- Email: [email protected]
The Interdisciplinary Team and Polytrauma Rehabilitation: Prescription for Partnership
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SPECIAL SECTION: SPECIAL COMMUNICATION
The Interdisciplinary Team and Polytrauma Rehabilitation: Prescription for Partnership Dale C. Strasser, MD, Jay M. Uomoto, PhD, Stanley J. Smits, PhD ABSTRACT. Strasser DC, Uomoto JM, Smits SJ. The interdisciplinary team and polytrauma rehabilitation: prescription for partnership. Arch Phys Med Rehabil 2008;89:179-81. Optimal outcomes for polytrauma survivors depend on the integration of complex medical, psychosocial, financial, educational, and vocational resources across diverse specialties and multiple medical centers, programs, and organizations and all in a setting of high public visibility and family involvement. Well-functioning teams are critical to service integration, and teams are more effective in supportive hospital environments. Here, we offer a model of team functioning relevant to polytrauma and outline a team training program to improve services. Furthermore, we propose a partnership among the team, hospital administrators, and national leaders and with patients and their families. Integrated care requires partnerships among the various stakeholders, and those working in polytrauma have a unique opportunity to create an updated paradigm of the team approach responsive to the complexities of contemporary health care. Key Words: Interdisciplinary health team; Rehabilitation; Trauma; Wounds and injuries. © 2008 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation BOUT 65 YEARS AGO, the interdisciplinary rehabilitation team emerged in response to the increasingly complex A health care needs arising from World War II. Thanks to antibiotics and other medical advances, many soldiers wounded in that war survived who would not have survived World War I or the U.S. Civil War. With this increased survival came a greater number of those with severe injuries and disabilities. Physicians, like the young internist Howard Rusk and others,1 confronted new challenges that could not be addressed in the prevailing medical model characterized by single-discipline care. Creative approaches and innovative strategies were needed, and central to their response was the development of the interdisciplinary team to promote comprehensive and collaborative care. This team approach eventually became a central tenet of a new field of medicine, physical medicine and rehabilitation. In a similar manner, the Veterans Health Administration (VHA) and the Department of Defense (DOD) rehabilitation providers now face the challenge of delivering
From the Department of Rehabilitation Medicine, Emory University, Atlanta, GA (Strasser); VA Medical Center, Atlanta, GA (Strasser); Center for Polytrauma Care, VA Puget Sound Health Care System (Seattle Division), Seattle, WA (Uomoto); and Department of Management Sciences, Robinson College of Business, Georgia State University, Atlanta, GA (Smits). No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated. Correspondence to Dale C. Strasser, MD, 1441 Clifton Rd. NE, Atlanta, GA 30322, e-mail: [email protected]. 0003-9993/08/8901-00099$34.00/0 doi:10.1016/j.apmr.2007.06.774
needed services to a new cohort of severely injured soldiers with polytrauma. The VHA has responded with an impressive new approach, the Polytrauma System of Care (PSC),2 and substantial resources including state of the art teleconferencing capabilities.3 Two distinct themes emerge when examining polytrauma services: the public visibility of these activities and the role of families. Polytrauma services are regularly featured in the national media, as are compelling stories of individual patients and their families. Such attention heightens expectations on service delivery, and it brings additional resources and enhanced public accountability. In our institutional review board approved pilot work on polytrauma teams, we asked 35 staff members at 2 polytrauma rehabilitation centers to rate the difficulty of each of 5 tasks. Staff members rated managing family expectations as significantly more difficult than the other 4 areas: treatment goals, length of stay, discharge planning, and prognosis. Families of wounded soldiers naturally look to professionals for advice and expert treatment. But, at the same time, they are increasingly expecting and demanding input into the major and the daily clinical care decisions traditionally afforded the professionals. Along with their active role in the management of the patient, they are also increasingly willing and effective advocates, system wide, for additional services and resources that may benefit their soldier. At face value, these trends in care promise to deliver the best possible outcomes for all concerned, but they also carry with them a growing challenge for rehabilitation professionals to help families hold onto their hopes while helping them plan for multiple outcomes scenarios. Even with the finest of care, rehabilitation can be a lengthy, complicated, uneven, and at times frustrating and discouraging period in their lives. Polytrauma services bring into greater relief a curious paradox that has pervaded rehabilitation since its inception. We promote the interdisciplinary team and yet devote comparatively little effort toward examining what it means or how to