Interprofessional Practice

Multiple health workers from different professional backgrounds providing comprehensive health services working with patients, their families, caregivers and communities to deliver the highest quality of care across settings.

Framework for Action on Interprofessional Education & Collaborative Practice WHO, 2010.

Interprofessional Collaboration“… the process of developing and maintaining effective working relationships with learners, practitioners, patients/clients/families and communities to enable optimal health outcomes. Elements of collaboration include respect, trust, shared decision-making, and partnerships.”

Canadian Interprofessional Health Collaborative, 2010

Interprofessionality is not• Simply sharing electronic health records• Sole profession teams (neurologist, pulmonologist, radiologist)• Learners hearing a talk about another profession• Reporting out at interdisciplinary team meetings• Co-location without intentional collaboration• Decision-making without client/patient input

Why IP Teamwork? Why Now?Since 1999 the Institute of Medicine (IOM) has urged the practice of IP team-based care to prevent medical errors. In 2013 the Journal of Patient Safety reported that between 210,000 and 440,000 patients each year suffer some type of preventable harm when receiving hospital care. If the Centers for Disease Control included preventable medical errors as a category, these conclusions would make it the third leading cause of death in America. James, J. T. (2013) . A new, evidence-based estimate of patient harms associated with hospital care. JPS, 9(3), 122-128.

• Demographic Changes, aging population• Chronic health conditions

needing complex care• Technological advances• Specialization in healthcare• Patient Safety & Quality

agenda

• Workforce pressures and gaps• Healthcare and payment

reforms

Evidence for Teamwork• Better continuity of care, access

to care, and patient • Satisfaction*• Higher patient-perceived

quality of care†• Superior care for diabetes

patientsॠImproved blood pressure

control• Reduction in medication side

effects and improved adherence+

*Stevenson K, Baker R, Farooqi A, et al. Features of primary health care teams associated with successful quality improvement of diabetes care. Fam Pract 2001;18:21-26.

† Campbell SM, Hann M, Hacker J, et al. Identifying predictors of high-quality care in English general practice: observational study. BMJ 2001;323:1-6.

‡ Bower P, Campbell S, Bojke C, et al. Team structure, team climate, and the quality of care in primary care: an observational study. Qual Saf Health Care 2003;12:273-9.

+ Iezzoni, LI. Make no assumptions: Communication between persons with disabilities and clinicians. Assist Tech 2006; 18(2): 212-219.

BIG Picture

Change

Core Competencieshttp://www.aacn.nche.edu/education-resources/ipecreport.pdf

Roles & Responsibilities• Know one’s own role and those of team members• Communicate team roles and responsibilities • Engage diverse healthcare professionals to meet the needs

of patients • Use the full scope of knowledge, skills, and abilities of

available health professionals and health care workers to provide safe, timely, efficient, effective, and equitable care

• Use respectful health care practices

Values & Ethics• Recognize and respect the unique cultures, values,

roles/responsibilities and expertise of other health professions

• Work in cooperation with those who receive care, those who provide care, and those who contribute to or support the delivery of prevention and health care services

• Place the interests of patients and populations at the center of interprofessional health care delivery

Communication• Use respectful and appropriate communication in all

situations• Organize and communicate information with patients,

families, and health care team members in a form and format that is understandable, avoiding jargon

• Listen actively and encourage ideas and opinions of all team members.

Teams & Teamwork• Work with others to deliver patient-centered, community-

responsive care• Engage when possible in shared patient-centered problem

solving• Integrate knowledge and experience of other professions

to inform effective/ethical decisions• Apply leadership and facilitation practices that support

collaboration and team effectivenesshttp://www.youtube.com/watch?v=cEHXkucl0lQ

Pat Closing Monologue.mpg

Patricia Chalmers, 31Patricia (Pat) Chalmers is a 31-year-old woman who prides herself on self-sufficiency and resourcefulness. She works part-time as a bookkeeper and gets paid to take care of her aging grandmother with whom she lives. Pat describes herself as having been a caretaker since adolescence. It is therefore difficult for her to acknowledge her own needs or to seek others for help. Pat is tired of people commenting on her weight, diet, and need to exercise. She avoids health care as much as possible because she knows she’ll be told to lose weight or be blamed for “being fat” (her words). “I know what risks I face” she says. “But I’ve tried everything and nothing works. I’ve accepted my size and would like others to respect that.”Pat found herself in the ED with a broken ankle several months ago. The break was significant enough to require surgery. Labs revealed elevated glucose levels and surgery was put off until further tests could be done to determine whether Pat might have diabetes. When asked about this possibility, Pat reacted strongly. “I don’t have the time or money for diabetes,” she explained.

Group Discussion• What do we know about Pat?• What role would your profession play on Pat’s team?• What role will the other professions play on the

team?• Describe the role of the following professions on

Pat’s team:PharmacistSocial WorkerPhysical TherapistOccupational Therapist

Interprofessional Competencies at UNE

Collaborative Leadership

Value contributions of all team membersInclude patient, family, and community Facilitate contributions from all team membersBuild support for working togetherPurposefully work towards ending health disparities and improving access and quality

Interprofessional Facilitation

Interprofessional learning is interactive and takes place when individuals from two or more professions learn about, from and with each other to enhance practice and improve the quality of patient care.

