Facilitators and Challenges to Conducting Interdisciplinary Research

Corbett, Cynthia F. PhD*; Costa, Linda L. PhD; Balas, Michele C. PhD; Burke, William J. MD§; Feroli, E. Robert PharmD; Daratha, Kenn B. PhD*

doi: 10.1097/MLR.0b013e31827dc3c9
Original Articles

Background: Complex, interconnected issues challenge the United States health care system and the patients and families it serves. System fragmentation, limited resources, rigid disciplinary boundaries, institutional culture, ineffective communication, and uncertainty surrounding health policy legislation are contributing to suboptimal care delivery and patient outcomes.

Methods: These problems are too complex to be solved by a single discipline. Interdisciplinary research affords the opportunity to examine and solve some of these problems from a more integrative perspective using innovative and rigorous methodological designs.

Results: In this paper, we explore lessons learned from exemplars funded by the Robert Wood Johnson Foundation’s Interdisciplinary Nursing Quality Research Initiative.

Discussion: The discussion is framed using an adaptation of the Interdisciplinary Research Model to evaluate improvements in individual health outcomes, health systems, and health policy. Barriers and facilitators to designing, conducting, and translating interdisciplinary research are discussed. Implications for health system and policy changes, including the need to provide funding mechanisms to implement interdisciplinary processes in both research and clinical practice, are provided.

*Washington State University College of Nursing, Spokane, WA

Johns Hopkins Hospital, Baltimore, MD

College of Nursing

§College of Medicine, University of Nebraska Medical Center, Omaha, NE

Supported partially by the Robert Wood Johnson Foundation.

The authors declare no conflict of interest.

Reprints: Cynthia F. Corbett, PhD, Washington State University College of Nursing, P.O. Box 1495, Spokane, WA 99210-1495. E-mail: corbett@wsu.edu.

Article Outline

Systematic changes to improve health care delivery are being driven by policy mandates from the 2010 Affordable Care Act. Care delivery redesign pilot tests are underway with funding from the Centers for Medicare and Medicaid Services through initiatives such as community-based transitional care contracts, bundled payment programs, and accountable care organizations. The role of nurses in high-functioning, patient-centered teams will be critical for the success of these initiatives and to health care delivery transformation.1 Nurses represent the largest segment of the health care workforce, yet knowledge about nurses’ contributions to safe, high-quality health care is limited.2

In this paper, lessons learned from selected Interdisciplinary Nursing Quality Research Initiative (INQRI) teams will be used to demonstrate nurses’ contribution to high-functioning, patient-centered teams to improve the safety, quality, and cost-effectiveness of health care (ie, high-value health care). The following exemplars of interdisciplinary research are provided: (1) a prospective study to improve medication reconciliation during hospitalization to reduce adverse drug events (ADEs); (2) a randomized trial to improve home care nurses’ abilities to reduce 30-day acute care utilization; and (3) a translational study to prevent or mitigate intensive care unit (ICU)-acquired delirium. Each exemplar provides readers with a brief overview of the complexity of the problem and why interdisciplinary solutions were required, a description of the research team, research methods, the new approach that was studied, and implications for improving patient outcomes. The discussion is framed using an adaptation of the Interdisciplinary Research Model proposed by Larson et al,3 to evaluate improvements in individual health outcomes, health systems, and health policy (Fig. 1). Facilitators and potential value-added health benefits for designing, conducting, and translating interdisciplinary research are discussed. Recommendations for health system and policy changes are provided.

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METHODS: INTERDISCIPLINARY RESEARCH

Complex, interconnected issues that challenge the United States (US) health care system and the patients and families it serves require interdisciplinary solutions.4,5 “Interdisciplinary research is any study or group of studies undertaken by scholars from ≥2 distinct scientific disciplines. Interdisciplinary research is based upon a conceptual model that links or integrates theoretical frameworks from those disciplines, uses study design and methodology that is not limited to any 1 field, and requires the use of perspectives and skills of the involved disciplines throughout multiple phases of the research process”4 (p341). Interdisciplinary teamwork to solve complex problems creates synergy that can improve individual patient and system outcomes and influence health policy (Fig. 1). Interdisciplinary collaboration is especially important in health systems research where patient outcomes are rarely dependent on the work of a single discipline. Thus, interdisciplinary research offers the potential to advance knowledge and improve health outcomes in a way that is consistent with health care delivery.3,5,6 Further, interdisciplinary partners can offer methodological expertise to enhance research design and rigor.7

