Interprofessional Collaboration: A Leadership Imperative to Value-Based Care

Abstract:  Top priorities in all healthcare organizations are improving patient safety and improving the patient experience.  Nationally, The Institute of Medicine (IOM) highlighted many concerns with broken systems and fragmented processes causing harm in the hospital setting (IOM, 2001).   The Centers for Medicare and Medicaid Services (CMS) approved the Value Based Purchasing (VBP) program with a goal of improving quality care in the inpatient setting (CMS, 2014; Raso, 2013).  Many healthcare organizations are focusing on the patient experience as part of their quality performance measures.  Our hospital wanted to focus on interprofessional collaboration as a key strategy in improving patient safety.  Therefore, the inpatient units implemented interprofessinal rounds at the bedside.  Our organization needed to improve the patient experience based on current HCAHPS scores at the start of this project.  Achieving HCAHPS benchmarks are a goal from the bedside clinicians to senior leadership.  A high importance to achieve top scores is part of the culture within the hospital.  Monthly HCAHPS data are analyzed and discussed at unit meetings, shared governance, amongst leadership, and with patients and families.  Our hospital had knowledge of rounding processes and had tried several different ways to implement to improve outcomes previously.  The team continued to use data, evidence, and collaboration to implement this project. The team focused on interprofessional rounds at the bedside as a process to communicate the patient’s plan of care, discuss any changes in a patient’s condition, allow patient and family involvement, and focus on discharge needs.  There is clear evidence that interprofessional rounds at the bedside improve quality including decreasing medical errors, decreasing mortality rates, and fewer hospital admissions (VanderWielen et al., 2014).  There is a lack of evidence on how interprofessional rounds at the bedside affect the patient experience or HCAHPS data.  Our team wanted to implement this project and determine the impact on HCAHPS data.

It is crucial for hospitals leaders to stay current with the best evidence and relay the information to their teams.  For example, the Joint Commission has highlighted the need to improve communication in the hospital setting to improve safety.  In fact, ineffective communication is recognized as a contributing factor in medical errors and patient harm (AHRQ, 2014).  The Joint Commission reports that approximately eighty percent of errors are related to miscommunication (Kitch et al., 2008).  Communication failures are reported as the root cause of seventy percent of sentinel events (AHRQ, 2014).  The Joint Commission supports process improvement focused on structured communication to ensure high quality care is provided (Kitch et al., 2008).  This is another key reason this project was selected from hospital leaders to improve collaboration and communication to ensure all patients receive the highest level of care.

Methods:  This project examined the effects of interprofessional rounds (IPR) at the bedside on three key areas:  nurse communication, doctor communication, and discharge information.  Interprofessional rounds at the bedside was implemented on a 28 bed medical surgical unit.  Process data was collected using an observational format. Outcome data was examined by comparing Hospital Consumer Assessment of Health Care Provider Systems (HCAHPS) data both before implementation of rounds and three months post implementation.

Discussion:  Effective communication with patients and families is important in increasing quality of care. There is clear evidence that IPR (interprofessional rounds) at the bedside improves quality including decreasing medical errors, decreasing mortality rates, and fewer hospital admissions (VanderWielen et al., 2014).  There is a lack of evidence on how IPR at the bedside affects the patient experience or HCAHPS data.  This study focused on the impact of IPR at the bedside on the patient experience by using data collected from a validated tool.  This project suggests that IPR at the bedside increases three areas on the HCAHPS survey:  nurse communication, physician communication, and discharge information.   Barriers exist in implementation of IPR at the bedside including the workload of the unit and the hospital.   Hospitalists also have difficulty with patients being admitted on several different units.  These hospitals decided the hospitalist would be assigned to a specific unit and oversee the patients on their assigned unit.  Barriers still exist with this model; however, much effort is placed on geographic localization of patients without impacting hospital flow of patients.  This unit also experienced barriers related the hospitalist first shift for the week.  The rotation of hospitalist on this unit started on Monday.  The team decided to continue interprofessional rounds but occurring in a conference room on Mondays. 

Conclusion:  According to the literature, evidence suggests that interprofessional rounds at the bedside are a way to increase communication and collaboration between the health care team and patients and their families.  Improving communication and collaboration improve quality of care and patient safety.  This project suggests a positive linkage between interprofessional rounds at the bedside and the patient experience metrics (nurse communication, physician communication, and discharge information).  This project can be implemented on any unit in the hospital setting with the support from leadership and physician involvement. With the right team and the desire to improve patient care, any hospital unit can implement this process. 

Results:  Process data:  Three to eight patients were rounded on with every session with an average of six patients per rounding session.  Time spent per patient (n=311) ranged from two minutes to eight minutes with an average time per patient of 3.94 minutes. Outcome data: HCAHPS data increased in all three areas identified for this study.  HCAHPS data in nurse communication increased from 69.4% in January to 82.4% in June.  Physician communication increased from 77.3 % in January to 82.0% in June.  Discharge information increased from 77.9% in January to 86.8% in June

References 

Agency for Healthcare Research and Quality (2014). Retrieved from http://www.ahrq.gov/downloads/pub/advances2/vol3/advances-dingley_14.pdf

Centers for Medicare and Medicaid Services. (2014). Hospital Value Based Purchasing. Retrieved from http://www.cms.gov/Medicare/Quality-Initiaties-Patient-Assessment-Instruments/hospital-value-based-purchasing/index.html?redirect=hospital-value-based-purchasing/

Institute of Medicine. (2001). Crossing the quality chasm:  A new healthcare system for the 21^st century.  Retrieved from http://iom.edu/Reports/2001/Crossing-the-Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx.

Kitch, B. T., Cooper, J. B., Zopol, W., Marder, J. E., Karson, A., Hutter, M., & Campbell, E. G. (2008). Handoffs causing patient harm: A survey of medical and surgical house staff. Joint Commission Journal on Quality and Patient Safety, 34(10), 563-570.

Raso, R. (2013). Value-based purchasing:  What’s the score? Nursing Management, 32 (1), 29-34.

VanderWielen, L. M., Do, E. K., Diallo, H. I., LaCoe, K. N., Nguyen, N. L., Parikh, S. A., ... Dow, A. W. (2014). Interprofessional collaboration led by health professional students:  A case study of the inter health professionals alliance at Virginia Commonwealth University. Journal of Research Interprofessional Practice and Education, 3(3), 1-13.

Zwarenstein M., Goldman J., Reeves S. (2009).  Interprofessional collaboration: effects of practice-based interventions on professional practice and healthcare outcomes.  Cochrane Database of Systematic Reviews, (3), 32-34.  doi: 10.1002/14651858.CD000072.pub2.