Interprofessional Collaborative Care DisclosuresImplementing Team-based Care Collaborative practice is a process involving mutually beneficial active participation between autonomous

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Interprofessional Collaborative Care

HOLLY POWELL KENNEDY, CNM, PhD, FACNM, FAANVarney Professor of Midwifery

Yale University

AIM ConferenceSan Francisco, CA

June 11, 2016

Disclosures

I have no conflicts of interest to declare.

With thanks to Russell K Laros Jr MD, Tekoa King, CNM, FACNM, Julian T. Parer MD, PhD, Richard Waldman, MD, and Susan Kendig, NP, JD

Objectives

Examine how the IOM core competencies for interprofessional collaborative practice can be translated into practice

Identify key components of team-based care and quality improvement

Consider specific strategies to enhance collaboration across all members of the team

In the long history of humankind (and animal kind, too) those who learned to collaborate and improvise most effectively have prevailed.

Charles Darwin

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An early & effective collaboration between nursing & medicine

Effective inter-professional collaboration is particularly important in maternity care because pregnant women move across professional boundaries when they develop complications

Joint Commission 2004, 2007; Schmidt M 2001; Laros RK 2005; Shiffrin BS 2007; Simpson KR 2003, Downe S 2010

Collaboration: why does it matter?

Changing health care arenas

The revolution in health care financing is forcing a revolution in health care delivery as we face a workforce shortage and fewer resources

– Horizontal integration: Private practices merging into larger groups and hospitals merging

– Vertical integration: Joint ventures between providers, hospitals and community clinicscollaboration is essential

DeJoy S 2011, Shaw-Batista J 2011, Darlington A 2011

IOM core competencies for interprofessional collaboration

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Baggs J et al 1999; Lemieux-Charles L 2006; Zwarenstein M et al Cochrane review 2009; WHO 2010, Laurent M Cochrane review 2004.

Benefits of collaborative practice

IMPROVED PATIENT OUTCOMES

� medical errors, improved mortality and morbidity measures,

� patient satisfaction,

� fragmentation of care,

� access to care,

� patient compliance

INCREASED EFFICIENCY

� duplication, cost-efficient use of resources, � length of stay

INCREASED PROVIDER SATISFACTION

� staff turnover

� OR time for physicians; � time for physician complex cases

Benefits of collaborative practice

Baggs J et al 1999; Lemieux-Charles L 2006; Zwarenstein M et al Cochrane review 2009; WHO 2010, Laurent M Cochrane review 2004

Root causes in obstetric malpractice cases consistently highlight miscommunication and failure of teams to function as a team as the primary cause

65-72% of preventable adverse outcomes are secondary to lack of collaboration and poor communication

The Joint Commission 2004, 2007; Schmidt M 2001; Laros RK 2005; Shiffrin BS 2007; Simpson KR 2003, Downe S 2010

Collaboration: why does it matter?

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Obstetric outcomes research….

Management of women with complex health care needs such as diabetes, cardiac disease, or opioid addiction results in better health outcomes when provided by an interprofessional team

“High reliability perinatal organizations” are exemplified by a high degree of effective teamwork

Andreatta P 2012, Simpson LL 2012, Unger A 2012,Guise JM 2008, Knox et al 2004

Formal system of communication

Effective communication

Shared decision makingOrganizational support

Identified and skilled leaders

Interprofessional education

San Martin-Rodriqguez L et al 2005; Ivey S 1988; D’Amour D et al 1999; Stichler JF 1995; Miller S 1999; Suter E et al 2009

Facilitators of collaborative practice

Collaboration - barriers

The Joint Commission 2004; Mickan S 2010; Xyrichis A 2008

We function as members of interprofessional teams

BUT we are often educated & socialized in single professions that each have a distinct set of methods, values, and philosophies . . .

Resulting in …

• minimal training in team-based skills

• minimal awareness of our partners’ roles

• miscommunication, competition, conflict, duplication of services

The Joint Commission 2004; Mickan S 2010; Xyrichis A 2008

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Positive implications for billing and reimbursement;

Increasing trend toward an integrated, universal curriculum for all learners;

Interdisciplinary collaborative facilitated by the decrease in resident work hours

Interprofessional education

Angelini, D.J. (2009). Midwifery and medical education: a decade of changes. JMWH, 54(4).

Effect of team training in obstetrics

Team training for treating obstetric emergencies– Improves communication– Improved confidence in managing

emergencies– Improved teamwork after the training– Shortens response times– Unclear effect on clinical outcomes, more

study needed

Merien et al 2012, Lipman SS 2013

Interprofessional educationInterprofessional Education

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Implementing Team-based Care

Team-based care is the provision of health services to individuals, families, &/or communities by at least two health care providers who work collaboratively with patients and their families – to the extent preferred by each patient – to accomplish shared goals within and across settings to achieve coordinated, high-quality care.

ACOG (2016). Collaboration in Practice: Implementing Team-based Care. Washington, D.C.: American College of Obstetricians & Gynecologists:

Implementing Team-based CareCollaborative practice is a process involving mutually beneficial active participation between autonomous individuals whose relationships are governed by negotiated norms and visions.• Collaboration is necessary for a team, but

team-based care requires more than collaboration

• Each member has knowledge and skills that contribute to the work

• Meaningful engagement of patients & families in decision-making

ACOG (2016). Collaboration in Practice: Implementing Team-based Care. Washington, D.C.: American College of Obstetricians & Gynecologists.

