Perspective: A Business School View of Medical Interprofessional Rounds: Transforming Rounding Groups Into Rounding Teams
Bharwani, Aleem M. MD, MPP; Harris, G. Chad; Southwick, Frederick S. MD
Dr. Bharwani is clinical assistant professor of medicine and director, Medical Teaching Unit, University of Calgary Faculty of Medicine, Calgary, Alberta, Canada.
Mr. Harris is program manager, Apple, Inc., Cupertino, California.
Dr. Southwick is professor of medicine, Division of Infectious Disease, University of Florida College of Medicine, and project manager, New Quality and Safety Programs, University of Florida and Shands Health System, Gainesville, Florida.
Correspondence should be addressed to Dr. Southwick, Division of Infectious Diseases/Department of Medicine, University of Florida College of Medicine, Box 100277, Gainesville, FL 32610; telephone: (352) 273-9511; e-mail: email@example.com.
An effective interprofessional medical team can efficiently coordinate health care providers to achieve the collective outcome of improving each patient’s health. To determine how current teams function, four groups of business students independently observed interprofessional work rounds on four different internal medicine services in a typical academic hospital and also interviewed the participants. In all instances, caregivers had formed working groups rather than working teams. Participants consistently exhibited parallel interdependence (individuals working alone and assuming their work would be coordinated with other caregivers) rather than reciprocal interdependence (individuals working together to actively coordinate patient care), the hallmark of effective teams. With one exception, the organization was hierarchical, with the senior attending physician possessing the authority. The interns exclusively communicated with the attending physician in one-on-one conversations that excluded all other members of the team. Although nurses and pharmacists were often present, they never contributed their ideas and rarely spoke.
The authors draw on these observations to form recommendations for enhancing interprofessional rounding teams. These are to include the bedside nurse, pharmacist, and case manager as team members, begin with a formal team launch that encourages active participation by all team members, use succinct communication protocols, conduct work rounds in a quiet, distraction-free environment, have teams remain together for longer durations, and receive teamwork training and periodic coaching. High-performing businesses have effectively used teams for decades to achieve their goals, and health care professionals should follow this example.
The medical attending, two interns, a resident, two medical students, and a pharmacist stand outside their patient’s door. One intern faces the attending with his back to the other members of the group, and recounts in excessive detail the patient’s long list of symptoms and past medical illnesses. As the attending begins grilling the presenting intern on diagnostic criteria, and beautifully dissects the pathophysiology of the patient’s illness, the medical students consult their pocket manuals. The resident checks his smart phone, and the other intern returns a page. The two-way conversation between the intern and attending is finally completed, and those remaining in the group enter the patient’s room. The floor nurse is nowhere to be found, and the pharmacist is noticeably silent. Is this a highly functional interprofessional team?
Teams are the ideal solution for performing high-complexity tasks that require the interdependence of multiple experts to achieve a collective outcome. A successful team efficiently achieves the goals assigned, and over time team members increase their capacity to work together effectively.1–4 In medicine, successfully managing the hospitalized patient with multiple complex medical problems constitutes a high-complexity task that requires an effective team to efficiently coordinate multiple specialized health care providers to achieve the collective outcome of improving the patient’s well-being.5,6 Teamwork in health care can save lives,7,8 improve the quality of patient care,9–18 reduce errors,19–22 enhance patient flow,23,24 improve communication,25–28 and increase job satisfaction.29,30
Foundations of Our Team Observations
As students in the Harvard Business School, we devoted a semester to studying how business teams should be constructed and launched, and how to manage the complex dynamics of working teams. In the spring of 2010, one-fifth of our class chose to observe interprofessional medical teams and compare their behaviors with the best practices of high-performing business teams, to identify opportunities for improvement. We organized into four groups of three students to independently observe four ward-rounding “teams” (three in the medical intensive care unit [ICU] and one on the general medical service) at a Boston area hospital for two to four hours, and we conducted individual interviews with rounding participants. Our questions and field notes were open-ended. Each team organized their observational data into an analytical paper. We all signed HIPAA agreements, and the study was deemed to be exempt by our IRB.