improve it. Early on, the primary focus was on the development of a new paradigm of interdisciplinary care and not how to improve the approach. Later in the 1970s and early 1980s, high levels of funding for these services created few incentives to improve the basic model. Still, many clinicians believed the actual work of teams fell short in meeting the complex biopsychosocial needs of rehabilitation patients4 even though long hospitalizations reduced the likelihood of poor outcomes. During the last 15 years, empirical research has emerged on the determinants of rehabilitation outcomes, particularly for persons with stroke5,6 and acquired brain injury.7 DeJong et al8 have identified process variables such as amount and type of therapies and modes of service delivery to predict strokepatient outcomes. In our Veterans Administration (VA) rehabilitation teams project, characteristics of team functioning predicted functional improvement in stroke rehabilitation,9 and in a cluster randomized clinical trial on team functioning and process improvement, a team training intervention was associated with improved functional gains compared with patients treated by controlled teams.10 We have now glimpsed inside the black box of rehabilitation and seen its workings and parts. Arch Phys Med Rehabil Vol 89, January 2008
180
TEAM CARE AND POLYTRAUMA REHABILITATION, Strasser
We use a model of rehabilitation treatment effectiveness that consists of inputs, transformational processes, and outputs.11,12 In this model, the interdisciplinary team is a change agent between system inputs and patient outcomes.12,13 Inputs for polytrauma services include those at the organizational level (multiple facilities, 2 federal agencies, local hospital structure and culture), the treatment or technology level (eg, neurostimulants, cognitive rehabilitation, mobility training), and participants (eg, patients, families, health care providers, administrators, military liaison officers, representatives of referring organizations). The outcomes are patient centered and include functional improvement, optimal community reentry, health status, and quality of life. Although the centrality of the team in rehabilitation has empirical support and makes clinical sense, such an orientation often challenges established organizational (bureaucratic) processes and interprofessional relations. The PSC2 represents an unprecedented effort toward an integrated medicine approach to comprehensive health care service delivery. Such a nationally based approach would be unimaginable in the U.S. private sector. The PSC promotes a “proactive model of intensive care management” that includes a warm “hand off” among the VHA professionals at different locations, all supported by a state-of-the-art Polytrauma Telehealth Network3 system of communication. The spirit underlying this system makes intuitive sense and builds on the rationale for the development of the interdisciplinary rehabilitation team during World War II. Complex biopsychosocial interventions require integrated and coordinated care. The PSC promotes the organizational structure to support rehabilitation at multiple locations. Here, we propose that to fully realize the goals of the PSC, corresponding efforts are needed not only to reinvigorate individual team functioning but also to reconfigure the relationship of the team to the larger organizational and the overlying health care system. Remarkable transformations have occurred within the VHA during the last 15 years as evidenced by its national recognition in patient satisfaction14-16 and a Rand study on appropriateness of care.17 In July 2006, the VHA received the Innovations in Government Award from the Harvard Kennedy School and Ash Institute for its leadership in combining performance measurement and electronic health records.15 The PSC offers another reminder of the advantages of a centralized system of health care. Nevertheless, as expected of a large complex bureaucracy with diverse stakeholders, the VHA has shortcomings. In our work on hospital culture and rehabilitation team functioning, we identified a discrepancy between the way hospitals are managed and the give-and-take manner in which interdisciplinary rehabilitation team members achieve patient-care objectives.12 Staff were more likely to see the dominant VA hospital culture as highly structured and bureaucratic rather than more professional forms of hospital leadership and associated this culture type with lower rehabilitation team functioning. Subsequent work18 suggested that effective team leadership and hands-on physician support could mediate the adverse effects of bureaucracy. The public outcry over outpatient conditions at Walter Reed Army Medical Center, a DOD facility, highlighted the continuing demand for a more efficient and responsive system of care. Our research suggests the work of rehabilitation teams captures essential and desirable attributes of larger health care organization and may serve as a model for the VHA itself. Rehabilitation teams merge multiple professional subcultures into an integrated force directed toward targeted patient outcomes. The team is more professional than bureaucratic in its processes, more open to multiple inputs in decision making, and more Arch Phys Med Rehabil Vol 89, January 2008
