Original Research

Improving teamwork: Impact of structured interdisciplinary rounds on a hospitalist unit

Abstract

Abstract

BACKGROUND:

Effective collaboration and teamwork is essential in providing safe and effective care. Research reveals deficiencies in teamwork on medical units involving hospitalists.

OBJECTIVE:

The aim of this study was to assess the impact of an intervention, Structured Inter‐Disciplinary Rounds (SIDR), on nurses' ratings of collaboration and teamwork.

METHODS:

The study was a controlled trial involving an intervention and control hospitalist unit. The intervention, SIDR, combined a structured format for communication with a forum for regular interdisciplinary meetings. We asked nurses to rate the quality of communication and collaboration with hospitalists using a 5‐point ordinal scale. We also assessed teamwork and safety climate using a validated instrument. Multivariable regression analyses were used to assess the impact on length of stay (LOS) and cost using both a concurrent and historic control.

RESULTS:

A total of 49 of 58 (84%) nurses completed surveys. A larger percentage of nurses rated the quality of communication and collaboration with hospitalists as high or very high on the intervention unit compared to the control unit (80% vs. 54%; P = 0.05). Nurses also rated the teamwork and safety climate significantly higher on the intervention unit (P = 0.008 and P = 0.03 for teamwork and safety climate, respectively). Multivariable analyses demonstrated no difference in the adjusted LOS and an inconsistent effect on cost.

CONCLUSIONS:

SIDR had a positive effect on nurses' ratings of collaboration and teamwork on a hospitalist unit, yet no impact on LOS and cost. Further study is required to assess the impact of SIDR on patient safety measures. Journal of Hospital Medicine 2010. © 2010 Society of Hospital Medicine.

Copyright © 2010 Society of Hospital Medicine

Communication among hospital care providers is critically important to provide safe and effective care.15 Yet, studies in operating rooms, intensive care units (ICUs), and general medical units have revealed widely discrepant views on the quality of collaboration and communication between physicians and nurses.68 Although physicians consistently gave high ratings to the quality of collaboration with nurses, nurses rated the quality of collaboration with physicians relatively poorly.

A significant barrier to communication among providers on patient care units is the fluidity and geographic dispersion of team members.8 Physicians, nurses, and other hospital care providers have difficulty finding a way to discuss the care of their patients in person. Research has shown that nurses and physicians on patient care units do not communicate consistently and frequently are not in agreement about their patients' plans of care9, 10

Interdisciplinary Rounds (IDR) have been used as a means to assemble patient care unit team members and improve collaboration on the plan of care.1114 Prior research has demonstrated improved ratings of collaboration on the part of physicians,13, 14 but the effect of IDR on nurses' ratings of collaboration and teamwork has not been adequately assessed. One IDR study did not assess nurses' perceptions,13 while others used instruments not previously described and/or validated in the literature.12, 14 Regarding more concrete outcomes, research indicates variable effects of IDR on length of stay (LOS) and cost. Although 2 studies documented a reduction in LOS and cost with the use of IDR,12, 13 another study showed no effect.15 Furthermore, prior studies evaluated the use of IDR on resident‐covered teaching services. The effect IDR has on collaboration, LOS, and cost in a nonteaching hospitalist service setting is not known.

This study had 3 aims. The first was to assess the impact of an intervention, Structured Inter‐Disciplinary Rounds (SIDR), on nurses' ratings of collaboration and teamwork. The second was to assess the feasibility and sustainability of the intervention. The third was to assess the impact of the intervention on hospital LOS and cost.

Methods

Setting and Study Design

The study was conducted at Northwestern Memorial Hospital (NMH), an 897‐bed tertiary care teaching hospital in Chicago, IL, and was approved by the Institutional Review Board of Northwestern University. The study was a controlled trial of an intervention, SIDR, on collaboration and teamwork on patient care units. One of 2 similar hospitalist service units was randomly selected for the intervention, while the other served as a control unit. SIDR was implemented in August 2008 and data were collected over a 24 week study period.

