Describe own strengths, limitations, and values in functioning as a member of a team

Skills

 Demonstrate awareness of own strengths and limitaions as a tam member

 Initiation plan for self-development as a team member

 Act with integrity, consistence, and respect for differing views

 Attitudes

 Acknowledge own potential to contribute to effective team functioning

 Appreciate importance of intra- and inter-professional collaboration

Describe scopes of practice & roles of health care team members

Skills

o   Function competently within own scope of practice as a member of the health care team

Attitudes        

o  Value the perspectives and expertise of all health team members

Describe strategies for identifying and managing overlaps in team member roles and accountabilities

Skills

Assume role of team member or leader based on the situation  

Initiate requests for help when appropriate to situation

Clarify roles and accountabilities under conditions of potential overlap in team member functioning

Attitudes

Respect the unique attributes that members bring to a team, including variations in professional orientations and accountabilities

Recognize contributions of other individuals and groups in helping patient/family achieve health goals

Skills

Integrate the contributions of others who play a role in helping patient/family achieve health goals

Attitudes

Respect the centrality of the patient/family as core members of any health care team

Analyze differences in communication style preferences among patients and families, nurses and other members of the health team

Skills

Communicate with team members, adapting own style of communicating to needs of the team and situation

Attitudes

Value teamwork and the relationships upon which it is based

Describe impact of own communication style on others

Skills

Demonstrate commitment to team goals  

Solicit input from other team members to improve individual, as well as team, performance

Attitudes

Value different styles of communication used by patients, families and health care providers

QSEN Competency 7

Definition

Skills

Attitudes

Discuss effective strategies for communicating and resolving conflict

Skills

Initiate actions to resolve conflict

Attitudes

Contribute to resolution of conflict and disagreement

QSEN Competency 8

Definition

Skills

Attitudes

Describe examples of the impact of team functioning on safety and quality of care

Skills

Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care  

Assert own position/perspective in discussions about patient care

Attitudes

Appreciate the risks associated with handoffs among providers and across transitions in care

QSEN Comptency 9

Definition

Skills

Attitudes

Explain how authority gradients influence teamwork and patient safety

·       Skills

• Assert own position/perspective in discussions about patient care
• Choose communication styles that diminish the risks associated with authority gradients among team members

·       Attitudes

o   Appreciate the risks associated with handoffs among providers and across transitions in care

QSEN Comptency 9

Definition

Skills

Attitudes

Identify system barriers and facilitators of effective team functioning, and examine strategies for improving systems to support team functioning

·       Skills

o   Participate in designing systems that support effective teamwork

·       Attitudes

o   Value the influence of system solutions in achieving effective team functioning

QSEN Competency 10

Definition

Attitudes

Participate in designing systems that support effective teamwork

·       Attitude

o   Value the influence of system solutions in achieving effective team functioning

·       Decreased length of hospital stay

·       RN perceptions of good quality patient care

·       Increased patient satisfaction

·       Better coordination of patient care

·       Increased use of hospital rehabilitation services

·       Improved ADL functioning

·       Decreased ER visitation

·       Fewer nursing home admissions post-hospitalization

·       Decreased mortality1 yr after DC

·       Decreased psychotropic meds usage among nursing home residents

·       Decreased over-all health care costs

Types of payment models

Structural Payment Models for health care systems

1. Fee for service: payment to practitioners based on serviaces rendered

2. Cpitation: practitioners are paid a sum for each patient they are responsible for, with attention to demographics like age & gender of client

3. Salary: determined b employee's insitution or self-determined if self-employed

Types of payment models

(financial recourses for health care systems)

1. Taxation to state, county or municipality

2. Social health insurance

3. Voluntary or private insurance

4. Out-of-pocket payment systems

5. Donations/charities

Health care inurance models

(name and how insurance reimbursement occurs)

Defining Health Insurance healthcare models:

·       Managed care:  contractual agreements between MDs, RNs, hospitals, clinics, labs, diagnostic providers form a “network”.  A health care where nonmedical administrators such as insurance companies control and limit the provision of such things as procedures and medicines

·       HMOs:  Health Maintenance Organization. utilize in-network healthcare providers, with PCP acting as personal doctor & coordinator of care & source of referrals.  Premiums pay a corporation who pays healthcare workers.

