© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011
Handoffs and Coordination of Care
Armstrong Institute for Patient Safety and Quality
Presented by: Ayse Gurses, PhD and Jill Marsteller, MPP, PhD
Agenda
• Communication versus Coordination
• Coordination
– Care Coordination
– Coordination in other disciplines
• Importance of Coordination
• Barriers to Effective Coordination
• Strategies to Improve Coordination
• Gap in Care Coordination Research
• Improving Coordination Across Departments Toolkit
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Defining Communication
• “Reproducing at one point either exactly or approximately the message selected at another point” (Shannon & Weaver, 1949; Shannon, 2001)
• Creation and exchange of messages (Goldhaber, 2003)
• Involves continuous encoding and decoding in one’s context
• Has directionality and intentionality
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Components of Communication
• Five essential components of communication system (Shannon & Weaver, 1949)– Information Source
– Transmitter
– Channel
– Receiver
– Destination
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Elizabeth Dayton et al., Joint Commission Journal, Jan. 2007
Stage 5: Escalate
Stage 1: Decide on message
Stage 2: Encode
Stage3: Decode
Stage 4: NegotiateGroupthink,
tunnel vision, low input
Problems:
Solutions: Psychological safety, pause points, diversity, situational awareness
Ambiguous language
Problems:
Solutions: Structured communication tools such as SBAR, Nonverbal communication tool
Fatigue, distraction, noise, closed culture
Problems:
Solutions: Read back
Failure to speak up, bullying, judging
Problems:
Solutions: Assertive communication, role playing, nonverbal communication tool
Failure to seek mediation
Problems:
Solutions: Set up clear chain of command and expectations for use
Figure 2: Stages of communication, common problems and solutions
Defining Coordination
• “The joint efforts of independent communicating actors towards mutually defined goals” (NSF, 1989)
• “Activities required to maintain consistency within a work product or to manage dependencies within the workflow” (Curtis, 1989)
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Defining Coordination
• “Managing dependencies among activities”• Actors performing interdependent activities
may have conflicting interests that need to be managed
• Complexity of a system impacts coordination• Example Dependencies
– Shared Resources
– Task/Sub task Management
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(Malone and Crowston, 1994)
Task Interdependencies in Coordination
• Pooled Interdependence– Separable sub-tasks
• Sequential Interdependence – Specific time-order
• Reciprocal Interdependence– Iterative work among members
• Team Interdependence– Simultaneous and multi-directional workflow
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9Thompson, J. D. (1967). Organizations in action. New York, McGraw-Hill.
Performance and Interdependency
• Highly interdependent groups of maintenance technicians had better performance than hybrid groups of independent and interdependent technicians
• Interdependent teams have better internal processes– e.g., cooperation and learning
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Wageman, R. (1995). “Interdependence and group effectiveness.” Administrative Science Quarterly 40: 145-180
Communication and Coordination: Differences
• Communication is exchange of messages• Coordination is the set of joint actions
towards the same goal• Communication facilitates coordination
– e.g., patient communicates insurance issue, which helps coordinate post-discharge planning
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Communication and Coordination
• Frequency, mode and medium of communication can impact coordination– Depends on the urgency and pertinence
– e.g., nurse updates the electronic system twice per day on patient’s status vs. talks to the NP at least twice a day about the status
– Nurse to NP communication facilitates NP’s decisions about the patient’s care
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Care Coordination is…
• “the deliberate organization of patient care activities between two or more participants (including patient) involved in a patient’s care to facilitate the appropriate delivery of health care services. Organizing care involves the marshaling of personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among participants responsible for different aspects of care”(AHRQ 2007).
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Care Coordination: A Case Example
Care Coordination: Distributed Cognition
• Distributed cognition– Cognition/knowledge possessed and distributed
across individuals, artifacts, and tools in the environment.
– E.g., Flow of cooperative work settings
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Care Coordination: Distributed Cognition
• OR RN hand off information to ICU RN– “Report Card”– ICU RN knows what and how to prepare for the
incoming patient– Steps:
1. OR RN hangs “Report Card” on the OR door2. Technician picks up “Report Card”3. Technician gives “Report Card” to ICU RN in
exchange for ICU transport bed.4. ICU RN prepares for incoming patient
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Importance of Care Coordination
• Care coordination is one of the six strategies to accomplish improved quality (IOM, 2001)
• Coordination of multiple people and units can:– Minimize financial risk and Maximize value of
services delivered to patient (e.g., through reducing/eliminating non-value adding activities) (AHRQ, 2007)
– Promote an effective patient transfer workflow—Care of patient requires activities from multiple departments (e.g., clinical and non clinical) (Abraham and Reddy, 2010)
– Reduce preventable adverse events (Chen et al., 2000)
– Improve patient outcomes (Mitchell et al., 2002)
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Impacts of Care Coordination
• Studies in multiple areas (AHRQ, 2007):– Especially in Chronically ill patients– Trauma, pediatric, etc.
