Opinion
VIEWPOINT
Peter W. Dillon, MD, MSc Department of Surgery, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey. Harold L. Paz, MD, MS Office of the Dean and CEO, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey.
Corresponding Author: Peter W. Dillon, MD, MSc, Department of Surgery, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, HO51, 500 University Dr, Hershey, PA 170330850 (pdillon1@hmc .psu.edu).
Team-Based Surgical Care An Important Role for Academic Health Centers It is an inescapable fact that the expectations for the delivery of high-value, safe, and effective patient care in the hospital setting have changed dramatically over the last few years, and nowhere is this evolution more evident than in acute surgical care. The increasing number of process and outcome measures, the growing importance of patient satisfaction scores, and the evolving changes in reimbursement intensify this emphasis on the total patient experience. Physicians must focus on value for patients and can no longer see themselves as “self-contained, isolated actors.”1 Instead, they must lead the formation of collaborative care teams, based in integrated practice units (IPUs) across the care continuum. The degree of this care transformation is evident in the recent report from the Institute of Medicine embracing a new professional culture of teamwork and collaboration.2 This move toward team-based collaborative care is also supported by the development of valid psychometric survey instruments used to assess various dimensions of teamwork, while demonstrating significant relationships to clinical outcomes and performance metrics.3 Unfortunately the capacity for collaborative care is often constrained by the current rigid hierarchy of health care occupations and the silo divisions of labor.4 Traditional surgical care has routinely been taught and delivered within that vertically oriented authority gradient. How often has a senior surgeon expounded with great seriousness that the “surgeon is captain of the ship”? In the academic culture, the attending physician often communicates with the senior-level resident who, in turn, deals with the junior residents and interns who then write the orders to be acted on by the nurses and other health care professionals. The focus is personal and on individual knowledge and skills. The problem with this approach is that care in the floor environment is delivered in a hierarchical fashion that fails to take into account the importance that relationally coordinated team-based interactions have in delivering inpatient surgical care.5 If there are any deficiencies in the shared knowledge, misalignment of goals, lack of respect, or a failure in the communication of information, patient care is potentially compromised. Current inpatient surgical units are complex environments in which multiple health care professionals must work interdependently to deliver care. Depending on the time constraints and the acuity of patients’ conditions, the care environment will be characterized by increasing levels of interdependency, ambiguity, and task complexity. At the unit level, capacity for collaborative care may be improved through a focus on patient-centered care and a context that supports health care professionals’ work.4 At Penn State Hershey, this fundamental rede-
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sign includes team-based care and a focus on the inpatient surgical floor as the IPU. With the importance of process spanners and inclusive meetings as methods to support collaborative care within an IPU, 2 structures were established—daily collaborative care rounds (the care team gathers in the patient’s room to discuss the current plan of care, patient goals, and a discharge plan and to answer patient and family questions) and a weekly collaborative care forum (a venue in which all IPU caregivers can openly and safely discuss issues and ideas related to the conduct of patient care, to foster a sense of unity and teaming). Measurement of IPU outcomes performed 12 months into the program revealed that collaborative care was associated with lower readmission rates, shorter lengths of stay, and lower direct costs per discharge and an increase in the Hospital Consumer Assessment of Healthcare Providers and Systems overall satisfaction score. Survey measures of teamwork along the dimensions of frequent, timely, accurate, and problem-solving communication, shared goals, shared knowledge, and mutual respect, within and between various workgroups, including nurses, physicians, advanced practice clinicians, care coordinators, and personal care assistants, revealed a high degree of relational coordination between the care coordinators and nurses with other workgroups, as well as within the advanced practice clinicians.6 The survey identified several opportunities to improve communication and promote mutual respect, shared knowledge, and goals. The surgical collaborative care pilot supported plans for organizationalwide dissemination and was an early success. However, the process of initiating this paradigm change in surgical care delivery was not without significant challenges; for at its core, it represented a change in the culture of surgical care. Challenges were both philosophical and practical. Attending and resident physician buy-in required focused discussions on patientcentered care, relational coordination, and the process of teaming. Choosing a consistent time of day for the collaborative rounds and the forum was difficult because the daily hectic schedules of surgeons, nurses, and the other health care professionals on the surgical floor meant that no common time was ever acceptable, and in the end, it was determined that the best time was that which was the least disruptive to floor work flows. The delivery of high-quality health care in the setting of an acute surgical environment requires healthy relationships among team members, as well as the capacity to be able to learn together and adapt to change.7 This enables caregivers from different professional disciplines to overcome the status barriers and hierarchy that have existed in health care and to create an environment that values teaming, high-quality communicaJAMA Surgery October 2014 Volume 149, Number 10
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a J H Quillen College User on 06/05/2015
999
Opinion Viewpoint
tion, and problem solving. Most importantly, these concepts, when combined, shift the paradigm of surgical care in the acute inpatient setting from the classic physician-focused hierarchical structure to patient-centered teamwork and coordination. Academic health centers have an opportunity to reframe care, as well as the training environment, and nowhere is the necessity of this change more evident than in the acute care surgical unit. To deliver high-
3. Valentine MA, Nembhard IM, Edmondson AC. Measuring teamwork in health care settings: a review of survey instruments [published online April 30, 2014]. Med Care. doi:10.1097/MLR .0b013e31827feef6.