Health care reform emphasizes system redesign and high-value health care necessitating interdisciplinary collaboration and care coordination that places patients at the center of care. These changes create opportunities to cultivate integrated models of scientific inquiry, which are partnership oriented and center on solving complex problems to improve health outcomes.6,8 The INQRI program provided interdisciplinary teams of nurses and other researchers the opportunity to investigate the contribution of nurses to safe, quality health care. The exemplars in this paper illustrate that interdisciplinary research provides a context to achieve new insights and solutions to complex problems.9 Five cohorts of interdisciplinary teams were funded between 2006 and 2010, and the exemplars in this paper were chosen, in part, because they represent 3 of those cohorts, including an exemplar for each of the 3 foci of the INQRI program.10 The first 2 INQRI cohorts focused their work on nurses’ contributions to patients’ health and safety in the acute care setting (exemplar 1). Beginning in 2008, studies examining nurses’ contributions to patient safety and quality outcomes in any care setting were funded (exemplar 2) and in the final cohort (2010), interdisciplinary research to translate and/or disseminate existing knowledge into practice to improve patient outcomes was prioritized for funding (exemplar 3). In addition, the exemplars depicted the importance of interdisciplinary research to solve complex problems across the care continuum: acute care, home care, and critical care. The exemplar methods were provided by the paper authors who were investigators for the studies discussed in this paper.

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Exemplar 1: Acute Care Medication Reconciliation

Problem and Complexity

Research in health care organizations (HCOs) is a dynamic process.11 Medication reconciliation is governed by a regulatory rule requiring comparison of the active home list of medicines provided to the patient at the time of admission to the medicines prescribed at the HCO to provide optimal pharmacotherapy and to mitigate harm caused by ADEs. Unintended medication discrepancies occur when there is a difference between the active home medication list and admission or discharge orders because of incomplete history. Incomplete medication information is a noted cause of ADEs. Preventable ADEs per 100 inpatient admissions are expected at a rate of 1.2 to 1.8.12,13 Incremental costs associated with preventable ADEs are estimated at $3.5 billion a year in the US.14 Several studies have reported that unintended inpatient medication discrepancies are common ranging from 36% to 70%.15–18 An INQRI-funded prospective study, conducted in a 1000-bed tertiary HCO, explored whether a nurse-pharmacist led medication reconciliation process could prevent potential ADEs by discovering and correcting unintended medication discrepancies within 48 hours of hospital admission and just before discharge.

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Research Team, Methods, and New Approaches for Interdisciplinary Solutions

The interdisciplinary team that designed this medication reconciliation protocol included pharmacists, nurses, physicians, and an economist. The team was lead by the hospital-based nurse researcher and a pharmacist who was the hospital Medication Safety Officer. Team members met several times to design the intervention protocol (Fig. 2). The contribution of each discipline was different but critical to the development of studying processes and outcomes. Pharmacists provided consultation about pharmacotherapy and drug-to-drug interactions. Attending physicians recommended the methods to analyze medication discrepancies in the context of the inpatient therapeutic plan. Nurses provided expertise in developing relationships with patients to gather the information, identify medications, and extract subtleties during interviews that led to concerns with some patients’ abilities to self-manage medications. The team economist planned the method to update cost data reported for ADEs.19 Team members brought significant experience in their respective fields including members with over 20 years of service in the HCO.

Two medicine units became the study sites. Each nurse selected 1 primary unit to recruit patients, thereby providing the ability to work with specific unit-based interdisciplinary teams. The research nurses rounded with the unit-based team to discuss medication discrepancies identified during patient interviews. During rounds, the physician determined whether the discrepancy was intended (a deliberate change in the home medication regimen) or unintended (did not intend for the home medication regimen to change). This process avoided the need to page physicians to discuss discrepancies.