• Care coordination can:– Reduce mortality (Holland et al., 2005; McAlister et al, 2004)
– Reduce re-hospitalizations/re-admissions (Gohler et al., 2006)
– Reduce excessive utilization of drugs (Chen et al., 2000)
– Reduce medical errors (Chen et al., 2000)
– Improve care provider’s satisfaction (Gittell et al., 2008)
– Improve family’s and patient’s satisfaction (Weinberg et a., 2007)
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Impact of Coordination in Other Sectors
• Aircraft maintenance (Suzuki et al 2006)
– Lack of or wrong information delivered causing safety issues
• Manufacturing (Terwiesch et al., 2002)
– Better planning and less perceived goal differences
– Concurrent development processes requires tight coordination
• Service industries (Gittell, 2002)
– Coordination among service providers can improve customer satisfaction
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Barriers to Effective Care Coordination
• Lack of or inadequate/poorly designed technology (Abraham and Reddy, 2010)
• Limited understanding about the need of care coordination
• Lack of trust (McAllister et al., 1995)
• Lack of responsibility and assertiveness (Weinberg et al., 2007)
• Lack of awareness of other people roles and what information may be required
• Organizational structure (e.g., physical setting, social norm) (Solet et al., 2005)
• Language barrier (Solet et al., 2005)
• Workload
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Example of Barriers to Effective Care Coordination
• No mechanism to talk about problems between units• No mechanism to engage members routinely and
consistently to improve care coordination between units – E.g., Key players are sometimes missing in routine QI
meetings• Ambiguity in time limitations
– E.g., Do I need to follow up about a patient who has left my unit?
• Ambiguity in Boundary/Unit limitations – E.g., Is it still my patient if the patient has already left
my unit?
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Strategies to Improve Coordination
• Disease Management Program(Neumeyer-Gromen et al., 2004)
– Enhance coordination between care providers and a patient
• Case Management (Richards & Coast, 2002)
– “Cross boundary spanner”– Assign one person to coordinate care with multiple
providers• Interprofessional Education (Reeves 2001)
– Educate professionals from multiple health areas together interactively
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Strategies to Improve Coordination
• Team adaptation (Serfaty et al. 1998)
– Model-driven team strategy • Prosocial orientation (Nauta et al., 2002)
– Employees show a high concern for the goals of other departments
• Transformation of occupation (Bechky 2003)
– Create awareness of common ground and goals
• These strategies can be implemented together to improve care coordination.
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Strategies to Improve Coordination
• Expansion of the in-group
• Joint problem-solving behavior
• Increased information to improve decisions
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Example: Care Coordination Strategy and Outcomes (Gittell et al., 2000)
• Relational Coordination• Measure: Cross-Sectional Questionnaire• Subjects: 338 care providers and 878
patients from 9 hospitals• Outcomes:
– Post-operative pain reduced
– Length of Stay reduced
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Gap
• Lack of studies looking at care coordination for surgical patient
• Strategies implemented to improve care coordination do not strongly promote– Effective and efficient communication
– Complete and accurate information transfer between units.
• E.g., OR does not know what information to provide to ICU and vice versa.
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Improving Coordination Across Departments (I-CAD)
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Goals
• Thinking about keeping patients safe during entire episode of inpatient care
• Increased cross-unit interactions would encourage shared goals and problem-solving with respect to quality and safety issues/ initiatives across units within a hospital
• Improved understanding and interactions across units within a hospital
Conceptual Support
• Improvement of relationships due to:– Work on common topics– Increased exposure to problems/ successes of other units– Shared problem-solving– Creation of a super-ordinate identity
• Faster/ greater improvement in QI/PS issues due to:– Increased availability of information/ ideas– Benefits of multiple perspectives– Coordinated approach across units with common issues
Interventions
• Meetings of an All-unit CUSP team
• Sharing local safety assessment and LFD results
• Joint LFD investigations of common safety issues
• Joint designation/development of new QI initiatives
• Cross-unit Shadowing
• Face-to-face exercise examining needs across units.
References
• Curtis, B. (1989). Modeling coordination from field experiments. In Proceedings of the Conference on Organizational Computing, Coordination and Collaboration: Theories and Technologies for Computer-Supported Work.
• Malone, T.W., and Crowston, K. (1994). The interdisciplinary study of coordination. ACM Computing Surveys, 26(1).
