Evaluating the responsiveness and clinical utility of the Australian Therapy Outcome Measure for Indigenous Clients (ATOMIC)

Mr Nicholas Sheahan1, Dr  Rosamund  Harrington, Dr Alison Nelson, Associate Professor Loretta Sheppard

1The Institute For Urban Indigenous Health, Brisbane, Australia

Introduction: Research suggests a current dearth of culturally responsive outcome measures for use with First Australian peoples. Most outcome measurement tools have been developed with participants from Western backgrounds. The Australian Therapy Outcome Measure for Indigenous Clients (ATOMIC) is an outcome measure that has been specifically designed to consider the more holistic views of health held by First Australians. This research aimed to determine the responsiveness and clinical utility of ATOMIC when applied to First Australian adults within an urban context.

Methods: This research was conducted as two studies. Study 1 investigated the responsiveness of ATOMIC to change over time using data gathered from First Australian clients, tracking changes in their goal achievement pre- and post- intervention.  Study 2 investigated the clinical utility of ATOMIC (i) from the perspective of the client to determine whether they understood the purpose of the tool and whether it aligned with their philosophical views on health care; and (ii) from the perspective of the clinicians using the tool

Results: Study 1: Paired t-tests showed a statistically significant increase (p=0.00) in ATOMIC scores pre (mean = 1.8) and post (mean = 8) intervention. Effect size (Cohen d) was calculated as 2.1 and thus also statistically significant. Both calculations indicate ATOMIC is responsive to change. Study 2: Synthesis of interview and focus group data resulted in four overarching themes. These were (i) First Australians are on their own journey and are adept at self-managing their conditions (ii) ATOMIC is a clinically useful outcome measure, that is acceptable to First Australian clients and clinicians, (iii) ATOMIC supports culturally responsive goal-setting, and (iv) ATOMIC supports occupational therapy practice

Conclusion: This research demonstrates ATOMIC is a responsive and clinically useful outcome measure when used with urban First Australian adults.


Biography:

Nick recently graduated with honours from an occupational therapy degree at the Australian Catholic University. He is passionate about helping others and has a strong interest in First Australian health. Nick is employed as an occupational therapist with The Institute for Urban Indigenous Health and he feels that his role at IUIH allows him to contribute to the health and wellbeing of his clients in a positive and holistic manner. He is passionate about evidence-based practice and hopes to positively contribute to the occupational therapy profession for many years to come

I. C. U. I Hear U? The patient experience of being voiceless in the ICU

Gabrielle Salisbury-baker1

1St George Hospital, South Eastern Sydney Local Health District, Kogarah, Australia

Background: Patients requiring prolonged mechanical ventilation and tracheostomy within the ICU setting regularly experience a period of voicelessness. The psychosocial effects of voicelessness are well documented, with high levels of frustration, anxiety, and depression reported.

Method: A quality improvement project was initiated within an urban, tertiary level hospital to explore the consumer experience of being voiceless in the ICU. Secondary aims were to determine staff communication-training needs, and to guide development of a communication tool that meets the needs of our consumers. A survey or semi-structured interview was completed with ICU staff, and patients who experienced a period of voiceless following intubation and/or tracheostomy.

Results: 15 patients and 32 ICU staff from medical, nursing, and allied health backgrounds completed this survey. 87% of patients indicated communication was inadequate, and 80% did not feel included in care decisions. All emotions described by patients were negative, with common themes of isolation, frustration and fear reported. 66% of ICU staff “frequently” experience difficulty communicating with voiceless patients. Staff reported that patients most want to communicate care needs (e.g. toilet, water, pain), whereas patients most wanted to request information on medical status and management (e.g. “how is my treatment going?”).

Discussion: Voicelessness is a distressing and isolating experience for ICU patients. ICU staff should prioritise the facilitation of successful communication for voiceless patients, and be aware of their need for information on their medical status and management. Results of this survey reveal a discrepancy between what ICU staff and patients feel is important to communicate. For this reason, consumer engagement is essential when developing services and resources that meet the needs of its service users. As a communication tool that encompassed our consumers’ preferences was unable to be located, this tool has been developed for use within our facility.


Biography:

Gabrielle is a senior speech pathologist working in the areas of intensive care and trauma at St George Hospital. She has a special interest in tracheostomy, traumatic brain injury, and alternative and augmentative communication within the critical care setting.