willing to customize care. The system itself must strive to integrate its various components of bureaucracy into a more flexible and responsive service delivery entity that responds to the expectations of patients, their families, the professional caregivers it employs, the congressional oversight committees that control its resources and mandates, and the public it serves. Our work also provides evidence that the skills that enable the team to effect change in its process and outcome can be applied at all levels of the organization. Rehabilitation providers and senior leadership can learn further how to more effectively support the rehabilitation process. At the team level, 1 approach is to teach skills to team leaders, in effect training the trainers as shown in the recent clinical trial.19 In the interactive workshops our group used, participants showed skills in team problem solving and the use of outcomes data and designed site-specific action plans to improve team functioning.19 We can envision a similar process improvement initiative with the interdisciplinary team and senior leadership that targets the interface of team functioning and organizational support for these activities. Whatever specific strategy is used, VHA and DOD professionals responsible for polytrauma services have the opportunity to forge new insights into interdisciplinary care and the relationship between service delivery, organizational structure, and technical support on patient outcomes, not only for those with polytrauma but also for other disability groups in which complex and collaborative care is required. The subtitle of this commentary, a prescription for partnership, was selected to parallel Kizer’s seminal work, Prescription for Change.20 Kizer, the former undersecretary of health affairs of the VHA during the mid to late 1990s, initiated a major restructuring of VA services, and these efforts are credited with laying the foundation for the remarkable improvements in quality of care in the VHA during the last 5 years.15,16 Nevertheless, these changes were imposed from above. Our “prescription for partnership” represents a progression to a cellular level of the organization, namely, the interdisciplinary team. This partnership needs to be an interactive process in which insights gained at the level of the team integrate with other service providers, senior leadership, and stakeholders in other key organizations. CONCLUSIONS Optimal outcomes in polytrauma care depend on the successful integration of medical, psychosocial, financial, educational, and vocational resources across an array of specialties and multiple medical centers, programs, and organizations. Throughout our history, upheaval and uncertainty caused by crisis and war have resulted in more effective treatment and paradigms for those immediately affected and for future generations. Polytrauma professionals are now being called on to act. We propose that senior leadership adapt a bottom-up feedback loop to compliment and enlarge the top-down approach currently being implemented. Increases in funding for research and clinical demonstration projects in polytrauma provide the means to critically examine and codify the insights of these new paradigms. Such work should have significant implications not only for our field but also other medical areas in which complexities of care coordination and geographic dispersion of expertise hamper treatment effectiveness such as intensive care, emergency medicine, mental health, and extended care. We owe it to our patients and our future patients to critically examine the underpinnings of the rehabilitation process and to incorporate the knowledge gained into new practice strategies and approaches.
TEAM CARE AND POLYTRAUMA REHABILITATION, Strasser
References 1. Rusk HA. A world to care for: the autobiography of Howard A. Rusk, M.D. New York: Reader’s Digest Press Book, Random House; 1977. 2. Sigford BJ. “To care for him who shall have borne the battle and for his widow and his orphan” (Abraham Lincoln): The Department of Veterans Affairs Polytrauma System of Care. Arch Phys Med Rehabil 2008;89:160-2. 3. Darkins A, Cruise C, Armstrong M, Peters J, Finn M. Enhancing access of combat wounded veterans to specialist rehabilitation services: The VA Polytrauma Telehealth Network. Arch Phys Med Rehabil 2008;89:182-7. 4. Keith RA. The comprehensive treatment team in rehabilitation. Arch Phys Med Rehabil 1991;72:269-74. 5. Langhorne P, Martin SD. Stroke units: the next 10 years. Lancet 2004;363:834-5. 6. Collaborative systematic review of the randomised trials of organised inpatient (stroke unit) care after stroke. Stroke Unit Trialists’ Collaboration. BMJ 1997;314:1151-9. 7. Sarajuuri JM, Kaipio ML, Koskinen SK, Niemela MR, Servo AR, Vilkki JS. Outcome of a comprehensive neurorehabilitation program for patients with traumatic brain injury. Arch Phys Med Rehabil 2005;86:2296-302. 8. DeJong G, Horn SD, Conroy B, Nichols D, Healton EB. Opening the black box of poststroke rehabilitation: stroke rehabilitation patients, processes, and outcomes. Arch Phys Med Rehabil 2005; 86(12 Suppl 2):S1-7. 9. Strasser DC, Falconer JA, Herrin J, Bowen SE, Stevens AB, Uomoto J. Team functioning and patient outcomes in stroke rehabilitation. Arch Phys Med Rehabil 2005;86:403-9. 10. Strasser DC, Falconer JA, Stevens AB, et al. Team training and stroke rehabilitation outcomes: a cluster randomized trial. Arch Phys Med Rehabil 2008;89:10-5.
