Interdisciplinary Collaboration to Enhance Patient Care

On an overcast Sunday in January, Amy Pulido, MD, packed a poncho in her tote bag and ventured out on a water taxi to explore Fort Lauderdale’s art scene. Joining her were about 20 physicians — all women — in different specialties. They got to know each other while touring the mansions and exploring the artwork for sale at various destination stops.

The clinicians are affiliated with Envision Physician Services, a Plantation, Florida-based multispecialty group that partners with healthcare facilities in 45 states and the nation’s capital. Their specialties range from anesthesiology to emergency care, hospital medicine, radiology, surgery, and women’s and children’s health.

“Having the introduction to some other like-minded professional women within our company is helpful for advancing the delivery of quality patient care,” says Pulido, the event’s co-organizer and chief of anesthesiology at Memorial Regional Hospital in Hollywood, Florida.

For instance, she met an Envision radiologist from the same hospital with whom she had never interacted. Now, they have established a rapport and when the need for consultation arises, she can easily reach out to the radiologist for assistance.

“A lot of medicine is practiced in silos, and you tend to keep to your core group of people,” Pulido says. But she learned that when physicians broaden their team-building efforts, they can enhance the overall delivery of care. “Coordination of care is an important part of taking care of patients and becomes easier when you grow your network,” she adds.

Uniting for Patient Care

Finding innovative ways to build teamwork is essential in an interdisciplinary environment where multiple constituencies — physicians, nurses, pharmacists, and business officers — all have resounding voices. And when team members come together from different walks of life and embody unique perspectives, it’s not so simple to achieve convergence in patient care.

“One of the biggest complaints from patients is ‘Everyone tells me something different,’ ” says Carla J. Rotering, MD, MA, medical director of respiratory and pulmonary rehabilitation at Banner Thunderbird Medical Center in Phoenix and White Mountains Regional Medical Center in Springerville, Arizona.

Imagine yourself as a patient, surrounded by “a parade of people,” she says. “Independent voices showing up at the bedside may not be in alignment with the other conversations going on.”

When healthcare team members act independently and cause confusion, it can erode a patient’s trust. Staying in close communication with each other helps each team member best serve the patient’s needs, says Rotering, an executive coach with an emphasis on leadership development and co-author of the book The Language of Caring Guide for Physicians.

“These are really simple skills that make a difference,” she says. “They’re learnable in very short periods of time.” The information can be “delivered in very short sound bites” and practiced in the form of checklists and rules of thumb.

A Seamless Process

With so many healthcare professionals involved in patient care, it’s not surprising that individuals entering a hospital today often wonder how many doctors they are going to see, says Amrendra Miranpuri, MD, an endovascular neurosurgeon at Carle Neuroscience Institute in Urbana, Illinois.

Not only can they expect to encounter doctors, but also many other healthcare providers. A patient experiencing a stroke typically interacts with emergency medicine physicians, hospitalists, and neurologists, as well as nurses, nurse practitioners, pharmacists, and speech and physical therapists, among others.

“Physicians need leaders to make sure that process is somewhat seamless,” Miranpuri says. Knowing when and to whom to delegate based on employees’ strengths are important leadership qualities to deploy in a patient’s treatment. For example, he explains, some providers are more comfortable than others in having difficult conversations with families about challenging diagnoses and prognoses.

Very challenging cases, in particular, require well-thought-out interdisciplinary collaboration. Miranpuri and his colleagues in neurology and radiology, and sometimes other specialties such as hematology and oncology, meet to discuss such cases on a weekly basis. Then they try to arrive at a consensus as to what would be best for each patient.

One of their consistent goals is to reduce readmissions — a significant risk factor stroke patients face. Additional risks they attempt to mitigate in these patients are the incidence of falls, Miranpuri says, and failing to take medications as prescribed — both of which can result in rehospitalization soon after discharge.

“Physicians think we’re naturally born leaders,” he says. “But in reality, it’s not something we learn in medical education.”

Taking the Lead

Leadership skills are acquired over time. Teams of physicians and staff “work synergistically” with clinical investigators to create evidence-based operations that integrate research into clinical care, according to Kenneth W. Mahaffey, MD, professor and director of the Stanford Center for Clinical Research at the Stanford University School of Medicine.

On clinical service lines, quick morning huddles of doctors, nurses, and case managers are effective in formulating care plans for hospitalized patients who are likely be discharged that day and possibly the following day, so that appropriate steps are put in place, he says.

“Because of the complexity of medical conditions and therapeutic interventions, you need to have expertise across multiple domains in order to be able to address all the issues in that complex setting,” Mahaffey says. However, “it’s the leadership team that really has to set the stage for a collaborative and respected environment,” fostering a sense of openness to identify areas for improvement.

“I don’t think we need to shy away from any controversy or differences of opinion or approaches,” he says. “We have to be able to bring people together to air their differences. This can’t be done in isolation.”

Among the qualities effective leaders must cultivate are superior listening skills. “When we actively listen, we offer our presence, which conveys to each person on the team that we value them as unique individuals and what they are saying is important,” says Richard L. Pullen Jr., EdD, MSN, RN, CMSRN, CNE-cl, professor of nursing at Texas Tech University Health Sciences Center in Lubbock.