Are two or more professions involved?

Are you capitalizing on learning moments?

Is the session interactive?

Are contributions of different team members acknowledged?

Are IP communication strategies discussed?

Who’s doing most of the talking, you or the learners?

IP Facilitation Skills• Open to multiple perspectives• Value people and their ideas• Think quickly and logically• Excellent and comfortable communicators• Groupwork skills: patience, comfort with

silence, focus, redirection, conflict management

• Product and process oriented

Role Modeling• Role model collaborative competencies in

everyday practice• Share your own process – what were your

misperceptions of other professions• Orient learners to interprofessional principles

and values• Facilitate introductions• Clarify your role and have learners identify

theirs

Facilitate IP Team Meeting• Orient learners to goals of the session• Prompt learners to discuss their observations • Encourage a non-judgmental environment• Make interprofessional learning explicit (e. g. let’s

get the [discipline] view of Pat’s needs)• What do we know about Pat?• What information is missing and where might we

find it?• Capture teachable moments• Prompt self-reflection - model• Encourage closure and final case determinations

Facilitation Video • Observe group facilitation process• Write down observations and critique• What were the facilitator’s strengths• What could have been handled better?

TeamSTEPPS & Primary CareEvidence for Positive Teamwork Outcomes:• Significant improvement in communication and

supportive behavior• Increases in patient satisfaction and adherence• Improved perceptions of teamwork* • Reductions in worker turnover rate• Increases in employee satisfaction†

* Weaver, SJ, Rosen MA, DiazGranados D, et al. Does teamwork improve performance in the operating room? A multilevel evaluation. Jt Comm J Qual Patient Saf 2010 Mar;36(3):133-42.

† Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care 2004;13 Suppl 1:85-90.

What is TeamSTEPPS™• A teamwork system designed for healthcare

professionals and workers. • Developed by Department of Defense's in

collaboration with the Agency for Healthcare Research and Quality (AHRQ).

• Provides attitudes, knowledge and skills for improving patient safety and quality within health and health-related settings.

• Informed by evidence-based research aimed at improving communication and teamwork skills among healthcare professionals and workers.

"Your spoken word, your courage to challenge, your will to engage in teamwork, and your determination to ensure no harm can all be pivotal in determining if a patient lives or dies.“ Sue Sheridan

http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/instructor/videos/ts_Sue_Sheridan/Sue_Sheridan-400-300.html

A Shared Mental Model Is...

The perception of, understanding of, or knowledge about a situation or process that is

shared among team members through communication.

"Teams that perform well hold shared mental models." (Rouse, Cannon-Bowers, and Salas 1992)

ISBAR

Introduce Situation Background Assessment Recommendation

A Shared Mental Model for Communication

Patient • Sally Hinton is a 55 year old single women who lives on her own, receives

MaineCare and SSI disability. She previously worked for 30 years as a school bus driver and continues to do volunteer work in the schools.

• Sally was discharged a week ago after 2 days in the hospital being worked up for angina. Her diagnoses include insulin dependent diabetes, obesity, depression, and hydradenitis suppurativa (i.e., the development of cysts in the breasts, arm pits, neck and groin which require occasional draining). She takes nine different medications.

• During a routine office visit today Sally seems uncharacteristically disoriented. She denies using alcohol or other intoxicating substances. You ask if she’s taking her medication appropriately to which she replies that she thinks so. When you ask to see her medications she tells you that they are stored in their vials in a kitchen drawer. She cannot however tell you which medications she takes, when she takes them or their dosages.

• Sally also describes two falling incidents that occurred last week during the night. Although nothing was apparently broken, she shows you large bruises on her hip and forearm. She also has an open injury on her shin that she says is painful and not healing properly.

• What are your thoughts about Sally’s health and well-being?• Describe how you would use ISBAR when transferring or referring Sally’s care.

Stop the Line: CUS

• I am Concerned• I am Uncomfortable• There is a Safety issue

CUSSally’s friend Alma brings her to the ED after another fall during which time she badly injures her arm. The ED is very busy. The attending evaluates Sally’s arm and disorientation. He asks her about any substance misuse which she denies and her friend agrees. Sally’s arm is x-rayed and it appears to be a severe bruise, not a fracture. The attending prescribes Tylenol with codeine for the pain and is ready to discharge her home. • What if any concerns do you have about Sally given her recent medical

history? How and to whom might these be raised in the medical setting? • Would you be uncomfortable with sending Sally home and if so, how

might you convey this dilemma/differences with the attending practitioner?

• Might these recommendations cause an unsafe situation for Sally. If you’re concern about patient safety has not yet been acknowledged, what would you do next?

