An Evaluation of Shared Mental Models and Mutual Trust on General Medical Units: Implications for Collaboration, Teamwork, and Patient Safety.

OBJECTIVES: This study examines nurse-physician teamwork and collaboration, a critical component in the delivery of safe patient care, on general medical units. To that end, we assess shared mental models and mutual trust, 2 coordinating mechanisms that help facilitate teamwork, among nurses and physicians working on general medical units. METHODS: Data were collected from 37 nurses and 42 physicians at an urban teaching medical center in the Northeastern United States. Shared mental model questionnaire items were iteratively developed with experts' input to ensure content validity. Mutual trust items were adapted from an existing scale; items were reliable. Data were analyzed using χ and independent 2-tailed t tests. RESULTS: Physicians and nurses reported significant differences in their perceptions of the professional responsible for a variety of roles (e.g., advocating for the patient [P = 0.0007], identifying a near miss/error [P = 0.003]). Medication reconciliation is only role for which nurses perceive less responsibility than physicians perceive nurses have. Regarding mutual trust, both groups reported significantly more trust within their own professions; both groups reported similar levels of trust in physicians, with physicians reporting significantly less trust in their nursing colleagues than nurses perceive (P < 0.0001). CONCLUSIONS: Although many efforts have been directed at improving nurse-physician collaboration, more work is needed. To that end, we propose increasing knowledge about their respective roles, providing opportunities for nurse and physician collaboration through rounding or committee work and enhancing the preparedness and professionalism of interactions.

Integrating Quality Improvement With Graduate Medical Education: Lessons Learned From the AIAMC National Initiatives.

Quality and safety initiatives (QI) are national priorities for health care, yet the role of residents in QI has not always been clear. In academic medical centers, residents and fellows play a critical role in patient care and, as such, their integration into QI presents a unique opportunity to affect change. The Alliance for Independent Academic Medical Centers (AIAMC) began a national campaign in 2007 to harness the potential of infusing graduate medical education (GME) with QI, through their AIAMC National Initiative: Improving Patient Care Through Medical Education. This article describes the National Initiatives (NIs) and the reflections of NI participants, including their reflections on the goals they set for integrating GME with QI, the barriers they encountered along the way, and their advice to others beginning the challenge. These reflections provide some insight into the pathways of promoting organizational change and offer practical insight and inspiring advice for others embarking on the journey.

TRACER: an 'eye-opener' to the patient experience across the transition of care in an internal medicine resident program.

BACKGROUND: A safe patient transition requires a complex set of physician skills within the interprofessional practice. OBJECTIVE: To evaluate a rotation which applies self-reflection and workplace learning in a TRAnsition of CarE Rotation (TRACER) for internal medicine (IM) residents. TRACER is a 2-week required IM resident rotation where trainees join a ward team as a quality officer and follow patients into postacute care. METHODS: In 2010, residents participated in semistructured, one-on-one interviews as part of ongoing program evaluation. They were asked what they had learned on TRACER, the year prior, and how they used those skills in their practice. Using transcripts, the authors reviewed and coded each transcript to develop themes. RESULTS: Five themes emerged from a qualitative, grounded theory analysis: seeing things from the other side, the 'ah ha' moment of fragmented care, team collaboration including understanding nursing scope of practice in different settings, patient understanding, and passing the learning on. TRACER gives residents a moment to breathe and open their eyes to the interprofessional practice setting and the patient's experience of care in transition. CONCLUSIONS: Residents learn about transitions of care through self-reflection. This learning is sustained over time and is valued enough to teach to their junior colleagues.

The Power of Collaboration: Experiences From the Educational Innovations Project and Implications for the Next Accreditation System.