Each hospitalist service unit consisted of 30 beds and was equipped with continuous cardiac telemetry monitoring. Units were also identical in structure and staffing of nonphysician personnel. The intervention unit included a heart failure‐hospitalist comanagement service. Patients followed at the Center for Heart Failure in the Bluhm Cardiovascular Institute of Northwestern were preferentially admitted to this service. All other patients were admitted to units based on bed availability in a quasi‐randomized fashion. Hospitalists worked 7 consecutive days while on service and cared for patients primarily on the units involved in this study. Therefore, hospitalists cared for patients on both the intervention and control units during their weeks on service. Hospitalists cared for patients independently without the assistance of resident physicians or mid‐level providers (ie, physician assistants or nurse practitioners).

Intervention

SIDR combined a structured format for communication with a forum for regular interdisciplinary meetings. A working group, consisting of nurses, hospitalists, and the unit pharmacist, social worker, and case manager, met weekly for 12 weeks prior to implementation. The working group determined the optimal timing, frequency, and location for SIDR. Additionally, the working group finalized the content of a structured communication tool (Supporting Information) to be used during SIDR. The structured communication tool was modeled after prior research demonstrating the benefit of daily goals of care forms16, 17 and ensured that important elements of the daily plan of care were discussed. Based on the working group's recommendation, SIDR took place each weekday at 11:00 AM in the unit conference room and lasted approximately 30 minutes. The nurse manager and a unit medical director co‐led rounds each day. SIDR was attended by all nurses and hospitalists caring for patients on the unit, as well as the pharmacist, social worker, and case manager assigned to the unit.

Provider Survey

Nurses working on the intervention and control units during the study period were administered a survey 16 weeks to 20 weeks after implementation of SIDR to assess ratings of collaboration and teamwork. The first portion of the survey was based on previously published surveys assessing teamwork attitudes among providers.6, 7 We asked nurses to rate the quality of communication and collaboration they had experienced with hospitalists using a 5‐point ordinal scale (1 = very low, 2 = low, 3 = adequate, 4 = high, 5 = very high). The second portion of the survey assessed teamwork and safety climate using the teamwork and safety domains of the Safety Attitudes Questionnaire (SAQ) developed by Sexton et al.18 The SAQ is based on previous research in aviation and medicine and has been validated in clinical settings.19, 20 Because hospitalists worked with nurses on both units, and in light of our prior research demonstrating that hospitalists rate the quality of collaboration with nurses highly,8 we did not assess hospitalists' ratings of collaboration. A final portion of the survey assessed nurses' perceptions of whether SIDR improved efficiency of communication, collaboration among team members, and patient care using a 5‐point Likert scale (1 = strongly disagree; 2 = disagree; 3 = neutral; 4 = agree; 5 = strongly agree). Hospitalists also received this portion of the survey at the completion of each clinical rotation. All surveys were administered in a web‐based format using an internet link (www.formsite.com from Vroman Systems, Inc.) delivered through email. Respondents entered the survey website using a unique login, which allowed for identification of nonresponders. However, survey responses were de‐identified. We sent nonresponders up to 3 reminder emails. The low number of social workers, case managers, and pharmacists on each unit precluded our ability to meaningfully assess their perceptions of collaboration and ratings of teamwork and safety climate.

SIDR Characteristics and Attendance

The unit medical director recorded the duration of SIDR, the number of patients on the unit, and the number of patients discussed each day. Attendance for each discipline was also recorded each day during the study period.

Data Analysis

Provider demographic data were obtained from completed surveys and group comparisons were done using chi‐square and t tests. The percentage of nurses on each unit rating of the quality of communication and collaboration with hospitalist physicians as high or very high was compared using chi‐square. Teamwork and safety climate scores were compared using the Mann Whitney U test.

