamwork in a given service, thus maximizing team performance within that service. The task content and procedures that define this service would drive the identification of relevant team competencies. Virtually no previous research has addressed the manner in which differences within and among health care services should be reflected in servicespecific taxonomies and customized training. Yet we find this issue sufficiently compelling, particularly with the context of HROs, because it suggests that customized solutions are warranted to achieve high reliability. Therefore, while a generic taxonomy of team KSAs is the foundation to teamwork in health care, we argue that these competencies must be refined and training must be tailored to a specific service to maximize team performance and safety. Challenge 4: Team Training Must Be Institutionalized throughout Health Care and Professional Training Finally, health care must work to integrate teamwork throughout every level of training and education of health care professionals. By ‘‘integrated’’ we mean 1592 HSR: Health Services Research 41:4, Part II (August 2006) instruction, measurement, and feedback on critical team KSAs occurs as part of a health care professional’s technical education and training. Using this approach, team concepts become a part of everyday practice. Several initiatives by physician education, certification, and licensing boards have already begun to move health care toward integrating team concepts. For example, the ACGME has identified several teamworkrelated competencies that residents must master as part of the ACGME outcomes project (www.acgme.org). Similarly, AAMC funded a ‘‘critical incident’’ analysis to investigate the behaviors that result in successful and unsuccessful performance during medical school and residency (Adams et al. 2001). Although not originally targeted toward team performance, the results revealed the importance of a number of teamwork-related competencies. Building off existing initiatives, we believe that the structure of health care, as currently conceptualized, offers appropriate junctures where teamwork skills could be evaluated. For example, like the examinations that are constructed for board certification in medical specialties, it might ultimately be useful to develop a board certification test for teamwork. Such an exam might combine a written test of knowledge and situational judgment with performance in a simulated scenario. Because the board examinations are practicespecific, their teamwork component could assess practice-specific teamwork competencies. In addition, the JCAHO currently evaluates hospitals on criteria that range from medical practices to managerial systems to facilities maintenance. At some point in the future, folding team competency criteria into the JCAHO evaluation might focus providers’ attention on the importance of teamwork in medical settings, as well as yielding valuable research data. In summary, we have argued that teamwork is an essential component of achieving high reliability for health care organizations. HRO environments demand teamwork and, as a result, the science of team training can provide great insights and proven techniques for improving performance within such organizations. In closing, we recommend that health care gain traction from the more than 20 years of research on team performance and training and that these principles be first tested and then integrated into the practice of health care and the training of health professionals. Although this will take considerable time, perhaps spanning a generation, this approach has been one of the key drivers in other industries achieving the highest reliability possible. We believe that the challenges we have presented here provide a roadmap with which health care can continue. Essential Component of High-Reliability Organizations 1593 REFERENCES Adams, K. A., G. F. Goodwin, C. A. Searcy, D. G. 