Enhancing Speech Pathology scope with scoping

Ms Nicola Veness1, Ms Mary-Ellen  Tarrant1

1Royal North Shore & Ryde Hospitals, St Leonards, Australia

Fibre-optic Endoscopic Evaluation of Swallow (FEES) is an advanced scope of practice for speech pathology (SP). The Royal North Shore (RNSH) & Ryde Hospital SP department have adapted the QLD FEES competency to develop appropriate skills to provide speech pathology led FEES service across this department. This department covers two sites across three different service models: acute, rehab & community. This process has been refined since its introduction in 2015, enabling more clinicians to become competent over short periods of time. In conjunction with this, both sites have recently have recently secured funding and donations for Karl Storz C-MAC (RNSH n=2 , Ryde Hospital n=1) which is a more portal FEES equipment and dedicated for speech pathology usage

Results: Skill enhancement: In 2015, one clinician (of 15 FTE) was independently scoping on the wards; whereas is 2019, 8 clinicians (of 18 FTE) are independently scoping after achieving competency. A further 7 clinicians are working towards this competency at various stages.

Clinical Care: Overall the FEES service at Ryde Hospital demonstrated service enhancement and cost savings over the period of  The number of patients who received an instrumental assessment increased from 12 to 29 and the average wait time reduced from 6.6 to 1.2 days. The total annual cost for instrumental swallow assessments for patients based at Ryde Hospital reduced from $15, 595 to $6,347, and the average cost of an individual objective assessment reduced from $770 to $163.   This service enhancement was replicated at RNSH. The results of RNSH no longer using borrowed cumbersome equipment from the ENT specialists was an increase in the number of instrumental assessment being performed on the wards, optimising outcomes for patients with dysphagia.

Conclusion:  This new and dedicated speech pathology equipment has enabled our competency training process to be refined and increased efficiency in the development of this competency and dysphagia management for our patients while providing an enhanced service for our patients at a lower overall cost.


Biography:

Nicola is the Senior Allied Health Project Officer in the Workforce Planning and Talent Development branch of the NSW Ministry of Health. Prior to this role, she was a senior speech pathologist and A/deputy manager at Royal North Shore and Ryde Hospitals in the Northern Sydney Local Health District. She has worked clinically as a speech pathologist in tertiary, metro and affiliate hospitals across Sydney, with a particular interest in acute, rehabilitation and palliative care for stroke and other neurological condition. Nicola holds a Bachelor of Commerce and a  Masters of Speech and Language Pathology. She is currently enrolled in a Masters of Public Health (UNSW).

Mary-Ellen is a Speech Pathologist with 20 years’ experience in the profession; 10 of those as the Head of Department of the Speech Pathology Department across Royal North Shore and Ryde Hospitals in Sydney’s lower North Shore. Prior to moving into management, Mary-Ellen had over 10 years’ experience working with adult caseloads in two major tertiary teaching hospitals in Sydney and similar settings in the UK. Her main clinical area of interest was in Neuroscience across the spectrum of neurology with a particularly focus in stroke and neurodegenerative disorders. Mary-Ellen holds a Diploma in Education, a Bachelor of Applied Science in Speech pathology & and MBA in Health Management.

Reality or rhetoric: Is Allied Health clinical supervision really all that?

Mrs Janelle Roby1, Mrs Rebekah Reurich1, Dr Sue Fitzpatrick1

1Illawarra Shoalhaven Local Health District, Wollongong, Australia

Background:The complex demands of modern healthcare and clinical governance has resulted in increasing demand for effective clinical supervision (CS) for Allied Health professionals (AHP’s).  A growing body of literature has explored models and frameworks for delivering effective clinical supervision, however, how this translates in experience and value for AHP’s warrants exploration.

Clinical supervision for AHP’s in the Illawarra Shoalhaven Local Health District (ISLHD) is supported by a mandatory policy outlining principles of CS, and this research sought to explore their experience.

The themes uncovered will be shared in our presentation as we answer the question: Is a clinical supervision policy for AHP’s reality or rhetoric?

Methods: A cross sectional series of thirteen action research focus groups were held across nine rural and regional sites.  Participant experiences were recorded in view of the groups on butcher’s paper.  Demographic data was captured via a de-identified questionnaire. Theming was conducted by the moderators alongside an independent researcher.

