"Sometimes people don't fit in boxes": attitudes toward the minimum data set among clinical leadership in VA nursing homes.

OBJECTIVE: To describe attitudes toward the Minimum Data Set (MDS) among Department of Veterans Affairs (VA) nursing home care unit (NHCU) clinical leadership. DESIGN: Cross-sectional online survey using structured (quantitative) and open-ended (qualitative) items. SETTING: Approximately 97 VA Medical Center NCHUs nationwide. PARTICIPANTS: A total of 289 directors of nursing, medical directors, MDS coordinators, nurse managers and other clinical management staff. MEASUREMENTS: Quantitative ratings of the MDS's accuracy, usefulness for initial and ongoing care planning, and utility for quality improvement; content analysis of open-ended items describing perceived causes of inaccuracy and reasons for use/nonuse in care planning and quality improvement. RESULTS: Although quantitative ratings were generally positive, qualitative analysis yielded a number of emergent themes regarding data accuracy, team functioning, timeliness of assessments, and validity of the MDS tool itself. Medical directors were somewhat less positive about the MDS than were other NHCU leadership. Very large and very small facilities were less likely to view the tool as useful and to use it for care planning and quality improvement. CONCLUSIONS: NHCU clinical leadership clearly has a "love-hate" relationship with the MDS. They value information it provides, but identify a number of weaknesses that limit its utility for clinical use.

Team training and stroke rehabilitation outcomes: a cluster randomized trial.

OBJECTIVE: To test whether a team training intervention in stroke rehabilitation is associated with improved patient outcomes. DESIGN: A cluster randomized trial of 31 rehabilitation units comparing stroke outcomes between intervention and control groups. SETTING: Thirty-one Veterans Affairs medical centers. PARTICIPANTS: A total of 237 clinical staff on 16 control teams and 227 staff on 15 intervention teams. Stroke patients (N=487) treated by these teams before and after the intervention. INTERVENTION: The intervention consisted of a multiphase, staff training program delivered over 6 months, including: an off-site workshop emphasizing team dynamics, problem solving, and the use of performance feedback data; and action plans for process improvement; and telephone and videoconference consultations. Control and intervention teams received site-specific team performance profiles with recommendations to use this information to modify team process. MAIN OUTCOME MEASURES: Three patient outcomes: functional improvement as measured by the change in motor items of the FIM instrument, community discharge, and length of stay (LOS). RESULTS: For both the primary (stroke only) and secondary analyses (all patients), there was a significant difference in improvement of functional outcome between the 2 groups, with the percentage of stroke patients gaining more than a median FIM gain of 23 points increasing significantly more in the intervention group (difference in increase, 13.6%; P=.032). There was no significant difference in LOS or rates of community discharge. CONCLUSIONS: Stroke patients treated by staff who participated in a team training program were more likely to make functional gains than those treated by staff receiving information only. Team based clinicians are encouraged to examine their own team. (ClinicalTrials.gov identifier NCT00237757).

Utility of Treatment Implementation methods in clinical trial with rehabilitation teams.

Clinical trials of rehabilitation interventions pose unique challenges to researchers. Treatments can be technically complex, often requiring a multidisciplinary team of professions. This article demonstrates the application of Treatment Implementation (TI) methods in a rehabilitation team-training intervention conducted with 29 team leaders (12 medical doctors, 4 physical therapists, 3 speech-language pathologists, 2 occupational therapists, 3 kinesiotherapists, 2 registered nurses, 1 social worker, 1 program coordinator, and 1 administrator) from 15 Department of Veterans Affairs hospitals. We describe the intervention along with the influence of three TI categories (delivery, receipt, and enactment) on the design and implementation of the team-training intervention. Positive findings from the use of TI methods include (1) consistent and accurate presentation of intervention components and (2) evidence of study participants' receipt and enactment of intervention strategies.

Team functioning and patient outcomes in stroke rehabilitation.

OBJECTIVE: To evaluate the relationship between rehabilitation team functioning and stroke patient outcomes. DESIGN: Prospective observational study. SETTING: Veterans Administration (VA) inpatient and subacute rehabilitation units. PARTICIPANTS: Forty-six VA rehabilitation teams, including 530 rehabilitation team members from 6 disciplines (medicine, nursing, social work, physical therapy, occupational therapy, speech language pathology) and 1688 stroke patients treated by the teams. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Ten scales assessing team member perceptions of team functioning (communication, perceived effectiveness, physician involvement, physician support, teamness, utility of quality information, innovation, interprofessional relationships, order and organization, task orientation) and 3 primary patient outcome variables-functional improvement, discharge home, and length of rehabilitation stay (LOS). RESULTS: Three of the 10 measures of team functioning were significantly associated with patient functional improvement ( P <.05): task orientation, order and organization, and utility of quality information. One measure of team functioning-effectiveness-was significantly associated with LOS ( P <.05). None of the team variables predicted discharge destination. Aspects of team functioning that were important to outcomes differed depending on the outcome of interests. Efforts directed toward improving team activities and relationships, including collaborative planning and problem solving and the use of feedback information, may enhance rehabilitation treatment effectiveness. CONCLUSIONS: Characteristics of team functioning predict selected rehabilitation outcomes.

Patient-focused rehabilitation team cohesiveness in veterans administration hospitals.

OBJECTIVE: To quantify the relation of hospital culture, 3 levels of leadership (hospital-level administrators, discipline-specific supervisors, attending physician on the team), and physician involvement to patient-focused rehabilitation team cohesiveness. DESIGN: Survey research. SETTING: 48 Veterans Administration hospitals (VAHs). PARTICIPANTS: Six hundred fifty members of 50 rehabilitation teams. INTERVENTIONS: Not applicable. Main outcome measures Scales measuring hospital culture, administrative support, supervisor expectations, attending physician support, and physician involvement (independent variables), and patient-focused rehabilitation team cohesiveness (dependent variable). Associations between scales were examined by using a hierarchical linear regression model. RESULTS: Patient-focused team rehabilitation cohesiveness was significantly (P<.05) associated with administrative support, supervisor expectations, attending physician support, and physician involvement (Wald chi(2)=1192.66, P<.0001) (R(2)=.6431). There was no statistically significant independent association with hospital culture. CONCLUSIONS: Expectations of discipline-specific supervisors and hands-on team leadership and involvement by the attending physician were associated to a significant degree with the extent to which rehabilitation teams in VAHs reported functioning in a cohesive manner. Higher functioning on patient-focused team cohesion indicates that patient services were likely delivered with greater interprofessional communication and joint effort.

The influence of hospital culture on rehabilitation team functioning in VA hospitals.

A conceptual model of rehabilitation effectiveness, in which team functioning is influenced by hospital culture, has been previously suggested by several authors of this study. The current study tested the efficacy of the hospital culture portion of the model using survey data from 523 rehabilitation team members and 162 administrators from 50 participating Veterans Administration Hospitals (VAHs). We assessed four types of hospital culture (personal, dynamic, formal, and production-oriented) using an instrument developed originally for a Competing Values Model. Rehabilitation team members and administrators perceived three of the four hospital cultures differently (p < 0.0001), agreeing only on production-oriented culture. With the use of VAH dominant culture as the independent variable, statistically significant differences were found among all nine measures of team functioning (dependent variables). The major contrast was between personal versus formal hospital culture types.