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Briefs, Huddles & Debriefs

Brief

Who is on the team?Agree on Goals

Roles & Responsibilities Understood

Plan of CareAvailability

Access Resources

Huddle

Problem-solvingReview situation Discuss new &

emerging events

Anticipate outcomes & possibilities

Assign resourcesExpress Concerns

DebriefCommunicate clearly

about eventGo over detailsWere roles &

responsibilities understood?

What went wellWhat should change

Can we improve?

Situation Monitoring• Process of actively scanning behaviors and

actions to assess elements of the situation or environment

• Fosters mutual respect and team accountability

• Provides safety net for team and patient• Includes cross-monitoring

…Remember, engage the patient whenever possible.

Check-Back Is when Practitioners…

Teach-Back Is…• Confirmation of understanding• Opportunity to correct miscommunication• Comprehensive– “Tell me in your own words how you will take

this medicine when you get home…”

Patient

• Frank is a 71 year old married male who is in and out of the hospital for a variety of health conditions. He is currently in the hospital admitted for dehydration and kidney failure. His other diagnoses include heart disease, renal insufficiency, alcohol abuse, renal insufficiency and a past medical history of stroke, quadruple bypass, and multiple joint replacements. He walks slowly with a walker and smokes a pack a day.

• Frank and his wife, Mollie, 74, are waiting for his discharge to be authorized. He’s leaving the hospital with an indwelling catheter that will require home care and also new medications that advise no alcohol usage. The couple has been at odds since Frank flunked his driving test and Mollie took away his car keys.

• It is your job to make sure that Frank and Mollie understand how to manage his care. How will you ensure this is done? What variables do you need to check?

• A nurse practitioner and social worker will follow up on Frank’s situation through home visits. How will you guarantee that they understand his physical, emotional, and psychosocial care needs?

Team-based Leaders:• Motivate people to work together to accomplish common goals• Model facilitation and collaboration • Share information and listen• Offer constructive and timely feedback• Include patients and families as decision-makers

Patient- and Family-Centered Care

• Hear the patient’s stories • Be open and honest• Respect the patient and family as the central hub

of the care team• Make sure patients share fully in decision making• Speak to patients in a way they can understand

and enable them to feel empowered to be in control of their care

Equipping Patients & Families• Quality care is a team effort • Patients and families can

improve their care by taking active roles in the process

• Invite patients to ask questions, and evaluate their option

• Be culturally responsive to patients

• Encourage shared decision-making in their health care

• The AHRQ Web site ―www.ahrq.gov/questionsaretheanswer/

Questions Your Patients Should Ask

What is the test for?When will I get the results?Why do I need this treatment?Are there any alternatives?What are the possible complications?Which hospital is best for my needs?How do you spell the name of that drug?Are there any side effects?

Racial & Ethnic Disparities• IOM’s Unequal Treatment

highlighted evidence of racial and ethnic disparities in health care

• Language barriers are less well documented

• The root causes of patient safety events for non-English speaking patients in are: (1) poor communication and (2) insufficient use of qualified medical interpreters and cultural navigators

http://www.youtube.com/watch?v=ABn0sE1aiGo

References1. Barrett, J., Curran, V., Glynn, L., & Godwin, M. (2007). CHSRF Synthesis: Interprofessional

Collaboration and Quality Primary Healthcare. Ottawa: Canadian Health Services Research Foundation.

2. Dow, A., Konrad, S. C., Blue, A. V., Earnest, M., & Reeves, S. (2013). The Moving Target: Outcomes of Interprofessional Education, Journal of Interprofessional Care, 27, (5), 353.

3. Driessen, E., van Tartwijk & Dorman, T. (2008). The self-critical doctor: Helping students become more reflective. British Medical Journal, 336, 827-829.

4. Haynes, A. B., Weiser, T. G. et al (2009). A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. New England J of Med (360; 5), 419.

5. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D. C. National Academies Press.

6. Interprofessional Education Collaborative Expert Panel. Core Competencies for Interprofessional Collaborative Practice: Report of an Expert Panel. Washington D. C.: Interprofessional Education Collaborative 2011.

7. Konrad, S. C. & Browning, D. M. (2012). Relational Learning and Interprofessional Practice: Transforming Health Education for the 21st Century. WORK: The Journal of Prevention,

Assessment & Rehabilitation, 41, 247.8. Reeves, S., Lewin, S., Espin, S, Zwarenstein, M. (2010). Interprofessional Teamwork for Health

and Social Care. Oxford: Blackwell Publishing.9. World Health Organization. Framework for Action on Interprofessional Education and

Collaborative Practice. Geneva: WHO 2010.10. Zwarenstein, Reeves, Perrier. (2005). Effectiveness of pre-licensure interprofessional

education and post-licensure collaborative interventions. J of Interprofessional Care(Supplement 1), 148.

Shelley Cohen Konrad PhD, LCSW, FNAPJennifer Morton D.N.P., M.S., M.P.H., RNUniversity of New Englandscohenkonrad@une.edu; jmorton@une.edu