The IOM noted 10 years ago that the lack of interprofessional cooperation/collaboration was a hindrance to a culture of safety. In the 2003 report A Bridge to Quality it stated that health care education should involve training students to be part of an interdisciplinary team to increase patient centered health care quality. Since then there has been growing awareness of the importance of collaboration. Health care today is ever changing, more complex, and involves sicker patients. More than clinical skills are needed to provide high quality health care. Many medical errors that occur are a result of ineffective communication, thus they are errors that can be avoided.
Collaboration can be defined as the decision of a group of people to work together to achieve a common goal or vision. The effectiveness of team work and the sharing of expertise and responsibility leads to care that is greater than the sum of its parts. Collaboration fosters synergy that patients will notice.
Health care today involves many more professionals who are sometimes a formal team with defined roles, but often, especially for nurses it is less formal. A nurse may deal with different professionals for each patient, each shift and each day he or she works.
What are the necessary components to ensure collaboration?
In An Integrative Model for Organization-Wide Quality Improvement Shortell et al named four basic tenets that must exist together for any interprofessional innovation to be successful and long lasting.
The executive of a health care organization must have a vision or strategic perspective of interdisciplinary collaboration and be committed to fostering its process over time. This would involve committing time and resources. A staff that is overworked and pressed for time will not enable collaboration. A structure must be in place to make the innovation organization wide. In their commitment to fostering and advancing collaboration management can ask questions such as: Do hierarchical learning or reporting structures hinder collaboration? Which technologies can our medical center adopt that would enable information sharing? Do we have a formal evaluation of the progress of communication and collaboration? Do we ensure that every team member knows they could contribute to the outcome? Human resource policies must be adopted that outline behavioral expectations. Technical expertise is the third tenet, and cultural elements are the underlying values and beliefs that will hinder or support change.
Two examples of successful leadership initiatives are Sentara Hospital in Norfolk Virginia which enacted a system wide culture change program aimed at increasing patient safety. Behavioral expectations were set and monitored, analytic capabilities were enhanced, and key policies were streamlined and focused. As a result communication behaviors increased by 42%.
At Kaiser Permanente in Orange County and Northern California an organizational learning program was developed that involved preoperative safety briefing and perinatal patient safety though effective teamwork and communication. The results were a significant increase in positive OR staff and teamwork atmosphere, as well as a decrease in OR nurse turnover.
Effective communication and collaboration begins with mutual respect for another professional’s knowledge and clinical competence. The team also needs to understand the context of the patient population.
How is collaboration built? Leadership must first model collaboration. They must also allocate resources and time to increasing nurse expertise. The design of the work environment can also hinder or help collaboration. Interdisciplinary practice mechanisms must also be developed.
At Concord Hospital in New Hampshire, the entire care team carries out collaborative rounds focusing on the patient and the patient’s family to identify possible errors and adverse events. This has resulted in an over 50% reduction in expected mortality rates of cardiac surgery patients and an increase in positive staff ratings of teamwork and job satisfaction.
Training in collaboration is also essential to enabling it. This begins with the recognition and acknowledgement that people skills are as important as clinical skills. Staff needs to be trained in areas such as group skills, negotiation, time management, and understanding of group dynamics. Professionals also need to develop skills of self awareness, advocacy and the awareness of nonverbal cues or body language.
Since the 1950s The University of Washington has had a history of interdisciplinary education starting when the faculties of medicine, nursing, and dentistry were deliberately located in one building.
Their Child Health Care program had inter professional staff from medicine, nursing, psychiatry, social work, dentistry, and medical technology providing family health care and at the same time teaching students of those faculties together in a clinical environment. Today it is known as the Center of Human Development and Disabilities at the University of Washington.
Through many years of working across educational boundaries UW established the UW Initiative Fund for infrastructure to sustain inter professional education. Its name today is the Health Science Partnership in Inter professional Clinical Education(HSPICE). HSPICE is a catalyst for externally funded initiatives such as the development of a national patient safety curriculum, and a standardized assessment of inter professional competencies.
In perhaps the most encouraging sign of progress in interdisciplinary collaboration Emory Woodruff School has started an inter professional communication class last fall, in conjunction with the Grady Health System. There were 45 interdisciplinary groups of 10 students each. involved in discussion, role playing, and lectures. This class stemmed from the Inter professional Team Training day in 2008. That day senior nursing students and 3rd year medical students ran emergency code on patient mannequins. In 2009 Emory partnered with Georgia Tech to run that training day again. It then became the Inter Professional Communication class for first year nursing and medical students. Its success became well known and students from other years and streams joined in. This fall the same 450 students meet for a class on role identity and a class will be held in early 2011 on team identity.
Collaboration must become the norm for health care of the future. Bethany Robertson professor and one of the planners of these innovative classes states: ‘The root cause of all sentinel events from 1995-2007 as reported by the Joint Commission is poor communication. Communication is a critical skill that crosses all health profession disciplines.’
Sources:
http://book.nap.edu/openbook.php?record_id=10851
http://journals.lww.com/academicmedicine/Fulltext/2006/10000/Working_Across_the_Boundaries_of_Health.8.aspx
http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2006/Apr/Committed-To-Safety-Ten-Case-Studies-on-Reducing-Harm-to-Patients.aspx
http://whsc.emory.edu/home/publications/nursing/emory-nursing/winter2010/interdisciplinary-class.html
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