The nurse informaticist facilitated a pilot test of an automated medication reconciliation record. The automated home medication record enabled the entry of medication information while keeping health professionals providing direct care blinded to the information until completed and released by the research team. The physicians viewed the electronic home medication list to compare with the home medication list recorded during original history. The research nurses spent an average of 11 minutes conducting the initial admission interview and an additional 29 minutes to complete the total reconciliation protocol. The study pharmacist was consulted to evaluate discrepancies in 30% of cases. The study team physicians and pharmacists independently rated the severity of each medication discrepancy on a scale from 1 (no harm) to 3 (potential significant harm). Of the 563 study participants, 225 had at least 1 discrepancy. Overall, 530 discrepancies were rated. Intraclass correlation among raters was 0.58. Data analyses of patient variables revealed that the only statistically significant variables associated with the presence of discrepancies was the number of medicines. Each additional medicine increased the odds of an unintended discrepancy by 8.7%. Although discrepancies were fewer at discharge, the severity ratings of discrepancies unexpectedly increased (Table 1). The intervention cost $31.82 per patient.20

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How New Approaches can Improve Patient Outcomes, Health Systems, and Policy

Although not a part of the initial study plan, the team’s ability to adapt the research processes enabled testing of an electronic home medication list that became the platform for a hospital-wide interdisciplinary home medication list. An important discovery was the trend for potential ADEs with higher severity ratings to occur after hospital discharge. For example, the same discrepancy at admission would often be rated with a lower severity than if the same discrepancy occurred at discharge, because the “exposure” to the discrepancy at admission was 3 days (average length of stay), whereas the discrepancy at discharge was assumed to remain uncorrected for a long time—this assumption was a study limitation because the PCP might in fact have resolved the discharge discrepancy quickly. As a result of this finding, the interdisciplinary team designed subsequent pilot studies to follow patients discharged on complex medication regimens by telephone and home visit.21 Uncertainty is inherent in HCOs, and research designs for studying complex systems need to be dynamic, moving systematically along a pathway building one design after another, anticipating change, and capitalizing on understanding the environment.11 Thus, an advantage of interdisciplinary research is that a series of studies can facilitate health system and policy redesign in a manner that reflects the interdisciplinary teamwork needed to improve patient-centered care.

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Exemplar 2: Home Care Nursing Intervention to Reduce Hospital Readmissions

Problem and Complexity

Reducing hospital readmissions is a national priority. Approximately 20% of Medicare patients are readmitted within 30 days of hospital discharge22 with a cost of over $17 billion.23 Bundled transitional care interventions reduce unplanned hospital readmissions.24–26 Medication management is a major component of all bundled transitional care interventions. Unfortunately, evidence-based transitional care interventions and the associated medication management strategies are not routinely provided by HCOs. Medication discrepancies lead to ADEs, the most common adverse event after hospital discharge,27 and have been linked to hospital readmission.28

Home care patients are particularly vulnerable to medication discrepancies during the transition from hospital to home because of their high acuity, multiple comorbid conditions, functional impairments, complex medication regimens, often with prescriptions from several providers, and frequent changes in medicines during hospitalization.29–31 At the time of home care admission, nurses are ideally suited to identify and facilitate resolution of medication discrepancies. Regrettably, several barriers limit nurses’ abilities to identify and resolve transition-related medication discrepancies, including: patients’ and families’ lack of knowledge regarding current medications; inaccurate and incomplete hospital discharge medication instructions; the presence of multiple medication lists from several potentially conflicting sources; and lack resources to efficiently and effectively resolve detected discrepancies. The second exemplar rigorously tested an intervention to improve home care nurses’ abilities to effectively identify and resolve medication discrepancies, thereby reducing medication problems that can lead to emergency department visits and unplanned hospital readmissions.29

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Research Team Members, Methods, and New Approaches for Interdisciplinary Solutions

Research team members included nursing leaders, nurse interventionists, pharmacists, a computer scientist, a biostatistician, a pharmacoeconomist, and a lawyer. The computer scientist created a seamless method for transferring the discharge medication list from the hospital electronic health record to the home care nurses, designed and built systems for nurse interventionists to securely record medication discrepancy data at the point of care, and generated a mechanism to efficiently identify participants’ 30-day emergency room visits or unplanned hospitalizations from among 34 regional HCOs. In addition to leading the statistical analyses of the study findings, the biostatistician conducted a power analyses during the planning phases of the research to ensure that an adequate sample was recruited. The pharmacoeconomist evaluated the cost-effectiveness of the intervention. The pharmacists facilitated training for nurse interventionists to advance knowledge in identifying and resolving medication discrepancies and the pharmacists provided consultation to the nurses throughout the study. Nurses and nursing leaders contributed to the study design and led implementation of the intervention and interpretation of the findings. The lawyer provided expertise regarding policy implications of the study findings.