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S TUD Y P RO TOCO L Open Access Effectiveness of a new health care organization model in primary care for chronic cardiovascular disease patients based on a multifactorial intervention: the PROPRESE randomized controlled trial Domingo Orozco-Beltran1*, Esther Ruescas-Escolano1 , Ana Isabel Navarro-Palazón1 , Alberto Cordero2 , María Gaubert-Tortosa1 , Jorge Navarro-Perez3 , Concepción Carratalá-Munuera4 , Salvador Pertusa-Martínez5 , Enrique Soler-Bahilo6 , Francisco Brotons-Muntó7 , Jose Bort-Cubero7 , Miguel Angel Nuñez-Martinez1 , Vicente Bertomeu-Martinez2 , Vicente Francisco Gil-Guillen4 and PROPRESE research team Abstract Background: To evaluate the effectiveness of a new multifactorial intervention to improve health care for chronic ischemic heart disease patients in primary care. The strategy has two components: a) organizational for the patient/professional relationship and b) training for professionals. Methods/design: Experimental study. Randomized clinical trial. Follow-up period: one year. Study setting: primary care, multicenter (15 health centers). For the intervention group 15 health centers are selected from those participating in ESCARVAL study. Once the center agreed to participate patients are randomly selected from the total amount of patients with ischemic heart disease registered in the electronic health records. For the control group a random sample of patients with ischemic heart disease is selected from all 72 health centers electronic records. Intervention components: a) Organizational intervention on the patient/professional relationship. Centered on the Chronic Care Model, the Stanford Expert Patient Program and the Kaiser Permanente model: Teamwork, informed and active patient, decision making shared with the patient, recommendations based on clinical guidelines, single electronic medical history per patient that allows the use of indicators for risk monitoring and stratification. b) Formative strategy for professionals: 4 face-to-face training workshops (one every 3 months), monthly update clinical sessions, online tutorial by a cardiologist, availability through the intranet of the action protocol and related documents. Measurements: Blood pressure, blood glucose, HbA1c, lipid profile and smoking. Frequent health care visits. Number of hospitalizations related to vascular disease. Therapeutic compliance. Drug use. (Continued on next page) * Correspondence: dorozcobeltran@gmail.com 1 Unidad de docencia e investigación, Hospital Universitario de Sant Joan d’Alacant, Ctra. Nnal. 332 Alicante, Valencia s/n, Sant Joan d’Alacant Alicante 03550, Spain Full list of author information is available at the end of the article © 2013 Orozco-Beltran et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Orozco-Beltran et al. BMC Health Services Research 2013, 13:293 http://www.biomedcentral.com/1472-6963/13/293 (Continued from previous page) Discussion: This study aims to evaluate the efficacy of a multifactorial intervention strategy involving patients with ischemic heart disease for the improvement of the degree of control of the cardiovascular risk factors and of the quality of life, number of visits, and number of hospitalizations. Trial registration: NCT01826929 Keywords: Health services research, Cardiovascular diseases, Primary care, Secondary prevention Background The medical, health care, financial, personal and family burden of chronic disease is one of the main threats to the sustainability of the health system. At present, 70% of health care expenditure is used to treat chronic diseases [1]. Accordingly, health care systems are now moving towards more patient-centered models based on self-care and therapeutic education as ways of promoting the participation of the patients in their own treatment [2]. Cardiovascular disease (CVD) is one of the main chronic diseases, and is in fact the leading cause of death in the Spanish population. In 2007 it accounted for 124,126 deaths in Spain, representing 32% of all deaths [3]. In Spain, ischemic heart disease (IHD) causes most CVD deaths (30% overall; 37% in men and 24% in women). The hospital morbidity rate for IHD was 317 per 100,000 inhabitants (447 in men and 189 in women) [3–5]. Lifestyle changes (giving up smoking, a Mediterranean diet and exercise) have been shown to decrease cardiovascular morbidity and mortality in patients with IHD. In addition, much evidence now exists concerning pharmacological treatment aimed at the associated risk factors [5]. The latest European guidelines aim to increase the involvement of the primary care professionals in the implementation of the preventive activities for these patients. The guidelines emphasize a patient-centered approach, joint decision-making, and the importance of establishing realistic and feasible objectives, as tools to improve compliance with medication and lifestyle changes [6–8]. A recent Cochrane library review stresses the importance of primary care and the need to improve the organization of the health care services