Results: Sixty-seven participants from ten allied health professions attended the focus groups, with broad representation of professional levels/experience. Three central domains which affect experience of CS were identified being people, performance and process; which sit within the multidirectional meta-theme of culture.  A model has been proposed to demonstrate this interplay.

The existing ISLHD policy was updated and a district portfolio created for the ongoing development of AHP CS.

 

Conclusion: A collaboratively developed and organisationally endorsed policy is important in engaging AHP’s in clinical supervision, however, its implementation including culture and the identified CS domains need careful consideration to ensure the policy and experience is effective and valuable for participants.

It is hoped that sharing this process with conference participants will continue the discourse around clinical supervision and facilitate a shift from rhetoric into a valuable resource.


Biography:

Janelle Roby is a Senior Physiotherapist and Disability Liaison Clinician with the Illawarra Shoalhaven Local Health District (ISLHD).  She holds a Masters in Health Leadership and Management and a Bachelor of Physiotherapy.

Rebekah Reurich is a Senior Social Worker with the Illawarra Brain Injury Service in the Illawarra Shoalhaven Local Health District.  She holds a Master of Social Work degree.

Dr Sue Fitzpatrick is the Illawarra Shoalhaven Local Health District Executive Director of Allied Health and the former

ISLHD Speech Pathology Head of Department.  She is a Doctor of Health Science having completed her thesis in the field of clinical supervision.

Sound thinking: Neurologic music therapy for cognitive training in adult mental health rehabilitation

Mr Cameron Haigh1

1Metro South Health, Brisbane, Australia

BACKGROUND: Cognitive impairment is a key factor limiting long term function and quality of life for individuals with mental illness. While a number of Cognitive Remediation Therapy (CRT) approaches have shown to provide benefits, they often exclude more severely impaired consumers. Access to, and engagement with, CRT remains limited. Neurologic Music Therapy (NMT) is an emerging treatment approach drawing on the neuroscience of music perception and music production to inform clinical techniques for cognitive, communication and sensorimotor dysfunctions. The ‘Sound Thinking’ group incorporates NMT techniques to create an engaging program for individuals in mental health rehabilitation.

AIMS: This project examines whether a group NMT program can provide engaging and effective cognitive training for mental disorders, including for individuals who may not participate in existing CRT programs.

METHODS and RESULTS: Participants were asked to rate the helpfulness of the program’s goals, methodology and overall effectiveness, and provide free text comments on their experience of the program. Survey responses showed strong acceptability and engagement from consumers as well as positive self-reported cognitive outcomes. Consumers also highlighted strong affective and social responses. A further controlled research study is commencing in 2019 using psychometric measures to examine changes in participants’ cognition during the program.

DISCUSSION: The utilisation of group musical experiences to teach and train improved cognition holds promise for increased engagement in cognitive rehabilitation.  This project addresses a need for rigorous evaluation of NMT in the psychiatric setting and may lead to improved treatment options for consumers with cognitive deficit.


Biography:

Cameron Haigh is Senior Registered Music Therapist and Music Therapy Clinical Educator in Metro South Health, working in mental health rehabilitation, clinical education and acquired brain injury rehabilitation. Cameron is a Fellow of the Academy of Neurologic Music Therapy and is completing Masters research with the University of Melbourne on the use of music therapy for cognitive rehabilitation.

Co-production & consumer co-investigators in Allied Health research – Initial explorations in Gold Coast Health

Dr Kelly Weir1,2, Dr  Shelley  Roberts1,2, Mrs Kylie Gill2, Mrs Zara Howard2,3, Mrs Heidi Townsend4, Mrs Jane  Standen4, Mrs Michelle Drienne4, Professor Sharon Mickan1,2

1Menzies Health Institute Qld & Allied Health Sciences, Griffith University , Gold Coast Campus, Southport, Australia, 2Allied Health Clinical Governance, Education & Research, Gold Coast Health, Southport, Australia, 3Physiotherapy Department, Gold Coast Health, Southport, Australia, 4Consumer Coinvestigator, Gold Coast Health, Southport, Australia

Background/Objectives: Coproduction in research is the inclusion of patient and public involvement to provide a unique ‘insider perspective’ across the research cycle. This aids generation of different ideas and solutions, and value-adds to the health researcher and health service perspectives. Key factors for successful coproduction include early involvement of consumer research partners in the pre-development stage including scientific design, ethics and grant applications; early identification of team strengths/expertise; regular team communication; a flexible and pragmatic approach to research design; shared decision making, responsibility and power sharing; and providing support to each other. Thus, research coproduction may produce higher quality research with greater relevance to patients, potentially increasing effectiveness of interventions, evidence uptake and reducing research wastage. This presentation explores coproduction and the use of consumer coinvestigators in allied health research, and presents initial experiences of coproduction at Gold Coast Health.

