By Debra Wood, RN, contributor

May 5, 2010 - Old ways may die hard, but times are changing in healthcare as the emphasis on patient safety continues and the federal government encourages collaboration among physicians, nurses and other care providers with financial incentives and other initiatives.

On ThedaCare's Collaborative Care Unit, a physician, pharmacist and nurse admit and round on the patient and develop a plan of care as a team. Photo credit: ThedaCare

“When there is an alignment, the organization is able to move forward quicker with less effort,” said Kevin Haeberle, executive vice president and practice leader at the consulting firm Integrated Healthcare Strategies in Kansas City, Mo.. “When misaligned, you are putting a lot of time and energy into keeping the place functioning.”

Potential reimbursement changes may force healthcare organizations toward collaboration, as bundled payments, readmission penalties and accountable care organizations — in which primary care physicians, specialists and hospitals are held accountable for cost and quality — become realities.

“There’s a search for a new type of organizational structure for community hospitals to reach out and make sure physicians are at the table and buy into the dialogue,” said Tracey Mayberry, a partner with consultant CSC Healthcare Group in Falls Church, Va.

Challenges to integrated health care

A fundamental difference exists between community-based physicians, who are independent business people, and nurses and other people helping deliver patient care who are employees of an organization and tend to have a different mindset.

“That creates an interesting division and conflict,” said Haeberle, explaining that the physician aims to perform his or her work as efficiently as possible, getting in and getting out, while the employee tends to look at completing a task in whatever time it takes. But this is changing as more physicians become health-system employees.

“As you see more employment environments, the opportunity for creating teams is easier, because now you are more aligned with the same business goals,” Haeberle said. “It changes the motivation to work as a team.”

Mayberry agreed, indicating that salaried physicians help with developing a team environment focused on the quality of patient care.

“It’s little easier to achieve because you have an organizational construct to drive those improvements,” Mayberry said. 

Overcoming differences

The physician remains the head of the clinical team, but the nurse may know the patients and their concerns better.

“It creates tension when the knowledge level is different,” Haeberle said. “If the physician is good at reaching out to the RN and asking for that knowledge, you tend to have a good team environment. … And if the nurses recognize the physician has a certain level of skill and knowledge, the team works better, too.”

Haeberle recommends hospitals and physicians clearly define and reach consensus on roles and responsibilities.

“Having some robust conversations about that tends to be very helpful,” Haeberle said. “Not everyone will agree once you have the definition, but at least you have one.”

In addition, he suggested doctors, nurses and other members of the team discuss what they agree to and disagree about, what works well and what doesn’t, what are acceptable behaviors and performance, and what are the outliers that create tension, and then work on those.

Team-building, simulation and role-playing exercises can help, but hospitals tend to drive those initiatives, Haberle says. He added that physicians will participate if motivated to improve the environment.

Community physicians cannot give up a day seeing patients to participate in hospital committees or training events, Mayberry says. They do not have the financial flexibility. He recommended structuring it as a partnership.

“I think the strategy is figuring out the right form of governance and aligning the incentives so there is reason to participate,” Mayberry said.

A strong, effective managerial leader contributes to better teamwork, especially in emergency departments and surgical suites where physicians, nurses and other staff work side by side all day long.

Mike Chamberlain, president of Simpler Consulting in Pittsburgh, Pa., added that senior leadership must support the initiative, and before rolling something out, the organization must obtain commitment through involvement.

“There has to be a level of trust, so everyone buys into what you are doing,” Chamberlain said.

Innovative collaborative model

Patient handoffs lead to errors. Chamberlain helps organizations avoid these mistakes by bringing physicians and nurses together or streamlining the number of handoffs.

Aiming to decrease medical errors, ThedaCare, a health system in Wisconsin, worked with Simpler Healthcare to develop safer practices. ThedaCare leadership set the goal for zero errors, but the nurses, physicians and pharmacists developed the model.

“You have to put it in the hands of the people doing the work,” Chamberlain said.

The team developed the Collaborate Care Unit on which a nurse, hospitalist and pharmacist meet with the patient within the first 90 minutes of admission to develop a single plan of care and then round together daily to update goals depending on test results and changes in the patient’s condition and explain the reason for the plan of care.

“It was a different level of understanding about why we are doing what we are doing,” said Shana Herzfeldt, RN, business unit manager for the Collaborate Care Unit at Appleton Medical Center. “It was a different way for [the physicians] to practice.”

Herzfeldt indicated it took physicians about six months to feel comfortable explaining why they were doing certain things. But it led to fewer calls to physicians, and nurses were able to answer more of the patients’ and families’ questions.

The health system piloted the concept on a 12-bed medical unit at Appleton Medical Center in Appleton, Wis. The team developed an electronic medical record to help facilitate everyone documenting similarly, added other technology to notify nurses when medications arrive and brought supplies to the patient’s room. It has since implemented the program at an 18-bed unit at Theda Clark Medical Center in Neenah, Wis., and it plans to role it out this year on a 24-bed cardiovascular unit at Appleton.

The Appleton unit has experienced no medication errors in the past two years, decreased the total cost of care by 24 percent, reduced length of stay by 16 percent, and increased patient satisfaction. However despite that success, reimbursement decreased, frustrating administration.

“Healthcare does not always pay people for the value they deliver,” Chamberlain said. “It pays people for the services they provide, whether they are needed or not.” 

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