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11. Strasser DC, Falconer JA. Linking treatment to outcomes through teams: building a conceptual model of rehabilitation effectiveness. Top Stroke Rehabil 1997;4:15-27. 12. Strasser DC, Smits SJ, Falconer JA, Herrin JS, Bowen SE. The influence of hospital culture on rehabilitation team functioning in VA hospitals. J Rehabil Res Dev 2002;39:115-25. 13. Strasser DC, Falconer JA. Rehabilitation team process. Top Stroke Rehabil 1997;4:34-9. 14. Waller D. How VA hospitals became the best. Time 2006 Aug 27. Available at: http://www.time.com/time/magazine/article/ 0,9171,1376238,00.html. Accessed June 19, 2007. 15. Innovations in Government Award. Harvard University–Ash Institute and Kennedy School of Government; 2006. Available at: http:// www.ashinstitute.harvard.edu/Ash/pdfs/VAVistAreleasefinale.pdf. Accessed June 19, 2007. 16. Department of Veterans Affairs outperforms private health care facilities in consumer satisfaction, survey finds. Ann Arbor: University of Michigan; 2006. Available at: http://www.consumerwatchdog.org/ healthcare/veteransaffairs. Accessed June 19, 2007. 17. Selim AJ, Kazis LE, Rogers W, et al. Risk-adjusted mortality as an indicator of outcomes: comparisons of the Medicare advantage program with the veterans’ health administration. Med Care 2006; 44:359-65. 18. Smits SJ, Falconer JA, Herrin J, Bowen SE, Strasser DC. Patient-focused rehabilitation team cohesiveness in Veterans Administration hospitals. Arch Phys Med Rehabil 2003;84: 1332-8. 19. Stevens AB, Strasser DC, Uomoto J, Bowen SE, Falconer JA. Utility of treatment implementation methods in a clinical trial with rehabilitation teams. J Rehabil Res Dev 2007;44:537-46. 20. Kizer KM. Prescription for change: the guiding principles and strategic objectives underlying the transformation of the veterans’ healthcare system. Washington (DC): Office of the Under Secretary for Health; Mar 1996.
Arch Phys Med Rehabil Vol 89, January 2008
SPECIAL SECTION: SPECIAL COMMUNICATION
The Interdisciplinary Team and Polytrauma Rehabilitation: Prescription for Partnership Dale C. Strasser, MD, Jay M. Uomoto, PhD, Stanley J. Smits, PhD ABSTRACT. Strasser DC, Uomoto JM, Smits SJ. The interdisciplinary team and polytrauma rehabilitation: prescription for partnership. Arch Phys Med Rehabil 2008;89:179-81. Optimal outcomes for polytrauma survivors depend on the integration of complex medical, psychosocial, financial, educational, and vocational resources across diverse specialties and multiple medical centers, programs, and organizations and all in a setting of high public visibility and family involvement. Well-functioning teams are critical to service integration, and teams are more effective in supportive hospital environments. Here, we offer a model of team functioning relevant to polytrauma and outline a team training program to improve services. Furthermore, we propose a partnership among the team, hospital administrators, and national leaders and with patients and their families. Integrated care requires partnerships among the various stakeholders, and those working in polytrauma have a unique opportunity to create an updated paradigm of the team approach responsive to the complexities of contemporary health care. Key Words: Interdisciplinary health team; Rehabilitation; Trauma; Wounds and injuries. © 2008 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation BOUT 65 YEARS AGO, the interdisciplinary rehabilitation team emerged in response to the increasingly complex A health care needs arising from World War II. Thanks to antibiotics and other medical advances, many soldiers wounded in that war survived who would not have survived World War I or the U.S. Civil War. With this increased survival came a greater number of those with severe injuries and disabilities. Physicians, like the young internist Howard Rusk and others,1 confronted new challenges that could not be addressed in the prevailing medical model characterized by single-discipline care. Creative approaches and innovative strategies were needed, and central to their response was the development of the interdisciplinary team to promote comprehensive and collaborative care. This team approach eventually became a central tenet of a new field of medicine, physical medicine and rehabilitation. In a similar manner, the Veterans Health Administration (VHA) and the Department of Defense (DOD) rehabilitation providers now face the challenge of delivering
From the Department of Rehabilitation Medicine, Emory University, Atlanta, GA (Strasser); VA Medical Center, Atlanta, GA (Strasser); Center for Polytrauma Care, VA Puget Sound Health Care System (Seattle Division), Seattle, WA (Uomoto); and Department of Management Sciences, Robinson College of Business, Georgia State University, Atlanta, GA (Smits). No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated. Correspondence to Dale C. Strasser, MD, 1441 Clifton Rd. NE, Atlanta, GA 30322, e-mail: [email protected]. 0003-9993/08/8901-00099$34.00/0 doi:10.1016/j.apmr.2007.06.774