BACKGROUND: The Internal Medicine Educational Innovations Project (EIP) is a 10-year pilot project for innovating in accreditation, which involves annual reporting of information and less-restrictive requirements for a group of high-performing programs. The EIP program directors' experiences offer insight into the benefits and challenges of innovative approaches to accreditation as the Accreditation Council for Graduate Medical Education transitions to the Next Accreditation System. OBJECTIVE: We assessed participating program directors' perceptions of the EIP at the midpoint of the project's 10-year life span. METHODS: We conducted telephone interviews with 15 of 18 current EIP programs (83% response rate) using a 19-item, open-ended, structured survey. Emerging themes were identified with content analysis. RESULTS: Respondents identified a number of the benefits from the EIP, most prominent among them, collaboration between programs (87%, 13 of 15) and culture change around quality improvement (47%, 7 of 15). The greatest benefit for residents was training in quality improvement methods (53%, 8 of 15), enhancing those residents' ability to become change agents in their future careers. Although the requirement for annual data reporting was identified by 60% (9 of 15) of program directors as the biggest challenge, respondents also considered it an important element for achieving progress on innovations. Program directors unanimously reported their ability to sustain innovation projects beyond the 10-year participation in EIP. CONCLUSIONS: The work of EIP was not viewed as "more work," but as "different work," which created a new mindset of continuous quality improvement in residency training. Lessons learned offer insight into the value of collaboration and opportunities to use accreditation to foster innovation.

Development of a checklist for documenting team and collaborative behaviors during multidisciplinary bedside rounds.

OBJECTIVE: The objective of this study was to develop a reliable and valid checklist for documenting team and collaborative behaviors occurring during multidisciplinary bedside rounds. BACKGROUND: Teamwork and collaboration are important for providing high-quality patient care, yet there are no objective means of evaluating the occurrence of team and collaborative behaviors during bedside rounds. METHODS: A checklist was developed and tested on 3 general medical units. Items on the checklist were derived from the literature and our medical center's patient-family-centered values. RESULTS: The final version of the checklist was determined to be reliable, valid, and easy to use in the clinical setting. CONCLUSION: Clinicians, administrators, and investigators are encouraged to use and/or modify this checklist for use in their setting. Further research identifying instruments to objectively measure teamwork and collaboration is needed.

From theory to actual practice: creation and application of milestones in an internal medicine residency program, 2004-2010.

BACKGROUND: In the USA, the Accreditation Council of Graduate Medical Education, Educational Innovations Project is a partner in reshaping residency training to meet increasingly complex systems of health care delivery. AIM: We describe the creation and implementation of milestones as a vehicle for translating educational theory into practice in preparing residents to provide safe, autonomous patient care. METHOD: Six program faculty leaders, all with advanced medical education training, met in an iterative process of developing, implementing, and modifying milestones until a final set were vetted. RESULTS: We first formed the profile of a Master Internist. We then translated it into milestone language and implemented its integration across the program. Thirty-seven milestones were applied in all settings and rotations to reach explicit educational outcomes. We created three types of milestones: Progressive, build one on top of the other to mastery; additive, adding multiple behaviors together to culminate in mastery; and descriptive, using a proscribe set of complex, predetermined steps toward mastery. CONCLUSIONS: Using milestones, our program has enhanced an educational model into explicit, end of training goals. Milestone implementation has yielded positive results toward competency-based training and others may adapt our strategies in a similar effort.

"I can do patient care on my own": autonomy and the manager role.

PURPOSE: An internal medicine (IM) residency program redesigned its second year, the Manager Year, to restore balance among autonomy, supervision, and clinical competence. This study examined the response of residents and some supervising attendings to this innovation. METHOD: In this qualitative study-part of a total program evaluation-two authors gathered data from 36 second-year resident-managers, 3 third-year residents, and 8 attendings through semistructured interviews between spring 2005 and spring 2007. All resident-managers in 2005-2006 and all but one in 2006-2007 were interviewed. From verbatim transcripts, two of the authors coded the responses into themes; then all four reviewed and revised these themes. RESULTS: Coding revealed that second-year residents associated four qualities with their experience as managers: ownership of patients, accountability to others, competence in patient management skills, and personal satisfaction. They described the manager role as being as being "on your own." They were accountable to fellow managers, attendings, and nursing staff at a different level from that of an intern. Without an intern to teach, they learned critical management skills to complete their work. They became adult learners around their own patient cases. CONCLUSIONS: Successful preparation of physicians for independent practice requires a careful balance between autonomy and supervision, increasing the former during the training program sequence. For resident-managers, the assignment as principle caregiver occurs at the interface between the two. Managers identify themselves as a great deal more autonomous while still valuing attending supervision and input from co-managers to meet responsibilities.