for the secondary prevention of IHD [9]. However, difficulties exist when incorporating the results of the various studies into clinical practice. Comparison of the results from the EUROASPIRE I to the EUROASPIRE III studies, in patients with IHD, shows that the prevalence of risk factors remains high: smoking hardly changed (20.3%, 21.2%, and 18.2%), obesity (body mass index ≤ 30) increased from 25% to 32.6% and 38%, and poorly controlled blood pressure (BP) (≥ 140/ 90 mmHg) changed very little (58.1%, 58.3%, and 60.9%). Only in the prevalence of hypercholesterolemia was an important decrease observed, from 94.5% to 76.7% and 46.2%. Concerning the use of drugs, between the EUROASPIRE I and the EUROASPIRE III studies [10] antiplatelet drugs rose from 80.8% to 93.2%, beta blockers from 56% to 85.5%, antihypertensive drugs from 84.5% to 96.8%, and lipid-lowering drugs from 32.2% to 88.8%. Although improvements have been noted, an important percentage of patients still exists in whom the control of risk factors could be improved. Studies carried out in our area show that 54% of the patients with a history of myocardial infarction had hypercholesterolemia, 41% had high blood pressure, 11% were smokers, and 19% were obese; in addition, there was a clear underuse of medication [11]. Therapeutic educational interventions, such as the Chronic Care Model (CCM) that includes educational, organizational and community participation interventions; the Stanford Expert Patient Program (EPP); and the Kaiser Permanente model [12,13] have all shown their benefit in patients with a high CVD risk and their effect on clinical measures and health care use. Based on these models, various initiatives to improve the secondary prevention of coronary disease patients have been undertaken in our area [14,15]. The ICAR study assessed the efficacy of an intensive secondary prevention program of coronary disease carried out in primary care. However, improvement was only found in blood pressure control and an increase in HDL-cholesterol concentrations [14]. The PREseAP study assessed the efficacy of an intervention carried out by nurses, but with no positive results [16,17]. Another intervention study also from primary care [18] found that admissions to hospital were significantly reduced, but no other clinical benefits were shown, possibly because of a ceiling effect related to improved management of the disease. Given these poor results, we designed a multifactorial intervention based on the CCM, integrating professionals from cardiology services and primary care, in an attempt to improve the degree of control of CVRF and reduce the number of hospital admissions. Main objective To evaluate the effectiveness of a new multifactorial intervention in order to improve health care for chronic IHD Orozco-Beltran et al. BMC Health Services Research 2013, 13:293 Page 2 of 9 http://www.biomedcentral.com/1472-6963/13/293 patients in primary care. The strategy consisted of two components: a) organizational for the patient/professional relationship, and b) formative for the professionals. Specific objectives Level of control/follow-up of the following variables: blood pressure, capillary blood glucose, HbA1c, LDL cholesterol, body mass index, therapeutic compliance, exercise, smoking, adherence to a Mediterranean diet, incidence of hospital admissions related to vascular disease, annual primary care visits (number of visits in one year) and drug use (antiplateled drugs, beta blockers, ACE inhibitors/ARA II, statins). Hypothesis A multifactorial primary care intervention based on chronic models [12] can improve the level of control and reduce the number of hospital admissions in patients with IHD. Methods/design Study design Experimental design. Type of study: open randomized clinical trial. Follow-up period: one year. Participants Setting: Primary Health Care. Valencian Community (Spain). 