·       PPOs:  Preferred Provider Organization.  Contract with a network of “preferred” healthcare providers for reduced cost, with access to and higher fees for services provided “out-of-network”.  Healthcare if paid for as it is recieved vs. pre-paid preimums.

Generally do not share perceptions of theri own and others' roles in providing care

Traditional Dr./Nurse game

No differences in collaboration found with more female MDs (? drinking koolaid of male dominated enviornment)

Collaboration critical in lowering mortality rates in hospital ICUs

Control between NPs and physicians still unresolved

Collaboration should increase efficiency and cost-effectivienss of patient care

Realtively new area for collaborative research

Exists along a continuum

•  Traditional MDs "have little interst in psycosocial factors" and "reluctantly accept their function of obtaining specific services

MDs beginning to recognize social workers are interdependent colleagues and willingly sare info with one another

Tension is inevitable d/t nature of relationship

Pharmacists use polietness and face-saving strtegies ot present recommendations to physicians

There is an increased collaboration required for geriatric patients becuase of all the meds they are on

Has traditionally focused on negotiation of medical mistakes, collegial (power-sharing) control and other negatively perceived aspects of medical control

Other resarche exams the culture of medicine and socalization of medical students (i.e. there isn't any)

1. Collaborative Patient Care Teams
• sharing owenrership of patients, including clinicians outside of the hospital, and creating an enviornment to support learning agility and adaptation to change
2. Resources Stewardship
• opportunity to reduce dosts with sharing accountability for management decisions. Leadership practices: entrepreneurial attitude with accountability, transparency and integrity to combine caring with business needs
3. Talent Transformation
• ability to motivate/inspire emploees/peers, build relationships, accessing all available resources and leaderships opportunities across disciplines
4. Boundary Spanning
• working acrouss numerbous dets, hierarchy etc; eliminate us vs. them mentality"
5. Capacity for complexity, innovation & change
• embace and realize changes coming into healthcare and encourage others to do the same
6. Employee engagement & well-being
• model health promotion, physical and mental wellness for healthcare employees

• driven by capping costs
• individuals take the responsibility to pay for the more services they need
• healthcare providers develop services that address cost concerns yet ensure patient satisfaction & good medical outcomes 

Integrates cost sefvices & outcomes which:

• shifts costs to consumers
• lowers insurance company costs
• influences consumers to use less health care
• increases individual's financial obligations for their own healthcare services

Consumers now accountable for their health....they "own" it

• it supports the idea of traditional models
• individual rights of physicians have been protected by broadly permissive state practice acts and a legally protectionis physician/patient relationship.

How it helped drive change: people do not want the medical separatism anymore ?

A value-driven, evidence-based movement that has resulted in  amore cost-effective, functional and service oriented healthcare delivery system

Outcomes (value)-driven demand focuses on performance of healthcare providers

Team-based relationships required for providers

1. Decide to listen & concentrate on the speaker
2. Use your imagination to consider the speaker's situation
3. Pay attention to verbal and non-verbal communication
4. Don't interrupt
5. Re-phrase the speaker's message by using clarifying questions, to be sure the message you've recieved is accurate
6. Provide appropriate feedback (as needed)

1. Emotional interference
2. Defensiveness
3. Hearing only facts, not feelings
4. Not asking clarifying questions
5. Hearing what you expect to hear, not what is actually said
6. Stereotyping
7. Resistance to change
8. "Halo effect"
• the tendency for something to be influenced by a loosely associated factor
9. Automatic dismissal
• "we've never done it that way before" 

1. Make eye contact
2. Adjust your posture
3. Provide verbal or non-verbal feedback and/or acknowledgement
4. Have open, clear mind
5. Avoid distracting behaviors 

Don't assume "sameness" between yourself and speaker

Don't assume you understand the meaning of the message

Dont inadvertently cause the behavior

Normal: 0.8-1.1

Anti-coag:1.5-2 times greater

Hepatocellular disease

Obstructive biliary disease

monitor coumadin therapy (antidote of OD = Vit K)

PTT: 60-70 seconds

aPTT: 30-40 seconds

measures clot formation time (or activation time)

used ot mointor heparin therapy

Genetic disease (hemophilia)

