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Improving physician engagement in interprofessional collaborative practice in rural emergency departments
Journal of Interprofessional Education & Practice 11 (2018) 51e57
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Improving physician engagement in interprofessional collaborative practice in rural emergency departments Kelly Might Wilson a, Jennifer Leeman b, Barry Saunders c, Donna Sullivan Havens d, * a
UNC Health Care, 211 Friday Center Dr., Suite 1069, Chapel Hill, NC 27517, USA University of North Carolina School of Nursing, Carrington Hall Office #5004, CB#7460, Chapel Hill, NC 27599-7240, USA c Department of Social Medicine, University of North Carolina School of Medicine, MacNider Hall, Office #348, CB#7240, Chapel Hill, NC 27599-7240, USA d University of North Carolina School of Nursing, Carrington Hall Office #403, CB#7460, Chapel Hill, NC 27599-7240, USA b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 2 October 2017 Received in revised form 3 December 2017 Accepted 17 December 2017
Background: Interprofessional collaborative practice (IPCP) is critical to managing care complexity and improving patient outcomes in emergency departments. Efforts to improve IPCP are constrained by low levels of physician engagement. Purpose. This study aimed to explore contextual factors and strategies that influenced physicians' engagement in efforts to improve IPCP in emergency departments. Methods: This study was conducted within a HRSA-sponsored project that aimed to improve IPCP in four rural emergency departments. Data collection included in-depth interviews (n ¼ 12) and observations over two years. Content analysis was applied to code and integrate findings. Results: Physician engagement in efforts to improve IPCP was influenced by five categories of contextual factors (employment arrangements, scheduling, competing priorities, leadership, infrastructure) and six strategies (build on existing infrastructure, attend to logistics, strengthen interpersonal relationships, take physicians' perspective into account, engage leadership, communicate goals and successes). Discussion/Conclusion: Emergency department staff can use these results to promote physician engagement in efforts to improve IPCP, an essential step toward improving patient outcomes. © 2017 Elsevier Inc. All rights reserved.
1. Introduction Emergency Departments (EDs) in the United States are treating more patients each year,1 with more than 130 million ED visits made in 2013 as compared to 96.5 million in 2005.2,3 ED patients are older, sicker, and require more complex care than in the past4e6 exacerbating efforts to provide high quality and efficient ED care.7,8 In their 2007 report “Hospital-Based Emergency Care: At the Breaking Point”, the Institute of Medicine highlighted the challenges EDs face and identified an urgent need to improve interprofessional collaborative practice (IPCP) in the ED setting. The World Health Organization9 defines IPCP as occurring “When multiple health workers from different professional backgrounds work together with patients, families, carers, and communities to deliver the highest quality of care.” IPCP is particularly
challenging, yet critical to implement, in the often chaotic, busy, and stressful ED environment10 where inadequate collaboration contributes to overcrowding, long wait times, large numbers of patients leaving without being seen, and clinical errors.11,7,12 Despite evidence of IPCP's positive effects on patient outcomes, many healthcare organizations find IPCP difficult to implement.7,13,14 One factor limiting efforts to improve IPCP is low physician engagement.15,16 Physicians play a key role in healthcare processes and practices, which makes their involvement in collaborative practice essential.17,18 The purpose of this study was to identify factors that limit or facilitate physician engagement and strategies that are effective at engaging physicians in IPCP in the ED. The study was conducted as part of an ongoing quality improvement collaborative involving four rural North Carolina EDs (D. Havens, PI). 1.1. Conceptual framework
* Corresponding author. E-mail addresses: [email protected] (K.M. Wilson), jleeman@ email.unc.edu (J. Leeman), [email protected] (B. Saunders), dhavens@email. unc.edu (D.S. Havens). https://doi.org/10.1016/j.xjep.2017.12.005 2405-4526/© 2017 Elsevier Inc. All rights reserved.
This study was guided by the theory of relational coordination (RC), which conceptualizes coordination as a set of relationship and communication ties among participants in a work process.19
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Relationship dimensions that are central to effective coordination include shared goals, shared knowledge, and mutual respect. To be effective, communication needs to be frequent, timely, accurate, and problem-solving.19 The theory further posits that relationship dimensions and communication are mutually reinforcing and together affect the quality and efficiency of patient care. Initiatives to strengthen relational coordination are effective at improving IPCP, but only to the extent that staff from multiple professions engage in those initiatives. This study's conceptual framework (Fig. 1) extends Gittell's RC theory to address the importance of identifying strategies to engage physicians in IPCP and contextual factors that influence physician engagement.
were important to quality ED care in their setting. In addition, each hospital designated a site coordinator for the project. Participants for this study included the site coordinators and a convenience sample of project team members available at each data collection time point. 2.3. Data collection Data for this study were obtained during the second and third years of the three-year Shaping Systems project. Data collection included observations and interviews. 2.4. Observations
2. Methods 2.1. Design An exploratory multi-case study was conducted with four rural North Carolina EDs. Qualitative data were collected through observation and scheduled interviews. The University of North Carolina at Chapel Hill Institutional Review Board (IRB) reviewed the study and identified it as exempt. 2.2. Setting and participants This study was conducted within the context of the HRSAsponsored project, “Shaping Systems to Promote Desired Outcomes: Interprofessional Collaborative Practice in Rural North Carolina EDs” (Shaping Systems e D. Havens, PI). The Shaping Systems project implemented a four-hospital quality improvement collaborative to develop nursing's capacity to promote IPCP environments in the ED setting. The project provided participating hospitals with a range of resources and activities through quarterly learning collaborative meetings, site visits, video conferences and an interactive website. Hospital teams could adapt what they learned and implement strategies they felt would work in their local context. The four hospitals participating in this project were chosen based on their location in rural Health Professional Shortage and Medically Underserved Areas. Table 1 provides an overview of participating hospitals. Each hospital formed an interdisciplinary team to engage in Shaping System project activities. Hospitals were encouraged to create teams that included ED nurses and physicians as well as professionals from other disciplines and units or departments who
The lead author conducted observations during five two-day Shaping Systems collaborative meetings and four site visits to participating hospitals' EDs. Field notes were taken to document observations related to physician participation in IPCP. 2.5. Interviews The two lead authors conducted telephone interviews with site coordinators at the start of the second and third years of the project. Interviews followed a structured guide that included questions about IPCP improvement strategies the hospital had implemented in the past year and barriers and facilitators to their implementation with a focus on physician engagement. 2.6. Data analysis The following strategies were applied to enhance the rigor of data analysis. Field notes were typed and interviews were recorded and transcribed. The lead author applied content analysis with deductive coding to organize transcripts and data according to the study's central constructs (barriers and facilitators to physician engagement and strategies used to engage physicians). She then used inductive methods to identify themes within each construct.20 A matrix was created and cross-case analysis used to explore similarities and differences across the four participating ED sites.20 The identified themes for each hospital and cross-case analysis were reviewed by other members of the research team, who had participated in interviews (JL) or in collaborative meetings and site visits (DH, BS). Findings were then presented at a Shaping Systems collaborative meeting to ensure that they accurately represented the site teams' perspectives.21
Fig. 1. Study Conceptual framework based on Gittell's19 Theory of Relational Coordination.
