JHQ 141 - Patient Safety: A Case Study in Team Building and Interdisciplinary Collaboration

Bernard J. Horak, PhD FACHE CPHQ; Joyce Pauig, RN; Ben Keidan, MD; Jennifer Kerns, MD
Keywords: Collaboration, Communication, Patient safety, Performance measurement and improvement, Physician-nurse relations, Quality of care, Team building
March/April 2004

The literature has shown the importance and effect of interdisciplinary collaboration in healthcare, for example:

• A significant relationship exists regarding better interaction among team members and decreased risk-adjusted length of stay (Shortell et al., 1994).
• Coordination of care among clinicians results in greater efficiency and improved clinical outcomes (Aiken, 2001; Gitell et al., 2000; Knaus, Draper, & Douglas, 1986; Shortell et al., 1994; Shortell, Gillies, & Anderson, 2000; Shortell, Jones, & Rademaker, 2000).
• Team-building interventions result in greater problem solving, improved morale, and better coordination of work among physicians, nurses, and administrators (Horak, Guarino, Knight, & Kweder, 1991; Liedtka & Whitten, 1998).
• Interdisciplinary rounds, particularly with pharmacists, reduce medication error variance and adverse drug events (Sim & Joyner, 2002; Leape et al., 1999).

Unfortunately, most research does not provide healthcare quality professionals with specific guidance on how to achieve collaboration or conduct team-building sessions. Thus, this case study is offered as a framework for team-building interventions designed to improve patient care and interdisciplinary collaboration, particularly between physicians and nurses.

The case site is the 4-South medical unit at The George Washington University Hospital in Washington, DC. The unit has an average census of 39 patients. The nursing staff comprises 25 RNs, 10 LPNs, and 15 multiskilled technicians (MSTs), organized in teams. In addition, 4-South employs three business associates (i.e., unit secretaries or clerks). Medical care is primarily provided by five teams of interns, residents, and medical students. These medical teams are formed from the approximately 100 interns and residents and 30 medical students rotating monthly through the unit.

A number of factors make a medical unit unique in a teaching hospital and present major challenges to coordination and delivery of care. Complexity of medical conditions (e.g., AIDS patients with pneumonia and encephalopathy; older patients with congestive heart failure and dementia; and renal patients with hypertension and diabetes) is one such factor. In addition, the house staff and medical students rotate monthly through the unit, making it difficult to become familiar with unit procedures and establish collaborative working relationships with nurses in the care of the patient (i.e., "it's hard to know the players without a scorecard").

In the fall of 2002, a number of issues arose that added to the general aforementioned issues, causing concern that patient care might be adversely affected. These issues included difficulties in recruiting nurses, a new computer system (i.e., additional portable terminals and clinical software functionality), and change in working space because of the move of the unit (i.e., all nursing units moved to a new hospital facility in August 2002). These issues strained working relations between the nursing staff and house staff and caused concern about morale and quality of care. Physicians typically complained about the "attitude" of nurses (e.g., not as receptive or responsive to requests) and delays in care (e.g., getting medications or X rays in a timely manner). Nurses complained similarly that physicians were not receptive or responsive to their requests, showed a lack of professional respect toward them, and did not communicate fully with them on the condition of patients. Also, physicians often projected their frustrations with "the system" (e.g., delays in getting supplies, medications, or meals) onto the nurses.

Several initial attempts were made to address these issues on the unit. A communication book was placed at the nursing station to provide a means for any staff member-nursing or medical-to identify problems. Unfortunately few used the book. The unit also tried weekly problem-solving meetings between nurses and residents. However, these meetings were not successful as the nurses believed that the physicians simply "dumped on them," by providing a long list of problems and issues without participating in problem resolution. The physicians shared similar feelings, indicating that the nurses brought only their list of issues (e.g., not returning charts after rounds, monopolizing the phone, eating at the nursing station, and so forth). Thus, these meetings were terminated with both the nurses and physicians stating that nothing was accomplished. At a meeting of house staff, the chief of the medical staff and chief executive officer of the hospital were presented with a list of issues and concerns about the unit. At this point, a quality improvement consultant was asked to assess the issues and facilitate their resolution by focusing on relationships between nurses and house staff in order to improve patient care.