Liver cirrhosis

Vit K deficiency

DIC (clotting factors consumed in end-stages of process)

Heparin/Coumadin administration (should be 1.5-2.5 x normal value)

DIC (early stages; clotting occurs)

Cancers (ovarian, pancreatic, colon)

•        It is a model for systems management

•        It relies on mutual accountability and responsibility between all partner teams

•        Its purpose is to create a framework to support all stakeholders within an organization, and support the work of the organization

•        It is an open system, with more horizontal loci of control then vertical (hierarchal)

1. The whole defines the parts
2. Parts suppor the whole
3. A problem anywhere effects the whole system
4. Systems "live" where they provide services
5. People either serve customer, or serve someone who does
6. Point-of-service is at center, structure is configured around it
7. Form should follow function
8. All members are stakeholders
9. Managers are facilitators, integrators, and coordinators of processes supporting the work
10. Outcomes define the overall value of the process 

• The basis is that it is all about focusing primarily on plan of care

• Decisision-making in a clinical enviornment should occur where the provder and patient meet
• information must be provided at point of care to support decisions and clinical activities
• organizational structure should not impede decision-making processes
• an effective clinical structure occurs from point of care outward; all systems and activities should serve to support point of care 

Principles of Shared Governance

(OPEA)

•        PARTNERSHIP

•        Role expectations are negotiated

•        Players are equals

•        Relationships are founded on shared risk

•        Expectations are clear

•        Horizontal linkages are well-defined

•        Team & individual contributions to outcomes is established

•        EQUITY

•        Each player’s contribution is understood by team

•        Payment reflect value of contributions to outcomes

•        Role is based on relationship to team, not status/ discipline

•        Team defines roles & expected outcomes

•        Evaluation assesses team outcomes & contributions

•        ACCOUNTABILITY

•        Defines roles, not jobs

•        Is based on outcomes, not process-driven

•        Is internalized by each team member

•        Is assumed before performance

•        Leads to desired outcomes

•        Performance is validated by the results/outcomes achieved

•        OWNERSHIP

•        All workers hold a vested interest in system

•        Each role has a stake in outcomes

•        Rewards are directly related to outcomes

•        Processes support team relationships

•        Opportunity is based on competence (and licensure)

•        Some thoughts about shared governance, accountability & decision-making…

•        POINT OF SERVICE TEAMS or SERVICE TEAMS

(to deliver health care; deliver the product)

•        Basic unit of work

•        Facilitate a client’s journey through the system

•        Provider-based & foundation for health care delivery

•        Population defines the work of the team

•        SERVICE PATHWAYS or UNIT COUNCILS

(systems management)

•        Focus is on system & relationship issues

•        Considers structures/ frameworks for support for point of service teams’ work

•        Follows the trajectory of the client through the system not the provider(s)

•        Address relationship of system to internal & external communities

• some may not be happy
• review existing sstructure and current interface with paitnet care/point of care system
• identify key structural suppors needed at point of service
• articulte characteristics and accountabiliyt in roles in new system
• identify teams, service pathwyas, and system council plan for decision-making within the system
• identify the key change events needed for implementation of new model
• garner intitutional support for implementation, leadership and role changes, and perfrmance and outcome expectations
• define evaulation modes and timeline for implementation 

•        BS or BA degree

•        Medical School Admission Test (MCAT)

•        MD degree

•        1^st 2 years: classes/labs, then 1^st part of USMLE

•        2^nd 2 years: clinical practicums, then 2^nd part of USMLE

•        Residency: 3-7 years

•        After 1^st year, final part of USMLE given

• Critical thinking
• Empathy
• Physical stamina
• Leadership and communication
• Attention to details
• Computer skills
• Psychomotor skills 

•        Same initial requirements as for an MD

•        Additional 300-500 hours training of Osteopathic Manipulative Treatment (OMT)

•        Can specialize and become Board certified (like MDs)

•        Average salary: around $100,000

• Holistic approach to medical practice
• Manual manipulative skills
• Focus is on primary and preventative are
• Schools not associated with teaching hospitals; so less emphasis on research 

