Development and Clinical Supervision of

Multidisciplinary TeamsGary L. Munn, M.D.

Naval Medical CenterPortsmouth, VA

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Debbie Forsythe, LCSWSouthside Counseling

CenterSuffolk, VA

Our Goals forToday’s

Presentation• Understand the benefits of a team [MDT] approach in treating dual-diagnosis patients.• Learn how to develop a MDT.• Develop understanding in regard to the challenges of supervising and maintaining a MDT.

• A Multi-disciplinary Team is a group of professionals with different areas of expertise who unite to plan and carry out the treatment of patients/clients.

Definition

• May use resources more efficiently• On intake, client/patient does not have to repeat

their story to each member• Decreases “system-inflicted” trauma• Utilizes perspectives of different disciplines –

brings in NEW ideas• Enhances communication between the various

professionals caring for the same patient/client• Provides continuity and consistency of care• Diffuses transference.

Benefits of Team Approach

• Mitigates splitting• Enhances the overall quality of care and patient satisfaction• Improves success rates• Shortens hospitalizations• Lowers cost of treatment long-term • Reduces burnout among professionals

- allows staff members to compensate for the weaknesses of others

- gives staff the opportunity to process their reactions to particular clients.

• Facilitates processing of counter-transference.

More Benefits of a Team Approach

1. Forming: a group of people come together to accomplish a shared purpose

2. Storming: Disagreement about mission, vision, and approaches; team members are now really getting to know each other, which can cause strained relationships and conflict

3. Norming: The team has [consciously or unconsciously] formed working relationships that enable progress towards the team’s objectives

4. Performing: Relationships, team processes, and the team’s effectiveness in working on its objectives are synchronizing in a successfully functioning team

5. Transforming: The team is performing so well that members believe it is the most successful team they have experienced

6. Ending / Out-the-door-ming: The team has completed its mission or purpose [or funding has been terminated] and it is time for team members to pursue other goals or projects.

Stages of Team Development

• Know the need: Team must know the needs of the population it is serving and how it can meet those needs (Leader must know the need and communicate it to the team members.)

• Secure funding sources. “Buy-in” from management• (The most innovative ideas come from the deck-plates /

people actually doing the work.)• Establish roles and responsibilities of team members• Determine competencies required by the team• Establish the who, what, when, and where of the team

meetings • Establish team rules and standards of procedure• Provide appropriate ongoing training and support.

Process of Team Development

① Leadership is defined ② Members understand their roles. No “turf wars”③ Members understand & respect differences④ Members assume mentorship responsibility for all

new members⑤ Team schedules the work to be done and commits to

their tasks and deadlines⑥ Team develops tangible work results⑦ Team members are mutually accountable for work

results⑧ Individuals’ performance is assessed based on

achieving team results⑨ Problems are discussed and resolved by the team⑩ The Team incorporates the Patient(s).

Ten Characteristics of an Effective Treatment Team

• Respect the leader• Respect others: respect the process and agree

to disagree• Meet regularly• Honest• Listen to one another• Open to constructive criticism• Know personal abilities and limitations • Understand respective roles and

responsibilities• Keep treatment of individual as the focus.

Characteristics of Effective MDT Members

• Teacher• Counselor• Consultant • Monitor of the quality of professional

services • Gatekeeper of those who enter the team.

Role of the Supervisor

• Develop program policies and procedures• Manage program referrals• Monitor fidelity of evidence-based

treatment• Oversee quality control and financial

responsibilities• Provide treatment to patients• Provide weekly group supervision• Provide individual supervision as needed.

Supervisors

Be an Excellent Team Member – model the process

Motivate your Team Support your Team Liaison with Management Encourage Staff Development and

Training Plan and Meet Targets Maintain Discipline.

Tips for Supervisors - 1

• Hone your Skill Set Build and Sustain a Team Culture Practice Transparency Strengthen Team Bonding Manage Resources Effectively Criticize Constructively. Praise in

public. Reprimand/correct in private

Tips for Supervisors -2

Adopt Corrective Measures Be Approachable Be a Good Listener Shoulder Responsibility Take Initiative Celebrate the Success of your

Team.

Tips for Supervisors - 3

Available-Open, receptive, trusting, and non-threatening

Accessible-Easy to approach and speak with

“Able” [capable]-Possess real knowledge and skills to share

Affable-Pleasant, friendly, and reassuring

Anticipating -Train their relief.