Methods: A comprehensive scoping review investigating research coproduction and use of consumer coinvestigators in allied health research in hospital and healthcare settings was undertaken. Variables of interest included coproduction across phases of the research cycle (concept development to publication/dissemination), patient populations, allied health professions, perceived impact on clinical/patient outcomes and research team perspectives of coproduction.

Results: Findings of the scoping review and two case studies will be presented. The first case study describes participation of a consumer co-investigator in a research team investigating the development and implementation of a multi-component exercise and dietary intervention for women who are overweight/obese, and experiencing urinary incontinence. The second case study explores coproduction in research exploring carer and staff perceptions of palliative care services to children within Gold Coast Health.

Conclusion: Consumer coinvestigators and coproduction widens research team perspectives and enhances relevance of allied health research to patient care.


Biography:

Dr Kelly Weir is a Conjoint Principal Research Fellow (Allied Health) at Griffith University & Gold Coast Health, Queensland Australia. She is a certified practicing speech pathologist with over 29 years clinical experience, predominantly in tertiary state-wide paediatric and adult hospitals. Kelly researches in the area of paediatric dysphagia, management of medically fragile infants and children in intensive care and acute care settings; and building research capacity in allied health professionals at Gold Coast Health. Kelly lectures at Griffith University, is an international speaker and has over 56 peer reviewed journal publications.

Realising our value through Clinical Education: Health students’ experiences of clinical placements in Indigenous contexts

Dr. Alison Nelson1,2, Dr.  Kate Odgers-Jewell1

1The Institute for Urban Indigenous Health, Windsor, Australia, 2The University of Queensland, St Lucia, Australia

Background: The teaching of “cultural competency” in relation to Indigenous Health is a requirement or aspiration of all Australian universities offering health programs to broaden student’s knowledge and promote culturally responsive care (Universities Australia, 2011). However, content is often taught in isolation from practical experiences  and has the potential to promote only negative aspects of Indigenous health. In addition, health professionals report experiencing anxiety or inadequacy about working in this area (Wilson et. al, 2015). The Institute for Urban Indigenous health has worked with local universities to develop clinical placements which are used to provide practical experience in a scaffolded Indigenous health learning environment. This presentation will describe the clinical placements offered to students by IUIH and describe the change in attitudes and beliefs of students throughout the course of their placement.

Method: Student placement experiences are evaluated using  20 five-point Likert items relating to students’ perceptions of the learning environment, skills development, awareness and self-development, supervision and their overall experience. Two open-ended response items on the positive and negative aspects of the practicum and how these impacted students’ learning are also collected.

Results from the IUIH student database indicate an increase from 30 students/year across three disciplines to over 370 students/year across 20 disciplines. In addition, student clinical hours have increased by 440% over the past 8 years. Survey results will be reported in detail but indicate areas of strength and potential for growth and improvement.

Discussion: Service-learning experiences in urban First Australian contexts are shown to equip the emerging workforce with supportive networks, experience in culturally-responsive service provision and supported opportunities to develop ways of thinking, doing and partnering with First Australians towards optimising health and well-being.

References:

Universities Australia. (2011). National Best Practice Framework for Indigenous Cultural Competency. Canberra: Australian Government Department of Education, Employment and Workplace Relations. Retrieved September 9, 2015, from https://www.universitiesaustralia.edu.au/uni-participation-quality/Indigenous-Higher-Education/Indigenous-Cultural-Compet

Wilson, A.M., Magarey, A.M., Jones, M., O’Donnell, K. & Kelly, J. (2015). Attitudes and characteristic of health professionals working in Aboriginal health. The International Electronic Journal of Rural and Remote Health Research, Education Practice and Policy, 15(2). Retrieved  September 18, 2015 from http://www.rrh.org.au/publishedarticles/article_print_2739.pdf.