15 Health centers: Alicante-Cabo-Huertas, AlicanteCampello, Alicante-Plà Hospital, Castellón-Dolores-CanoRoyo-Villareal, Castellón-La-Bobila-Villareal, CastellónCariñena-Villareal, Castellón-Nules, Castellón-Vall d’Uxo I and II; Valencia-S Pau, Valencia-R-Argentina, ValenciaBenimaclet and Valencia-Serreria-II. Inclusion criteria: patients with a diagnosis of IHD of any site (ICD-10 codes from 410 to 414 inclusive); age from 30 to 80 years; signed written informed consent. Exclusion criteria: lack of consent; immobilized patients; patients with serious health problems or with a low life expectancy. Data are collected from electronic health record system. Interventions Organized intervention strategy aimed at patients and professionals: 1. Organized intervention strategy: a) Informed active patient. By means of therapeutic education of the patient according to the CCM recommendations and following the Stanford EPP model. To promote patient autonomy: self-measurement of blood pressure and blood glucose control. Use of recommendations for patients in a uniform format and content for all the professionals using the recommendation forms for patients with chronic diseases (hypertension, diabetes, IHD, obesity, smoking) available in the electronic medical history. b) Shared decision making. Personalized control objectives. To seek ways of promoting the increased participation of chronic patients in their treatment and the sharing of decisions. Creation of a patient follow-up record showing the state of the different study variables. The achievement of the objectives is evaluated with a traffic light type graph identifying the degree of compliance in the colors green, amber or red. Personalized and agreed objectives are established for each patient and shown on the record (see Figure 1). The IHD patient care protocol of the SVMFiC (2010 update) is used [19], available via the Abucasis intranet. The criteria used to define good control of the variables (Table 1) are those of the Cardiovascular Disease Prevention Group of the Preventive Activity and Health Promotion Program (PAPPS) [5]. c) Appointment planning. Every three months, although variable depending on the patient, to provide time to evaluate the agreed changes. At nurse/patient visits to assess: diet, exercise and therapeutic compliance at 2 weekly sessions every 3 months (Tables 2 and 3). d) Primary care doctor-nurse teamwork. Joint work with agreed aims in a basic primary care health unit. e) Actions based on scientific evidence. Work following electronically available protocols validated by scientific societies integrated in the Valencian Medical Institute. Communication with the cardiology service, to facilitate the interconsultation between primary and secondary care. f ) To promote information systems through a single electronic history shared between primary and secondary care. Evaluation of indicators of program follow-up. 2. Formative intervention strategy for professionals: a) Formative. Four face-to-face workshops (every 3 months); monthly clinical session on cardiovascular disease; online tutorials with the cardiology service to solve any doubts. Faceto-face tutorials with a team, reference doctor/nurse, in each health center. b) Strategies to avoid clinical inertia: carry out therapeutic changes if there is poor control before 3 months. Orozco-Beltran et al. BMC Health Services Research 2013, 13:293 Page 3 of 9 http://www.biomedcentral.com/1472-6963/13/293 Outcome measures Primary outcome measure: number of hospitalizations/ cause. It is measured at the beginning and end of the study. Secondary outcomes: a) Level of control of CVRF: Blood pressure, LDL cholesterol, body mass index, basal blood glucose, HbA1c, therapeutic compliance (pill count), smoking. They are measured at each visit. b) Healthy life habits: Exercise, mediterranean diet. They are measured at each visit. c) Management: Number of annual primary care visits. It is measured at the end of the study. To enhance the quality of measurements a training program is performed and there was one assessor for every three health centers. Sample size The calculation of the sample size is carried out to compare means, with an alpha risk of 0.05 (95% confidence level) and a beta risk of 0.20 (80% power). For an estimated difference in SBP of 5 mmHg and a standard deviation of SBP of 2.5 mmHg, the number of persons necessary is 251 patients per group. Increased by 20% for possible losses, giving a total of 301 patients in each group. Randomization, allocation and implementation Valencia is a Mediterranean Spanish Region with 5 million inhabitants. In 2007, 800 primary care physicians and nurses started the ESCARVAL primary prevention cohort study [20]. 