Sustainable interprofessional teamwork needs a team-friendly healthcare system: Experiences from a collaborative Dutch programme

ABSTRACT

The significance of effective interprofessional teamwork to improve the quality of care has been widely recognised. Effective interprofessional teamwork calls on good collaboration between professionals and patients, coordination between professionals, and the development of teamwork over time. Effective development of teams also requires support from the wider organisational context. In a Dutch village, healthcare professionals work closely together, and mutual consultations as well as interprofessional meetings take place on a regular basis. The network was created as a precondition for sustainable interprofessional teamwork in elderly care. However, several external barriers were experienced regarding the supportive structure and cooperative attitude of the healthcare insurer and municipality. The aim of the article is to examine these experience-based issues regarding internal organisation, perspective, and definition of effective teamwork. Complicating factors refer to finding the right key figures, and the different perspectives on team development and team effectiveness. Our conclusion is that the organisation of healthcare insurance companies needs to implement fundamental changes to facilitate an interprofessional care approach. Furthermore, municipalities should work on their vision of the needs and benefits of a fruitful collaboration with interprofessional healthcare teams. The challenge for healthcare teams is to learn to speak the language of external partners. To support the development of interprofessional teams, external parties need to recognise and trust in a shared aim to provide quality of care in an efficient and effective way.

KEYWORDS:

• Community care
• interprofessional care
• interprofessional policy
• team-based practice
• teamwork

Introduction

Demographic trends refer to a proportionate rise of the ageing population with larger numbers of patients with chronic, complex needs (Robustill, Corsini, Marcu, Vasileva, & Marchetti, 2013; Van Campen, 2011). Most of their care is delivered in the primary care setting by a range of health professionals. The goals of chronic care management are generally not to cure, but to enhance patients’ daily functioning and quality of life. This calls for effective interactions between patients and healthcare professionals, but also for professionals who work together in an integrated and interdependent manner.

Four layers of interprofessional collaborative practice can be distinguished (see Figure 1). Layer 1 refers to the interactions between a patient and a healthcare professional. In Layer 2, professionals communicate and coordinate on the care around one patient. This takes place in informal ways and by means of formal structures like planned interprofessional team meetings, in which interprofessional care plans are formulated. Research suggests that interprofessional teamwork contributes to staff satisfaction, quality of care, and control of costs through a reduction of duplication and gaps in service provision (Xyrichis & Lowton, 2008). Several facilitators and barriers regarding team structures and team processes have been identified (Poulton & West, 1999; Xyrichis & Lowton, 2008). Besides, interventions are developed to foster interprofessional teamwork (Körner et al., 2016).

Figure 1. Layers of interprofessional collaboration.

However, as interprofessional teams are not fixed entities and group dynamics and team composition develop over time, it is not clear whether these interventions can be implemented in a sustainable way. Research has shown that a shared vision and mission, participation of team members, an emphasis on quality, and support for innovation and change are related to overall team effectiveness and quality of team working (Poulton & West, 1999; Xyrichis & Lowton, 2008). Layer 3 of interprofessional collaborative practice refers to this longitudinal process of team development, which requires a deeper level of collaboration than in Layer 2.

As studies show the need for supportive systems to maintain the collaborative practice of interprofessional teams (e.g. Cashman, Reidy, Cody, & Lemay, 2004), the interaction between a team and external partners is considered to be a fourth layer of collaborative practice.

In 2013, a funding programme of the Dutch government provided support to set up a sustainable interprofessional network in the care for frail elderly in Elsloo, a village with 8,000 inhabitants in the Netherlands. See Table 1 for more information about this network. The funding programme was aimed to learn about facilitators of and barriers to the sustainable implementation of interprofessional teamwork in the primary care setting. A systematic evaluation of the project provided insight into factors related to all four levels of collaboration. The aim of this article is to use the experiences to examine the fourth level, in order to illustrate the need for a team-friendly healthcare system that supports sustainable interprofessional teamwork in daily practice.

Table 1. The interprofessional network in the Dutch village Elsloo.

Issue	Details
Local setting	Elsloo is a village of 8,000 inhabitants, located within a larger municipality, in the south of the Netherlands. In the village, the number of elderly people, aged 75 or more, are supposed to double in the next 20 years up to approximately 1,300 people (18%). In 2013, a new health centre was built that included primary care facilities as well as a nursing home and care apartments. This was a momentum to realise a mutual approach in the care for the older people in the community. The professionals got funding from a programme of the Dutch government aimed at sustainable organisation of multidisciplinary care in the community. The project included: Development of an integrated care process, including structural team meetings Arrangement of an administratively, legally, and financially sustainable network organisation Regular input from patients’ expertise Providing opportunities for other professionals in prevention, care, and welfare, working in the community to join the network
	The organisational structure was aimed at the effectiveness and sustainability of the team. To foster the interprofessional bond, the professionals in the network not only meet each other to discuss patients’ care plans, but also collaborate in projects to improve their joint quality of care. Furthermore, they meet each other during informal network meetings.
Dutch context	Since 2015, municipalities have been responsible for all social support and assistance, while health insurance companies have become responsible for the purchasing policy of all medical and paramedical care and nursing care. The healthcare system reform is aimed at keeping people as self-supported as possible (Kroneman, 2015).