Guiding Principles

1. The patient and families are central to and actively engaged as members of the health care team.

2. The team has shared vision.3. Role clarity is essential to optimal team building

and team functioning.4. All team members are accountable for their

own practice and to the team.5. Effective communication is key to quality

teams.6. Team leadership is situational and dynamic.

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CASE STUDIES

ACNM – ACOG

US MERA

CLINICAL SCENARIO

Which of the following is true about physicians, nurses, and midwives?

A. They consistently understand the breadth and depth of each others’ discipline.

B. It is essential for safety that physicians always lead and supervise the efforts of the maternity team.

C. Nurses, midwives, and physicians are accountable for their practice.

T h ey c o

n s i st e n

t l y un d e

r s . ..

I t i s e s s

e n ti a l

f o r s a f e

t y t. . .

N u rs e s

, m id w

i v e s, a n

d ph . . .

1%

97%

2%

The American College of Obstetricians and Gynecologists (ACOG) and the American College of Nurse-Midwives (ACNM) affirm our shared goal of safe women’s health care in the United States through the promotion of evidence-based models provided by obstetricians-gynecologists (ob-gyns), certified nurse-midwives (CNMs), and certified midwives (CMs).

JOINT STATEMENT of PRACTICE RELATIONS BETWEEN OBSTETRICIAN-GYNECOLOGISTS &

CERTIFIED NURSE-MIDWIVES/CERTIFIED MIDWIVES

(Approved ACOG & ACNM Boards February 2011)

ACOG and ACNM believe health care is most effective when it occurs in a system that facilitates communication across care settings and among providers.

Ob-gyns and CNMs/CMs are experts in their respective fields of practice and are educated, trained, and licensed, independent providers who may collaborate with each other based on the needs of their patients.

JOINT STATEMENT of PRACTICE RELATIONS BETWEEN OBSTETRICIAN-GYNECOLOGISTS &

CERTIFIED NURSE-MIDWIVES/CERTIFIED MIDWIVES

(Approved ACOG & ACNM Boards February 2011)

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Quality of care is enhanced by collegial relationships characterized by mutual respect and trust, as well as professional responsibility and accountability.

To provide highest quality and seamless care, OB/GYNs and CNMs/CMs should have access to a system of care that fosters collaboration among licensed, independent providers.

JOINT STATEMENT of PRACTICE RELATIONS BETWEEN OBSTETRICIAN-GYNECOLOGISTS &

CERTIFIED NURSE-MIDWIVES/CERTIFIED MIDWIVES

(Approved ACOG & ACNM Boards February 2011)

Examples of collaborative practice

Waldman, R. & Kennedy, H.P. (Editors) Collaborative Practice in Obstetrics and Gynecology. Obstetrics and Gynecology Clinics of North America, 39(3), 323-452 (September 2012)

Midwifery is recognized as an independent discipline in how many U.S. states?

A. None

B. All

C. 6D. 15

E. 25

N on e

A l l 6 1 5 2 5

8%

26%

42%

16%

7%

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Examples of collaboration on safety

Lyndon, A., Zlatnik, M.G., Maxfield, D.G., Lewis, A., MacMillan, C., Kennedy, H.P. (2014). Contributions of clinical disconnections and unresolved conflict to failures in intrapartum safety. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 43(1), 2-12.

Maxfield, D.G., Lyndon, A., Kennedy, H.P., O’Keefe, D., Zlatnik, M.G. (2013). Confronting safety gaps across labor and delivery teams. American Journal of Obstetrics & Gynecology, 209(5), 402-08.

American College of Nurse-Midwives

Midwives Alliance of Midwives

National Association of Certified Professional Midwives

Midwifery coming together … small steps with common interest

USA midwives coming together to examine the evidence about normal physiologic birth

Identify factors that facilitate or disrupt normal physiological birth based on the best available evidence;

Create a template for system changes through clinical practice, education, research, and health policy.

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The other outcome …

ComING together …US MERA

International Confederation of Midwives --- Global Standards for Midwifery Education, Regulation, and Association

(Durban, South Africa, 2011)

“… to create a shared vision for U.S. midwifery within a global context, generate an action plan for collaboration to strengthen and promote the profession of midwifery in the United States, thereby engendering a positive impact on U.S. maternity care that will improve the health of women and infants.”

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“… to create a shared vision for U.S. midwifery within a global context, generate an action plan for collaboration to strengthen and promote the profession of midwifery in the United States, thereby engendering a positive impact on U.S. maternity care that will improve the health of women and infants.”

Midwifery professional pillars

Education – to provide a highly competent, qualified workforce

Regulation – of professional activities

Association – strong organization of members

Three years of dialogue and debate about the issues of midwifery in the United States

Memorandum of UnderstandingConsensus statement on principles of

model legislation & regulation

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Effective inter-professional collaboration is particularly important in maternity care because pregnant women move across professional boundaries when they develop complications

Joint Commission 2004, 2007; Schmidt M 2001; Laros RK 2005; Shiffrin BS 2007; Simpson KR 2003, Downe S 2010

Collaboration: why does it matter? If you want to go fast, go alone. If you want to go far, go together

African Proverb