72 Health centers (HC) participated including 50000 patients. Figure 1 Personalized follow-up record. Table 1 Therapeutic objectives Variable Objective Basal blood glucose < 126 mg/dl HbA1c < 7%; Blood pressure ≤140/90 mmHg LDL cholesterol ≤ 100 mg/dl Therapeutic compliance* 80-110% Practice of exercise 30 minutes per day > 3 days per week Mediterranean diet Validated survey. (*)Pill count. Table 2 Primary care visit timeline Visit timeline Follow-up months 1 2 3 4 5 6 7 8 9 10 11 12 Nurse √ √ √ √ √ √ √ √ Physician √√√√ Orozco-Beltran et al. BMC Health Services Research 2013, 13:293 Page 4 of 9 http://www.biomedcentral.com/1472-6963/13/293 For the intervention group in the PROPRESE study 15 HC are selected from those participating in ESCARVAL. Once the center agreed to participate patients are randomly selected from the total amount of patients with IHD registered in the electronic health records. For the control group a random sample of patients with IHD is selected from all 72 HC electronic records. Patients are enrolled by their primary care physicians who will offer to participate to the randomly selected patient. Blinding Blinding is not possible as the intervention is a multifactorial approach. That’s why the control group is selected after the intervention is made but for the same period of time. Statistical analysis The results are expressed as frequencies and percentages for qualitative variables and as mean and standard deviation for the quantitative variables. For the statistical analysis, the study of categorical variables is carried out by the ×2 test and the comparison of the continuous variables between groups of patients by the Student t test and ANOVA. A multivariate analysis will be carried out to evaluate the effect of the intervention. The SPSS PC 15.0 program will be used. The reference search was performed in the Medline database through PubMed. The MeSH terms used were: “Myocardial Ischaemia/prevention and control” [Mesh]” OR “Myocardial Ischaemia/epidemiology” [MeSH], OR “Coronary Artery Disease”[MeSH Terms] AND “Secondary prevention”. A second search included: “Patient Education” as Topic/methods OR “Patient Participation” OR “Self-Help Groups” OR “Program Evaluation” AND “Myocardial Ischaemia”. In the Cochrane database we used the MeSH terms: Patient Education, Lifestyle. The search was limited to publications in the last 5 years, only items with abstracts, studies in humans, and a publication type of Meta-Analysis and Systematic Review. In the Cochrane database we also used the search limit of the last 5 years. Follow-up Table 4 shows the follow-up plan and patient data collection. Functions of the professionals participating in the study are described in Table 5. Figure 2 provides a flow diagram of the study. Ethical and legal issues This study protocol has been reviewed and approved by the Ethics Committee for Clinical Trials from San Juan de Alicante Hospital (Comite Ético de Investigación Clínica (CEIC) del Hospital Universitario de San Juan de Alicante), on December 2nd, 2009. The study is conducted according to the standards of the International Guidelines for Ethical Review of Epidemiological Studies (Council for International Organizations of Medical Sciences- CIOMS-Geneva, 1991) and the recommendations of the Spanish Society of Epidemiology about the review of ethical aspects of epidemiological research. Confidentiality of the data All information relative to the patient’s identity is considered confidential. The data generated during the study will be handled according to the Law 5/1999 and corresponding normative. Any researcher with access to the data used in the study will be required to sign a document guaranteeing confidentiality. Informed consent All patients must read the “Patient Information Form” and sign a document giving their consent. Discussion IHD is one of the main causes of death despite the great capacity for prevention that is available. Nowadays, multiple therapeutic tools of proven efficacy exist to control the main CVRF, as well as guidelines and protocols endorsed by the main scientific societies [5–7,19]. However, the degree of control of the CVRF in patients with IHD is low [15–17], which results in a higher use of health services. The frequency of primary care visits of a person with diabetes in Spain is 28 per year, even though this does not necessarily imply greater control [21]. Two of the main reasons for this are lack of treatment compliance and therapeutic inertia in the office, control of which has not improved in recent years [22–25]. Table 3 Task distribution in the follow-up clinics Risk factors Physician Nurse 1 Assess Abucasis register. ++ ++ 2 Establish personalized objectives. ++ ++ 3 Assess degree of control. ++ ++ 4 Assess therapeutic compliance. + ++ 5 Assess attitude towards each objective. ++ ++ 6 Agree interventions with the patient. ++ ++ 7 