To obtain a complete picture of the issues regarding 4-South, the consultant used interviews, focus groups, and observations on the unit to define key issues.

Interviews were held with the two chief medical residents and the nursing clinical supervisor. Focus groups were convened separately with two groups; nursing staff and residents/interns. The chief medical residents and the nursing clinical supervisor did not attend the focus group meetings to ensure candor. The goals of the meetings were to obtain a comprehensive list of issues and to identify areas for follow-up observation on the units. Two basic and critical questions were asked at all interviews and during focus group meetings:

• What is getting in the way of patient care?
• What should be done?

The first question focused all participants on the most important issue. The second question required participants to think about solutions and provided the impetus for problem solving and team building, which is elaborated on later. Based on analysis of the responses, major issues included the following, ranked in order of frequency of mention:

1. Communication/relations between nursing and house staff. Physicians did not update the nurse on patient's condition, physicians do not communicate with nurses regarding patient concerns, nurses do not seek out physicians to resolve issues with orders, and so forth.
2. Systems problems/ancillary support. Delays or lack of responsiveness were noted from the following services: pharmacy, dietary, radiology, transport, materials management, and the laboratory. In addition it was found that the 4-South unit nurses were typically blamed for problems with these services and other systems beyond their control.
3. Organization and coordination of work. The five medical teams often overwhelmed nursing staff with orders after completing rounds; there was no effective procedure to notify nurses when "stat" orders were written; and there was no readily available information regarding who is on each medical team, who is on call, and so forth.
4. Unit procedures. Medical students interrupted nurses during their reports for information on drugs; physicians did not return charts to the nursing station; physicians drank and ate food on the unit, and so forth.
5. Administrative issues/support. There was a need for additional training on computer systems and software, a need for dedicated conference rooms on the unit to facilitate nurse-nurse, physician-physician, and nurse-physician communication, and so forth.

The consultant spent 3 days attending medical rounds, reviewing nursing reports, and observing staff interaction. This allowed the consultant to observe problems first-hand as well as conduct on-the-spot interviews with those unable to attend the focus groups.

After the interviews, focus groups, and observations, the consultant held one-on-one meetings with the chief of the medical staff, chair of the department of medicine, the program director, chief residents, and the clinical supervisor of 4-South. These meetings were designed to discuss assessment findings and to obtain approval for follow-up interventions. Based on the results of the assessment, all agreed that the focus should be on team building, because communication between nurses and physicians was the most frequently mentioned area that could affect patient care.

The first meeting was held on December 3, 2002. Nine nurses and 12 residents/interns attended, along with the nursing clinical supervisor and chief residents. The meeting was highly effective in establishing trust and communication between nurses and physicians. The agenda of the meeting was as follows:

Each participant first introduced themselves by identifying his or her hometown, professional background, and outside interests. This exchange put the group at ease and allowed nurses and physicians to find common areas of personal interest. In addition, each participant was asked to identify the major challenges of his or her respective job. Based on a post-session evaluation, this conversation created an appreciation for the roles of others and the stress they may face, further building interpersonal rapport and professional respect.

Next, a team-building exercise (i.e., "ball toss") was conducted, which required the nurses and physicians to work together to improve a process. Participants were asked to form a circle and toss a ball across the room until all members had a turn in the sequence. The group then repeated the exercise and was challenged to decrease the time to complete the sequence by 20%. The exercise was both fun and instructive, increased the comfort level of interacting and working together, and showed the efficacy of teamwork in improving a process-a lesson that could be extended to the patient care unit.

The nurses and physicians were then placed in separate rooms with a facilitator. Both groups were given 30 minutes to answer two questions:

1. What do we need from the other group to effectively enhance patient care?
2. What are we willing to do for the other group, so that they can be more effective?

Both groups then reported their findings, followed by a discussion to clarify items, identify commonalities, and develop a list of new behaviors for each group. For example, the nurses agreed to be more proactive in following up on outstanding orders from pharmacy, radiology, and so on. The house staff agreed to "touch base" with the nurse before they left the floor and to notify either the business associate or the charge nurse when a "stat" order was written.

