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Collaboration in Healthcare

While instructing students on a burn unit, after practicing as an RN for 7 years, I finally learned the scope of practice for physical and occupational therapists. Every morning during interdisciplinary walking rounds, I listened to these therapists discuss the short- and long-term goals for their patients and evaluate outcomes on a daily basis. If there was a duplication of services or a conflict about the care plan among the team members, these differences were discussed and changes made immediately - not days or weeks later.

From that time on, I made sure the students I taught on the burn and hematology units at the Los Angeles County-University of Southern California Medical Center became active members of these high-functioning interdisciplinary teams. They attended team meetings, shared their contributions, and learned much more than the diagnosis and treatment plan for each patient. They learned the roles and responsibilities of other allied professionals. They learned how certain patients shared information with some caregivers and not others - and how vital it was all team members had this information. They learned from team members about community resources they never knew existed. They even observed that these team members cared about their patients.

How many of you have a good understanding of the full range of competencies of your allied team members? Do you consult these professionals regularly when planning and providing care to patients?

No Longer Voluntary

Collaboration in healthcare no longer is simply recommended as a voluntary initiative or an ambiguous goal that appears in a healthcare system's annual report. As healthcare costs continue to climb, with millions of Americans among the medically uninsured and medical errors reported by the Institute of Medicine (IOM) as the eighth leading cause of death in the United States, there is a great need for teams of healthcare professionals to work collaboratively to find solutions to these critical problems.

After the release of the IOM's report, government and regulatory agencies such as JCAHO and IOM mandated that collaborative solutions be found to reduce these deficiencies within a 5-year period. However, in its 2003 annual report on the state of healthcare quality, the National Committee for Quality Assurance (NCQA) reported there remains a "lack of widespread collaboration among healthcare agencies in addressing local and regional healthcare issues."1

Why Collaborate?

Collaboration allows organizations to achieve benefits and reduce duplication of services they cannot achieve as an individual entity. Yet, how many times have you seen several hospitals in the same community offering the same programs/services, with each acquiring its own high-tech, expensive technology? It doesn't take a degree in economics to recognize this practice drives up costs.

Why is it so difficult to sell the benefits of collaboration to healthcare organizations? First, groups are not homogenous in their structure; diversity exists among group members who have been named to teams or task forces. For example, convincing various groups, such as business, industry and labor unions, that their expertise can be valuable in working toward common healthcare solutions can take months or even years. Combining complementary financial and human resources and skills can be a powerful combination for getting things done - once everyone is on the same page.

However, progressing from the getting-to-know-you stage to a mutual trust level among policymakers requires skilled leadership. If this is not present, often the consensus by the majority of the group is that this is at best an academic exercise - and a waste of time for busy, talented professionals. To sustain a collaborative that eventually gets to a productive stage, all stakeholders must believe they are gaining something from the partnership.

Other prerequisites to successful collaboration include commitment to a common mission with everyone having a clear understanding of the process and a realistic idea of the amount of time and effort required to complete the project. The group must be given realistic timelines from the beginning, and each member must make a verbal commitment to be an active participant or the mission will be doomed - and much costly time wasted.

Visionary, Yet Pragmatic

Strong leadership is required to define, clarify and amplify the group's mission. Certainly, leadership can be shared once the group has set its ground rules for group maintenance - and as long as each person agrees upon the common goals and can help keep the group focused on the mission.

Participation by group members, who should be selected for their expertise and experience, can provide quality information and feedback, as well as the potential for higher-level decision-making. However, even when group member relationships have been cemented and mutual trust exists, the process still can be time-consuming.

Strong leadership is essential to establish ground rules related to problem solving as well as group maintenance. Leaders need to be visionaries, but they also need to be pragmatic. Conflict management skills can be the most difficult for leaders to teach to and model for team members. However, for leaders to help team members learn conflict can be a positive behavior and essential to team progress, the culture of the organization must sanction conflict as essential to team-building necessary in the growth of any team.

Leapfrog Group

As an example of a successful collaborative, let's look at an initiative that has resulted in healthcare providers posting positive outcomes in healthcare quality and safety as well as cutting medical costs. In 1998, a group of employers from a number of Fortune 500 companies across the country met for the first time to discuss the inferior quality and the high cost of healthcare services they were purchasing for their employees. The 1997 IOM report, related to medical errors, provided these business leaders with the impetus and data to move ahead with their mission "to initiate breakthrough improvements in the safety, quality and affordability of healthcare for Americans."2

A voluntary program now comprising 170 companies, the Leapfrog Group was established in 2000. Its aim simply is to mobilize employer purchasing power by alerting America's health industry there is an incentive for "big leaps in healthcare safety, quality and customer value." Healthcare providers complying with the guidelines set by the collaborative are rewarded with business from Leapfrog Group members.

In a relatively short time, this group has been able to identify and refine four major areas in hospital quality and safety practices:

1. computerized order entry by physicians;

2. evidence-based hospital referral;

3. ICU staffing directed by physicians experienced in critical care medicine (intensivists); and

4. the Leapfrog Safe Practices Score, based on the National Quality Forum-endorsed Safe Practices.

These quality indicators, based on scientific evidence, have become a frequently used benchmark to measure and compare performance by healthcare providers. A noteworthy point about this partnership is there were many differences and much diversity among the 170 Leapfrog companies, but the stakeholders recognized action was needed now to achieve the outcomes - and team-building trumped personal differences.

Unit-Based Stakeholders

Collaboration in healthcare is not intended only for policymakers and healthcare administrators. Its benefits are far-reaching when the process is extended to treatment planning by allied professionals, on every unit, in every hospital or department within a healthcare organization.

