Chesluk B, Bernabeo E, Reddy S, Lynn L, Odhner T. — American Board of Internal Medicine
Hess B. — Hess Consulting
Holmboe ES. — Accreditation Council for Graduate Medical Education
Presented: Society of General Internal Medicine Annual Meeting, April 2015
Background: Interprofessional teamwork is a basic component of health care; physicians and other providers need to directly and indirectly coordinate and collaborate with each other to care for patients. However, this necessary coordination and collaboration often depends primarily on the diligence of providers, who must exercise their own individual skills in teamwork to reach across professional boundaries and overcome systemic challenges. Ethnography has proven a useful method of studying health care teams in practice; previous ethnographic research has focused on information systems and teamwork in settings where teams are well-defined (such as emergency departments). Additional research is needed to define what teamwork means and how it is achieved in other contexts, particularly for groups with distinct challenges such as hospitalist physicians, for whom teamwork is a core competency.
Methods: Ethnographic fieldwork was conducted with a sample of four hospitalists in three hospitals in a single U.S. metropolitan area. Sites and participants were selected to represent a range of practice types and settings (academic/nonacademic; urban/suburban; large research/small community hospital). This entailed close observation in practice over the course of approximately seven days with each physician, for a total of 160 hours of data collection. Fieldwork was led by a cultural anthropologist with extensive experience in observing health care providers; other team members provided expertise in medicine, public health, psychology and usability research. Detailed field notes were recorded describing observations and conversational interviews with providers in context. Qualitative, iterative analyses of all data were conducted using the constant comparative method, during and after fieldwork, to identify themes and illustrative quotes and incidents. A preliminary analysis was presented to providers at the field sites, which allowed for refinement of the analysis to incorporate informants’ perspectives.
Results: Hospital providers work in conditions that often undermine effective teamwork for a variety of reasons: geographically scattered patients, unreliable information systems and ordering processes, fragmented care teams, and lack of consistent formal support for effective teamwork. These conditions can pose threats to the timeliness, efficacy and safety of the care that patients receive, especially at transition points when patients or patient information must move between departments within the hospital or between the hospital and other institutions. Providers must exercise a great deal of individual effort to mitigate these challenges; individuals may innovate ways to improve their teamwork, but these are not typically tested or shared, even with close collaborators. Beyond the burden on providers, these conditions can pose serious problems for patients and their family members, who may need to play a critical, active role in coordinating their own care to make up for the system’s shortcomings. However, these expectations put on patients and family members are rarely clearly stated; they may not be aware of their role on their own care team, or be fully able to fulfill that role.
Conclusions: Expectations for the practice of effective teamwork and how to overcome common challenges must be acknowledged and taught. Systems for sharing information and coordinating care within and between institutions, and mechanisms for identifying and resolving conflicts within members of the team, must be strengthened. Expectations for the roles that providers, patients and family members play must be clarified and made explicit, and support in fulfilling these roles must be provided by health care providers and the organizations in which they work.
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