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Table 1 Participating hospitals.
Hospital Hospital Hospital Hospital
1 2 3 4
Hospital Size
Affiliation
Number of ED visits in 2013
ED Size
ED Physician employment status
25 beds 222 beds 453 beds 52 beds
Part of larger integrated health care system Part of larger integrated health care system Not affiliated with a larger system Part of a larger independent community hospital system
14,449 31,800 74, 650 14,077
10 32 63 10
Contracted Changed during project from contracted to employed Contracted Employed
3. Findings 3.1. Sample Twelve site coordinators and other staff participated in in-depth phone interviews, all of whom were nurses and most of whom were nurse managers. Sixty-six staff participated in collaborative meetings and site visits; the majority were nurses (64%), 15% were physicians, and 21% were from other disciplines including respiratory therapists, paramedics, psychologists, and physician assistants among others. 3.2. Findings on physician engagement in interprofessional collaborative practice activities
beds beds beds beds
that “scheduling is honestly probably the biggest challenge” to physician participation in the Shaping Systems project and other interprofessional efforts at her hospital. Engaging physicians in IPCP required that their available time align with that of nurses and other staff in the ED and with physicians in other departments. Finding times when physicians were available was difficult because the EDs needed to ensure adequate staffing for patient care. One ED director noted that the small number of physicians on staff meant that “someone has just worked or is currently working” at all times. Physicians who worked the night shift were least likely to participate in IPCP activities. Scheduling challenges were particularly acute when IPCP efforts required travel off site, as was the case for the four annual Shaping Systems collaborative meetings. 3.6. Competing priorities
Participants described physician engagement (or lack of engagement) in two categories of efforts to improve IPCP: Shaping System collaborative activities and other quality improvement (QI) initiatives. Findings are organized around the contextual factors that influenced physician engagement in IPCP and strategies that sites used to successfully engage physicians.
Five categories of contextual factors influenced physician engagement in IPCP activities: employment arrangements, scheduling, competing priorities, leadership, and infrastructure.
All four sites experienced challenges related to the high number of competing priorities for physician time and attention. Participants reported many different quality improvement and other initiatives that hospitals and their EDs were involved in during the course of this study. For example, one hospital spent over a year preparing for and initiating the use of a new electronic health record (EHR) system. Although these initiatives limited participating in Shaping Systems, they often had a positive impact on IPCP as in the case of mandatory hospital-wide Language of Caring classes and TeamSTEPPS, both of which provided opportunities for interdisciplinary communication and collaboration.
3.4. Employment arrangements
3.7. Leadership
All four site teams mentioned challenges related to physicians' employment arrangements. Employment arrangements varied among sites, as noted in Table 1, with some physicians employed by outside contract agencies and others working as employees of the hospital or healthcare system. A number of the contract ED physicians commuted long distances to work in the rural EDs, ranging from one or more hours to from another state. As one participant noted, “I feel like physicians are still not vested in the hospital. They are contract employees in their mind. They are also not locally vested and don't live in the community.” Employment arrangements determined how physicians' time was allotted and their accountability to and investment in the hospital. At three sites, physicians' contracts specified the amount of time they could allot to administrative versus clinical activities. To participate in Shaping Systems or other QI initiatives, physicians had to use their administrative time, which was limited and also had to cover continuing education and vacation time. At one hospital, patient care metrics had been written into physician contracts, which was perceived to increase physician accountability.
All four site teams mentioned the importance of leadership support for physician participation in IPCP efforts. Leadership included physician leadership, nursing leadership, hospital administration, and the ED director. Examples of leadership that supported physician engagement included “administration sets the expectation” that participation in IPCP will occur and encourages physician participation in meetings. Leadership support was constrained by both the absence and turnover of individuals in leadership positions. One hospital experienced turnover in several ED and hospital leadership positions over this study's two-year time period. Another reported that their Chief Medical Officer was often absent, resulting in lower levels of physician engagement because no one was overseeing their activities or holding them accountable.