Adequate pharmacological treatment. ++ – 8 Individual intervention. ++ ++ 9 Team intervention. – ++ 10 Community intervention. – ++ Orozco-Beltran et al. BMC Health Services Research 2013, 13:293 Page 5 of 9 http://www.biomedcentral.com/1472-6963/13/293 The CCM [12] consider acting on these factors through new approaches. These models involve patient training to achieve greater autonomy and information, and the identification of high-risk patients to give them a more individualized and protocolized care. Accordingly, the present study involved an organizational intervention based on CCM together with an educational intervention, integrating cardiology service professionals and primary care professionals (general practitioners and nurses), in an attempt to improve the degree of control of CVRF and decrease the number of hospitalizations. This intervention aims to increase the degree of selfcontrol for these patients as well as their ability for selfcare and decision making to improve their long-term survival. At the same time, the greater degree of information and education can facilitate the increase in compliance that should result in an improvement in the therapeutic objectives. The health care team-work methodology will be modified with more resolute and specific patient-centered Table 4 Follow-up plan and collection of patient data Enrolment allocation Intervention group: 15 HC selected from those participating in ESCARVAL-risk study. 350 patients randomly selected from the total amount of patients with IHD registered in the electronic health records. Patients are enrolled by their primary care physicians. (Inclusion and exclusion criteria). Control group: A random sample of patients (350) with IHD selected from 72 HC electronic records (from ESCARVAL-risk study) Intervention follow-up: 1 year Baseline data Personalized follow-up record Starting formative intervention strategy for professionals and patients: Intervention Patients Professionals First visit Evaluate monitoring of CVRF Advice online by cardiologist Accord control objectives Monthly updates Adherence control Protocols, guides and bibliography reviews Therapeutic education In-class training course Second visit Evaluate monitoring of CVRF Advice online by cardiologist Accord control objectives Monthly updates Adherence control Protocols, guides and bibliography reviews Therapeutic education In-class training course Third visit Evaluate monitoring of CVRF Advice online by cardiologist Accord control objectives Monthly updates Adherence control Protocols, guides and bibliography reviews Therapeutic education In-class training course Number of hospital admissions Outcomes Statistical analysis. Loses to follow-up. Presentation of results at participating HC. Final report HC, Health Center. Table 5 Functions of the professionals participating in the study Functions of each professional in the study Primary care physicians/ nurses: – Identification of patients to include. – Inclusion and contact with patients. – Adaptation of therapeutic interventions. – Therapeutic compliance. Reference cardiologists and group of experts – Workshop teaching. – Online tutorials. – Selection of documents, guidelines and protocols. San Juan Alicante Department Research Unit – Analysis of the data and interpretation of the results Abucasis responsible – Facilitate the use of the electronic medical history through response to doubts or information about not very used resources. Orozco-Beltran et al. BMC Health Services Research 2013, 13:293 Page 6 of 9 http://www.biomedcentral.com/1472-6963/13/293 office visits, without increasing the work load in the primary care offices. This is aimed at reducing clinical inertia. The Abucasis computer system, available in secondary and primary care offices, facilitates the interaction between levels of health care as well as being a common and unique site for the patient to record and control the main CVRF. The validity of the results, which depends on the representativeness of the sample, is controlled by the selection criteria designed and in relation to study power, through the sample size calculated taking into account any unexpected loss by controlling the random error. Some multifactorial interventions have been published specially based on nurse work [26] but no very good results have been obtained. Our study has some different aspects that can be mentioned: we use an unique electronic health record for primary and secondary care improving communication between