Biography:

Dr Alison Nelson (B. Occ Thy, M.Occ Thy (research), PhD) is an occupational therapist with extensive research, teaching and practice experience working alongside urban Aboriginal and Torres Strait Islander people. Alison has completed both a research Master’s degree and PhD in the areas of service delivery and perceptions of health for urban Aboriginal and Torres Strait Islander children and young people, and she has published widely in these fields. Alison is currently the Director for Organisational  Development at the Institute for Urban Indigenous Health where she brings together her experience working in both clinical and academic settings.  Alison has a particular interest in developing practical strategies which enable non-Indigenous students, researchers and practitioners to understand effective ways of working alongside Aboriginal and Torres Strait Islander Australians.

PREPARE for Practice: A statewide Allied Health workforce survey

Dr Belinda Gavaghan1, Ms Liza-Jane McBride1, Professor Lisa Nissen2, Professor  Patsy Yates3, Ms Michelle Rochin2, Mr Peter Buttrum4, Ms Michelle Stute5, Ms Julie  Hulcombe2

1Allied Health Professions’ Office Of Queensland, Clinical Excellence Queensland, Brisbane, Australia, 2School of Clinical Sciences, Queensland University of Technology, Brisbane, Australia, 3School of Nursing, Queensland University of Technology, Brisbane, Australia, 4Royal Brisbane and Women’s Hospital, Brisbane, Australia, 5Metro North Hospital and Health Service, Brisbane, Australia

Background: Allied health expanded scope of practice roles can assist health services to meet escalating service demands, rising costs and changing community expectations. Recent investment in new allied health models of care have resulted in a confusing array of advanced practice titles, profiles and roles, with corresponding uncertainty as to the scope and level of allied health professional practice. The aim of this study is to investigate patterns of practice activity within and across the allied health professions.

Method: A cross-sectional electronic survey of Queensland Health allied health professionals was undertaken using a modified version of the Advanced Practice Role Delineation tool based on the Strong Model of Advanced Practice. Survey questions explored domains of allied health practice, including clinical management, education, research and leadership. Descriptive analysis was undertaken to explore characteristics of the allied health workforce and scores for individual items and domains. Domain means were calculated within and across health services, allied health practitioner levels and between professional groups.

Results: A sample of 2575 Queensland public sector allied health professionals completed the survey (response rate of 27%). While participation in clinical care activities was consistently high, contribution to education, research and leadership varied considerably across allied health practitioner levels, professional groups and health service areas. However, allied health professionals practicing at an advanced level were identified and delineated front the group based on high scores across all domains of the Strong Model of Advanced Practice.

Discussion: A variety of practice activities and participation in domains of practice were identified within and across allied health professions and geographical areas. Findings will be used to develop targeted strategies to build workforce capacity and capability to enhance contributions to clinical, research and management for all allied health professionals.


Biography:

Dr Belinda Gavaghan is currently A/Director at the Allied Health Professions’ Office of Queensland. Her research focuses on allied health workforce reform and redesign, and particularly the development, implementation and evaluation of new and innovative models of care that optimise scope of practice for allied health professionals. Belinda has degrees in speech pathology (Hons) and public health. She has over 15 years experience as a speech pathologist in public and private healthcare settings and is a graduate of the NSW Public Health Training Program

Keeping kids closer to home : Experiences of an expanded scope and Allied Health assistant delegation model for paediatric burn rehabilitation

Ms Debra Phillips1, Ms Lauren Matheson1, Dr Tilley Pain1,2, Dr  Gail Kingston1,2

1The Townsville Hospital, Townsville, Australia, 2James Cook University, Townsville, Australia

Background: Post burn injury, rural and remote children are geographically disadvantaged compared to metropolitan children in Australia. Specialist services for burn management are in tertiary hospitals located regional or metropolitan centres; and rural and remote children are more likely to have complications following a burn injury. Children with deeper burns require complicated rehabilitation, including allied health intervention, to achieve optimal outcomes. The Townsville Hospital established the Occupational Therapy Led Paediatric Burns Telehealth Clinic (OTPBTC) to reduce rural disadvantage. In this expanded scope model, the occupational therapist is responsible for monitoring children undergoing active burn rehabilitation rather than a Paediatric Surgeon. Clinical indicators are used to guide re-engagement of the surgeon when review is indicated and Allied Health Assistants are delegated clinical and non-clinical tasks to increase efficiencies.