6. Gittell JH. Coordinating mechanisms in care provider groups: relational coordination as a mediator and input uncertainty as a moderator of performance effects. Manage Sci. 2002;48(11): 1408-1426. doi:10.1287/mnsc.48.11.1408.268.
1. Porter ME, Teisberg EO. How physicians can change the future of health care. JAMA. 2007;297 (10):1103-1111.
4. Weinberg DB, Cooney-Miner D, Perloff JN, Babington L, Avgar AC. Building collaborative capacity: promoting interdisciplinary teamwork in the absence of formal teams. Med Care. 2011;49(8): 716-723.
7. Ricketts TC, Fraher EP. Reconfiguring health workforce policy so that education, training, and actual delivery of care are closely connected. Health Aff (Millwood). 2013;32(11):1874-1880.
2. Mitchell P, Wynia M, Golden R, et al. Core principles and values of effective team-based health care: discussion paper. http://www.iom.edu /Global/Perspectives/2012/TeamBasedCare.aspx. Published October 2, 2012. Accessed July 9, 2014.
5. Gittell JH, Fairfield KM, Bierbaum B, et al. Impact of relational coordination on quality of care, postoperative pain and functioning, and length of stay: a nine-hospital study of surgical patients. Med Care. 2000;38(8):807-819.
ARTICLE INFORMATION Published Online: August 13, 2014. doi:10.1001/jamasurg.2014.219. Conflict of Interest Disclosures: None reported. REFERENCES
1000
performance health care and education, boundaries must be eliminated, and all caregivers must be part of a process that promotes collaboration and effective communication in an integrated fashion that is centered solely on the needs of the patient. In the acute care surgical environment, that goal can best be achieved by developing a paradigm of care that is based on the patient, the surgical unit, and all who work there.
JAMA Surgery October 2014 Volume 149, Number 10
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a J H Quillen College User on 06/05/2015
jamasurgery.com
VIEWPOINT
Peter W. Dillon, MD, MSc Department of Surgery, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey. Harold L. Paz, MD, MS Office of the Dean and CEO, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey.
Corresponding Author: Peter W. Dillon, MD, MSc, Department of Surgery, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, HO51, 500 University Dr, Hershey, PA 170330850 (pdillon1@hmc .psu.edu).
Team-Based Surgical Care An Important Role for Academic Health Centers It is an inescapable fact that the expectations for the delivery of high-value, safe, and effective patient care in the hospital setting have changed dramatically over the last few years, and nowhere is this evolution more evident than in acute surgical care. The increasing number of process and outcome measures, the growing importance of patient satisfaction scores, and the evolving changes in reimbursement intensify this emphasis on the total patient experience. Physicians must focus on value for patients and can no longer see themselves as “self-contained, isolated actors.”1 Instead, they must lead the formation of collaborative care teams, based in integrated practice units (IPUs) across the care continuum. The degree of this care transformation is evident in the recent report from the Institute of Medicine embracing a new professional culture of teamwork and collaboration.2 This move toward team-based collaborative care is also supported by the development of valid psychometric survey instruments used to assess various dimensions of teamwork, while demonstrating significant relationships to clinical outcomes and performance metrics.3 Unfortunately the capacity for collaborative care is often constrained by the current rigid hierarchy of health care occupations and the silo divisions of labor.4 Traditional surgical care has routinely been taught and delivered within that vertically oriented authority gradient. How often has a senior surgeon expounded with great seriousness that the “surgeon is captain of the ship”? In the academic culture, the attending physician often communicates with the senior-level resident who, in turn, deals with the junior residents and interns who then write the orders to be acted on by the nurses and other health care professionals. The focus is personal and on individual knowledge and skills. The problem with this approach is that care in the floor environment is delivered in a hierarchical fashion that fails to take into account the importance that relationally coordinated team-based interactions have in delivering inpatient surgical care.5 If there are any deficiencies in the shared knowledge, misalignment of goals, lack of respect, or a failure in the communication of information, patient care is potentially compromised. Current inpatient surgical units are complex environments in which multiple health care professionals must work interdependently to deliver care. Depending on the time constraints and the acuity of patients’ conditions, the care environment will be characterized by increasing levels of interdependency, ambiguity, and task complexity. At the unit level, capacity for collaborative care may be improved through a focus on patient-centered care and a context that supports health care professionals’ work.4 At Penn State Hershey, this fundamental rede-
jamasurgery.com