Despite our diverse work experiences in business, pharmacy, and medicine prior to attending business school, and four sets of independent observations, there was a remarkable consensus across our observational teams regarding our findings. On the basis of the consistency of these observations, as well as our senior author’s (F.S.) experience observing over 50 medical work rounds at four other major hospitals, we believe that what we observed is representative of medical rounding “teams” in many, if not all, medical centers. Here, we draw on those observations to make an argument for team-based practice.
Differentiating Groups From Teams
We found that the health care professionals we observed participating on ward rounds in all instances represented working groups rather than working teams.31 We observed parallel interdependence (individuals working alone and assuming that their work would be coordinated with other health care providers) rather than reciprocal interdependence (individuals working together actively coordinating their care of the patient).1
Reciprocal interdependence can only occur if the appropriate experts are part of the team and if all team members can speak freely, openly, and meaningfully.32 We observed neither of these key conditions. The composition of the rounding groups varied, consistently containing physicians and physicians in training, including one senior physician attending, three to four residents, and one or two medical students, but it only intermittently included bedside nurses in two, and excluded nurses in a third. One ICU rounding group included one nurse throughout their rounds, and two included a pharmacist. In no instance did the rounding groups include a case manager. The number of group members varied from four to nine.
With one exception, the organizational structure was hierarchical, with the senior attending physician possessing the authority. In our interviews, nurses, physician trainees, and pharmacists admitted to feeling psychologically unsafe in expressing their opinions. These attitudes were supported by our observations that nurses rarely spoke, and pharmacists never spoke during rounds. The communication pattern was predominantly one-on-one between the physician trainee presenting the patient’s progress and the attending physician. Because they were not actively included in the rounding discussions, other members of the group frequently performed unrelated tasks and often appeared inattentive. Rounds were usually conducted in the hallways outside the patients’ rooms. Multiple distractions were apparent, including beeping pagers, loud equipment warning sounds, rumbling carts, and members of the group continually coming and going. Excessive noise often interfered with the ability to hear the case discussion.
Furthermore, the content and organization of the patient presentations varied from physician to physician, and the time devoted to each patient varied from 10 to 45 minutes. Some patients received prolonged attention; for others, clinical progress was only cursorily reviewed. The general ward team also had the physical challenge of caring for patients on six different floors, requiring extra time to walk from floor to floor. After observing these uncoordinated and variable processes, two of our fellow students expressed the opinion that they hoped they would “never have to be hospitalized.”
Evolving From Group to Team
On the basis of the lessons learned in our teams class as well as our review of the medical, business, and social science literature, we suggest a number of improvements to interprofessional rounds that have the potential to create the optimal interprofessional teams required to provide the highest-quality care for patients.
First, rounding teams must be truly interprofessional and relatively small in size. The ideal composition of such teams has not been explicitly defined, but it will vary depending on the team’s goals.5 For general medical teams, physicians, nurses, a pharmacist, a case manager, and a social worker have been recommended.29 Intuition may suggest that the larger the team, the more productive it will be. However, as teams get larger there are significant process losses including motivation decrement and coordination difficulties. These process losses reduce productivity, and when teams reach a certain size, the process losses outweigh the incremental increase in resources represented by the addition of a new member.33 In general, for decision-making teams, the ideal number should be 6 to 7, remembering that a 6-member team consists of 15 different pairs and a 7-member team consists of 21.4
Second, successful rounding teams need an effective team launch that fosters fruitful collaborations. During the team launch, expectations for each member of the team should be clearly described, common goals established, and team norms defined,3 including the expectation that all team members should be fully engaged in the rounding conversations, refraining from unrelated activities except in true emergencies.4 The attending should explicitly state that every voice and every perspective on the team is valuable, including nurses, pharmacists, and the case manager.34 Whenever possible, the majority of the team members should join the rounding team within a few days of each other, so that all team members have synchronized expectations, goals, and team norms defined by the team launch. How the team leader sets the stage for a newly formed team is a critical determinant of a team’s future success. Investigations of the airline industry as well as surgical teams reveal that the likelihood of forming a highly functional team is determined within the first few minutes by the initial briefing of the airline captain or the lead surgeon.6,8,35,36 We recognize that many residency and hospitalist programs rotate physicians and nurses at very short intervals; however, administrators should consider how this condition disrupts team dynamics and undermines the benefits of a team launch.
