Mid Sweden University

Team collaboration is a fundamental part of Quality Management (QM), and working together successfully is an important part of improving an organization. Team collaboration is also essential for achieving quality of care, patient safety and care continuity, especially when handling critically ill patients. Transferring a patient from an intensive care unit (ICU) to a general ward demands planning, communication, competence, a system view, and a quality culture. This patient transfer process, called ICU transitional care, extends across hospital boundaries, which have different organizational cultures, technologies, and knowledge. It is a challenge to manage these differences in order for team collaboration to meet the needs of patients, relatives and co-workers. To achieve this, further research is required to understand how care teams, both within hospital units and between organizational boundaries, can collaborate more successfully and efficiently to achieve quality of care in the ICU transitional care process.

The overall purpose of this thesis is to contribute to a deeper understanding of how to improve team collaboration within ICU transitional care aiming to increase quality of care. To achieve this, four research questions were formulated and three case studies conducted. In the first case, a systematic literature review was performed to explore the extent to which Quality Management and Nursing Science can offer complementary perspectives to provide better quality of care by looking at Quality Management core concepts and tools. Findings from this study revealed, among other things, a need for further research on team collaboration in ICU transitional care. The purpose of the second study was to develop and test a questionnaire aiming to measure the perception of team collaboration in the patient transfer process from the ICU to the general ward. This study also aimed to analyze the results to see how the questionnaire could help improve team collaboration within ICU transitional care. Empirical data were collected from two ICUs at two hospitals. Participants at the ICUs answered the developed questionnaire, and the results showed that it could be used for measuring perceived team collaboration in this patient transfer process. The results from the questionnaire also gave insights that might be useful for improving team collaboration in this ICU transitional care process. The purposes of the third study were, first, to describe how co-workers’, within a team, perceived team collaboration in patient transfers from ICU to general wards and, second, to describe co-workers’ suggestions for an improved future state of team collaboration. Focus group discussions (FGDs) were conducted at two hospitals to answer the two questions. There were several findings from the study, and the results indicated that team collaboration has an important role when creating prerequisites for a holistic view of the process, and that there was a perceived need among the co-workers to improve team collaboration over organizational boundaries. Co-workers also expressed a need for more involving patients and relatives when improving team collaboration.  

Four overarching conclusions can be drawn from this research. Firstly, Quality Management is used in ICU transitional care to improve the quality of care. Secondly, multi-professional team collaboration is perceived to be easier and better developed within hospital units than between them. Collaborating in teams between hospital units is challenging for several reasons. Some reasons are unclarity in routines for communication and decision-making, for example who decides what.  A third conclusion is the importance of how teams and team collaboration are defined and structured in ICU transitional care. This involves roles and responsibilities of teams. Teams have specific characteristics that are important for their performance. A fourth conclusion is an expressed need to involve patients and relatives more when it comes to improve team collaboration in ICU transitional care. The main findings from the three studies presented in this thesis have given insight and deeper understanding of how co-workers perceive team collaboration within ICU transitional care at two hospitals located in Sweden, and co-workers’ suggestions for how team collaboration can be improved aiming to increase quality of care.

Today's organisations are faced with increasingly complicated and complex challenges. To master these challenges, organisations need to work more together, both within their own organisations and in collaboration with others. Working as a ‘real’ team, while also creating a sustainable quality culture, can be one way to address these challenges. The top management team within the organisation will play a crucial role in determining the organisation's success. 

The purpose of this thesis was to contribute to a deeper understanding of real teamwork and how real teamwork relates to a sustainable quality culture. The purpose was also to describe perceived success factors in creating real teamwork and sustainable quality culture, aiming at increasing an organisation’s performance. 

Conclusions drawn from this research can be summarised into seven overarching proposals or recommendations on how to increase the abilities for real teamwork alongside with creating a sustainable quality culture: 

• Embrace the heart and develop ‘emotional commitment’: this involves ‘touching the hearts’ of individuals in the organisation, both when it comes to ‘real’ teamwork and in creating sustainable quality culture. 
• Balance between structure and culture: structure and culture should go ‘hand in hand’ and harmoniously complement each other. 
• Apply a systems view: this entails considering ‘real’ teamwork within the broader context and viewing core values as a system. 
• Foster a culture of continuous improvement: improvement is achieved through reflexivity and the adoption of novel perspectives. Continuous improvement is fundamental for both ‘real’ teamwork and the development of sustainable quality culture. 
• Apply a customer perspective on value creation: this is critical for practicing ‘real’ teamwork, as well as in developing a sustainable quality culture aiming to increase organisational performance.
• Apply long-term and sustainable thinking: as a part of practicing ‘real’ teamwork and when creating a sustainable quality culture. Both the presence and the future should be built into the system.
• Measuring and assessing ‘real’ teamwork and sustainable quality culture is valuable in establishing the prerequisites and abilities necessary for ‘real’ teamwork, as well as for advancing the development of a sustainable quality culture within an organisation.

The research has also led to practical suggestions on how the participating organisations can enhance their abilities for real teamwork and strengthen the culture of quality within their organisations.