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Interprofessional Collaborative Care
HOLLY POWELL KENNEDY, CNM, PhD, FACNM, FAAN Varney Professor of Midwifery Yale University AIM Conference San 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,
- r opioid addiction results in better health
- utcomes 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 making Organizational 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
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
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 education
Interprofessional 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 Care
Collaborative 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
- wn 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
- f the maternity team.
- C. Nurses, midwives, and physicians are
accountable for their practice.
T h e y c
s i s t e n t l y u n d e r s . . . I t i s e s s e n t i a l f
s a f e t y t . . . N u r s e s , m i d w i v e s , a n d p h . . .
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. 6
- D. 15
- E. 25
N
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 Understanding Consensus statement on principles of model legislation & regulation
SLIDE 12 12 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