In this single-blind randomized controlled trial (N=232), participants assigned to the intervention group (n=117) were admitted to home care services by one of the 2 nurse interventionists. Within the home environment, nurse interventionists identified and resolved medication discrepancies using the Medication Discrepancy Tool.32 Total time required for the discrepancy identification and resolution intervention averaged <30 minutes per patient. Control group participants (n=115) received usual care from other home care nurses blinded to patients’ participation in the study. Intervention group participants had a total of 12 ED visits and unplanned hospitalizations within the 30 days following their index hospital discharge, whereas control group participants had 33 ED visits and unplanned hospitalizations within 30 days following their index hospital discharge (P=0.002). A 48.5% reduction in hospital charges within 30 days of discharge were observed between the intervention and control groups. Analyses revealed that only 6 patients would need to receive the discrepancy identification and resolution intervention to prevent an unplanned acute care encounter within 30 days after hospital discharge.

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How New Approaches can Improve Patient Outcomes, Health Systems, and Policy

The interdisciplinary team significantly contributed to the quality and rigor of the study and provided novel insights regarding implications of the study findings, which would have been otherwise unrecognized. Study results heightened the HCO’s awareness of the need to improve transitional care and prompted the HCO to fund and conduct an internal pilot program. The interventions trialed in the pilot program improved care quality and were cost neutral. Accordingly, the interventions were sustained for selected high-risk patients. In summary, the INQRI-funded study implemented patient-centered collaborative methods and created teamwork and synergy to significantly improve patient outcomes. In addition, the positive findings led to sustained transitional care delivery improvements at the HCO and generated further research that has the potential to impact health policy.

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Exemplar 3: Preventing and Mitigating ICU-acquired Delirium

Problem and Complexity

The often devastating effects of hospital-acquired delirium can no longer be ignored. Ubiquitous in the ICU, delirium is an independent predictor of higher ICU, hospital, and long-term mortality with each day of delirium in the ICU increasing the risk of death by 10%.33–35 Patients who survive an episode of ICU delirium are more likely to be discharged to a location other than home,36 experience greater functional decline,36 and suffer substantially higher rates of psychological impairment than those who remain delirium free.37 Over one half of ICU survivors suffer a functionally debilitating dementia-like illness, which appears related to the duration of delirium.38,39 In addition to the tremendous personal burden placed on informal caregivers, it is estimated that the cost of delirium to the US health care system ranges from $38 to $152 billion annually.40 Interdisciplinary efforts to prevent and/or treat ICU delirium are urgently needed to improve individual health outcomes, ease the transition from hospital to home, reduce costs, and influence policy.

Despite decades of research documenting the hazards of delirium in the hospital setting, little progress has been made in terms of reducing its frequency or mitigating its effect in the ICU setting.41 The reasons behind this lack of quality improvement are complex. One of the biggest challenges clinicians and researchers encounter is that delirium is believed to be caused by several modifiable (eg, sedation, mechanical ventilation, and weakness) and nonmodifiable risk factors that are influenced by the practice of several different disciplines (Fig. 2). Synergy, teamwork, and effective communication among disciplines are ingredients necessary for effective delirium management. Unfortunately, these elements are not typical features of the fast-paced, often chaotic, and stressful ICU environment.

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Research Team, Methods, and New Approaches for Interdisciplinary Solutions

The ongoing INQRI study is focused on implementing, evaluating, and disseminating an interprofessional, multicomponent plan for managing ICU delirium. The evidence supporting the individual components of the intervention [the Awakening and Breathing Coordination, Delirium monitoring and management, and Early mobility (ABCDE) bundle] is strong, being supported by a series of high-quality, randomized controlled trials.41–44 Although each component of the ABCDE bundle has been shown to improve patient outcomes, the effect of “bundling” these interventions together has yet to be determined. Equally important, the ABCDE bundle has not been formally studied in a “real world” setting, so little is known about the barriers and facilitators ICU providers would face when adopting this bundle into everyday clinical care.