The second team-building session was held January 10, 2003 and was attended by seven nurses, seven interns/residents, the chief medical residents, and the nursing clinical supervisor. Session objectives were to continue the momentum built during the first meeting and to follow up and reinforce the agreed-upon behaviors from the first meeting. These objectives are reflected in the following agenda items.

Appreciative session: The meeting began with a "round-robin," in which each person expressed at least one quality appreciated about the other group. For example, one nurse stated that she appreciated that the house staff now takes the time to keep her updated on a patient's condition. A resident expressed appreciation to the nurses for their positive attitude and increased responsiveness to requests and orders. This exercise clearly served to validate the behaviors established at the first team-building meeting.

Ground rules for collaboration: The attendees reviewed the list of behaviors defined in the first meeting and evaluated how well they implemented each. After this discussion, the participants decided on a set of "collaborative ground rules" for the unit, based on the desired behaviors discussed previously. These ground rules would apply to all residents, interns, medical students, and nurses. The ground rules would also serve as an excellent reference point for orientation of new staff to the unit, because of the nearly 100% turnover of house staff and medical students monthly. The 10 ground rules are as follows:

1. Communicate daily on the plan for the patient: Hold a "touch-base" meeting before the physician leaves the floor.
2. Show respect: Be mindful of others, do not interrupt or yell, realize all staff play an important role.
3. Respect patient confidentiality: Talk out of earshot from patients, family members, or other visitors on the unit.
4. Ensure staff availability, particularly during shift changes and reports.
5. Seek out staff directly, if concerned about the patient.
6. Update immediately any changes to patient assignments and call rosters.
7. Identify patients to be discharged as soon as possible, annotating this on the dry-erase board.
8. Inform the charge nurse or business associate that a "stat" order has been written and return the chart to the chart rack.
9. Designate one medical team member as the single point of contact for the patient.
10. Bring unresolved problems or concerns about the unit directly to the nursing clinical supervisor or the chief medical resident.

Unit procedures/changes: The participants then discussed and came to consensus on a number of procedural or organizational changes to improve patient care and interdisciplinary staff communication. These changes included the following:

• Reinstitute the monthly meetings between nurses and physicians. This time, however, the meetings should focus on achieving consensus of the issues and solutions, rather than just "firing off" a list of problems. In addition, these meetings would monitor progress and follow up on the ground rules and other items agreed to at the team-building meetings.
• Revitalize discharge planning meetings. Meetings are now held twice per week with each of the five medical teams. Previous meetings were not well structured or attended and did not include the necessary interdisciplinary representation. The charge nurse, social worker, dietitian, physical therapist, and entire medical team-versus, previously, just one or two of the interns/residents-now attend these meetings.
• Post pictures of all members of the nursing staff and the house staff assigned to the unit during the month. This allows for easy staff identification and facilitates communication.
• Use the dry-erase board as a communications center for both nurses and physicians. The board would include up-to-date team and on-call rosters, the assigned nurse for each patient, and a place where staff could leave a message for another staff member.
• Provide medical students and interns/ residents with a more comprehensive orientation to the unit, including materials and presentations coordinated by chief medical residents and nursing clinical supervisor.
• Place a label on the front of the chart to show the team and physician responsible for the care of each patient.

The effectiveness of the team-building efforts was evaluated through a survey of RNs, residents/interns, and feedback from participants after the two team-building sessions, and observations from managers who oversaw the unit.

A survey was administered to all RNs (n = 24) and interns and residents working on the unit in the month of January 2003 (n = 20). Seven RNs (i.e., 29%) and six interns/residents (i.e., 30%) returned surveys. Participants were asked to complete a "before-now" (i.e., September 2002 versus January 2003) evaluation of the survey variables. The results are shown in Table 1

After each team-building meeting, participants were asked to provide closing comments. These comments not only helped gauge the effectiveness of the meeting, but also served to reinforce desired behaviors and ground rules. The following are some representative comments:

• "I now realize that we need to take a step back from what we're doing and respect each other more."
• "There needs to be a behavior adjustment on all our part."
• "It is good that we acknowledged, from both sides, that there are problems and that we're willing to work them out."
• "I am happy with the momentum we generated. Now we must disseminate it."
• "The meeting reduced a lot of tension."
• "Concrete ideas were formulated."
• "There now seems to be team focus among the group."