3.3. Contextual factors influencing physician engagement
3.5. Scheduling All four site teams discussed challenges related to scheduling and physician engagement in IPCP. One nurse manager asserted
3.8. Infrastructure Across all four hospitals, the physical layout, use of the EHR, and existing committee structures influenced physician engagement in IPCP. The physical layout of the ED can either facilitate or impede IPCP. In one hospital's ED the central workstation was divided into separate nurse and physician stations separated by a medication workspace creating a structural barrier to collaboration. At another site, the ED director's office was next to the medical director's, thereby facilitating collaboration. At another hospital, physician
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participation in huddles was facilitated by a shared nurse/physician workspace. As one participant observed, the physicians “have nowhere else to run to except their break room, so they are there listening passively and actively, kind of forced to participate because we're standing around them.” All of the site teams brought up challenges related to the impact that their EHR systems had on physician engagement in IPCP. At one site, physicians charted in a different EHR system than the rest of the staff, limiting the EHR systems' potential to facilitate interdisciplinary communication. Although other sites' physicians, nurses, and other staff used the same EHR system, they reported that physicians could not access information that other staff entered, necessitating development of “workarounds” to enable physicians and nurses to communicate. One site noted that required EHR documentation related to mental health patients being boarded in the ED has facilitated IPCP by clarifying who is responsible for different aspects of care. 3.9. Effective strategies for increasing physician engagement ED site teams shared the following categories of strategies used to engage physicians in IPCP efforts: build on existing infrastructure, attend to logistics, strengthen interpersonal relationships, take physicians' perspective into account, engage leadership, and communicate goals and successes. 3.10. Build on existing structures Site teams identified strategies that they used to hardwire physician engagement into existing meetings, huddles, educational activities, initiatives to create new policies or processes, and physician contracts. 3.10.1. Meetings All four site teams used existing meetings to engage physicians with other staff or leaders. The meetings described as most successful were those that involved medical and/or nursing leadership. One site noted that these meetings allowed nurse leaders to communicate with physicians about issues identified by the nursing staff. Based on experience with many different hospitals, the Director of Clinical Services for a physician contract company stated that regular, weekly or daily, meetings between medical and nursing directors is the most important step toward better IPCP in EDs. Another successful strategy involved a nursing leader or other nursing representative participating in existing physician meetings. At one site, information related to ED throughput data and quality scores was shared in many different types of meetings, including hospitalist meetings as these non-ED physicians affect ED throughput. Meetings provided opportunities for IPCP, particularly in smaller hospitals where committees often are hospital-wide and interdisciplinary. 3.10.2. Huddles Two of the site's teams have successfully integrated physicians into daily huddles involving frontline staff within the ED. A third site reported that while they have daily huddles, they have not yet successfully engaged physicians. Huddles were perceived as most successful at engaging physicians when information was shared that was relevant to physicians. For example, morning huddles at one site were used to give daily updates on available services, review staffing, and introduce the resident working that day. Another site reported that they invited ED physicians to present “Medical Minutes” during the huddles, during which they provided a brief presentation on a new evidence-based practice or on their preferences related to patient care during the upcoming shift.
3.10.3. Education Three of the ED site teams described engaging physicians in interprofessional education, which included hands-on or gaming simulations and classroom courses. Some educational opportunities were provided specifically for the ED unit while others were offered for a wider audience. Simulation activities were particularly successful. One hospital used a mobile simulation lab, which allowed them to block off an ED bed and invite physicians and other staff to participate during their normal work hours. The Shaping Systems collaborative exposed hospital teams to the simulation game Friday Night in the ER®, and three sites were successful at engaging physicians in the game, which simulates IPCP and a systems approach to patient care. Classroom-based educational events were less successful in engaging physicians in IPCP because physicians typically attended classes with other physicians. 3.10.4. Policy or process Team members from all four sites shared at least one example of a policy or process that was designed to facilitate physician engagement in IPCP. Sites reported on boarder patient policy, a rapid admit process, and a sepsis protocol that were revised to clarify the respective responsibilities that physicians, nurses, and other staff had for documenting and providing care. Sites also reported on the use of a standardized communication tool (SituationBackground-Assessment-Recommendation, SBAR) to facilitate communication and collaboration with physicians. 3.10.5. Physician contracts Three of the site teams reported that they included performance goals in their physicians' contracts such as hospital goals and expectations regarding participation in meetings and committees. As a result, physician compensation was based on their quality metrics. One site reported physician metrics weekly. As one team member stated, physicians now “feel the heat” and “they own it.” Although participants in this study were not responsible for writing physicians' contracts, they were able to learn more about what physicians are accountable for and to leverage those arrangements to encourage participation in quality improvement efforts. 3.11. Attend to logistics All four ED teams reported strategies related to the logistics of involving physicians in their IPCP activities. These included scheduling meetings during times that would be best for physicians, such as times when the unit was typically not busy, and holding meetings and events in the ED. Sites also used video or phone conferencing to increase physician participation in meetings or other events, particularly when meetings were held offsite. 3.12. Strengthen interpersonal relationships Three of the site teams discussed strategies they have used to build stronger relationships with physicians. These approaches included using first names, personally inviting physicians to participate, engaging with physicians in social events outside of work, addressing physicians directly with their concerns rather than using administrative channels, and using appreciative inquiry.22,23 With the exception of appreciative inquiry, these strategies are self-explanatory. Appreciative inquiry is a strategy from the science of positive organizational scholarship that the Shaping Systems collaborative introduced to the hospitals as a way to frame discussions and improvement initiatives around what is working well and how can we do more of it, as an alternative to focusing on what is not working.