The research team, led by scholars in nursing and geriatric psychiatry, was strengthened by the inclusion of experts representing several specialties/disciplines including: biostatistics, qualitative methodology, program evaluation, quality/outcomes measurement, critical care medicine/surgery, pharmacy, and respiratory and physical therapy. The design and methodological expertise of the research team will facilitate rigorously evaluating the bundle’s effectiveness using both the quantitative and qualitative paradigms. The research team also melds the expertise of an institution with extensive experience in large-scale clinical trials to a facility firmly committed to adopting best ICU practices. Active engagement with direct care providers and the leadership team of the partner hospital has been essential to the study’s research translation and dissemination efforts.

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How New Approaches can Improve Patient Outcomes, Health Systems, and Policy

This INQRI team’s experience suggest that implementation of the ABCDE bundle requires 2 fundamental adaptations. First, it transforms current clinical practice by integrating a well-researched, coordinated set of interventions that challenge the clinical paradigm that the current state of critical care delivery is as “good as it gets.” In a more global way, true incorporation of the bundle rewrites the script of every single person involved in providing ICU care. Each individual must collaborate on every aspect of the bundle, everyday, on every shift. This ultimately challenges the status quo and leads to a more integrated vision of care.

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RESULTS—TEAMWORK, SYNERGY, AND IMPROVING HEALTH CARE

As suggested by the model (Fig. 3), interdisciplinary research can create synergistic relationships to produce outcomes that are greater than those that could be realized by homogenous disciplinary research.45 To accomplish teamwork and synergy to improve health care, several barriers to interdisciplinary research must be overcome including time constraints, lack of shared values, expectations, experiences and goals, physical and bureaucratic environments that reduce team members’ interactions, and the tendency for ineffective team leadership.3,5,6,44–49 The INQRI research teams discussed that the aforementioned exemplars encountered each of those barriers and used common and innovative methods to overcome them.

The first method that the INQRI teams used to overcome barriers was garnering support from leaders of the involved institutions during the planning phases of the research. Institutional support was sustained by either involving leaders as members of the research team or by frequently communicating with leaders throughout the research process. For example, in the first exemplar several team members were clinical leaders at the institution, having ≥20 years of work history with that particular HCO.

A second strategy for overcoming barriers to interdisciplinary research was conducting regularly scheduled team meetings. Team meetings served to promote communication, shared values, expectations, and goals, which in turn created excitement and synergy for the research. Meetings provided a venue for addressing design and methodological issues, which were sometimes solved by novel ideas that could only be generated within an interdisciplinary team. For example, in the third exemplar, the researchers implemented a coordinated set of interventions that changed the way each person in the ICU provided care. Each individual had to collaborate on every aspect of the bundled intervention everyday, on every shift. Consequently, the research challenged the status quo and led to a novel method of more integrated care delivery. Successfully implementing those coordinated interventions required problem solving during team meetings and frequent interaction with clinical staff on the unit.

Each INQRI research team also had to implement effective methods of leadership within their respective teams. The co-principal investigators of each study facilitated overall coordination and communication among team members, but leadership for certain aspects of the research was generally assumed by the disciplinary member with the greatest expertise in that aspect of the study. For instance, in the second exemplar, the pharmacist facilitated medication discrepancy training for the nurse interventionists, whereas the computer scientist coordinated data extraction from the EHRs, and the lawyer provided expertise in interpreting the health policy implications of the findings. The interaction between interdisciplinary team members resulted in unique shared decisions, approaches, and outcomes that were realized by appreciating that greater success would be achieved through interdependence. The research teams exemplified in this paper succeeded by respecting one another’s disciplinary knowledge and, as depicted in the model, using teamwork to create synergy and solutions that would not have been possible without the unique disciplinary skills and expertise of each team member.

Both the literature3,50 and the experiences of the exemplar research teams suggest that the extensive time and resources needed to create teamwork among interdisciplinary health care professionals can have lasting influences. As predicted by The Interdisciplinary Research Model (Fig. 1), the research exemplars presented in this paper demonstrate that interdisciplinary contributions can strengthen study methods and transform patient outcomes, delivery systems, and health policy.