Third, to optimize communication, the senior leader of the team should use the Socratic method and serve as the discussion facilitator.4,6 Effective team leaders ask guiding questions and encourage the participation of all team members. They create a zone of safety by flattening hierarchy and encouraging every member of the team to share their ideas.34 Groupthink—everyone agreeing simply to be agreeable37—is avoided, and creative abrasion—open and polite disagreement—is encouraged.38 On completion of the discussion, the effective leader summarizes the conclusions and arbitrates any disagreements. Team members should organize themselves in a full circle that includes the bedside nurse to encourage horizontal communication.4 Communication protocols must be carefully designed for clarity, content, and efficiency and should be consistent throughout the hospital. SBAR (situation, background, assessment, recommendations) has proved to be a highly effective communication tool allowing nurses and physicians to effectively describe unexpected clinical events.39 The problem-based SOAP (Subjective, Objective, Assessment, Plan) presentation can efficiently relay routine daily progress and is also recommended.40 These communication protocols can usually relay the necessary medical information for an individual patient within two to three minutes.40–43 Prespecified time limits should be established for each patient that are based on the complexity and severity of the illness. When possible, the specific time when the team will be at the bedside should be estimated to facilitate participation by the bedside nurse and patient’s family.4
Fourth, the rounding environment should be quiet and free of distractions to ensure meaningful discussions and management decisions. Harsh, noisy environments may impair decision making and increase the likelihood of cognitive errors.44 We suggest designating a two-hour quiet time on the wards, when noise, pages, etc., are minimized. To avoid the potentially distracting hospital corridors, the team may be tempted to meet in a quiet conference room; however, this condition results in the loss of face-to-face time with the bedside nurses, as well as with patients, and has the potential to impair communication.9 On wards with single beds, the team can conduct the majority of their communication at the bedside with the door closed to increase privacy and eliminate hallway distractions.
Fifth, conditions should be established to create bounded, stable teams. Resident and attending rotations should be lengthened for each rounding team to allow sufficient time for trust and an understanding of the strengths and weaknesses of each member to develop—critical conditions for the formation of true teams.3 Rather than the present practice of reconfiguring resident teams every two to four weeks, three to four residents could be designated as teammates for a three- to six-month block and rotate to different wards as a team. To prevent disruption of maturing teams, temporary substitutions of team members should be avoided whenever possible. Time is required for individuals to learn to modify information on the basis of the input of teammates and to make decisions that are truly the culmination of the input from the entire team. Furthermore, to establish stable relationships with the bedside nurses, the medical team’s patients should be housed on a single floor.19 Whenever possible, nurses should care for the same patient on consecutive days to ensure that they remain part of the same interprofessional team. This condition would also allow the nurse to more effectively recruit the patient and patient’s family to become part of the team. We recognize that scheduling necessities and bed availability may compromise these ideal conditions for teamwork. However, caregivers possessing team skills should also be able to work more effectively in short-lived teams.
Finally, we realize that team building is a skill that needs to be taught, and we, along with many health care experts, recommend teamwork exercises to encourage nurses, case managers, pharmacists, and physicians to work together as true teams.5,28,45–47 Scenario-based exercises during which team members are placed in realistic situations commonly encountered on the wards followed by video critiques have proved to be one of the most effective forms of team training.48 Teams also need to be periodically observed and coached by a teamwork expert to ensure optimal function.3,4,48,49 Periodic reflection on the pluses and minuses of each team’s processes needs to become a regular part of each team’s routine. All caregivers should learn and model the modern principles of team design, launching of teams, and management of ongoing team dynamics.
The Power of Teams
The benefits of teamwork are indisputable, and working effectively in teams is a fundamental skill required for 21st-century medicine.50 The business community has embraced working teams for over a decade. Isn’t it time for physicians, nurses, and other caregivers to recognize the power of teams to truly transform the delivery of health care?
Acknowledgments: The authors thank Professor Robin Ely for teaching the “Leading Teams” class at Harvard Business School, as well as the other members of the class who participated in the original observations: Derek Aguirre, Mia Boserup, Maria Carmona, Partha Chakrabarti, Victor Clausen, Elias Goraieb, Creighton Hicks, Fabio Katayama, Wing Province, Karthik Ranganathan, and Brian Shroder.
Other disclosures: None.
Ethical approval: This study was exempted by the University of Florida IRB #359-2010.
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