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3.13. Take the physicians' perspective into account Three of the site teams reported efforts to discover physicians' specific interests related to patient care issues and then engage them in activities that aligned with their interests. Teams also reported employing a range of other strategies to better align with physicians' needs and preferences, such as (1) prioritizing which projects require physician participation and only inviting physicians to participate in those that are high priority, (2) careful preparation so that meeting time is used efficiently and physicianrelated issues are consolidated, and (3) telling physicians exactly what is needed from them and why. For example, one site included the medical director at the beginning of the project and then, as the project progressed, included additional physicians when their input was needed. Another site held a rapid improvement event to work on patient throughput in the ED, and two physicians joined in the four-day event. This strategy allowed the ED team to engage physicians during a concentrated period of time rather than spreading it out. 3.14. Engage leadership All the ED site teams addressed the importance of engaging organizational leadership support to improve IPCP with physicians. One site team stated that meeting with administration enabled them “to get physicians on board with improving and meeting performance metrics such as ED patient throughput.” Another site team communicated the work they have done in the Shaping Systems collaborative with their leadership in order gain more buyin and support for physician engagement in IPCP. 3.15. Communicate data, goals, and successes All four site teams spoke about communication strategies they used to apprise physicians of the goals and successes of quality improvement and other initiatives. Communicating data was viewed as a particularly effective approach for engaging physicians. As one participant noted, “we share data with providers to get buyin and to get them to see their part and what they control.” Site teams provided physician-specific feedback on performancerelated department metrics that impacted larger hospital goals such as productivity reports. They also shared data to make the case for a change, such as data on ED patient volume to get buy-in for changes in staffing patterns. According to one participant, “people respond to what you measure.” Two of the ED site teams
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emphasized the role of sharing successes to improve physician engagement. They noticed increased physician engagement when physicians saw the successful results of improvement efforts. 4. Discussion As summarized in Fig. 2, this study identified strategies that might be applied to improve physician engagement in IPCP in the ED as well as contextual factors that need to be considered when selecting and adapting strategies for use in different settings. 4.1. Implications for practice Engaging physicians in efforts to improve IPCP is essential to improving patient outcomes. This is particularly true in the ED, where the work environment is often chaotic, busy, and stressful. Recent changes to health care delivery systems create further incentives to improve IPCP through the increasing alignment of reimbursement with outcomes.24,25 The strategies identified through this project can be used by nurse leaders or others interested in engaging physicians in efforts to improve IPCP. This includes quality or process improvement projects or the implementation of new evidence-based practices for routine patient care. Although this study was conducted in rural EDs, the identified strategies and contextual factors may have relevance for EDs more generally. To apply this study's findings, an ED taskforce would first assess the nature of the identified contextual factors in their setting. How are physicians employed and what is included in their contracts or position descriptions? To whom are physicians accountable in the organization and is that individual committed to engaging physicians in efforts to improve IPCP? What else is going on in the organization that may compete with new improvement projects? What committees and meetings are physicians already attending? After considering the context, the ED taskforce would then select the strategies that best fit the ED's needs and strengths and then adapt them to align with the existing context. Many of the strategies identified in this study also have been noted previously. In prior studies, authors have noted the value of building on existing infrastructure, such as meetings,26,25 interprofessional ward rounds, educational programs27,25,28 and formal policies or procedures.16 Prior authors also have noted the importance of taking the physicians' needs and concerns into account27,24,29,30,31 engaging leadership support for physician engagement,32,33 and communicating goals and providing databased feedback on success toward meeting those goals.34,33,35,25
Fig. 2. Framework for improving physician engagement in IPCP (Adapted from Gittell.19).
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The findings from this study also note strategies that have not previously been identified such as attending to logistics and strengthening interpersonal relationships as strategies to engage physicians in IPCP. The contextual factors identified in this study also are similar to those reported in prior literature on physician engagement in IPCP and quality improvement initiatives. Employment arrangements,36,16 scheduling difficulties,18 and existing infrastructure all have been identified as barriers to engagement in prior studies. This study is distinct in its focus on IPCP in rural community hospitals, an understudied group that represents 41% of US hospitals.37 4.2. Limitations and future work We acknowledge limitations associated with interpretation of findings from this study. Findings are based on input from a convenience sample that was not representative of all professions working in the ED. All participants in the in-depth interviews were nurses and observations included those who attended events or were present during site visits. Input from physicians was therefore limited. Future research would benefit from greater input from physicians. 5. Conclusion Interprofessional collaborative practice can positively impact the quality of patient care in EDs by improving communication and collaboration among members of the healthcare team. Physicians are integral members of this team and need to be engaged in IPCP activities and efforts; however, physician engagement in IPCP can be challenging. This study identified several strategies that have been used in rural EDs to promote physician participation in IPCP efforts. Contextual factors that influence physician engagement were also identified. These contextual factors and strategies can be used to inform efforts to improve physician engagement. While additional physician input would strengthen these efforts, the strategies outlined in this project create a foundation for improving physician engagement in IPCP in rural EDs to improve the quality of patient care. References 1. Weiss AJ, Wier LM, Stocks C, Blanchard J. Overview of Emergency Department Visits in the United States, 2011; 2014. HCUP Statistical Brief #174. June 2014. Agency for Healthcare Research and Quality, Rockville, MD. Retrieved on March 5, 2016 from http://www.hcup-us.ahrq.gov/reports/statbriefs/sb174Emergency-Department-Visits-Overview.pdf. 2. Centers for Disease Control and Prevention (CDC). FastStats: emergency department visits. Retrieved February 12, 2017 from https://www.cdc.gov/ nchs/fastats/emergency-department.htm ; 2017. 3. Nawar EW, Niska RW, Xu J. National Hospital Ambulatory Medical Care Survey: 2005 Emergency Department Summary. Advance Data from Vital and Health Statistics (Number 386). Hyattsville, MD: National Center for Health Statistics; 2007. Retrieved from https://www.cdc.gov/nchs/data/ad/ad386.pdf. 4. Greenwald PW, Estevez RM, Clark S, Stern ME, Rosen T, Flomenbaum N. The emergency department as the primary source of hospital admission for older (but not younger) adults. Am J Emerg Med. 2015. https://doi.org/10.1016/ j.ajem.2015.05.041. 5. Herring AA, Ginde AA, Fahimi J, et al. Increasing critical care admissions from U.S. emergency departments, 2001-2009. Crit Care Med. 2013;41(5): 1197e1204. https://doi.org/10.1097/CCM.0b013e31827c086f. 6. Pines JM, Mullens PM, Cooper JK, Feng LB, Roth KE. National trends in emergency department use, care patterns, and quality of care of older adults in the United States. J Am Geriatr Soc. 2012;61(1):12e17. https://doi.org/10.1111/ jgs.12072. 7. Institute of Medicine (IOM). Hospital-based Emergency Care at the Breaking Point. Washington, DC: The National Academies Press; 2007. 8. Mullins PM, Pines JM. National ED crowding and hospital quality: results from the 2013 hospital compare data. Am J Emerg Med. 2014;32(6):634e639. https:// doi.org/10.1016/j.ajem.2014.02.008. 9. World Health Organization. Framework for Action on Interprofessional Education and Collaborative Practice. Geneva: WHO; 2010. Retrieved September 5, 2015