He adds, “we must remember that the patient is an integral member of the team in this time of patient-centered care. The concept is that teams are comprised of anyone who can address the multiple dimensions of a patient’s suffering or condition.”

Diversity factors into successful interdisciplinary collaboration as well, Pullen says. It includes but is not limited to issues related to the disease process, religion, race, culture, ethnicity, age, gender, and sexual orientation. “We must also remember that there is diversity in learning styles and socioeconomic status,” Pullen says.

Once teams are assembled and begin to identify specific problems, they may decide that another type of professional should be included. For example, he says, they could recommend daily massage for a patient with a painful neuromuscular disorder, in which case a massage therapist would join them. Sometimes a pet therapy coordinator and volunteer could be part of the patient’s healthcare experience.

Creative Improvement

Inspiring creativity and igniting a motivational fire among team members is also a valuable asset. A leader can use brainstorming tools such as formulating a list of problems and ranking priority status. In this process, the leader allows each person to share ideas in resolving those problems without permitting any one participant to dominate the conversation.

Learning boards are helpful for improvement purposes. They can be positioned in a visible area for frontline staff to raise their concerns over staffing, equipment, or anything else affecting quality and safety, says Russell “Rusty” L. Holman, MD, chief medical officer for LifePoint Health, a Brentwood, Tennessee-based healthcare company that owns and operates 89 hospital campuses across 30 states.

“We don’t have criteria for an issue too big or too small to put on a learning board,” he says. “Some things are relatively small and can be resolved quickly, but not all. Others can take weeks or even months.”

For instance, a frontline person noted on a learning board that it was difficult to obtain access to bedside ultrasound machines. At this hospital, the issue revolved around the availability of these machines for quick diagnoses in the intensive care unit as well as for guidance of central peripheral lines in the telemetry unit. The equipment circulated back and forth between the two units instead of being stored in a common place when not in use, Holman says.

Another issue dealt with a slower-than-usual turnaround of blood test results posting in electronic health records. It turned out that the blood draw personnel had changed their process of collecting and delivering samples to the laboratory, and there also was a delay in the laboratory test being populated into the electronic chart, he says.

Problems are displayed initially on the left side of the learning board, typically with a posted sticky note. As a supervisor works toward resolution, progress notes appear in the center of the board, and the final resolution or uncovered barrier is posted on the right side. An issue moves horizontally across the board, so “there’s transparency and visibility that the issue has been resolved in such a way,” Holman says.

Empowering Engagement

Fluid team dynamics also result from understanding and honoring the roles and responsibilities of other healthcare professions. That means not allowing hierarchy to dictate who feels comfortable speaking up, says Brian Sick, MD, associate professor of internal medicine and pediatrics at the University of Minnesota Medical School in Minneapolis.

“The people who traditionally had the power, whether it’s physicians or other members of the team, we need to make sure that everybody on the team has a voice and that they’re welcomed into the conversation,” he says.

A case in point would be an interaction Sick had with a pharmacist in one of the university’s clinics. When Sick prescribed a new form of regular insulin — a high-concentration version — without mentioning discontinuation of the patient’s long-acting insulin, the pharmacist took the initiative to call and inquire, as he had done in other instances of uncertainty. Taking both forms of insulin would have led to dangerously low blood sugar for the patient, Sick says.

“The pharmacist was really just double-checking that those are things I really wanted and was really looking out for the best interest of the patients,” he says. If he had accused the pharmacist of “second-guessing” him, Sick believes the pharmacist may have been reluctant to call in the future and as a result, failed to catch an error.

To facilitate collaborative relationships, some professional physician societies have opened up their fellowship programs to other advanced practice specialists. Among them is the American College of Chest Physicians. Respiratory therapists, nurse practitioners, physician assistants, and others involved in pulmonary and critical care or sleep medicine can attain the designation of FCCP (Fellow of the College of Chest Physicians), says Chad Jackson, MS, RRT, FCCP, chief innovation officer and vice president of market growth at the association based in Glenview, Illinois.

Prior to this change in 2015, these professionals “didn’t feel that they had a home” in the organization unless they were researchers with doctoral degrees, Jackson says. “Now, we encourage the doctors to bring their advanced practice professionals with them and interface with them while they’re doing their actual training,” which consists of intensive, hands-on, simulation-based experience in airway management, bronchoscopy, critical care, mechanical ventilation, pulmonary function testing, sleep, and ultrasound.

A model of care in which patients get to know an entire team of caregivers equally well, not just their doctor, has become a cornerstone of Christiana Care Health System in Wilmington, Delaware. The new approach was piloted in 2017 and then, after much success, expanded to multiple locations, says Sarah Schenck, MD, clinical director of practice transformation for primary care at Christiana Care.

The health system routinely screens patients for depression, and the medical assistants working on teams bond with patients, who call and ask for them by name. In one instance, a patient who came in complaining of low back pain screened positive for depression and disclosed to a medical assistant that she was planning to commit suicide that night. Fortunately, the assistant intervened by bringing in a behavioral health consultant and thwarting the patient’s plan, Schenck says.

Sharing the care has provided more support to physicians and increased satisfaction among all caregivers on the team, she says, adding, “They felt more connected to the patients and their work had more meaning for them.”