Tonight I happened to catch a few minutes of the Wizard of Oz- a great classic and our daughter was in delight watching the munchkins dance and sing for Dorothy. It also reminded me of the importance of a great team—Dorothy needed the Scarecrow, the Tin Man, and the Cowardly Lion to get to her final destination. Likewise, it takes a great team (and less singing and dancing ability fortunately) to take care of a patient in the hospital. We all know this, but if so, why is it sometimes so hard to work together in a team?
Well, one reason is that doctors have not received formal training in how to interact with the multitude of team members that they will come into contact with while taking care of patients. That is now changing. The Association of American Medical Colleges now states that graduating medical students must be prepared to collaborate in an interprofessional team. Moreover, this is an important skill for residents as well according to the Accreditation Council of Graduate Medical Education.
Well, how should we accomplish such training? While some may think just “mixing” students of different professions in didactic training could count as interprofessional training; however this is not the experiential learning that would translate into the behavior that we need it to. In trying to find out how best to promote this type of behavior, we convened focus groups with residents and nurses. We started with nurses first because we knew that there was a strong desire to improve physician-nurse relationships at our organizations. Our findings were twofold: (1) promoting the right culture starts on day one; and (2) it’s important to recognize the positive role models who do this well.
With this in mind, we implemented two new programs – first an interactive discharge role play with nurse facilitators on day one of intern orientation. Why a discharge role play? Because all 130 clinical interns would at some point be asked to discharge the patient before noon, while nurses would not know the plan for the day, and the patient would also likely be left in the dark. The results were astounding and summed up by an intern’s comment, “Perhaps my most favorite thing of intern orientation so far.” Given the boatloads of Epic training, maybe this was easy to do, but it still highlights that interns were excited to learn from the nurses. One thing that our team was especially proud of is that of the 16 nurse facilitators who were involved (we had more who volunteered than we could accommodate) said that their opinions were valued as teachers, which was great evidence that the “culture” we want to promote did indeed start on day one.
The second program we launched last month is designed to recognize positive deviants and “IGNITE” more substantive change. IGNITE stands for Improving GME Nursing Interprofessional Team Experiences. The program pairs two residents from a program with one to two nurses from a unit to execute a project that aims to improve interprofessional practice. What is unique about IGNITE is that the team members are selected by a vote for who best models interprofessional practice. We have IGNITE teams just starting their project in medicine and surgery, and a new one starting in pediatrics.
Interestingly, IGNITE is spreading itself. We have already had more service lines come forward to “sign up” for IGNITE before we were even planning to scale up! While it’s way too early to say how IGNITE will catalyze change, it’s noteworthy that both surgery and medicine teams chose communication and specifically paging as the focus of their project. The discussions were also fascinating. Nurses wondered what residents did when they were not on the unit, and residents wondered how many patients nurses were caring for during a shift.
These programs are just the tip of the iceberg for improving interprofessional care – they are just the start. Moreover, hospitalists, who are experienced leading interprofesional care teams, are natural leaders in the movement to promoting interprofessional education for medical trainees. The next time you are working in an interprofessional care team, take a moment and give thanks to the other professionals on your care team. If you happen have a student or resident with you, you will also be “IGNITING” change by showing how your Tin Man, Lion and Scarecrow are essential to the care of your patients.