needed services to a new cohort of severely injured soldiers with polytrauma. The VHA has responded with an impressive new approach, the Polytrauma System of Care (PSC),2 and substantial resources including state of the art teleconferencing capabilities.3 Two distinct themes emerge when examining polytrauma services: the public visibility of these activities and the role of families. Polytrauma services are regularly featured in the national media, as are compelling stories of individual patients and their families. Such attention heightens expectations on service delivery, and it brings additional resources and enhanced public accountability. In our institutional review board approved pilot work on polytrauma teams, we asked 35 staff members at 2 polytrauma rehabilitation centers to rate the difficulty of each of 5 tasks. Staff members rated managing family expectations as significantly more difficult than the other 4 areas: treatment goals, length of stay, discharge planning, and prognosis. Families of wounded soldiers naturally look to professionals for advice and expert treatment. But, at the same time, they are increasingly expecting and demanding input into the major and the daily clinical care decisions traditionally afforded the professionals. Along with their active role in the management of the patient, they are also increasingly willing and effective advocates, system wide, for additional services and resources that may benefit their soldier. At face value, these trends in care promise to deliver the best possible outcomes for all concerned, but they also carry with them a growing challenge for rehabilitation professionals to help families hold onto their hopes while helping them plan for multiple outcomes scenarios. Even with the finest of care, rehabilitation can be a lengthy, complicated, uneven, and at times frustrating and discouraging period in their lives. Polytrauma services bring into greater relief a curious paradox that has pervaded rehabilitation since its inception. We promote the interdisciplinary team and yet devote comparatively little effort toward examining what it means or how to improve it. Early on, the primary focus was on the development of a new paradigm of interdisciplinary care and not how to improve the approach. Later in the 1970s and early 1980s, high levels of funding for these services created few incentives to improve the basic model. Still, many clinicians believed the actual work of teams fell short in meeting the complex biopsychosocial needs of rehabilitation patients4 even though long hospitalizations reduced the likelihood of poor outcomes. During the last 15 years, empirical research has emerged on the determinants of rehabilitation outcomes, particularly for persons with stroke5,6 and acquired brain injury.7 DeJong et al8 have identified process variables such as amount and type of therapies and modes of service delivery to predict strokepatient outcomes. In our Veterans Administration (VA) rehabilitation teams project, characteristics of team functioning predicted functional improvement in stroke rehabilitation,9 and in a cluster randomized clinical trial on team functioning and process improvement, a team training intervention was associated with improved functional gains compared with patients treated by controlled teams.10 We have now glimpsed inside the black box of rehabilitation and seen its workings and parts. Arch Phys Med Rehabil Vol 89, January 2008
180
TEAM CARE AND POLYTRAUMA REHABILITATION, Strasser
We use a model of rehabilitation treatment effectiveness that consists of inputs, transformational processes, and outputs.11,12 In this model, the interdisciplinary team is a change agent between system inputs and patient outcomes.12,13 Inputs for polytrauma services include those at the organizational level (multiple facilities, 2 federal agencies, local hospital structure and culture), the treatment or technology level (eg, neurostimulants, cognitive rehabilitation, mobility training), and participants (eg, patients, families, health care providers, administrators, military liaison officers, representatives of referring organizations). The outcomes are patient centered and include functional improvement, optimal community reentry, health status, and quality of life. Although the centrality of the team in rehabilitation has empirical support and makes clinical sense, such an orientation often challenges established organizational (bureaucratic) processes and interprofessional relations. The PSC2 represents an unprecedented effort toward an integrated medicine approach to comprehensive health care service delivery. Such a nationally based approach would be unimaginable in the U.S. private sector. The PSC promotes a “proactive model of intensive care management” that includes a warm “hand off” among the VHA professionals at different locations, all supported by a state-of-the-art Polytrauma Telehealth Network3 system of communication. The spirit underlying this system makes intuitive sense and builds on the rationale for the development of the interdisciplinary rehabilitation team during World War II. Complex biopsychosocial interventions require integrated and coordinated care. The PSC promotes the organizational structure to support rehabilitation at multiple locations. Here, we propose that to fully realize the goals of the PSC, corresponding efforts are needed not only to reinvigorate individual team functioning but also to reconfigure the relationship of the team to the larger organizational and the overlying health care system. Remarkable transformations have occurred within the VHA during the last 15 years as evidenced by its national recognition in patient satisfaction14-16 and a Rand study on appropriateness of care.17 In