The quality consultant met with senior managers with a direct interest in or oversight of the unit and the house staff. These managers included the director of the residency program, chief nurse executive, chair of the Department of Medicine, and the chief executive officer. All commented that better communication between physicians and nurses, more positive attitudes on the part of both nurses and interns/residents, and a greater willingness of nurses and physicians to jointly address patient care issues were the result.

Cumulatively, positive change was observed as most remarkable for the first six areas of the survey (i.e., patient care, nurse-physician communication/collaboration, problem solving, unit procedures, nurse morale, and physician morale.) Moreover, this improvement was reported by both physicians and nurses. In addition, the efficacy of team building is supported by feedback from participants and comments from senior managers. These results support previous research showing that physician and nurse interaction and other forms of interdisciplinary collaboration contribute to improved patient care and organizational effectiveness.

The lack of similar improvements in ancillary/support services (i.e., items 7-14 in Table 1) may have limited the scores for patient care (i.e., item 1) and staff morale (i.e., items 5 and 6). Thus, the entire system needs to be evaluated to ensure that the full benefits of team building or other organizational change efforts occur.

Finally, based on follow-up interviews with staff, it appears that the perceived increase in problem solving (i.e., item 3 on the survey) was most likely because of four interventions: the establishment of ground rules, brief implementation of daily meetings between the charge nurse and medical team, revitalization of interdisciplinary discharge planning, and reinstitution of the monthly nurse and physician meetings.

The survey had a low response rate (i.e., 29% of the nurses, 30% of residents/interns). However, this team-building effort was carried out to meet a pressing organizational need, to improve nurse-physician collaboration before patient care was adversely affected. Thus, it was not designed or intended to be a rigorous scientific study. Future studies would be desirable, particularly with a larger sample size to allow for a more robust statistical analysis (e.g., tests of statistical significance).

In addition to physician and nurse collaboration, problem solving, and team-building, other variables might have contributed to the perception that patient care and morale improved. These variables might include staff adjustments when the unit was moved and attention focused on the unit by the quality consultant, which is sometimes called the "halo," "placebo," or "Hawthorne" effect. Thus, replicating the interventions in other units and organizations would further validate the effect of team-building interventions on patient care and staff morale.

What follows are key lessons learned and implications for future implementation of team-building efforts:

1. A third party (e.g., a quality improvement consultant or other person not on the unit or member of the house staff) should conduct the assessment and facilitate all interventions. This person should have creditability with and access to senior management, particularly to present systems issues that are beyond the unit's or house staff's control. An internal quality professional would be an excellent candidate for this role for three reasons: (a) experience in working with both nursing and medical staff, (b) familiarity with systems and cultural issues that affect patient care, and (c) skill in facilitation and meeting management.
2. The assessment took longer than expected. Three full days are needed to conduct the observations on the unit. However, the observations are a critical part of the assessment because it allows an observer to understand the issues fully, gain credibility with the nursing and house staff, and conduct "on-the-spot" interviews with those who could not attend the focus groups.
3. The two most important questions of the assessment were as follows: "What is getting in the way of patient care?" and "What should be done?" The first question focused on what is most important; the second provided the impetus to problem solving and team-building.
4. The agendas for the two team-building meetings worked well and will be used as a framework for sessions on other units of the hospital. The only change might be the addition of a team-building exercise for the second (i.e., follow-up) team-building session. This exercise would allow the group to practice and reflect on team skills.
5. The "ground rules for collaboration" was probably the most important document produced from the team-building sessions. It formally established new ways of behaving. However, these goals should be prominently displayed and reinforced daily by team leaders and charge nurses and at staff meetings held by the clinical supervisor and the chief medical residents.
6. When possible, team-building sessions should include all who work on the unit. Therefore, future team-building meetings for 4-South will include MSTs, business associates, and medical students.
7. The decisions from the team-building meeting must be documented and disseminated among those who could not attend. To ensure continuity, this information should also be presented to and discussed with the new nursing staff and interns, residents, and medical students who rotate to the unit monthly.
8. Finally, a total systems approach should be employed, particularly addressing issues with ancillary and support services to realize the full benefit of team-building efforts and to improve patient care. Thus, the next set of team-building interventions will occur between the unit and each of the ancillary and support services.