• All of us need some time off• No one wants to be indispensible• Train a competent member to cover in your absence• Team members unconsciously need it

Effective Supervisors5 A’s

• Embrace individual differences • Discourage group think

• Zombies, 1000-yard stare, no discussion or disagreement, rubber-stamp decisions

• Embrace positive conflict • Facilitate open and honest conflict.

Managing a Team

How often should the treatment team

meet?

Length of Stay Patient

turnover

Cultures and backgrounds Theoretical constructs Opinions Expectations and needs Perceptions and facts Personalities, egos, and interest Knowledge and skills Goals and objectives.

Team Member Differences

• Understanding the differences• Collaborating is not the norm• Everyone has their own view• Trust can be really difficult to earn• People tend to remember the few times you messed

up• People have short-term memories• People want to have influence• You rarely get the opportunity to hand pick your

own team• You have to be willing to delegate• You are responsible for mediating conflicts of

difficult personalities.

Challenges of managing a team

Conflict is normal Conflict can be managed Conflict can lead to positive results Conflict can lead to negative results Conflict can lead to win/win

solutions Conflict can lead to improved

communication.

Team Conflict

Name calling Gossiping Sarcasm Airborne furniture Increased absenteeism Complaining / critical emails Anger Clique formation Not sharing information Lack of results Missed deadlines.

Signs of Team Conflict

Acknowledge the conflict - Conflict rarely heals itself.

Make it a team effort to resolve conflict Have the team define the conflict Focus on situation, don’t make it personal Brainstorm solutions Establish common ground Agree on plan to resolve conflict Execute plan.

Managing Conflict

Purposeful and goal-directed communication

Clear and well-defined boundariesStructure that has patient’s needs as the focus.

Creating a Safe Environment

• 300 +/- bed tertiary care Medical Center• “Detox ward” 12-bed Psychiatric Ward –

part of a 32-bed inpatient adult psychiatric service

• ASAM Level 4 care• Average length of stay: 3-5 days• Serving active duty military, military

retirees, and their family members

The Setting…

NOTE: We did not get to these next slides because of the duration of the Experiential Exercises. These describe the treatment teams I work in at Portsmouth, their evolution, and their outcomes.- Gary

• 65% active duty [USN>USA>USMC>USCG>USAF]• 15% AD Family members• 10% Retired• 10% Retired Family members

---------• 75% from Emergency Room• 20% from other wards [injury, illness, withdrawal]• 5% from Outpatient Psychiatric clinic

---------• 90% admitted with diagnosis suspicious for a SUD• 85% suicidal ideation/behavior• 15% seeking detox services

Clients served

• Psychiatrist [1]• Psychiatric Resident and/or Intern [1-2]• Registered Nurses [2-4 per shift]• Certified Addiction Counselors [2]• Licensed Clinical Social Worker [1]• Art Therapist [1]• Recreation Therapists [2 + 4]• Chaplain [1]• Psychiatric Technicians [3-5 per shift]• Case Managers [2]• Occupational Therapist [o/c]• Clinical Nutrition [o/c]

Team Members

Mission of our TeamPATIENT/CLIENT FOCUSED - 1

Patient diagnostic assessment

• Diagnostic interviews: • MD, RN, LCSW, CAC

• Physical Exam• Laboratory Studies• Radiologic Studies, if indicated• Psychological Testing• Art Therapy Assessment

Patient safety and stabilization

• Suicide / assault / elopement precautions• Detox protocol

Mission of our TeamPATIENT/CLIENT FOCUSED - 2

Psychological treatment• Therapeutic milieu • Group therapy• Individual therapy• Family therapy• Recovery workbooks

Medication Assessment and Management

Patient education• Addiction education groups

Twelve-step Meetings• AA & NA from local volunteers

Referral for rehabilitation/after-care

Mission of our TeamTRAINING-FOCUSED

Psychiatric Residency Training• PGY-1 and PGY-2

Medical Student Teaching• USUHS• EVMS

Psychology Interns and Post-doctoral Fellows

Art Therapy Interns

Recreational Therapy Interns

Social Work Students

Pastoral Care Residents

“Old school” [1980’s – early 90’s] o Off-going nurses give report to the “day team” at

morning report.o Doctors held their sessions with patients.o Nurses did their nursing assessments.o MDs, RNs, and Techs came together in Group

Therapy and post-group processing.o Ancillary staff performed in their roles.o Everybody wrote their own note. Sometimes they

were read by others…o Limitationso “Surprise!”