July 2006, the VHA received the Innovations in Government Award from the Harvard Kennedy School and Ash Institute for its leadership in combining performance measurement and electronic health records.15 The PSC offers another reminder of the advantages of a centralized system of health care. Nevertheless, as expected of a large complex bureaucracy with diverse stakeholders, the VHA has shortcomings. In our work on hospital culture and rehabilitation team functioning, we identified a discrepancy between the way hospitals are managed and the give-and-take manner in which interdisciplinary rehabilitation team members achieve patient-care objectives.12 Staff were more likely to see the dominant VA hospital culture as highly structured and bureaucratic rather than more professional forms of hospital leadership and associated this culture type with lower rehabilitation team functioning. Subsequent work18 suggested that effective team leadership and hands-on physician support could mediate the adverse effects of bureaucracy. The public outcry over outpatient conditions at Walter Reed Army Medical Center, a DOD facility, highlighted the continuing demand for a more efficient and responsive system of care. Our research suggests the work of rehabilitation teams captures essential and desirable attributes of larger health care organization and may serve as a model for the VHA itself. Rehabilitation teams merge multiple professional subcultures into an integrated force directed toward targeted patient outcomes. The team is more professional than bureaucratic in its processes, more open to multiple inputs in decision making, and more Arch Phys Med Rehabil Vol 89, January 2008
willing to customize care. The system itself must strive to integrate its various components of bureaucracy into a more flexible and responsive service delivery entity that responds to the expectations of patients, their families, the professional caregivers it employs, the congressional oversight committees that control its resources and mandates, and the public it serves. Our work also provides evidence that the skills that enable the team to effect change in its process and outcome can be applied at all levels of the organization. Rehabilitation providers and senior leadership can learn further how to more effectively support the rehabilitation process. At the team level, 1 approach is to teach skills to team leaders, in effect training the trainers as shown in the recent clinical trial.19 In the interactive workshops our group used, participants showed skills in team problem solving and the use of outcomes data and designed site-specific action plans to improve team functioning.19 We can envision a similar process improvement initiative with the interdisciplinary team and senior leadership that targets the interface of team functioning and organizational support for these activities. Whatever specific strategy is used, VHA and DOD professionals responsible for polytrauma services have the opportunity to forge new insights into interdisciplinary care and the relationship between service delivery, organizational structure, and technical support on patient outcomes, not only for those with polytrauma but also for other disability groups in which complex and collaborative care is required. The subtitle of this commentary, a prescription for partnership, was selected to parallel Kizer’s seminal work, Prescription for Change.20 Kizer, the former undersecretary of health affairs of the VHA during the mid to late 1990s, initiated a major restructuring of VA services, and these efforts are credited with laying the foundation for the remarkable improvements in quality of care in the VHA during the last 5 years.15,16 Nevertheless, these changes were imposed from above. Our “prescription for partnership” represents a progression to a cellular level of the organization, namely, the interdisciplinary team. This partnership needs to be an interactive process in which insights gained at the level of the team integrate with other service providers, senior leadership, and stakeholders in other key organizations. CONCLUSIONS Optimal outcomes in polytrauma care depend on the successful integration of medical, psychosocial, financial, educational, and vocational resources across an array of specialties and multiple medical centers, programs, and organizations. Throughout our history, upheaval and uncertainty caused by crisis and war have resulted in more effective treatment and paradigms for those immediately affected and for future generations. Polytrauma professionals are now being called on to act. We propose that senior leadership adapt a bottom-up feedback loop to compliment and enlarge the top-down approach currently being implemented. Increases in funding for research and clinical demonstration projects in polytrauma provide the means to critically examine and codify the insights of these new paradigms. Such work should have significant implications not only for our field but also other medical areas in which complexities of care coordination and geographic dispersion of expertise hamper treatment effectiveness such as intensive care, emergency medicine, mental health, and extended care. We owe it to our patients and our future patients to critically examine the underpinnings of the rehabilitation process and to incorporate the knowledge gained into new practice strategies and approaches.