• Shannon, C.E., and Weaver, W. (1949). The Mathematical Theory of Communication. University of Illinois Press, Urbana, IL.
• National Science Foundation. (1989). A report by the NSF-IRIS Review Panel for Research on Coordination Theory and Technology. NSFF Forms and Publication Unit, National Science Foundation, Washington, DC.
• Shannon, C.E. A mathematical theory of communication. (2001). Mobile Computing and Communications Review 5(1). (Reprinted for the Bell System Technical Journal, 1948, Lucent Technologies)
• Thompson, J. D. (1967). Organizations in action. New York, McGraw-Hill.• Wageman, R. (1995). “Interdependence and group effectiveness.” Administrative
Science Quarterly 40: 145-180.
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References
• AHRQ, Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies, in Technical Review, K.G. Shojania, et al., Editors. 2007, Agency for Healthcare Research and Quality.
• Institute of Medicine, Institute of Medicine: Crossing the quality chasm: a new health system for the 21st century. 2001.
• Terwiesch, C., C.H. Loch, and A. De Meyer, Exchanging Preliminary Information in Concurrent Engineering: Alternative Coordination Strategies. ORGANIZATION SCIENCE, 2002. 13(4).
• Gittell, J.H., Relationships between service providers and their impact on customers. Journal of Service Research, 2002. 4(4): p. 299.
• Richards S, Coast J. Interventions to improve access to health and social care after discharge from hospital: a systematic review. J Health Serv Res Policy. 2003 Jul;8(3):171-9.
• Neumeyer-Gromen A, Lampert T, Stark K, Kallischnigg G. Disease management programs for depression: a systematic review and meta-analysis of randomized controlled trials. Medical Care. 2004;42(12):1211-21.
• Reeves S. A systematic review of the effects of interprofessional education on staff involved in the care of adults with mental health problems. J Psychiatr Ment Health Nurs. 2001 Dec;8(6):533-42.
• Serfaty, et al., eds. Team coordination training. Making decisions under stress: Implications for individual and team training. Individual and team decision making under stress: Theoretical underpinnings, ed. Cannon-Bowers, A. Janis, and S. Eduardo. Vol. xxiii. 1998, American Psychological Association: Washington DC.
• Nauta, A. and K. Sanders, Causes and consequences of perceived goal differences between departments within manufacturing organizations. Journal of Occupational and Organization Psychology, 2001. 74.
• Bechky, B.A., Sharing Meaning Across Occupational Communities: The Transformation of Understanding on a Production Floor. ORGANIZATION SCIENCE, 2003. 14(3).
• Abraham, J. and M.C. Reddy, Challenges to inter-departmental coordination of patient transfers: A workflow perspective. International Journal of Medical Informatics, 2010. 79(2): p. 112-122.
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References
• Chen A, Brown R, Archibald N, Aliotta S, Fox PD. Best practices in coordinated care. March 22, 2000 [Accessed: January 30, 2006]; Available from: http://www.cms.hhs.gov/DemoProjectsEvalRp ts/downloads/CC_Full_Report.pdf
• Mitchell G, Del Mar C, Francis D. Does primary medical practitioner involvement with a specialist team improve patient outcomes? A systematic review. Br J Gen Pract. 2002 Nov;52(484):934-9.
• Gohler A, Januzzi JL, Worrell SS, et al. A systematic meta-analysis of the efficacy and heterogeneity of disease management programs in congestive heart failure. J Card Fail. 2006 Sep;12(7):554-67.
• Gittell, J.H., et al., Impact of Relational Coordination on Job Satisfaction and Quality Outcomes: a Study of Nursing Homes. Human Resource Management Journal, 2008.
• Weinberg, D.B., et al., Beyond our walls: Impact of patient and provider coordination across the continuum on outcomes for surgical patients. Health Services Research, 2007. 42(1p1): p. 7-24.
• Holland, R., et al., Systematic review of multidisciplinary interventions in heart failure. Heart, 2005. 91(7): p. 899-906.
• McAlister FA, Stewart S, Ferrua S, McMurray JJ. Multidisciplinary strategies for the management of heart failure patients at high risk for admission: a systematic review of randomized trials. J Am Coll Cardiol. 2004 Aug 18;44(4):810-9.
• Hazlehurst, B., C.K. McMullen, and P. Gorman, Distributed cognition in the heart room: How situation awareness arises from coordinated communications during cardiac surgery. Journal of Biomedical Informatics, 2007. 40: p. 539-551.
• Gittell, J.H., et al., Impact of relational coordination on quality of care, postoperative pain and functioning, and length of stay: a nine-hospital study of surgical patients. Med Care, 2000. 38(8): p. 807-19.
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