Disclosures Interprofessional Collaborative Care I have no conflicts of interest to declare. HOLLY POWELL KENNEDY, CNM, PhD, FACNM, FAAN Varney Professor of Midwifery Yale University AIM Conference With thanks to Russell K Laros Jr MD, Tekoa King, CNM, San Francisco, CA FACNM, Julian T. Parer MD, PhD, Richard Waldman, MD, and Susan Kendig, NP, JD June 11, 2016 In the long history of humankind (and animal kind, Objectives too) those who learned to collaborate and improvise most effectively have prevailed. 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 Charles Darwin 1
An early & effective collaboration Collaboration: why does it matter? 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 IOM core competencies for Changing health care arenas interprofessional collaboration 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 2
Benefits of collaborative practice IMPROVED PATIENT OUTCOMES � medical errors, improved mortality and morbidity measures, � patient satisfaction, � fragmentation of care, � access to care, � patient compliance 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 Collaboration: why does it matter? INCREASED EFFICIENCY Root causes in obstetric malpractice cases � duplication, cost-efficient use of consistently highlight miscommunication resources, � length of stay and failure of teams to function as a team as the primary cause INCREASED PROVIDER SATISFACTION 65-72% of preventable adverse outcomes � staff turnover are secondary to lack of collaboration and � OR time for physicians; � time for poor communication physician complex cases The Joint Commission 2004, 2007; Schmidt M 2001; Laros RK 2005; Shiffrin BS Baggs J et al 1999; Lemieux-Charles L 2006; Zwarenstein M et al Cochrane review 2007; Simpson KR 2003, Downe S 2010 2009; WHO 2010, Laurent M Cochrane review 2004 3
Obstetric outcomes research…. Facilitators of collaborative practice Formal system of communication Management of women with complex health care needs such as diabetes, cardiac disease, Effective communication or opioid addiction results in better health Shared decision making outcomes when provided by an interprofessional Organizational support team Identified and skilled leaders “High reliability perinatal organizations” are Interprofessional education exemplified by a high degree of effective teamwork San Martin-Rodriqguez L et al 2005; Ivey S 1988; D ’ Amour D et al Andreatta P 2012, Simpson LL 2012, Unger A 2012,Guise JM 2008, Knox et al 1999; Stichler JF 1995; Miller S 1999; Suter E et al 2009 2004 Collaboration - barriers Resulting in … • minimal training in team-based skills We function as members of interprofessional teams • minimal awareness of our partners’ roles BUT we are often educated & socialized in • miscommunication, competition, conflict, single professions that duplication of services each have a distinct set of methods, values, and philosophies . . . The Joint Commission 2004; Mickan The Joint Commission 2004; Mickan S 2010; Xyrichis A 2008 S 2010; Xyrichis A 2008 4
Interprofessional education Effect of team training in obstetrics Positive implications for billing and Team training for treating obstetric emergencies reimbursement; – Improves communication – Improved confidence in managing Increasing trend toward an integrated, universal emergencies curriculum for all learners; – Improved teamwork after the training – Shortens response times Interdisciplinary collaborative facilitated by the – Unclear effect on clinical outcomes, more decrease in resident work hours study needed Angelini, D.J. (2009). Midwifery and medical education: a decade of Merien et al 2012, Lipman SS 2013 changes. JMWH, 54 (4). Interprofessional Education Interprofessional education 5
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 Guiding Principles Collaborative practice is a process involving 1. The patient and families are central to and mutually beneficial active participation between actively engaged as members of the health autonomous individuals whose relationships are care team. governed by negotiated norms and visions. 2. The team has shared vision. • Collaboration is necessary for a team, but 3. Role clarity is essential to optimal team building team-based care requires more than and team functioning. collaboration 4. All team members are accountable for their • Each member has knowledge and skills that own practice and to the team. contribute to the work 5. Effective communication is key to quality • Meaningful engagement of patients & families teams. in decision-making 6. Team leadership is situational and dynamic. ACOG (2016). Collaboration in Practice: Implementing Team-based Care. Washington, D.C.: American College of Obstetricians & Gynecologists. 6
Which of the following is true about CASE STUDIES physicians, nurses, and midwives? ACNM – ACOG A. They consistently understand the breadth and depth of each others’ 97% discipline. US MERA B. It is essential for safety that physicians always lead and supervise the efforts of the maternity team. CLINICAL SCENARIO 2% 1% C. Nurses, midwives, and physicians are accountable for their practice. . . . . . . . . t . h s p r y e t d d e n n f a a u s , y r s l o e t v n f i e a l w t s i d i t i s n m n e o s , s s c e e y s s e r i u h t T I N JOINT STATEMENT of PRACTICE RELATIONS JOINT STATEMENT of PRACTICE RELATIONS BETWEEN OBSTETRICIAN-GYNECOLOGISTS & BETWEEN OBSTETRICIAN-GYNECOLOGISTS & CERTIFIED NURSE-MIDWIVES/CERTIFIED CERTIFIED NURSE-MIDWIVES/CERTIFIED MIDWIVES MIDWIVES ACOG and ACNM believe health care is most The American College of Obstetricians and effective when it occurs in a system that facilitates communication across care settings shared goal of safe women ’ s health care in the Gynecologists (ACOG) and the American and among providers. College of Nurse-Midwives (ACNM) affirm our United States through the promotion of evidence- Ob-gyns and CNMs/CMs are experts in their based models provided by obstetricians- respective fields of practice and are educated, gynecologists (ob-gyns), certified nurse-midwives trained, and licensed, independent providers who (CNMs), and certified midwives (CMs). may collaborate with each other based on the needs of their patients. (Approved ACOG & ACNM Boards February 2011) (Approved ACOG & ACNM Boards February 2011) 7
JOINT STATEMENT of PRACTICE RELATIONS BETWEEN OBSTETRICIAN-GYNECOLOGISTS & Examples of collaborative practice CERTIFIED NURSE-MIDWIVES/CERTIFIED MIDWIVES Waldman, R. & Kennedy, H.P. (Editors) Quality of care is enhanced by collegial Collaborative Practice in Obstetrics and relationships characterized by mutual respect Gynecology. Obstetrics and Gynecology and trust, as well as professional responsibility and accountability. Clinics of North America, 39(3), 323-452 (September 2012) 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. (Approved ACOG & ACNM Boards February 2011) Midwifery is recognized as an independent discipline in how many U.S. states? A. None 42% B. All C. 6 26% D. 15 16% E. 25 8% 7% 5 5 e l l 6 n A 1 2 o N 8
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