PAs

Education &

What they Do

Education

• BS or BA
• 2-year training and completion of Master's Degree
• Licensure required by all states: Physician Assistant National Certifying Exam (PANCE)
• No on the job trianing or work experience in a related field required

What they Do

• Physical Evals
• Order diagnostic & lab tests
• Diagnose
• Counseling
• Prescribe
• Documentation

PhDs

Education &

Skills

Education

• BA or BS
• Masters' sometimes required for admission, sometimes not
• Awarded in all disciplines
• Doctoral program takes 4-8 yrs to complete
• Comprehensive exams: successful passing hen Doctoral candidate
• dissertation required

Skills

• Critical thinking
• Research skills
• Specific discipline knowledge
• Professional practice knowledge

Syndrome of Inappropriate ADH (SIADH)

Definition &
S/S

An increased ADH secretion, causing increased blood volume and electrolyte abnormalities.  DILUTION PROBLEM

S/S

• Anorexia, N/V
• Hypervolemia
• Weight gain, edema
• Tachycardia
• Hypothermia
• Cerebral edema/change in LOC
• Decreaed DTR

Diabetes Insipidus

Definition and

S/S

an under-excretion of ADH resulting in hemoconcentration and dehydration.  PEEING/EXCRETING PROBLEM from reduced renal response to ADH

S/S

•  Polyuria: 3-10 L/day
• Polydipsia
• Dehydration
• Hypovolemia

Hypothyroidism/Hashimoto's thyroiditis

Definition and

S/S

Hashimoto's Thyroiditis: an autoimmune disease where antibodies destroy throid tissue

• Overall decreased BMR
• cools skin, cold intolerance
• slow P/RR
• Edema: puffy face, perirbital edema
• anorexia with weight gaine
• Dry, loose skin, coarse hair and nails
• Emotional instability

Hyperthyroidism/Graves Disease

Definition and

S/S

Graves: autoimmune disease act on TSH receptors to over-produce thyroid hormones

S/S

• Overall increase BMR
• hyperpyrexia, diaphoresis, heat intolerance
• Nervousness/tremors
• Inc appetite with weight loss
• Tachyardia, palpitations
• HTN with bounding pulse
• Warm, flushed skin

Blood Typing:

Antigens/Antibodies on

O+

O-

A+

A-

B+

B-

AB+

AB-

Method of regulating hormone secretion to the body....

Hormone secreted, reaches target tissue, target tissue sends message back to stop production, production stopped

BSW

• 4 year baccalaureate program
• Clinical fieldwork or internship
• Course work focus is on diverse populations, humna behaviors and social welfare policy

MSW

• 2 additional years academic work
• Speciality area of practice focus
• Clinical ieldwork/internship in practice area of focus

PhD

• 4-6 yrs post grad education in area of clinical focus
• Dissertation required

5 levels (all have different exams)

170 multiple choice qustion

4 hr exam

Associate (LASW), Bachelors (LBSW), Masteres level (LMSW)

Advanced generalist and clinical level (LCSW)

• requires 2 yrs extra clinical experience
• advanced degree needed to sit for either exam

Child and Family services

School Social Workers

Healthcare social workers

Direct-service

• Assess clients' needs/strengths/support networks
• Assist with life changes such as illness/divorce/unemployment/jail
• Refer for community services
• Assest clients to apply for govt. services
• Respond to crisis situations, such as child abuse or natural diseasters
• Advocate for clients

Clinical (LCSW)

• Diagnose and treat mental/behavioral and emotional disorders
• Provide individual, group, family and couples therapy
• Assess client histories, backgrounds and support systems
• Develop treatment plans for clients with doctors and other healthcare providers
• Refer clients as needed to other resources
   

Human Development, Diversity and Behavior in the Enviornment

Assessment

Direct and Indirect Practice

Professional Relationships, values and ethics

Human development, diversity, and behavior in the enviornment

Assessment and Intervention Planning

Direct and Indirect Practice

Professional Relationships, Values and Ethics

Psychologis

• PhD or PsyD degree
• 5-7 yrs post grad
• often research-based
• perfomr counseling, psychotherapy
• perform neuropsychological testing
• perform personality tests

Psychiatrists

• MD DEGREE
• CAN PRESCRIBE psychoactive and other meds
• following medical degree, 4 or more years residency in mental health
• Perform counseling, psychotherapy
• Often jus to medication changes/assessments for clients

Polydipsia

Polyuria

Feeling very hungry or tired

Losing weight without trying

Having sores that heal slowly

Having dry, itchy skin

Neuropathy

Blurry vision

Diabetic Ketoacidosis

What is it?