Process

Our experience-based examination of the external challenges in setting up sustainable interprofessional collaboration focused on fundamental differences in internal organisation, perspective, and definition of effective teamwork, between the healthcare team, healthcare insurer, and municipality. The examination is based on a business case analysis of the network, three conversations with the dominant health insurance company in the region, several interaction moments between network representatives and civil servants from the municipality, and on our evaluation report of the network development project.

Outcomes

First, we found that it was complex to find the right key persons within the healthcare insurance company and municipality. Dutch healthcare insurers are internally organised according to the type of care (i.e. medical care, paramedical care, and nursing home care). Moreover, persons that are responsible for innovation are not in charge of contracting care. These organisational structures appeared to be not supportive for interprofessional care arrangements that go beyond traditional boundaries. For example, reimbursement of team meetings for family physicians is provided, while paramedics are expected to attend these regular meetings without a financial reward. For each profession, a different contact person took the decision about arrangements. Interprofessional care arrangements were not available. Within the municipality, it was also hard to find the right persons, especially during times of elections and health reforms. Personnel changes, interim workers, and differences in contact persons’ power of decision resulted in collaboration on an ad hoc basis without long-term planning. Plans are made in the first year of an alderman’s four-year term, and policy effects must be visible in the fourth year. In this political domain, the development of sustainable juridical procedures to collaborate with health professionals in the elderly care is not a priority.

On the other hand, this also requires new competencies from health professionals, to be able to speak the language of the external partners. It requires time to learn the specific communication skills. We learnt that being present at informal meetings and to get informed about the political agenda are crucial in developing these skills.

A next complicating factor is the preferred level of stimulating improvement of care. With regard to innovation, the primary focus of our healthcare team is on the perceived needs in the local communities. Healthcare insurers and municipalities are more likely to benefit from innovation at a broader scale. For example, we suggested that minor surgical procedures, for which patients in the nursing home had to be referred to the hospital, could be done by the family physicians nearby. However, the financial structure of the healthcare insurer has not been arranged for this kind of local initiatives. At the side of the municipality, we noticed fear to show favour to an individual healthcare team over other professionals working within the municipality. Collaboration with healthcare teams may also conflict with their perceived need to remain in charge regarding procedures and decisions.

The third challenge in the collaborative practice between interprofessional healthcare teams and external partners referred to the perspective on the added value of effective teamwork. From the perspective of healthcare professionals, interprofessional teamwork has to contribute to the quality of care in an efficient and satisfying way. The dominant focus of our healthcare insurer is on cost minimisation. Our healthcare team was asked for indicators that provide insight into the cost-effectiveness of our interprofessional team. Together with external experts, we searched for indicators like a decrease of emergency admissions to the hospital. We concluded that team cost-effectiveness cannot be measured by simple indicators. The heterogeneous patient population, the small scale, and the need for longitudinal data were barriers in getting insight into the cost-effectiveness of our interprofessional network. With regard to the municipalities, their vision on effective teamwork in the health and welfare domain was still under development. Both their expertise and data on patients’ needs for collaborative care in the medical and social domains appeared to be lacking. Partly due to healthcare reforms, the energy of the municipalities has been spent on internal procedures and decisions.

Discussion

Although a large body of literature exists about determinants of an effective team, most of the issues that were experienced in organising sustainable interprofessional collaborative practice had not been related to the development of the team itself (San Martín-Rodríguez, Beaulieu, D’Amour, & Ferrada-Videla, 2005), but to the connection between a team and its external environment. Chances for the development and innovation of the interprofessional team were not optimally enforced by the healthcare insurer and municipality, both key players in the Dutch healthcare system. This article was aimed to provide an experience-based examination of these issues.

The experiences underline that leaders of interprofessional healthcare teams not only have to make a range of decisions and negotiations within the team, but also encounter economic, social, and political issues in building a collaborative relationship with external partners (Reeves, Macmillan, & Van Soeren, 2010). They highlighted that health professionals have to learn to communicate with external partners in an effective way.

Furthermore, the development of interprofessional teams over time requires long-term planning, interprofessional care arrangements, and innovation. Teams get stronger when they get the opportunities for innovative initiatives (Cashman et al., 2004). However, the priorities of external partners lay in broad, regional projects rather than in local initiatives. Moreover, team effectiveness outcomes cannot easily be measured. All these factors are barriers to the sustainability of interprofessional team development processes.

Concluding comments

Interprofessional teamwork in care for patients with complex needs is not only a challenge for healthcare professionals, striving for effective coordination and communication. The development of sustainable interprofessional teams also requires a team-friendly healthcare system. To make steps forward in realising sustainable interprofessional care, fundamental changes are needed in the internal organisation of healthcare insurance companies and municipalities. Insurance companies should remove interprofessional barriers inside their organisations, to reflect their vision on integral care. Also, promoting interprofessional teamwork requires support for initiatives at the community level. Municipalities need to develop a vision about the needs of inhabitants and the benefits of collaboration with the healthcare professionals in their area, and to translate their vision into policy. Members of interprofessional healthcare teams need to learn to speak the language of the external partners more. It seems useless to keep searching for simple indicators of effective team care. In our opinion, it is a shared challenge to define outcome measures that are useful for all stakeholders to evaluate the needs and results regarding effective teamwork. The implication is that healthcare teams, insurers, and municipalities together need to make long-term plans that focus on local communities. It calls for integrated care arrangements that are based on needs of the people in that specific area. This care should be evaluated with a focus on the extent of care that has been realised rather than on measuring effectiveness indicators.

Declaration of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.