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Journal of Interprofessional Education & Practice journal homepage: http://www.jieponline.com
Improving physician engagement in interprofessional collaborative practice in rural emergency departments Kelly Might Wilson a, Jennifer Leeman b, Barry Saunders c, Donna Sullivan Havens d, * a
UNC Health Care, 211 Friday Center Dr., Suite 1069, Chapel Hill, NC 27517, USA University of North Carolina School of Nursing, Carrington Hall Office #5004, CB#7460, Chapel Hill, NC 27599-7240, USA c Department of Social Medicine, University of North Carolina School of Medicine, MacNider Hall, Office #348, CB#7240, Chapel Hill, NC 27599-7240, USA d University of North Carolina School of Nursing, Carrington Hall Office #403, CB#7460, Chapel Hill, NC 27599-7240, USA b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 2 October 2017 Received in revised form 3 December 2017 Accepted 17 December 2017
Background: Interprofessional collaborative practice (IPCP) is critical to managing care complexity and improving patient outcomes in emergency departments. Efforts to improve IPCP are constrained by low levels of physician engagement. Purpose. This study aimed to explore contextual factors and strategies that influenced physicians' engagement in efforts to improve IPCP in emergency departments. Methods: This study was conducted within a HRSA-sponsored project that aimed to improve IPCP in four rural emergency departments. Data collection included in-depth interviews (n ¼ 12) and observations over two years. Content analysis was applied to code and integrate findings. Results: Physician engagement in efforts to improve IPCP was influenced by five categories of contextual factors (employment arrangements, scheduling, competing priorities, leadership, infrastructure) and six strategies (build on existing infrastructure, attend to logistics, strengthen interpersonal relationships, take physicians' perspective into account, engage leadership, communicate goals and successes). Discussion/Conclusion: Emergency department staff can use these results to promote physician engagement in efforts to improve IPCP, an essential step toward improving patient outcomes. © 2017 Elsevier Inc. All rights reserved.
1. Introduction Emergency Departments (EDs) in the United States are treating more patients each year,1 with more than 130 million ED visits made in 2013 as compared to 96.5 million in 2005.2,3 ED patients are older, sicker, and require more complex care than in the past4e6 exacerbating efforts to provide high quality and efficient ED care.7,8 In their 2007 report “Hospital-Based Emergency Care: At the Breaking Point”, the Institute of Medicine highlighted the challenges EDs face and identified an urgent need to improve interprofessional collaborative practice (IPCP) in the ED setting. The World Health Organization9 defines IPCP as occurring “When multiple health workers from different professional backgrounds work together with patients, families, carers, and communities to deliver the highest quality of care.” IPCP is particularly
challenging, yet critical to implement, in the often chaotic, busy, and stressful ED environment10 where inadequate collaboration contributes to overcrowding, long wait times, large numbers of patients leaving without being seen, and clinical errors.11,7,12 Despite evidence of IPCP's positive effects on patient outcomes, many healthcare organizations find IPCP difficult to implement.7,13,14 One factor limiting efforts to improve IPCP is low physician engagement.15,16 Physicians play a key role in healthcare processes and practices, which makes their involvement in collaborative practice essential.17,18 The purpose of this study was to identify factors that limit or facilitate physician engagement and strategies that are effective at engaging physicians in IPCP in the ED. The study was conducted as part of an ongoing quality improvement collaborative involving four rural North Carolina EDs (D. Havens, PI). 1.1. Conceptual framework
* Corresponding author. E-mail addresses: [email protected] (K.M. Wilson), jleeman@ email.unc.edu (J. Leeman), [email protected] (B. Saunders), dhavens@email. unc.edu (D.S. Havens). https://doi.org/10.1016/j.xjep.2017.12.005 2405-4526/© 2017 Elsevier Inc. All rights reserved.
This study was guided by the theory of relational coordination (RC), which conceptualizes coordination as a set of relationship and communication ties among participants in a work process.19
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Relationship dimensions that are central to effective coordination include shared goals, shared knowledge, and mutual respect. To be effective, communication needs to be frequent, timely, accurate, and problem-solving.19 The theory further posits that relationship dimensions and communication are mutually reinforcing and together affect the quality and efficiency of patient care. Initiatives to strengthen relational coordination are effective at improving IPCP, but only to the extent that staff from multiple professions engage in those initiatives. This study's conceptual framework (Fig. 1) extends Gittell's RC theory to address the importance of identifying strategies to engage physicians in IPCP and contextual factors that influence physician engagement.
were important to quality ED care in their setting. In addition, each hospital designated a site coordinator for the project. Participants for this study included the site coordinators and a convenience sample of project team members available at each data collection time point. 2.3. Data collection Data for this study were obtained during the second and third years of the three-year Shaping Systems project. Data collection included observations and interviews. 2.4. Observations
2. Methods 2.1. Design An exploratory multi-case study was conducted with four rural North Carolina EDs. Qualitative data were collected through observation and scheduled interviews. The University of North Carolina at Chapel Hill Institutional Review Board (IRB) reviewed the study and identified it as exempt. 2.2. Setting and participants This study was conducted within the context of the HRSAsponsored project, “Shaping Systems to Promote Desired Outcomes: Interprofessional Collaborative Practice in Rural North Carolina EDs” (Shaping Systems e D. Havens, PI). The Shaping Systems project implemented a four-hospital quality improvement collaborative to develop nursing's capacity to promote IPCP environments in the ED setting. The project provided participating hospitals with a range of resources and activities through quarterly learning collaborative meetings, site visits, video conferences and an interactive website. Hospital teams could adapt what they learned and implement strategies they felt would work in their local context. The four hospitals participating in this project were chosen based on their location in rural Health Professional Shortage and Medically Underserved Areas. Table 1 provides an overview of participating hospitals. Each hospital formed an interdisciplinary team to engage in Shaping System project activities. Hospitals were encouraged to create teams that included ED nurses and physicians as well as professionals from other disciplines and units or departments who
The lead author conducted observations during five two-day Shaping Systems collaborative meetings and four site visits to participating hospitals' EDs. Field notes were taken to document observations related to physician participation in IPCP. 2.5. Interviews The two lead authors conducted telephone interviews with site coordinators at the start of the second and third years of the project. Interviews followed a structured guide that included questions about IPCP improvement strategies the hospital had implemented in the past year and barriers and facilitators to their implementation with a focus on physician engagement. 2.6. Data analysis The following strategies were applied to enhance the rigor of data analysis. Field notes were typed and interviews were recorded and transcribed. The lead author applied content analysis with deductive coding to organize transcripts and data according to the study's central constructs (barriers and facilitators to physician engagement and strategies used to engage physicians). She then used inductive methods to identify themes within each construct.20 A matrix was created and cross-case analysis used to explore similarities and differences across the four participating ED sites.20 The identified themes for each hospital and cross-case analysis were reviewed by other members of the research team, who had participated in interviews (JL) or in collaborative meetings and site visits (DH, BS). Findings were then presented at a Shaping Systems collaborative meeting to ensure that they accurately represented the site teams' perspectives.21
Fig. 1. Study Conceptual framework based on Gittell's19 Theory of Relational Coordination.
