The Patient, the Multidisciplinary Team and the Assessment
3.9 Team Building and Team Working
The purpose of the team is to work in partnership with patients and others on their behalf to achieve optimal clinical outcomes. This would most commonly be the best achievable outcomes as judged by the clinical team although some patients will opt for less in accordance with their aspirations and beliefs. This shared goal setting with patients is a key element in planning care.
The team membership may be based on those people working together with spe- cific patients or, more broadly, by those working in a service setting with shared goals but not necessarily the same patients. The degree of interdependency and col- laboration between members will vary, and various terms are in use to describe these differences: multidisciplinary teams, interprofessional or interdisciplinary teams and transdisciplinary teams.
The use of these terms is not consistent internationally, but the relevant factors which distinguish patterns of collaboration include:
• A patient may be routinely assessed by several team members of different pro- fessions, or one leading member (usually a physician) determines their involve- ment (or not).
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• Team members agree a collective goal with the patient, or each member negoti- ates “their” specific goals with the patient individually.
• Team members share some assessment processes/tools and the information derived, whilst retaining specific expertise-based tools, or one team member has skills across the domains (wider than the usual skill set for that profession) and completes the initial assessment (and perhaps the treatment) on the team’s behalf.
• Each team member retains their own clinical records, or there is a shared clinical record to which all have equal access and entry rights. This is often cumbersome in practice unless facilitated by electronic records.
• The team has a shared clinical quality monitoring and review system, or mem- bers retain accountability and quality management only within their own profes- sional structures.
Whatever the degree of shared knowledge, skills and collaboration, communication and team governance are necessary for sustainable teamwork. A patient-centred approach requires as a minimum a negotiated goal and a shared vision in the team of the overall strategy to achieve this goal and a respect for the roles of each other in doing so.
Scheduled regular meetings to discuss patients’ progress, review goals and agree revi- sions to care plans are usually an essential component of successful team working.
Quality in care delivery can be judged by:
• Effectiveness – optimal outcome based on agreed goals
• Efficiency – best use of resources
• Experience of the patient during the journey of care
• Equitable – equal access for equal need regardless of age, sex, race, etc.
• Timeliness – the right care at the right time
Evaluations rarely encompass all these aspects, but comparative studies have demonstrated that at least effectiveness, efficiency and patient experience are enhanced by a closer collaboration in what would usually be regarded as an inter- disciplinary approach [6]. Professional guidance on standards of team working has been produced by the American Geriatrics Society [7] including a description of team member competencies.
Individual health professions tend to have distinct language and behaviours and different expectations of how dialogue is conducted. These differences have the potential both to enhance the team and its other members and also to become an obstacle to communication and collaboration. There is also an inevitable difference in levels of experience, which can result in hierarchies between members translating into an overemphasis on some aspects of the treatment approach. Experienced leadership can mitigate this pitfall.
The clinical complexity of older frail patients who benefit from CGA often requires careful scheduling of clinical inputs with contributions from less regular participants.
A holistic approach means respecting the differential contributions of medical treat- ments, functional rehabilitation and social and environmental adjustments.
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References
1. Mokkink LB, Terwee CB, Patrick DL, Alonso J, Stratford PW, Knol DL, Bouter LM, de Vet HCW (2010) The COSMIN checklist for assessing the methodological quality of studies on measurement properties of health status measurement instruments: an international Delphi stud. Qual Life Res 19(4):539–549
2. Terwee CB, Mokkink LB, Knol DL, Ostelo RW, Bouter LM, de Vet HC (2012) Rating the meth- odological quality in systematic reviews of studies on measurement properties: a scoring sys- tem for the COSMIN checklist. Qual Life Res 21(4):651–657. doi:10.1007/s11136-011-9960-1 3. Sullivan Pepe M, Janes H, Longton G, Leisenring W, Newcomb P (2004) Limitations of the
odds ratio in gauging the performance of a diagnostic, prognostic, or screening marker. Am J Epidemiol 159:882–890. doi:10.1093/aje/kwh101
4. Debray TPA, Damen JAAG, Snell KIE, Ensor J, Hooft L, Reitsma JB, Riley RD, Moons KGM (2017) A guide to systematic review and meta-analysis of prediction model performance. BMJ 356:i6460. doi:10.1136/bmj.i6460
5. Moons KGM, de Groot JAH, Bouwmeester W et al (2014) Critical appraisal and data extrac- tion for systematic reviews of prediction modelling studies: the CHARMS checklist. PLoS Med 11:e1001744. doi:10.1371/journal.pmed.1001744
6. Korner M (2010) Interprofessional teamwork in medical rehabilitation: a comparison of multi- disciplinary and interdisciplinary team approach. Clin Rehabil 24(8):745–755
7. American Geriatrics Society (2015) Care Coordination. Available from: http://www.american- geriatrics.org/advocacy_public_policy/care_coordination/. Accessed 7 Apr 2017
Further Reading
1. Debray TPA, Vergouwe Y, Kpoffijberg H, Nieboer D, Steyerberg EW, Moons KGM (2015) A new framework to enhance the interpretation of external validation studies of clinical predic- tion tools. J Clin Epidemiol 68:279–289
2. Mokkink LB, Prinsen CA, Bouter LM, Vet HC, Terwee CB (2016) The COnsensus-based standards for the selection of health measurement instruments (COSMIN) and how to select an outcome measurement instrument. Braz J Phys Ther 20(2):105–113. doi:10.1590/
bjpt-rbf.2014.0143
3. Steyerberg EW, Moons KGM, van der Windt DA et al (2013) PROGRESS group. Prognosis research strategy (PROGRESS) 3: prognostic model research. PLoS Med 10:e1001381.
doi:10.1371/journal
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© Springer International Publishing AG 2018
A. Pilotto, F.C. Martin (eds.), Comprehensive Geriatric Assessment, Practical Issues in Geriatrics, https://doi.org/10.1007/978-3-319-62503-4_4 A. Pilotto (*) • N. Veronese
Geriatrics Unit, Department of Geriatric Care, OrthoGeriatrics and Rehabilitation–Frailty Area, Galliera Hospital NR-HS, Genova, Italy
e-mail: [email protected]