TEAM CARE AND POLYTRAUMA REHABILITATION, Strasser
References 1. Rusk HA. A world to care for: the autobiography of Howard A. Rusk, M.D. New York: Reader’s Digest Press Book, Random House; 1977. 2. Sigford BJ. “To care for him who shall have borne the battle and for his widow and his orphan” (Abraham Lincoln): The Department of Veterans Affairs Polytrauma System of Care. Arch Phys Med Rehabil 2008;89:160-2. 3. Darkins A, Cruise C, Armstrong M, Peters J, Finn M. Enhancing access of combat wounded veterans to specialist rehabilitation services: The VA Polytrauma Telehealth Network. Arch Phys Med Rehabil 2008;89:182-7. 4. Keith RA. The comprehensive treatment team in rehabilitation. Arch Phys Med Rehabil 1991;72:269-74. 5. Langhorne P, Martin SD. Stroke units: the next 10 years. Lancet 2004;363:834-5. 6. Collaborative systematic review of the randomised trials of organised inpatient (stroke unit) care after stroke. Stroke Unit Trialists’ Collaboration. BMJ 1997;314:1151-9. 7. Sarajuuri JM, Kaipio ML, Koskinen SK, Niemela MR, Servo AR, Vilkki JS. Outcome of a comprehensive neurorehabilitation program for patients with traumatic brain injury. Arch Phys Med Rehabil 2005;86:2296-302. 8. DeJong G, Horn SD, Conroy B, Nichols D, Healton EB. Opening the black box of poststroke rehabilitation: stroke rehabilitation patients, processes, and outcomes. Arch Phys Med Rehabil 2005; 86(12 Suppl 2):S1-7. 9. Strasser DC, Falconer JA, Herrin J, Bowen SE, Stevens AB, Uomoto J. Team functioning and patient outcomes in stroke rehabilitation. Arch Phys Med Rehabil 2005;86:403-9. 10. Strasser DC, Falconer JA, Stevens AB, et al. Team training and stroke rehabilitation outcomes: a cluster randomized trial. Arch Phys Med Rehabil 2008;89:10-5.
181
11. Strasser DC, Falconer JA. Linking treatment to outcomes through teams: building a conceptual model of rehabilitation effectiveness. Top Stroke Rehabil 1997;4:15-27. 12. Strasser DC, Smits SJ, Falconer JA, Herrin JS, Bowen SE. The influence of hospital culture on rehabilitation team functioning in VA hospitals. J Rehabil Res Dev 2002;39:115-25. 13. Strasser DC, Falconer JA. Rehabilitation team process. Top Stroke Rehabil 1997;4:34-9. 14. Waller D. How VA hospitals became the best. Time 2006 Aug 27. Available at: http://www.time.com/time/magazine/article/ 0,9171,1376238,00.html. Accessed June 19, 2007. 15. Innovations in Government Award. Harvard University–Ash Institute and Kennedy School of Government; 2006. Available at: http:// www.ashinstitute.harvard.edu/Ash/pdfs/VAVistAreleasefinale.pdf. Accessed June 19, 2007. 16. Department of Veterans Affairs outperforms private health care facilities in consumer satisfaction, survey finds. Ann Arbor: University of Michigan; 2006. Available at: http://www.consumerwatchdog.org/ healthcare/veteransaffairs. Accessed June 19, 2007. 17. Selim AJ, Kazis LE, Rogers W, et al. Risk-adjusted mortality as an indicator of outcomes: comparisons of the Medicare advantage program with the veterans’ health administration. Med Care 2006; 44:359-65. 18. Smits SJ, Falconer JA, Herrin J, Bowen SE, Strasser DC. Patient-focused rehabilitation team cohesiveness in Veterans Administration hospitals. Arch Phys Med Rehabil 2003;84: 1332-8. 19. Stevens AB, Strasser DC, Uomoto J, Bowen SE, Falconer JA. Utility of treatment implementation methods in a clinical trial with rehabilitation teams. J Rehabil Res Dev 2007;44:537-46. 20. Kizer KM. Prescription for change: the guiding principles and strategic objectives underlying the transformation of the veterans’ healthcare system. Washington (DC): Office of the Under Secretary for Health; Mar 1996.
Arch Phys Med Rehabil Vol 89, January 2008