In conclusion, the importance of teamwork, particularly physician and nurse collaboration, to patient care and morale is demonstrated bt the results of this study. The techniques and lessons learned may provide a collaborative framework for nurses and physicians and motivate others to conduct similar interventions as part of their effort to create an environment for safe and effective patient care.

Take a test on the article you just read for continuing education credit!

Author's Biography
Bernard Horak is professor and Director of the Health Systems Administration Programs at Georgetown University in the School of Nursing and Health Studies. Dr. Horak also has been the Director of Total Quality Management and Strategic Planning at Walter Reed Army Medical Center, Washington, DC.

Joyce Pauig is the clinical supervisor of the Medical Unit (4-South) at The George Washington University Hospital, Washington, DC. Prior to this position, Ms. Pauig was a staff nurse there.

Ben Keidan is the cochief medical resident in the Department of Medicine at The George Washington University Hospital. Prior to this position, Dr. Keidan was a primary care internal medicine resident there.

Jennifer Kerns is the cochief medical resident in the Department of Medicine at The George Washington University Hospital. Prior to holding this position, Dr. Kerns completed a 3-year categorical medicine residency there.
For more information on this article, contact Bernard Horak by e-mail at bjh28@georgetown.edu or by phone at 202/687-4209.

References
Aiken, L.H. (2001). Evidence-based management: Key to hospital workforce stability. Journal of Health Administration Education Special Issue, 117-125.
Gitell, J.H., Fairfield, K.M., Bierbaum, B., Head, W., Jackson, R., Kelly, M., et al. (2000). Impact of relational coordination on quality of care, postoperative pain and functioning, and length of stay: A nine-hospital study of surgical patients. Medical Care, 38(8), 807-819.
Horak, B.J., Guarino, J., Knight, C., & Kweder, S. (1991). Building a team on a medical floor. Health Care Management Review, 16(2), 65-72.
Knaus, W.A., Draper, E.A., & Douglas, W. (1986). An evaluation of outcome from intensive care in major medical centers. Annals of Internal Medicine, 104(3), 410-418.
Leape, L.L., Cullen, D.J., Clapp, M.D., Burdick, E., Demonaco, H.J., Erickson, J.I., et al. (1999). Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. Journal of the American Medical Association, 283(3), 267-270.
Liedtka, J.M., & Whitten, E. (1998). Enhancing care delivery through cross-disciplinary collaboration: A case study. Journal of Healthcare Management, 43(2), 185-203.
Shortell, S.M., Gillies, R.R., & Anderson, D.A. (2000). Remaking health care in America (2nd ed.). San Francisco: Jossey-Bass.
Shortell, S.M., Jones, R.H., & Rademaker, A.W. (2000). Assessing the impact of total quality management and organizational culture on multiple outcomes of care for coronary artery bypass graft surgery patients. Medical Care, 38(2), 207-217.
Shortell, S.M., Zimmerman, J.E., Rousseau, D.M., Gillies, R.R., Wagner, D.P., Draper, E.A., et al. (1994). The performance of intensive care units: Does good management make a difference? Medical Care, 32(5), 508-525.
Sim, T.A., & Joyner, J. (2002). A multidisciplinary team approach to reducing medication variance. Journal on Quality Improvement, 28(7), 403-409.

Objectives
Journal for Healthcare Quality is pleased to offer the opportunity to earn continuing education (CE) credit to those who read this article and complete the form online. This continuing education offering, JHQ141, will provide one contact hour to those who complete it appropriately.

By participating in this independent study offering, the reader will be able to do the following:
1. Identify the critical issues in a team-building assessment.
2. Design appropriate and successful team-building interventions.
3. Discern key lessons learned from this case.

Core CPHQ Examination Content Area
IV. Performance Measurement and Improvement