sign includes team-based care and a focus on the inpatient surgical floor as the IPU. With the importance of process spanners and inclusive meetings as methods to support collaborative care within an IPU, 2 structures were established—daily collaborative care rounds (the care team gathers in the patient’s room to discuss the current plan of care, patient goals, and a discharge plan and to answer patient and family questions) and a weekly collaborative care forum (a venue in which all IPU caregivers can openly and safely discuss issues and ideas related to the conduct of patient care, to foster a sense of unity and teaming). Measurement of IPU outcomes performed 12 months into the program revealed that collaborative care was associated with lower readmission rates, shorter lengths of stay, and lower direct costs per discharge and an increase in the Hospital Consumer Assessment of Healthcare Providers and Systems overall satisfaction score. Survey measures of teamwork along the dimensions of frequent, timely, accurate, and problem-solving communication, shared goals, shared knowledge, and mutual respect, within and between various workgroups, including nurses, physicians, advanced practice clinicians, care coordinators, and personal care assistants, revealed a high degree of relational coordination between the care coordinators and nurses with other workgroups, as well as within the advanced practice clinicians.6 The survey identified several opportunities to improve communication and promote mutual respect, shared knowledge, and goals. The surgical collaborative care pilot supported plans for organizationalwide dissemination and was an early success. However, the process of initiating this paradigm change in surgical care delivery was not without significant challenges; for at its core, it represented a change in the culture of surgical care. Challenges were both philosophical and practical. Attending and resident physician buy-in required focused discussions on patientcentered care, relational coordination, and the process of teaming. Choosing a consistent time of day for the collaborative rounds and the forum was difficult because the daily hectic schedules of surgeons, nurses, and the other health care professionals on the surgical floor meant that no common time was ever acceptable, and in the end, it was determined that the best time was that which was the least disruptive to floor work flows. The delivery of high-quality health care in the setting of an acute surgical environment requires healthy relationships among team members, as well as the capacity to be able to learn together and adapt to change.7 This enables caregivers from different professional disciplines to overcome the status barriers and hierarchy that have existed in health care and to create an environment that values teaming, high-quality communicaJAMA Surgery October 2014 Volume 149, Number 10
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a J H Quillen College User on 06/05/2015
999
Opinion Viewpoint
tion, and problem solving. Most importantly, these concepts, when combined, shift the paradigm of surgical care in the acute inpatient setting from the classic physician-focused hierarchical structure to patient-centered teamwork and coordination. Academic health centers have an opportunity to reframe care, as well as the training environment, and nowhere is the necessity of this change more evident than in the acute care surgical unit. To deliver high-
3. Valentine MA, Nembhard IM, Edmondson AC. Measuring teamwork in health care settings: a review of survey instruments [published online April 30, 2014]. Med Care. doi:10.1097/MLR .0b013e31827feef6.
6. Gittell JH. Coordinating mechanisms in care provider groups: relational coordination as a mediator and input uncertainty as a moderator of performance effects. Manage Sci. 2002;48(11): 1408-1426. doi:10.1287/mnsc.48.11.1408.268.
1. Porter ME, Teisberg EO. How physicians can change the future of health care. JAMA. 2007;297 (10):1103-1111.
4. Weinberg DB, Cooney-Miner D, Perloff JN, Babington L, Avgar AC. Building collaborative capacity: promoting interdisciplinary teamwork in the absence of formal teams. Med Care. 2011;49(8): 716-723.
7. Ricketts TC, Fraher EP. Reconfiguring health workforce policy so that education, training, and actual delivery of care are closely connected. Health Aff (Millwood). 2013;32(11):1874-1880.
2. Mitchell P, Wynia M, Golden R, et al. Core principles and values of effective team-based health care: discussion paper. http://www.iom.edu /Global/Perspectives/2012/TeamBasedCare.aspx. Published October 2, 2012. Accessed July 9, 2014.
5. Gittell JH, Fairfield KM, Bierbaum B, et al. Impact of relational coordination on quality of care, postoperative pain and functioning, and length of stay: a nine-hospital study of surgical patients. Med Care. 2000;38(8):807-819.
ARTICLE INFORMATION Published Online: August 13, 2014. doi:10.1001/jamasurg.2014.219. Conflict of Interest Disclosures: None reported. REFERENCES
1000
performance health care and education, boundaries must be eliminated, and all caregivers must be part of a process that promotes collaboration and effective communication in an integrated fashion that is centered solely on the needs of the patient. In the acute care surgical environment, that goal can best be achieved by developing a paradigm of care that is based on the patient, the surgical unit, and all who work there.
JAMA Surgery October 2014 Volume 149, Number 10
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a J H Quillen College User on 06/05/2015
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