professionals, we implement CCM strategies involving patients with self-care, sharing decisions about the level of control to be reached and objective based treatments, involving all primary care team (physicians and nurses) and cardiologists. In conclusion, this study will provide information about the efficacy of a patient-centered intervention based on the CCM. Actions will be centered on identifying the higher-risk patients, such as those in secondary prevention; on greater patient information and capacity, favoring autonomy; on shared decision making to establish and reach the control objectives; and an individualized programming of appointments, relying for all this on the teamwork of primary care nurses and physicians under the supervision of the reference cardiology service. Abbreviations IHD: Ischemic heart disease; HC: Health centers; CVD: Cardiovascular disease; CVRF: Cardiovascular risk factors; CCM: Chronic care model; EPP: Expert patient program; LDL: Low density lipoprotein; HDL: High density lipoprotein; SVMFiC: Valencian medical society of family and community medicine. HbA1c: glycated hemoglobin. Competing interests The authors declare they have no competing interests. Authors’ contributions Conception of the idea for the study: DO, ER, MG and AIN. Development of the protocol, organization and funding: DO, ER, MG and AIN. Study design assistance: AC, JN, CC, SP, ES, FB, JB, MAN, VB and VFG. Writing of the manuscript: ER, DO and AIN. All authors have critically read the final manuscript draft, to make contributions, and have approved the final version. Acknowledgements This project was supported by governmental funds from Conselleria de Sanidad (Valencia Regional Ministry of Health) – Resolution 1 September 2010 (Exp. nº MLE 4/10) and managed by FISABIO. We gratefully thank PROPESE Study Research Team (Adriana Mabel Prina, Alba González Timoneda, Alberto Cordero Fort, Álvaro Bonet Plá, Amparo Andrés Pruñonosa, Amparo Biot Giner, Amparo Chalmeta Rosaleny, Amparo García Royo, Amparo Grau Estela, Amparo Zaragozá Muñoz, Ana Barber Moll, Ana Carmen Menero Pesudo, Ana Isabel Navarro Palazón, Ana Mª Melian Noguera, Ana María Cabrera Rodriguez, Ana Sanmartín Almenar, Ana Tchang Sánchez, Ana Vidal Ledesma, Angelina Morales Gisbert, Antoni Pastor Monerris, Antonia Torrent Soler, Figure 2 Flow diagram of the PROPRESE study. Orozco-Beltran et al. BMC Health Services Research 2013, 13:293 Page 7 of 9 http://www.biomedcentral.com/1472-6963/13/293 Antonio Latorre, Antonio Romero Aznar, Auxilio Aznar Montalt, Beatriz Valero Claramunt, Blanca Montagud Carda, Blas Cloquell Rodrigo, Carlos Castañeda Zapico, Carlos Fluixá Carrascosa, Carmen Fenoll Palomares, Carmen Hernández Pellicer, Carmen Miquel Roig, Carmen Rubio Martínez, Carmen Vicente Sol, Carmen Vives Casino, Carmen Zaragozá Cardells, Carmina Rubert Escrig, César Pérez Zaragoza, Concepción Barceló Iglesias, Concepción Carratalá Munuera, Concepción Laguarda Falomir, Concha Mora Marqués, Consuelo Aguilar Abad, Consuelo Arroyo Fernandez, Desamparados García Royo, Dolores García Cánovas, Dolores Jordá Prades, Dolores Larrey Aliaga, Domingo Guinot, Domingo Orozco Beltrán, Elena Giménez Esteban, Elena López Acuña, Elisa Fernández Ripoll, Elisa Medina Ferrer, Elvira Ferré Tortosa, Elvira Quelle Alonso, Emilia Ramis Ortega, Encarna Segarra Mestre, Enrique Guinot Martinez, Enrique Soler Bahilo, Estela Diaz Garcia, Esther Lara Fonfría, Esther Ruescas Escolano, Esther Santoro, Eugenia Avelino Hidalgo, Exaltación Vaquerizo, Feliciano Motilla López, Felin Gómez Piquer, Felipe Rico Noguera, Fernando Moreno Catalá, Francisca Ferrandiz Galvañ, Francisco Brotons Muntó, Francisco Cortés Traver, Francisco López, Francisco López Pérez, Francisco Milán Galvañ, Francisco Parra Godoy, Gema Gallego Triviño, Goretti Suarez, Hector Durá Ballester, Herminia Salla Granell, Ildefonso Espinosa Freire, Inma Guasp Pérez, Inma Mora Garzón, Inma Rosa Mora, Inmaculada De Scalz Giménez, Inmaculada Valls García, Isabel Cantarino Martí, Isabel Sierra Martín, J Enrique Martinez Jalvo, Jaime José Muñoz Gil, Javier Llopis Vicent, Jesús Bleda Cano, Joaquín Abad Carrasco, Joaquin Martínez Piquer, Jorge Gallego Peris, Jorge Navarro Perez, José E. Martínez Jalvo, José Garcia Gil, José Luis López Blasco, José Luis Martinez Perez, José Manuel Adría Micó, José María Tirado Meseguer, José Ramón Tárrega, Jose Vicente Armengol Bernabeu, José Vicente Bort Cubero, Jose Vicente Raga Casasus, Juan Alcamí Jaunzarás, Juan Antonio Sánchez Masiá , Juan