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Table 1 Participating hospitals.
Hospital Hospital Hospital Hospital
1 2 3 4
Hospital Size
Affiliation
Number of ED visits in 2013
ED Size
ED Physician employment status
25 beds 222 beds 453 beds 52 beds
Part of larger integrated health care system Part of larger integrated health care system Not affiliated with a larger system Part of a larger independent community hospital system
14,449 31,800 74, 650 14,077
10 32 63 10
Contracted Changed during project from contracted to employed Contracted Employed
3. Findings 3.1. Sample Twelve site coordinators and other staff participated in in-depth phone interviews, all of whom were nurses and most of whom were nurse managers. Sixty-six staff participated in collaborative meetings and site visits; the majority were nurses (64%), 15% were physicians, and 21% were from other disciplines including respiratory therapists, paramedics, psychologists, and physician assistants among others. 3.2. Findings on physician engagement in interprofessional collaborative practice activities
beds beds beds beds
that “scheduling is honestly probably the biggest challenge” to physician participation in the Shaping Systems project and other interprofessional efforts at her hospital. Engaging physicians in IPCP required that their available time align with that of nurses and other staff in the ED and with physicians in other departments. Finding times when physicians were available was difficult because the EDs needed to ensure adequate staffing for patient care. One ED director noted that the small number of physicians on staff meant that “someone has just worked or is currently working” at all times. Physicians who worked the night shift were least likely to participate in IPCP activities. Scheduling challenges were particularly acute when IPCP efforts required travel off site, as was the case for the four annual Shaping Systems collaborative meetings. 3.6. Competing priorities
Participants described physician engagement (or lack of engagement) in two categories of efforts to improve IPCP: Shaping System collaborative activities and other quality improvement (QI) initiatives. Findings are organized around the contextual factors that influenced physician engagement in IPCP and strategies that sites used to successfully engage physicians.
Five categories of contextual factors influenced physician engagement in IPCP activities: employment arrangements, scheduling, competing priorities, leadership, and infrastructure.
All four sites experienced challenges related to the high number of competing priorities for physician time and attention. Participants reported many different quality improvement and other initiatives that hospitals and their EDs were involved in during the course of this study. For example, one hospital spent over a year preparing for and initiating the use of a new electronic health record (EHR) system. Although these initiatives limited participating in Shaping Systems, they often had a positive impact on IPCP as in the case of mandatory hospital-wide Language of Caring classes and TeamSTEPPS, both of which provided opportunities for interdisciplinary communication and collaboration.
3.4. Employment arrangements
3.7. Leadership
All four site teams mentioned challenges related to physicians' employment arrangements. Employment arrangements varied among sites, as noted in Table 1, with some physicians employed by outside contract agencies and others working as employees of the hospital or healthcare system. A number of the contract ED physicians commuted long distances to work in the rural EDs, ranging from one or more hours to from another state. As one participant noted, “I feel like physicians are still not vested in the hospital. They are contract employees in their mind. They are also not locally vested and don't live in the community.” Employment arrangements determined how physicians' time was allotted and their accountability to and investment in the hospital. At three sites, physicians' contracts specified the amount of time they could allot to administrative versus clinical activities. To participate in Shaping Systems or other QI initiatives, physicians had to use their administrative time, which was limited and also had to cover continuing education and vacation time. At one hospital, patient care metrics had been written into physician contracts, which was perceived to increase physician accountability.
All four site teams mentioned the importance of leadership support for physician participation in IPCP efforts. Leadership included physician leadership, nursing leadership, hospital administration, and the ED director. Examples of leadership that supported physician engagement included “administration sets the expectation” that participation in IPCP will occur and encourages physician participation in meetings. Leadership support was constrained by both the absence and turnover of individuals in leadership positions. One hospital experienced turnover in several ED and hospital leadership positions over this study's two-year time period. Another reported that their Chief Medical Officer was often absent, resulting in lower levels of physician engagement because no one was overseeing their activities or holding them accountable.
