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Teamwork without teams: An ethnographic study of hospitalists' everyday work.

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Chesluk B, Reddy S, Bernabeo E, Hess B, Lynn L, Odhner T, Holmboe E. — American Board of Internal Medicine

Presented: Society of Hospital Medicine Annual Meeting, April 2012

Background: Teamwork is key to safe, effective health care, but care systems are often not designed to support teamwork. ABIM has developed an assessment of interprofessional teamwork for hospitalists, which gives physicians concrete, actionable feedback from other providers with whom they care for patients. In a recent pilot test, hospitalists found the assessment process and feedback highly useful. However, there remains much to learn about how hospitalists work with other professionals, and what strategies can improve interprofessional teamwork in their systems.

Methods: We conducted ethnographic fieldwork with 4 hospitalists (chosen to represent academic and community hospitals, and teaching and non-teaching services). We focused on their everyday patient-care routines and how they engaged in teamwork with other care providers. An ethnographer followed each hospitalist for 5-7 days, taking notes and conducting interviews with the hospitalists and their team members. The entire research team reviewed and analyzed all data together using thematic analysis within a narrative analytic perspective.

Results: Hospitalists collaborated extensively with providers from other professions, services and institutions in the care of every patient. The teams around each patient were variable, often complex, and usually very loosely organized. The hospitalists had to develop extensive personal networks throughout the hospital to exchange information and make decisions. They maintained these networks through opportunistic encounters with providers while rounding. We also observed some semi-systematic efforts to support teamwork, from hospital-wide (case management rounds) to idiosyncratic (one physician sent nursing units the hospitalists’ daily duty schedules and pager numbers). There were no strong, team-wide mechanisms to define patient needs, set goals or manage conflicts. At times, this lack of cohesive teamwork was observed to create potential patient-safety issues. The hospitalists and their teams faced further problems when working with providers outside the hospital (e.g., when obtaining patient history, planning for appropriate post-discharge care, etc.). These interactions with outside providers were frequently frustrating, inefficient and incomplete.

Conclusion: Hospitalists and their interprofessional colleagues often work together to care for patients despite being embedded in systems that make it difficult to practice effective teamwork. We identified multiple opportunities to potentially improve patient care by supporting effective teamwork. These include: designing IT systems to fit providers’ actual work routines; making better systems for sharing data and plans, both within and outside the hospital; reimbursing for care coordination with outpatient providers; and empowering patients and their caregivers to share the information that providers need, and to get the information and services patients need from their entire care team.

For more information about this presentation, please contact Research@abim.org.