Jose Molina Igual, Juan Pedro Chico Asensi, Juan Roses Yago, Juanjo Aragó Hervás, Laura Bordes García, Laura Pérez Buj, Leocadio Vegara Fernandez, Lola Nos, Lorena Salanova Chilet, Loreto Cruz Bonmati, Lucía Carbó Valverde, Luis Estal Andrés, Luis González Luján, Luis Jiménez Zarzero, Luisa Escalante Garcia, Luisa Picho Ramos, Luz Mª Roca Dobón, M José Cebrían Puertas, M Luisa Narciso Ramos, Mª Ángeles Martín Díaz, Mª Ángeles Pérez Corcoles, Mª Asunción Palomar Marín, Mª Carmen Ramos Almela, Mª Dolores Mechó Carreguí, Mª Dolores Espinosa, Mª Dolores Revert Vidal, Mª Jesús García Juan, Mª José Cebrián Puertas, Mª José Gil Tebar, Mª Luisa Asensio García, Mª Luisa Pichó Ramos, Mª Remedios Blasco Claramunt, Mª Rosario Forner Paris, Maite Alegría Bonias, Manuel Sanchez Miralles, Manuela Ruiz Martínez, Margarita Berenguer Jover, Maria Angeles Martí Sanmartín, María Gaubert Tortosa, María Montero Alarcon, María Serra Lluch, Marisa Narciso Ramos, Marisa Rico Bermejo, Marisa Romaguera Porta, Marisol Cantos Alcañiz, Marta Casanovas Mas, Marta Hernani Bengoa, Maruja Crespo Paredes, Mensin Herrero, Mercedes Pérez Rosado, Miguel Ángel Bregel Cebrián, Mónica Pellicer, Montserrat Ortells Ferrer, Nieves Gómez Moreno, Nieves Lambas Nuñez, Noelia Cruz Bernal, Nuria Domingo, Nuria Megía Rico, Nuria Pacual Regueiro, Nuria Paredes, Obdulia Castroverde Agudo, Paco Galán González, Paloma Ramos Ruiz, Patricia Sanahuja Gorris, Paula Ibáñez Trillez, Pepa Mayoll Jimenez, Pilar Blanco De Andrés, Pilar López López, Pilar Mallea Zuriaga, Pilar Martínez López, Pilar Roca Navarro, Pilar Sánchez Royo, Pilar Sendra Quevedo, Raquel Estrems Martín, Raquel Pérez Felip, Raquel Peris Roca, Remei Raga Marí, Ricardo Lequerica Llopis, Robert Mora Sancho, Roberto Carlos Paredes Carrillo, Rosa Carratalá Serra, Rosa Gonzalez Candelas, Rosa Llisterri De Losas, Rosa Mª Palacios Fort, Rosa Saiz Rodríguez, Rosario García Santafe, Rosario González Candelas, Rubén Solbes Francés, Salvador Alapont Ros, Salvador Espert Lozano, Salvador Pertusa Martínez, Santiago Gras Balague, Sara Carrascosa Gonzalvo, Serapio Sanchez García, Silvia García Piqueres, Silvia Segrera Manzano, Sonia Aguilar Godes, Sonia Alemañ Dabad, Susana Milián Beser, Teresa Almela Tejedo, Tomás Fernández Rodriguez, Trinidad Belenguer Sánchez, Vicent Badía Gimeno, Vicenta Pineda Ronda, Vicente Aquino Pérez, Victoria Broch Navarro, Victoria Gosalbes Soler, Xavier Bel Gausach) for undertaking the study. Author details 1 Unidad de docencia e investigación, Hospital Universitario de Sant Joan d’Alacant, Ctra. Nnal. 332 Alicante, Valencia s/n, Sant Joan d’Alacant Alicante 03550, Spain. 2 Servicio de Cardiología, Hospital Universitario de Sant Joan d’ Alacant, Ctra. Nnal. 332 Alicante, Valencia s/n, Sant Joan d’Alacant Alicante 03550, Spain. 3 CS Salvador Pau, c/ Salvador Pau, Nº 42, Valencia 46021, Spain. 4 Cátedra de Medicina de Familia. Departamento Medicina Clínica, Universidad Miguel Hernández, Ctra. Nnal. 332 Alicante-Valencia s/n, Sant Joan d’Alacant Alicante 03550, Spain. 5 CS Cabo Huertas, c/Arpón s/n, Alicante 03540, Spain. 6 CS Dolores Cano Royo, c/Martí l’Humá, 13, Vila-RealCastellón, Spain. 7 CS Carinyena c/Illes Columbretes, s/n 12540, Vila-Real, Castellon, Spain. Received: 9 April 2013 Accepted: 18 June 2013 Published: 2 August 2013 References 1. Strategy for Addressing Chronicity in the Spanish National Health System. (Executive Summary 2012). 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Submit your next manuscript to BioMed Central and take full advantage of: • Convenient online submission • Thorough peer review • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit Orozco-Beltran et al. BMC Health Services Research 2013, 13:293 Page 9 of 9 http://www.biomedcentral.com/1472-6963/13/293 BioMed Central publishes under the Creative Commons Attribution License (CCAL). Under the CCAL, authors retain copyright to the article but users are allowed to download, reprint, distribute and /or copy articles in BioMed Central journals, as long as the original work is properly cited.

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Teams

What are the advantages and challenges of teamwork in today’s health care organizations?  Provide examples of common obstacles to successful group communication that you have experienced or read about.  How did the group work through the challenges?  How does conflict affect communication in teams?  Is conflict negative or positive?

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