3.3. Contextual factors influencing physician engagement
3.5. Scheduling All four site teams discussed challenges related to scheduling and physician engagement in IPCP. One nurse manager asserted
3.8. Infrastructure Across all four hospitals, the physical layout, use of the EHR, and existing committee structures influenced physician engagement in IPCP. The physical layout of the ED can either facilitate or impede IPCP. In one hospital's ED the central workstation was divided into separate nurse and physician stations separated by a medication workspace creating a structural barrier to collaboration. At another site, the ED director's office was next to the medical director's, thereby facilitating collaboration. At another hospital, physician
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participation in huddles was facilitated by a shared nurse/physician workspace. As one participant observed, the physicians “have nowhere else to run to except their break room, so they are there listening passively and actively, kind of forced to participate because we're standing around them.” All of the site teams brought up challenges related to the impact that their EHR systems had on physician engagement in IPCP. At one site, physicians charted in a different EHR system than the rest of the staff, limiting the EHR systems' potential to facilitate interdisciplinary communication. Although other sites' physicians, nurses, and other staff used the same EHR system, they reported that physicians could not access information that other staff entered, necessitating development of “workarounds” to enable physicians and nurses to communicate. One site noted that required EHR documentation related to mental health patients being boarded in the ED has facilitated IPCP by clarifying who is responsible for different aspects of care. 3.9. Effective strategies for increasing physician engagement ED site teams shared the following categories of strategies used to engage physicians in IPCP efforts: build on existing infrastructure, attend to logistics, strengthen interpersonal relationships, take physicians' perspective into account, engage leadership, and communicate goals and successes. 3.10. Build on existing structures Site teams identified strategies that they used to hardwire physician engagement into existing meetings, huddles, educational activities, initiatives to create new policies or processes, and physician contracts. 3.10.1. Meetings All four site teams used existing meetings to engage physicians with other staff or leaders. The meetings described as most successful were those that involved medical and/or nursing leadership. One site noted that these meetings allowed nurse leaders to communicate with physicians about issues identified by the nursing staff. Based on experience with many different hospitals, the Director of Clinical Services for a physician contract company stated that regular, weekly or daily, meetings between medical and nursing directors is the most important step toward better IPCP in EDs. Another successful strategy involved a nursing leader or other nursing representative participating in existing physician meetings. At one site, information related to ED throughput data and quality scores was shared in many different types of meetings, including hospitalist meetings as these non-ED physicians affect ED throughput. Meetings provided opportunities for IPCP, particularly in smaller hospitals where committees often are hospital-wide and interdisciplinary. 3.10.2. Huddles Two of the site's teams have successfully integrated physicians into daily huddles involving frontline staff within the ED. A third site reported that while they have daily huddles, they have not yet successfully engaged physicians. Huddles were perceived as most successful at engaging physicians when information was shared that was relevant to physicians. For example, morning huddles at one site were used to give daily updates on available services, review staffing, and introduce the resident working that day. Another site reported that they invited ED physicians to present “Medical Minutes” during the huddles, during which they provided a brief presentation on a new evidence-based practice or on their preferences related to patient care during the upcoming shift.
3.10.3. Education Three of the ED site teams described engaging physicians in interprofessional education, which included hands-on or gaming simulations and classroom courses. Some educational opportunities were provided specifically for the ED unit while others were offered for a wider audience. Simulation activities were particularly successful. One hospital used a mobile simulation lab, which allowed them to block off an ED bed and invite physicians and other staff to participate during their normal work hours. The Shaping Systems collaborative exposed hospital teams to the simulation game Friday Night in the ER®, and three sites were successful at engaging physicians in the game, which simulates IPCP and a systems approach to patient care. Classroom-based educational events were less successful in engaging physicians in IPCP because physicians typically attended classes with other physicians. 3.10.4. Policy or process Team members from all four sites shared at least one example of a policy or process that was designed to facilitate physician engagement in IPCP. Sites reported on boarder patient policy, a rapid admit process, and a sepsis protocol that were revised to clarify the respective responsibilities that physicians, nurses, and other staff had for documenting and providing care. Sites also reported on the use of a standardized communication tool (SituationBackground-Assessment-Recommendation, SBAR) to facilitate communication and collaboration with physicians. 3.10.5. Physician contracts Three of the site teams reported that they included performance goals in their physicians' contracts such as hospital goals and expectations regarding participation in meetings and committees. As a result, physician compensation was based on their quality metrics. One site reported physician metrics weekly. As one team member stated, physicians now “feel the heat” and “they own it.” Although participants in this study were not responsible for writing physicians' contracts, they were able to learn more about what physicians are accountable for and to leverage those arrangements to encourage participation in quality improvement efforts. 3.11. Attend to logistics All four ED teams reported strategies related to the logistics of involving physicians in their IPCP activities. These included scheduling meetings during times that would be best for physicians, such as times when the unit was typically not busy, and holding meetings and events in the ED. Sites also used video or phone conferencing to increase physician participation in meetings or other events, particularly when meetings were held offsite. 3.12. Strengthen interpersonal relationships Three of the site teams discussed strategies they have used to build stronger relationships with physicians. These approaches included using first names, personally inviting physicians to participate, engaging with physicians in social events outside of work, addressing physicians directly with their concerns rather than using administrative channels, and using appreciative inquiry.22,23 With the exception of appreciative inquiry, these strategies are self-explanatory. Appreciative inquiry is a strategy from the science of positive organizational scholarship that the Shaping Systems collaborative introduced to the hospitals as a way to frame discussions and improvement initiatives around what is working well and how can we do more of it, as an alternative to focusing on what is not working.