Patient data were obtained from administrative databases for both the control and intervention unit during the study period as well as for the intervention unit in the 24 weeks preceding the study period. Demographic data were compared using chi‐square and t tests. Primary discharge diagnosis ICD‐9 codes were grouped into diagnosis clusters using the Healthcare Cost and Utilization Project system of the Agency for Healthcare Research and Quality.21 Diagnosis clusters were then analyzed using the chi‐square test. Because of case mix differences between patients on the intervention and control units, we analyzed LOS and cost using a concurrent control as well as an historic control. Unadjusted LOS and costs were compared using the Mann Whitney U test. We then conducted multivariable linear regression analyses to assess the impact of SIDR on LOS and cost. To satisfy normality requirements and distribution of residuals, we explored 2 methods of transforming skewed data on LOS and cost: logarithmic conversion and truncation at the mean LOS + 3 standard deviations (SDs). Since both techniques yielded similar results, we chose to present results by using truncation. Covariates for multivariable analyses included age, gender, race, payor, admission source, case‐mix, discharge disposition, presence of ICU stay during hospitalization, and Medicare Severity‐Diagnosis Related Group (MS‐DRG) weight. We used standard errors robust to the clustering of patients within each physician. All analyses were conducted using Stata version 10.0 (College Station, TX).

Results

Characteristics of Providers, Patients, and SIDR

Forty‐nine of 58 (84%) nurses completed the survey. Eighty‐eight of 96 (92%) surveys were completed by hospitalists at the end of their week on service. Hospitalist surveys represented 33 different hospitalists because individuals may have worked on study units more than once during the study period. Nurses were a mean 35.0 10.4 years of age and had been working at the hospital for a mean 5.0 6.3 years. Hospitalists were a mean 32.8 2.8 years of age and had been working at the hospital for a mean 2.6 1.9 years.

Patient characteristics are shown in Table 1. Intervention unit patients were admitted from the Emergency Department slightly more often in the postSIDR period. Patient case mix differed between the control and intervention unit, but was similar when comparing the intervention unit preSIDR and postSIDR. Intervention unit MS‐DRG weight was lower in the postSIDR period.

Characteristics of Patients*
 Control Unit (n = 815)Intervention Unit Pre‐SIDR (n = 722)Intervention Unit Post‐SIDR (n = 684)P Value for Comparison of Intervention Unit Post‐SIDR vs. ControlP Value for Comparison of Intervention Unit Post‐ vs. Pre‐SIDR
  • Percentages may not equal 100% because of rounding.

  • Abbreviations: SD, standard deviation; SIDR, Structured Inter‐Disciplinary Round.

Mean age, years (SD)63.8 (16.0)64.2 (16.3)64.1 (17.2)0.740.92
Women, n (%)403 (49)347 (48)336 (49)0.900.69
Ethnicity, n (%)   0.220.71
White438 (54)350 (48)334 (49)  
Black269 (33)266 (37)264 (39)  
Hispanic48 (6)40 (6)34 (5)  
Asian6 (1)8 (1)4 (1)  
Other54 (7)58 (8)48 (7)  
Payor, n (%)   0.070.67
Medicare456 (56)436 (60)399 (58)  
Private261 (32)176 (24)182 (27)  
Medicaid67 (8)75 (10)65 (10)  
Self pay31 (4)35 (5)38 (6)  
Admission source, n (%)   0.510.03
Emergency department695 (85)590 (82)593 (87)  
Direct admission92 (11)99 (14)65 (10)  
Transfer28 (3)33 (5)26 (4)  
Case mix, n (%)     
Congestive heart failure78 (10)164 (23)144 (21)<0.010.45
Cardiac dysrhythmia167 (20)69 (10)81 (12)<0.010.17
Chest pain100 (12)47 (7)59 (9)0.020.13
Coronary atherosclerosis52 (6)19 (3)19 (3)<0.010.87
Hypertension24 (3)38 (5)24 (4)0.540.11
Syncope27 (3)23 (3)26 (4)0.610.53
Fluid or electrolyte disorder11 (1)25 (3)23 (3)0.010.92
Pneumonia14 (2)13 (2)22 (3)0.060.09
Pulmonary heart disease16 (2)13 (2)14 (2)0.910.74
Intervertebral disc or other back problem32 (4)3 (0)6 (1)<0.010.28
Other diagnosis294 (36)308 (43)266 (39)0.260.15
Cardiovascular procedure during admission151 (19)95 (13)86 (13)<0.010.74
Intensive care unit stay during admission, n (%)39 (5)44 (6)27 (4)0.430.07
Discharge disposition, n (%)     
Home736 (90)646 (89)610 (89)0.880.82
Skilled nursing facility or rehabilitation66 (8)61 (8)63 (9)  
Other facility9 (1)11 (2)7 (1)  
Expired4 (0)4 (1)4 (1)  
Mean Medicare severity ‐diagnosis related group weight (SD)1.08 (0.73)1.14 (0.76)1.06 (0.72)0.610.04