Aim: The aim of this research is to explore the experiences had by families and clinicians utilizing the OTPBTC.

Method: This qualitative study used an interpretive phenomenological approach to explore family”s and clinician’s experiences with OTPBTC. Families and clinicians who have participated in telehealth reviews were purposefully selected and invited for interview. (HREC/17/QTHS/221)

Results: Themes from the interviews show families value accessing health care services close to home. Staying close to home reduces time off work and school with minimal disruption to daily life. Families and clinicians highlighted their confidence in the occupational therapist’s ability to manage the child’s rehabilitation via telehealth and act as the point of contact for their ongoing care. Rural clinicians benefitted from specialist advice and gained knowledge for their skill development.

Conclusions: This research demonstrates the value families place on receiving care close to home and the role telehealth and expanded scope positions plays in supporting this. Success of this local study demonstrates this model of care can be implemented in other health services across Australia.


Biography: 

Dr Gail Kingston Gail is the Assistant Director of Occupational Therapy at The Townsville Hospital. Since graduating from the University of Sydney in 1992, Gail has worked primarily within acute tertiary hospital settings in NSW and QLD.   She completed a PhD in 2014 titled Occupational therapy and/or physiotherapy services following a traumatic hand injury for people who live in rural and remote locations.  Gail’s ongoing research interests include occupational therapy models of care in acute hospitals and service delivery models for the management of hand and burn injuries in rural and remote residents.

 

Debra Phillips Deb Phillips is a Senior Paediatric Occupational Therapist at The Townsville Hospital.  She has worked with children with burn injuries for over fifteen years and is currently undertaking a post graduate diploma in burns rehabilitation. Debra developed the Occupational Therapy Led Paediatric Burns Telehealth Clinic in 2017 in conjunction with the Paediatric Surgery Department at The Townsville Hospital. This ground-breaking initiative received the Queensland Health Service Delivery Award in 2018.

What enables high performance dispersed teams of health professionals in community settings?: An exploratory study

Ms Annette Zucco1, Professor David Greenfield2, Ms Wendy Geddes1, Mr Ken Hampson1

1South Western Sydney Local Health District, Bankstown, Australia, 2University of Tasmania, Rozelle, Australia

Background: Allied health professionals, at South Western Sydney Local Health District, work in dispersed teams in the community. This arrangement enables services to be delivered across significant distances with continuous physical separation, while requiring individuals to work as a cohesive team. High performance healthcare teams are associated with excellent clinical and patient outcomes, innovation and greater staff satisfaction. This study explores the factors that enable high performance of dispersed allied health teams.

Methods: An exploratory, qualitative study was conducted. Recruitment occurred using non-random purposive sampling from Drug Health, Mental Health and Primary and Community Health services. These services were chosen because they operate from various community locations utilising a dispersed team structure. Semi-structured interviews were conducted with service managers. An inductive thematic analysis was undertaken.

Results: There were 13 study participants, who managed teams with nine to 23 members dispersed across two to ten community sites. Team performance was shaped by three components: dispersed team structure, challenges of managing a dispersed team, and enabling a high performance dispersed team. Geographical distance and the ability to adapt to meet community need were reported as distinct features of a dispersed team. Participants described four management challenges: addressing day-to-day logistics, developing team connection, ensuring clinical care across numerous sites, and ensuring effective operational management. Participants described seven characteristics of high performance teams: communication, leadership, trust, resolving conflict, commitment to team goals, accountability, collective orientation to results, and effort. Two further characteristics important for dispersed health teams were identified: clinical governance, including supervision of clinical practice, and the opportunity for team face-to-face interaction.

Discussion and implications: High performance dispersed teams are built on a foundation of strong relationships. In order to be high performing, dispersed teams need to: deliver a service that meets community need, acknowledge and overcome the challenges of being dispersed, and work together to develop high performance team characteristics.


Biography: 

Annette Zucco is an occupational therapist who has worked in paediatrics for the majority of her career. She is currently Head of Department of Occupational Therapy, Primary and Community Health at South Western Sydney Local Health District. Annette completed a Master of Health Service Management (University of Tasmania) in 2018. She has an interest in developing high performance health care teams.

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