Care Team Architecture
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For leaders, the first step to having optimal skill-task alignment is to develop a deeper understanding of the work—what does an RN really do all day, for example, says Gary Kaplan, MD, CEO of Virginia Mason. "It is amazing how little we really understand how we spend our time," he says.
The liberating aspect of freeing up caregivers—nurses and physicians—is a cornerstone of effective team medicine, he adds.
"One of the most frustrating aspects of healthcare is that we are asking physicians to do things that add no value and asking nurses to do what patient care technicians can do," Kaplan says. "People want to work at the higher end of their skill level."
2. Interdisciplinary rounds
The concept that rounds—the hospital version of the staff meeting—would include every relevant area of expertise is nothing new. In theory, interdisciplinary rounds provide obvious advantages in care coordination; but because of barriers ranging from physician alignment to culture, the benefits are not being optimized. The practice may vary from rounding in patient rooms in small groups to more global meetings in a conference room, but as demands grow for the spaces between care to be filled, interdisciplinary rounding is growing in sophistication.
Rounds at Griffin may have as many as 30 people from all relevant disciplines present every morning, and a typical patient's case may go through in less than a minute.
"Say we have a 72-year-old female with congestive heart failure," Stumpo says. "They walk through the clinical pathway we have for CHF, which tells us that in approximately three days this patient should be well enough to be discharged from acute care. We make sure the blood work is ordered. If respiratory therapy is involved, they will talk. If case management says this woman lives alone and is three stories up and there is no elevator, we know she is not going to be able to go home right away and may need extended care. We have pharmacy there, so we go through the entire meds. We have the interns or residents there to tell us any of the medical or clinical components. So if it is a discharge order, if it is an oxygen order, that is when the interns adjust or maintain the plan of care. It is a wonderful, well-spent 45 minutes of the day to go through the entire floor to make sure every patient is on the right point of their plan of care."
Baptist Health South Florida blends the interdisciplinary aspect with particular needs of each floor, so each morning on the neuroscience floor begins with rounds at 8:15 with the neurosurgeon, the neurologist, the nurse practitioner, the clinician, physical therapist, and a dietician, Montesino says. On the pulmonary floor the team has a respiratory therapist, and on the surgical floor there is a surgical ARNP. Whatever the customized mix, the idea is the same: "Expedited patient throughput. When the whole team sees the big picture, they know who needs to move where and when, as opposed to individuals just rounding on their patients."
Dana Nelson-Peterson is administrative director in Virginia Mason's Kaizen Promotion Office—which adopts a Japanese term that roughly translates into "continual focus on improvement." She says they build their interdisciplinary rounds based on what that patient may need.
"The team is made of ad hoc team members who will come and go and touch that patient's care across the continuum, as well as the core people being members of that team throughout their stay," Nelson-Peterson says. "Those core members would be the primary physician, the clinical nurse leader, perhaps the primary care nurse. And everybody else comes and goes throughout the patient's stay depending on what their care needs dictate."
An added innovation from Virginia Mason is that rounding takes place with the patient and their family. Rounds are initiated by nurses and include attending physicians, pharmacists, and the relevant therapists. "We schedule that rounding time with the family so they get an appointment every day for the time of day that their patient will be rounding," Tachibana says.
Griffin was able to overcome physician resistance to interdisciplinary rounds with a physician's second favorite carrot: time.
"They quickly learned that the plan of care with educating the patient and family decreases extra work for them," Stumpo says. "You spend the time in the morning. You describe the plan of care, and you are pretty well set."
3. Balance the 'ists'
The tendency toward the "ist-ization" of inpatient care teams is driven by some larger levers—in particular the breakdown of physician alignment models that have forced hospitals to turn to employed generalists ranging from hospitalists on med-surg floors to laborists in OB. While it may seem an unfettered movement toward generalizing every field of medical study, even hospitalist pioneer Robert Wachter, MD, chief of hospital medicine at UCSF Medical Center, says there will always be a balancing act between the need for the wide and the need for the deep. Particularly at an academic medical center a patient with complex needs requires both types of physician.
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