Development and Clinical
Supervision of
Multidisciplinary Teams
Gary L. Munn, M.D.
Naval Medical Center
Portsmouth, VA
hhhhh
Debbie Forsythe, LCSW
Southside Counseling Center
Suffolk, VA
Our Goals for
Today’s Presentation
Understand the benefits of a team
[MDT] approach in treating dualdiagnosis patients.
• Learn how to develop a MDT.
• Develop understanding in regard to
the challenges of supervising and
maintaining a MDT.
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Definition
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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.
Benefits of Team
Approach
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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.
More Benefits of a Team
Approach
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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
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- 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.
Stages of Team Development
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6.
Forming: a group of people come together to accomplish a shared
purpose
Storming: Disagreement about mission, vision, and approaches;
team members are now really getting to know each other, which can
cause strained relationships and conflict
Norming: The team has [consciously or unconsciously] formed
working relationships that enable progress towards the team’s
objectives
Performing: Relationships, team processes, and the team’s
effectiveness in working on its objectives are synchronizing in a
successfully functioning team
Transforming: The team is performing so well that members believe
it is the most successful team they have experienced
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.
Process of Team
Development
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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
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(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.
Ten Characteristics of an
Effective Treatment Team
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Leadership is defined
Members understand their roles. No “turf wars”
Members understand & respect differences
Members assume mentorship responsibility for all new
members
Team schedules the work to be done and commits to their
tasks and deadlines
Team develops tangible work results
Team members are mutually accountable for work results
Individuals’ performance is assessed based on achieving team
results
Problems are discussed and resolved by the team
The Team incorporates the Patient(s).
Characteristics of
Effective MDT Members
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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.
Role of the Supervisor
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Teacher
Counselor
Consultant
Monitor of the quality of professional services
Gatekeeper of those who enter the team.
Supervisors
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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.
Tips for Supervisors - 1
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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 -2
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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 - 3
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Adopt Corrective Measures
Be Approachable
Be a Good Listener
Shoulder Responsibility
Take Initiative
Celebrate the Success of your Team.
Effective Supervisors
5 A’s
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.
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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
Managing a Team
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Embrace individual differences
Discourage group think
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Zombies, 1000-yard stare, no discussion or disagreement,
rubber-stamp decisions
Embrace positive conflict
Facilitate open and honest conflict.
How often should the
treatment team meet?
 Length of Stay
 Patient turnover
Team Member Differences
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Cultures and backgrounds
Theoretical constructs
Opinions
Expectations and needs
Perceptions and facts
Personalities, egos, and interest
Knowledge and skills
Goals and objectives.
Challenges of
managing a team
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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.
Team Conflict
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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.
Signs of Team Conflict
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Name calling
Gossiping
Sarcasm
Airborne furniture
Increased absenteeism
Complaining / critical emails
Anger
Clique formation
Not sharing information
Lack of results
Missed deadlines.
Managing Conflict
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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.
Creating a Safe
Environment
Purposeful and goal-directed
communication
 Clear and well-defined boundaries
 Structure that has patient’s needs as the
focus.
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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
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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
Clients served
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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
Team Members
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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]
Mission of our Team
PATIENT/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
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Suicide / assault / elopement precautions
Detox protocol
Mission of our Team
PATIENT/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 Team
TRAINING-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
Development of our MDT
“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 Limitations
o “Surprise!”
Development of our MDT
Evolution mid-1990’s – 2000’s
o JCAHO - > BPSS added to team.
o Department Head with addiction background. AMS /
CAC added to team.
o ACGME mandated increase in supervision of
residents
o Mandated increase in staff physician involvement
o “Reimbursement” tied to workload calculations
based on documentation review.
Development of our MDT
“TODAY”
o Rounds expanded in scope and duration
o Interviews by teams, not individuals
o Other’s perspectives, wisdom, and experiences were
embraced and utilized
o Splitting less likely
o Staff’s reactions could be processed
o Trainees appreciated other discipline’s expertise
o Healthy staff interactions were modeled for trainees
o Continuity of care enhanced
o Fewer “surprises.”
Consequences -?
Patients found the team intimidating.
o Individual’s process may be slowed.
o Distractions from other members
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Challenges to the Practice
Rotating Interns, residents, and students
Inexperienced tech staff
Staff deployments / transfers
Three partially-overlapping electronic medical record systems
Sequestration / furlough of staff
Ineffective computer hardware
Not a Concierge Service
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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.
Outcomes?
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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
THE WONDERFULLY ALLITERATED
MDT CAN YIELD…
ollaboration
ollegiality
o-operation
ompetency
onfidence
reativity
NOT…
C
onfusion
alamity
risis
References
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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
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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
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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)
Thank you for
being with us!
Enjoy the rest of your VSIAS
Conference 2013 and your stay
in the “Colonial Capital!”
gary.munn.ctr@med.navy.mil