Development of our MDT

Evolution mid-1990’s – 2000’so JCAHO - > BPSS added to team.o Department Head with addiction background.

AMS / CAC added to team.o ACGME mandated increase in supervision of

residentso Mandated increase in staff physician

involvemento “Reimbursement” tied to workload

calculations based on documentation review.

Development of our MDT

“TODAY”o Rounds expanded in scope and durationo Interviews by teams, not individualso Other’s perspectives, wisdom, and experiences

were embraced and utilizedo Splitting less likelyo Staff’s reactions could be processedo Trainees appreciated other discipline’s expertiseo Healthy staff interactions were modeled for

traineeso Continuity of care enhancedo Fewer “surprises.”

Development of our MDT

o Patients found the team intimidating.

o Individual’s process may be slowed.

o Distractions from other members

Consequences -?

Challenges to the PracticeRotating Interns, residents, and students

Inexperienced tech staff

Staff deployments / transfers

Three partially-overlapping electronic medical record systems

Sequestration / furlough of staff

Ineffective computer hardware

• Must have a competent core / corps• MD, RNs, LCSW, CAS• Relatively high staff turnover does not allow us

to be selective about our staff: interns, residents, corps staff, spot-fill RN’s

• Junior staff members: malleable and mistaken, naïve and novice

• Indoctrination and training is critical.• Continuous improvement mentality – identify and

learn from your many mistakes• Take nothing for granted• Empower patients to critique us.

Not a Concierge Service

• 100% receive medical evaluation• 100% receive psychiatric evaluation• 99% receive RN evaluation• 95% receive individual CAS evaluation - all are reviewed by a LIP• 80% receive LCSW evaluation• 100% of diagnosed SUD’s referred for

rehabilitation/treatment [ASAM level 0.5 – 3]• 100% referred for SOME outpatient

treatment• 10% referred to Psych IOP• 50% placed immediately in ASAM level 3

rehab

Outcomes?

C ollaborationollegialityo-operationompetencyonfidencereativity Confusion

alamityrisis

NOT…

THE WONDERFULLY ALLITERATEDMDT CAN YIELD…

References Pleszkoch, Elisabeth NCC, CSAC, LPC, No Counselor

Left Behind: Challenges of Supervision in Substance Abuse Counseling. University of Virginia (2011)

Rajeev, Loveleena, How to Manage a Team. (2012) Walker, Diane, Career Training, Bella Online Career

Training (2013) Dallas E.M.A./HSDA, Standards of Care: Substance

Abuse Services. Ryan White Planning Council of the Dallas Area (2004)

Segal, Jeanne Ph.D. and Smith, Melinda M.A., Conflict Resolution Skills. (2013)

Schaufeli W, et al. (eds) Professional Burnout, Washington, DC: Taylor & Francis (1993)

References - continued

McGovern, Mark, Ph. D., Integrated Services for Substance Use and Mental Health Problems; Clinical Administrator’s Guidebook. (2008)

Jacobson, N. and Curtis, L., Recovery as policy in mental health services: Strategies emerging form the states. Psychiatric Rehabilitation Journal, 23, 333-341 (2000)

Kennedy, Frances A. Ph.D. and Nilson, Linda B., Ph.D., Successful Strategies for a Team (2012)

Avery, C., Teamwork Is an Individual Skill: Getting Your Work Done When Sharing Responsibility. San Francisco: Berrett-Koehler Publishers, Inc. (2001)

References - continued

• Lencioni, P., The FIVE Dysfunctions of a Team. San Francisco. Jossey- Bass (2002)

• Maginn, M. D., Effective Teamwork. Burr Ridge, IL: Irwin Professional Publishing. (1994)

• Parker, G. M. Team Players and Teamwork. San Francisco: John Wiley & Sons (1996)

Enjoy the rest of your VSIAS Conference 2013 and

your stay in the “Colonial Capital!”

gary.munn.ctr@med.navy.mil

Thank you for being with us!