SIDR occurred each weekday (with the exception of holidays) on the intervention unit and lasted a mean 27.7 4.6 minutes. The unit had a mean 27 patients per day and 86% of patients on the unit were discussed each day. Attendance exceeded 85% for each discipline (hospitalists, nurses, and the unit pharmacist, social worker, and case manager).

Ratings of Teamwork and Perceptions of SIDR

As shown in Figure 1, a larger percentage of nurses rated the quality of communication and collaboration with hospitalists as high or very high on the intervention unit compared to the control unit (80% vs. 54%; P = 0.05).

Figure 1
Nurses' ratings of the quality of communication and collaboration with hospitalists by unit. *P = 0.05.

Nurses' ratings of the teamwork and safety climate are summarized in Table 2. The median teamwork climate score was 85.7 (interquartile range [IQR], 75.092.9) for the intervention unit as compared to 61.6 (IQR, 48.283.9) for the control unit (P = 0.008). The median safety climate score was 75.0 (IQR, 70.581.3) for the intervention unit as compared to 61.1 (IQR, 30.281.3) for the control unit (P = 0.03).

Nurses' Ratings of Teamwork and Patient Safety Climate by Unit
 Control Unit, n = 24Intervention Unit, n = 25P Value
  • Abbreviation: IQR, interquartile range.

Median Teamwork Climate Score (IQR)75.0 (70.581.3)61.6 (48.283.9)0.008
Median Safety Climate Score (IQR)85.7 (75.092.9)61.1 (30.281.3)0.03

Sixty‐five of 88 (74%) hospitalists and 18 of 24 (75%) nurses agreed that SIDR improved the efficiency of their work day. Eighty of 88 (91%) hospitalists and 18 of 24 (75%) nurses agreed that SIDR improved team collaboration. Seventy‐six of 88 (86%) hospitalists and 18 of 24 (75%) nurses agreed that SIDR improved patient care. Sixty‐seven of 88 (76%) hospitalists and 22 of 25 (88%) nurses indicated that they wanted SIDR to continue indefinitely.

SIDR Impact on LOS and Cost

The unadjusted mean LOS was significantly higher for the intervention unit postSIDR as compared to the control unit (4.0 3.4 vs. 3.7 3.3 days; P = 0.03). However, the unadjusted mean LOS was not significantly different for the intervention unit postSIDR as compared to the intervention unit preSIDR (4.0 3.4 vs. 4.26 3.5 days; P = 0.10). The unadjusted cost was lower for the intervention unit postSIDR as compared to the control unit ($7,513.23 7,085.10 vs. $8,588.66 7,381.03; P < 0.001). The unadjusted mean cost was not significantly different for the invention unit postSIDR as compared to the intervention unit preSIDR ($7,513.23 7,085.10 vs. $7,937.00 7,512.23; P = 0.19).

Multivariable analyses of LOS and cost are summarized in Table 3. The adjusted LOS was not significantly different when comparing the intervention unit postSIDR to either the control unit or the intervention unit preSIDR. The adjusted cost for the intervention unit postSIDR was $739.55 less than the control unit (P = 0.02). The adjusted cost was not significantly different when comparing the intervention unit postSIDR to the intervention unit preSIDR.

Adjusted Analyses of Length of Stay and Cost
 Adjusted Difference for Intervention Unit Post‐SIDR vs. ControlP Value for Adjusted Difference for Intervention Unit Post‐SIDR vs. ControlAdjusted Difference for Intervention Unit Post‐ vs. Pre‐SIDRP Value for Adjusted Difference for Intervention Unit Post‐ vs. Pre‐SIDR
  • NOTE: Multivariable analyses included age, gender, ethnicity, payor type, admission source, case‐mix, intensive care unit stay, discharge disposition, and Medicare Severity‐Diagnosis Related Group (MS‐DRG) weight as covariates. Analyses were adjusted for clustering of physicians and truncated at the mean LOS + 3 SDs.