S/S?

Definition: Serious metabolic acidosis that results from a lack of insulin.  Fat stores break down and release fatty acds and ketones into the body.

S/S

Decrease LOC

Polyuria (leads to hypovolemia, hypotension, rapid pulse)

Kussmaul's Respirations

BG >300 mg/dl

ABG: ph < 7.35; HCO3 < 15 mEq/L

Diabetic Testing

3 types

• A1C
• normal value <5.7%
• avg BGL over 3 months
• the higher the value, the higher percentage of glucose has been in the blood

FPG (fasting plasma glucose)

• Normal value: <99 mg/dl
• Measures BG in a person who has fasted for at least 8 hrs
• FPG of 100-125 mg/dl = impaired fasting glucose (IFG)
• FPG of 126 or higher; confirmed 3x diagnostic of DM

OGTT (Oral Glucose Tolerance Test)

• Normal value <139 mg/dl
• Fasting
• 2 hrs after person drinks a liquid containing 75 gm glucose
• OGTT of 200 mg/ld or more; confirmed by 2nd test, means the person has diabetes

Insulins

Rapid

Short-acting

Intermediate

Long-acting

Partnership: players are euqals with shared risk

Equity: roles based upon relationship to team; no discipline credentials or licensure

Acounability: performance of team is assessed by outcomes

Ownership: each team member has a stake in and responsiblity for outcomes

Facilitate communication and collaboration with service pathway councils

Concered with organization, integratoin and coordination of services provided by the service pathway team members

Coordinates operational needs of the service pathways with the nedds of individual teams within the service pathways

Assumed shared accountability

No ultimate authority exists

NO SUCH THING AS THE BUCK STOPS HERE

contributions to sytem are expected from all system team members

System Accountability

• Refers to ystem/organization as a whole
• Ensures system integrity
• Accountabiliyt for resource and stewardship requires of the stysem such as:
• human, financial, materials and suppor systems

Service Accountability

• Referes to work of teh organization (provision of healthcare)
• accountability for the functions and activities pertaining to the purpose of the organization
• Concered with performance, quality and evaluation of service provided

Patient Care Council

Operations Council

Goverance Countil

Clinical leaders are reponsible for decisions about point-of-service and patient care, such as:

• Standards of practice
• Design of patient care delivery
• Quality assurance/imporvement in patient are delivery
• Clinical performance indicators
• Application of EBP

They are concerend with inter-relationships between practice disciplines

Council includes membership from Service Pathways and all provider disciplines, as well as leaders from Operations Countil and Governance Council

Responsible for management decisions regarding resources management and operational concerns

Includes leaders from:

• Service pathways
• Systems management
• Human Resources
• Financial/budgetary managment
• Development and planning administration
• Infromaion technolgoies
• Patient Care Council and Goverenance Coucil Leadership

Responsible for integration of the whole system, in conjunction with other councils

Elected and designated organizational leaders must

• assure institutional mission and goals are being achieved at all leveles of operation
• Integrate organization with community and population of interest
• Ensure all components within the system are well-integrated
• Maintain adherence to strategic plans, budgetary constraings
• Membership includes chair of medical staff, boardof trustees, CEO, CIO, and leadres from patient care council and operations council as well as community leader

Degree from accredited program

National board for Certification of Occupational Therapists (NBCOT) exam

Certification allows practitioner to be an OTR (Occupational Therapist, Registered)

Assess client's ability to do ADLs and other necessary (profressional) tasks

Evaluate client needs based on assessments

Identify resources to aid clients with disabilities to perform tasks

Evaluate client's enviornment to identify ways to accommodate/assist with client's needs

Recommend specific equipment to aid client's in ther every day activities

Educate client, family and employers about needed accommodatoins to assist client

Assist clients with mental health issues to perform ADLs, teach life skills, and utilize resources