In the first exemplar, the interdisciplinary research on medication reconciliation led to improving the likelihood of safe patient outcomes by significantly reducing the potential for ADEs. The research resulted in initiating health system improvements by implementing an electronic patient home medicine list, with shared input by physicians, nurses, and pharmacists in the EHR. The research described in the first exemplar also led to follow-up studies to improve patient safety at hospital discharge. Similarly, in the second exemplar, the medication discrepancy research aimed at reducing potentially preventable acute care use after hospital discharge, improved patient outcomes, and had a sustained impact for the involved HCO. Education and retraining was provided to home care nurses and therapists to improve medication discrepancy identification and resolution. Protocols to facilitate medication discrepancy documentation and tracking in the home care agency’s EHR were refined. On the basis of the findings of the second exemplar, the health system provided funding to improve transitional care processes. Successful reductions in 30-day acute care used during the pilot project resulted in sustained implementation of the new care models. In addition, the INQRI-funded study led to further research that has the potential to change policy to positively impact patient safety and reduce medical liability. The third exemplar was designed to translate strong clinical trial evidence for delirium prevention and management into real world ICU practice. Analysis of the study findings is ongoing; however, the research team’s experience to date suggests that the strategies that focused on improving interprofessional communication are essential for improving patient outcomes by addressing the numerous system-wide challenges that create barriers to effective adoption of the ABCDE bundle (Fig. 3). Thus, the outcomes of these projects funded by the RWJF’s INQRI program demonstrate the necessity of continuing to redesign health systems and health polices to facilitate the teamwork and synergy necessary for delivery of high-value, patient-centered health care designed to improve outcomes.

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DISCUSSION—IMPLICATIONS FOR HEALTH PROFESSIONALS, HEALTH SYSTEMS, HEALTH POLICY

Despite the wealth of information regarding the many challenges that hospitalized patients and their families experience during and after acute care,12,29,34 the INQRI research teams’ experiences suggest that substantial improvements can be made in care processes, delivery system design, and health care policy to enhance patients’ long-term well-being. Nonclinical team members such as biostatisticians, computer scientists, and economists can positively contribute to the design, methods, and analysis of research to improve care quality. The exemplars also depicted that teamwork among interprofessional researchers and clinicians improved patient-centered outcomes. In addition, the exemplars depicted the importance of team members’ contributions in providing synergistic insight about study implications, including novel ideas for future research. Finally, the 2 completed INQRI exemplars have led to other funded studies that would have been unimaginable or impossible in the absence of interdisciplinary research teams.

Results of these INQRI studies further suggest that there is a need for HCOs to enhance infrastructure to translate findings from interdisciplinary research into practice. Doing so will require support for developing and using evidence-based interdisciplinary protocols. Institutions need to develop pathways to move beyond the traditional “siloed” approach to nursing, medicine, respiratory, and pharmacy policies and procedures to interdisciplinary or interprofessional models that are evidence-based, patient-centered, and process/outcomes oriented. In addition to the time needed to develop interprofessional protocols, HCOs will need to invest resources to ensure intervention fidelity, account for effects on professionals’ workloads, and routinely monitor processes and evaluate outcomes. On the basis of the findings of the INQRI study exemplars, evidence-based interprofessional protocols are anticipated to improve care quality without increasing overall health care costs.

Interdisciplinary communication, coordination, and care planning that create teamwork and synergy require reimbursement.50 As the health care system strives to better integrate patient-centered care, progress will depend on rewarding successful implementation of interdisciplinary strategies that have been shown to effectively and efficiently improve patient outcomes. Likewise, it will be imperative to better coordinate and reconcile costs across systems. Strategies that use the entire continuum of care to provide value-added and cost effective care need to be evaluated and adopted.

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SUMMARY

Interdisciplinary team collaborations such as those presented in this paper are examples of creating improved outcomes as defined by Larson et al3 and include novel ideas, institutional changes, and innovative policies. Increased chronic illness prevalence requires care processes that encompasses a series of transitions from varying units within the hospital, hospital to home, to skilled care, and to home again and engages a host of interdisciplinary team members who must work together to provide a “seamless web” of health care services.9 Although teamwork has always been necessary, the INQRI program ensured that this work, including the contributions of nurses within complex HCO systems was supported, prioritized, and tested using rigorous research designs and study methods. As a result, the INQRI program has provided evidence to address significant knowledge gaps regarding the contributions of nurses and interdisciplinary teams, HCO delivery systems, and health policy in creating safe, high-quality patient outcomes.

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Keywords:

interdisciplinary research; interprofessional; multidisciplinary; research; team science

© 2013 Lippincott Williams & Wilkins, Inc.