  • Abbreviations: LOS, length of stay; SD, standard deviation; SIDR, Structured Inter‐Disciplinary Round.

Length of stay0.050.750.040.83
Cost739.550.02302.940.34

Discussion

We found that nurses working on a unit using SIDR rated the quality of communication and collaboration with hospitalists significantly higher as compared to a control unit. Notably, because hospitalists worked on both the intervention and control unit during their weeks on service, nurses on each unit were rating the quality of collaboration with the same hospitalists. Nurses also rated the teamwork and safety climate higher on the intervention unit. These findings are important because prior research has shown that nurses are often dissatisfied with the quality of collaboration and teamwork with physicians.68 Potential explanations include fundamental differences between nurses and physicians with regard to status/authority, gender, training, and patient care responsibilities.6 Unfortunately, a culture of poor teamwork may lead to a workplace in which team members feel unable to approach certain individuals and uncomfortable raising concerns. Not surprisingly, higher ratings of teamwork culture have been associated with nurse retention.22, 23 SIDR provided a facilitated forum for interdisciplinary discussion, exchange of critical clinical information, and collaboration on the plan of care.

Our findings are also important because poor communication represents a major etiology of preventable adverse events in hospitals.15 Higher ratings of collaboration and teamwork have been associated with better patient outcomes in observational studies.2426 Further research should evaluate the impact of improved interdisciplinary collaboration as a result of SIDR on the safety of care delivered on inpatient medical units.

The majority of providers agreed that SIDR improved patient care and that SIDR should continue indefinitely. Importantly, providers also felt that SIDR improved the efficiency of their workday and attendance was high among all disciplines. Prior studies on IDR either did not report attendance or struggled with attendance.11 Incorporating the input of frontline providers into the design of SIDR allowed us to create a sustainable intervention which fit into daily workflow.

Our bivariate analyses found significant patient case‐mix differences between the intervention and control unit, limiting our ability to perform direct comparisons in LOS and cost. Pre‐post analyses of LOS and cost may be affected by cyclical or secular trends. Because each approach has its own limitations, we felt that analyses using both an historic as well as a concurrent control would provide a more complete assessment of the effect of the intervention. We included case mix, among other variables, in out multivariable regression analyses and found no benefit to SIDR with regard to LOS and cost. Two prior studies have shown a reduction in LOS and cost with the use of IDR.12, 13 However, one study was conducted approximately 15 years ago and included patients with a longer mean LOS.12 The second study used a pre‐post study design which may not have accounted for unmeasured confounders affecting LOS and cost.13 A third, smaller study showed no effect on LOS and cost with the use of IDR.15 No prior study has evaluated the effect of IDR on LOS and cost in a nonteaching hospitalist service setting.

Our study has several limitations. First, our study reflects the experience of an intervention unit compared to a control unit in a single hospital. Larger studies will be required to test the reproducibility and generalizability of our findings. Second, we did not conduct preintervention provider surveys for comparison ratings of collaboration and teamwork. A prior study, conducted by our research group, found that nurses gave low ratings to the teamwork climate and the quality of collaboration with hospitalists.8 Because this baseline study showed consistently low nurse ratings of collaboration and teamwork across all medical units, and because the units in the current study were identical in size, structure, and staffing of nonphysician personnel, we did not repeat nurse surveys prior to the intervention. Third, as previously mentioned, our study did not directly assess the effect of improved teamwork and collaboration on patient safety. Further study is needed to evaluate this. Although we are not aware of any other interventions to improve interdisciplinary communication on the intervention unit, it is possible that other unknown factors contributed to our findings. We believe this is unlikely due to the magnitude of the improvement in collaboration and the high ratings of SIDR by nurses and physicians on the intervention unit.

In summary, SIDR had a positive effect on nurses' ratings of collaboration and teamwork on a nonteaching hospitalist unit. Future research efforts should assess whether improved teamwork as a result of SIDR also translates into safer patient care.

References

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