For the past several years, ADVANCE has included a collaborative session at each of its Job Fairs & CE Events. Because attendees at these educational programs are not just nurses, but readers of other ADVANCE newsmagazines and varied allied healthcare professionals such as physical and occupational therapists, speech-language pathologists, respiratory therapists and even health information professionals, to name just a few, we at ADVANCE decided this venue provided an excellent opportunity for simulated interdisciplinary team activities.

As moderator of many of these interactive sessions, I ask how many attendees have ever participated as a team member or leader on an effective interdisciplinary team - "effective" being the operative word. Rarely do more than 5-10 percent of participants indicate they had this experience either as a student or a practicing professional. Those individuals who have developed some interdisciplinary team skills report the experience was gained on specialty units such as rehabilitation, oncology and hospice, mental health and critical care. It's extremely rare to find interdisciplinary teams on general medical or surgical units within a healthcare organization.

Structured Events

When the ADVANCE Job Fair/CE Event participants arrive at the 90-minute collaborative session, our staff directs the attendees to form small groups. Ideally, we like to have at least one group member from each discipline represented. However, the demographic makeup at most of our programs is usually two-thirds nurse attendees and one-third from other professional groups. We have found that although some disciplines are not always represented in each group, it does not minimize the value of the activity.

A content expert/facilitator explains the format for the session and introduces the group to a specific case study related to the topic. The group then works together as a team for 45 minutes. The group identifies a leader and recorder, then discusses the case, calling upon each member's professional expertise and experience to formulate a treatment plan for the patient. For the remaining 30 minutes, the facilitator calls upon each group leader to share their plans with the rest of the participants. If there are differences in the plans, the facilitator guides the group in addressing the differences.

To date, the simulated interdisciplinary teams at ADVANCE programs have discussed ethical decision-making, cultural competence and a number of complex care scenarios where the sharing of information by the allied professional group members results in high-level treatment plans and interventions. It always is encouraging to observe group members teaching other group members and to note the nonverbal expressions of respect for colleagues they have just met. The feedback ADVANCE has received from those who have attended these sessions has been quite positive, with many attendees reporting they had no idea about the scope of practice of their healthcare colleagues.

Absent From Curricula

The strong need for healthcare professionals to work together on interdisciplinary teams was clearly identified in the IOM's report, Crossing the Quality Chasm, issued in 2001. In this seminal document, the IOM emphasized that if healthcare quality in this country was ever going to improve, collaboration among caregivers was essential.3 Greiner reported that the IOM and other researchers indicated it is becoming increasingly common to organize work groups into interdisciplinary teams to deal with the complexity of care, to coordinate and respond to multiple patient needs, to keep up with the demands of new technology, and to respond to the demands of payors and clinicians outside medicine and in some cases across healthcare settings.4

Following the release of Crossing the Quality Chasm, an IOM-sponsored Health Professions Summit was convened in June 2002 to consider how clinical education could be restructured for all healthcare professionals for the 21st century. During this 2-day meeting, 150 leaders and experts dedicated to health professions education met and concluded doctors, nurses, pharmacists and other healthcare professionals were not being prepared adequately to provide the highest quality and safest medical care possible - and that there was insufficient assessment of their clinical proficiencies. The group noted that despite changes made over the years, the fundamental approach to clinical education had not changed since 1910.3

Examining the lack of interdisciplinary teams in clinical practice, Hall and Weaver concluded that the motivation to include this content in health professions curricula is lacking. These researchers noted that healthcare professionals are trained in isolation, and a certain hierarchy among professional groups has been allowed to exist over the years.5 The IOM report further noted that in addition to the lack of formal curricula, the culture or "hidden curriculum" in educational institutions serves as a barrier to this type of training.

"The culture of educational settings often emphasizes hierarchy, frowns up challenges to authority and discourages admitting fault; thereby undermining collaborative teamwork that can enhance patient safety and quality," the IOM concluded.

Mandate for Change

This Health Professions Summit of 2002 recommended major changes to the curricula of all healthcare professionals. The group strongly recommended that educators and accreditation, licensing and certification organizations ensure students and working professionals maintain proficiency in five core areas:

1. delivering patient-centered care;

2. working as part of an interdisciplinary team;

3. practicing evidence-based care;

4. focusing on quality improvement; and

5. using information technology.

The Health Professions Summit report concluded that initial action steps related to these core areas be initiated within 1-3 years. It also noted the hope that healthcare leaders would become catalysts and "go beyond organizational and turf issues to take the steps for the reform of health professions education."

Although the 2003 NCQA report noted collaboration in healthcare agencies still is not the norm, an increasing number of examples demonstrate organizations and accrediting agencies are stepping up efforts to require evidence of interdisciplinary teams in practice. In the recently released American Association of Critical-Care Nurses (AACN) Standards for Establishing and Sustaining Healthy Work Environments, standard No. 2 describes the critical elements of the collaborative process.

AACN states its position on collaboration, saying, "True collaboration is a process, not an event. It must be ongoing and built over time, eventually resulting in a work culture where joint communications and decision-making between nurses and other disciplines and among nurses themselves becomes the 'norm.' AACN reports that 90 percent of its members state collaboration with physicians and administrators is among the most important elements in creating a healthy work environment.5

At the time of the Health Professions Summit meeting in 2002, educational accrediting agencies included interdisciplinary practice as a competency, but there was little interpretation or suggestion of how this should be implemented in training environments. In 2005, for the first time, the National League for Nursing Accrediting Commission (NLNAC) competencies included effective interdisciplinary team practice. However, NLNAC leaves the interpretation of this competency up to the individual program to include in its curriculum.5

Collaboration in Healthcare

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