It may seem strange that functioning as part of a team would cause discomfort, but the traditional paradigm of the physician as the sole controlling practitioner persists.
This article first appeared in the December 2015 issue of HealthLeaders magazine.
At Seattle's Virginia Mason MedicalCenter, teamwork is the name of the game. Healthcare providers who'd rather call an audible and play by their own rules are in for a surprise.
"Teamwork is one of our core values here, and has been since the beginning," says Charleen Tachibana, DNP, RN, FAAN, senior vice president for quality and safety and chief nursing officer at the medical center, which includes a 336-licensed-bed acute care facility that is part of the larger, nonprofit integrated healthcare system. "So the concept of forming teams and reforming teams and coming together and working together really becomes a way of being. If people want to work in silos here, that doesn't work very well; they're not very comfortable, and they aren't able to move agendas very quickly that way."
"Many healthcare professionals come with a mental model around what they expect when they're working with other healthcare professionals. I just think that's reflective of the profession and how they're educated in silos."
It may seem strange that functioning as part of a team would cause discomfort, but the traditional paradigm of the physician as the sole controlling practitioner persists.
"Many healthcare professionals come with a mental model around what they expect when they're working with other healthcare professionals," says Tachibana, who recalls a physician job candidate who declined a position after learning of Virginia Mason's emphasis on collaboration. "I just think that's reflective of the profession and how they're educated in silos."
But if provider organizations are to have success as healthcare emphasizes value-based payment models, quality metrics, and integrated care models, then team-based care and interprofessional collaboration need to be the rule rather than the exception. Groups such as the Institute of Medicine, the Institute for Healthcare Improvement, and the Robert Wood Johnson Foundation, are championing the cause.
"Interprofessional collaboration is when health professionals and others are able to work effectively together on a team, sharing responsibility, understanding and having respect for each other's roles and points of view, and working well together to accomplish a bigger goal in terms of better care for individuals and families," says Maryjoan Ladden, RN, PhD, FAAN, senior program officer at RWJF, which released the report Lessons From the Field: Promising Interprofessional Collaboration Practices. The report highlights healthcare organizations with strong IPC models, including Virginia Mason.
"When you have a model where the physician is paid and it's fee-for-service, the other professions are cost centers,"
IPC is hardly a new concept—the IOM has called for its use since its 1972 report Educating for the Health Team—but it has not fully taken hold in the workplace or in healthcare education in large part because of traditional payment models.
"When you have a model where the physician is paid and it's fee-for-service, the other professions are cost centers," notes Barbara F. Brandt, PhD, director of the Minneapolis-based National Center for Interprofessional Practice and Education at the University of Minnesota, a nonprofit center dedicated to furthering interprofessional practice and education in healthcare and funded by the Health Services and Resources Administration of the U.S. Department of Health and Human Services, RWJF, the Josiah Macy Jr. Foundation, and the Gordon and Betty Moore Foundation.
That is changing, Brandt says. "There's so much more emphasis on primary care [now], and so the changing incentive systems are really driving the need for teams."
More and more, healthcare facility leadership is realizing that quality of care, and subsequent reimbursement, hinges on the team-based approach to care, says Ladden. "When you think about returning hospitalizations within 30 days and all of the things that you can be financially accountable for that you weren't before, I think it has finally dawned on people that no one health profession or entity can really manage all of these issues alone and produce the financial outcomes and quality and safety outcomes alone," she says.
At Virginia Mason, the team approach to care delivery has been a key part of improving clinical and financial outcomes alike, says Tachibana.
"I don't think we could do what we're doing without having interprofessional collaboration," she says. "We couldn't move our quality agenda the way we're moving it; we couldn't drop our costs of care and have the care coordination that we have if we couldn't work together this way."
Tachibana points to the organization's initiative surrounding sepsis as one tangible example of how interprofessional collaboration can improve care. "Sepsis is our leading cause of death in the hospital, as it is in many hospitals across the country," she says. "We have taken our hospitalist team and our inpatient nursing team and really looked at ways that we reduce the time it takes to deliver the sepsis bundle."