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3.13. Take the physicians' perspective into account Three of the site teams reported efforts to discover physicians' specific interests related to patient care issues and then engage them in activities that aligned with their interests. Teams also reported employing a range of other strategies to better align with physicians' needs and preferences, such as (1) prioritizing which projects require physician participation and only inviting physicians to participate in those that are high priority, (2) careful preparation so that meeting time is used efficiently and physicianrelated issues are consolidated, and (3) telling physicians exactly what is needed from them and why. For example, one site included the medical director at the beginning of the project and then, as the project progressed, included additional physicians when their input was needed. Another site held a rapid improvement event to work on patient throughput in the ED, and two physicians joined in the four-day event. This strategy allowed the ED team to engage physicians during a concentrated period of time rather than spreading it out. 3.14. Engage leadership All the ED site teams addressed the importance of engaging organizational leadership support to improve IPCP with physicians. One site team stated that meeting with administration enabled them “to get physicians on board with improving and meeting performance metrics such as ED patient throughput.” Another site team communicated the work they have done in the Shaping Systems collaborative with their leadership in order gain more buyin and support for physician engagement in IPCP. 3.15. Communicate data, goals, and successes All four site teams spoke about communication strategies they used to apprise physicians of the goals and successes of quality improvement and other initiatives. Communicating data was viewed as a particularly effective approach for engaging physicians. As one participant noted, “we share data with providers to get buyin and to get them to see their part and what they control.” Site teams provided physician-specific feedback on performancerelated department metrics that impacted larger hospital goals such as productivity reports. They also shared data to make the case for a change, such as data on ED patient volume to get buy-in for changes in staffing patterns. According to one participant, “people respond to what you measure.” Two of the ED site teams
55
emphasized the role of sharing successes to improve physician engagement. They noticed increased physician engagement when physicians saw the successful results of improvement efforts. 4. Discussion As summarized in Fig. 2, this study identified strategies that might be applied to improve physician engagement in IPCP in the ED as well as contextual factors that need to be considered when selecting and adapting strategies for use in different settings. 4.1. Implications for practice Engaging physicians in efforts to improve IPCP is essential to improving patient outcomes. This is particularly true in the ED, where the work environment is often chaotic, busy, and stressful. Recent changes to health care delivery systems create further incentives to improve IPCP through the increasing alignment of reimbursement with outcomes.24,25 The strategies identified through this project can be used by nurse leaders or others interested in engaging physicians in efforts to improve IPCP. This includes quality or process improvement projects or the implementation of new evidence-based practices for routine patient care. Although this study was conducted in rural EDs, the identified strategies and contextual factors may have relevance for EDs more generally. To apply this study's findings, an ED taskforce would first assess the nature of the identified contextual factors in their setting. How are physicians employed and what is included in their contracts or position descriptions? To whom are physicians accountable in the organization and is that individual committed to engaging physicians in efforts to improve IPCP? What else is going on in the organization that may compete with new improvement projects? What committees and meetings are physicians already attending? After considering the context, the ED taskforce would then select the strategies that best fit the ED's needs and strengths and then adapt them to align with the existing context. Many of the strategies identified in this study also have been noted previously. In prior studies, authors have noted the value of building on existing infrastructure, such as meetings,26,25 interprofessional ward rounds, educational programs27,25,28 and formal policies or procedures.16 Prior authors also have noted the importance of taking the physicians' needs and concerns into account27,24,29,30,31 engaging leadership support for physician engagement,32,33 and communicating goals and providing databased feedback on success toward meeting those goals.34,33,35,25
Fig. 2. Framework for improving physician engagement in IPCP (Adapted from Gittell.19).
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The findings from this study also note strategies that have not previously been identified such as attending to logistics and strengthening interpersonal relationships as strategies to engage physicians in IPCP. The contextual factors identified in this study also are similar to those reported in prior literature on physician engagement in IPCP and quality improvement initiatives. Employment arrangements,36,16 scheduling difficulties,18 and existing infrastructure all have been identified as barriers to engagement in prior studies. This study is distinct in its focus on IPCP in rural community hospitals, an understudied group that represents 41% of US hospitals.37 4.2. Limitations and future work We acknowledge limitations associated with interpretation of findings from this study. Findings are based on input from a convenience sample that was not representative of all professions working in the ED. All participants in the in-depth interviews were nurses and observations included those who attended events or were present during site visits. Input from physicians was therefore limited. Future research would benefit from greater input from physicians. 5. Conclusion Interprofessional collaborative practice can positively impact the quality of patient care in EDs by improving communication and collaboration among members of the healthcare team. Physicians are integral members of this team and need to be engaged in IPCP activities and efforts; however, physician engagement in IPCP can be challenging. This study identified several strategies that have been used in rural EDs to promote physician participation in IPCP efforts. Contextual factors that influence physician engagement were also identified. These contextual factors and strategies can be used to inform efforts to improve physician engagement. While additional physician input would strengthen these efforts, the strategies outlined in this project create a foundation for improving physician engagement in IPCP in rural EDs to improve the quality of patient care. References 1. Weiss AJ, Wier LM, Stocks C, Blanchard J. Overview of Emergency Department Visits in the United States, 2011; 2014. HCUP Statistical Brief #174. June 2014. Agency for Healthcare Research and Quality, Rockville, MD. Retrieved on March 5, 2016 from http://www.hcup-us.ahrq.gov/reports/statbriefs/sb174Emergency-Department-Visits-Overview.pdf. 2. Centers for Disease Control and Prevention (CDC). FastStats: emergency department visits. Retrieved February 12, 2017 from https://www.cdc.gov/ nchs/fastats/emergency-department.htm ; 2017. 3. Nawar EW, Niska RW, Xu J. National Hospital Ambulatory Medical Care Survey: 2005 Emergency Department Summary. Advance Data from Vital and Health Statistics (Number 386). Hyattsville, MD: National Center for Health Statistics; 2007. Retrieved from https://www.cdc.gov/nchs/data/ad/ad386.pdf. 4. Greenwald PW, Estevez RM, Clark S, Stern ME, Rosen T, Flomenbaum N. The emergency department as the primary source of hospital admission for older (but not younger) adults. Am J Emerg Med. 2015. https://doi.org/10.1016/ j.ajem.2015.05.041. 5. Herring AA, Ginde AA, Fahimi J, et al. Increasing critical care admissions from U.S. emergency departments, 2001-2009. Crit Care Med. 2013;41(5): 1197e1204. https://doi.org/10.1097/CCM.0b013e31827c086f. 6. Pines JM, Mullens PM, Cooper JK, Feng LB, Roth KE. National trends in emergency department use, care patterns, and quality of care of older adults in the United States. J Am Geriatr Soc. 2012;61(1):12e17. https://doi.org/10.1111/ jgs.12072. 7. Institute of Medicine (IOM). Hospital-based Emergency Care at the Breaking Point. Washington, DC: The National Academies Press; 2007. 8. Mullins PM, Pines JM. National ED crowding and hospital quality: results from the 2013 hospital compare data. Am J Emerg Med. 2014;32(6):634e639. https:// doi.org/10.1016/j.ajem.2014.02.008. 9. World Health Organization. Framework for Action on Interprofessional Education and Collaborative Practice. Geneva: WHO; 2010. Retrieved September 5, 2015
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