Clinical recommendations from the Surviving Sepsis Campaign call for interventions to be started within three hours of the presentation of symptoms of sepsis. Virginia Mason completed bundled interventions in as low as 24 minutes thanks to the interprofessional problem solving, she says.
Working from interprofessionally developed protocols, nurses are able to implement the first three elements of the bundle prior to the patient being evaluated by a physician, who is required to implement the fourth component, delivery of an antibiotic. When it was identified that there was a delay in the administration of the antibiotic, team members in the pharmacy department stepped in to help address the bottleneck in care, which is how intervention time was dropped to minutes in some cases.
Virginia Mason implemented IPC by looking beyond the professions to the patient. The health system has worked to create a culture and structure that puts the patient first and models collaboration at the leadership level. In 2002, when the organization revamped its strategic plan, the patient was designated as the driving force behind its mission and vision.
"Our true north is centered on the patient and improving our care and our processes and experience from the patient's perspective," she says. "If I'm working with a physician and I'm a nurse, it's clear it's not about me, it's not about the doctor—it's about the patient. The clarity of purpose and the clarity of intent and vision has been a key component as you bring a number of different professions together."
Expectations for physicians, board members, the leadership team, and the organization itself are clearly outlined in Virginia Mason's three compact documents, which detail the responsibilities of each group. For example, according to the leadership compact, the organization is expected to "offer opportunities for constructive open dialogue" and leadership members are expected to "continuously improve quality, safety, and compliance."
"It holds us to our principles a little bit tighter and reminds us all of what we're accountable for, and how we're accountable to the organization," Tachibana says of the compacts. "I think it reestablished those norms and expectations about what teamwork is, and what it is to work together, and what respect looks like, and how we're going to focus on the patient."
Accountability is the key to making IPC part of the organizational culture, says Tachibana.
"If anybody is not willing to work collaboratively and respectfully with others, it's a problem and it's an unsafe situation," she says. "So, it's leaders being willing to do that hard work, to call it out, to coach it, to provide opportunity to improve, but, ultimately, if it doesn't improve, to say it's time to part." Tachibana adds, however, that it has gotten to that point rarely, not even once a year. "If there is an issue, leaders are expected to address it through training, coaching, referral to the employee assistance program, or through the use of other resources."
The health system also fosters IPC through its Virginia Mason Production System, its well-known management methodology based on Toyota's Lean principles. VMPS brings the various professions together during rapid process improvement workshops to improve care delivery processes.
Though collaboration is essential for healthcare systems in today's environment, interprofessional education is lagging, says Ladden.
"What we hear from the health systems is that new health professionals come into the health system very poorly prepared with how to work together because there hasn't been any interprofessional education or experiences at the entry level or the graduate level," says Ladden.
That's where the National Center for Interprofessional Practice and Education comes in, Brandt says. Her organization works with academic healthcare educators to develop team-based learning models that incorporate various disciplines and break down silos.
"We are charged with promoting teaching and learning of team-based skills and practice both in practice with the current practitioners and also with the pipeline, students that are in universities and the like," she says.
The center provides reports, training, and data for those interested in implementing IPE and IPC. Brandt says the center also is working to gather data on what types of teams are most effective in the new healthcare environment.
"As we go to value-based payments and we're redesigning healthcare, all those assumptions, we're throwing them out the window. So really understanding who's going to be on the team and what ways they're going to be working are all going to be called into question," she says.
Physicians, nurses, and other providers who have gotten used to working in silos will be forced to think differently, says Tachibana. "I think our patients will demand more" collaboration and teamwork, she says. "It has to happen because the cost curve on healthcare has to shift; so we have to learn to work differently to optimize everybody's contributions here. The economics of [healthcare], if nothing else, will demand that we begin doing it differently."
Jennifer Thew, RN, is the senior nursing editor at HealthLeaders.