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Communication Patterns in Interdisciplinary Patient Care Meetings

This study explores the communication patterns in interdisciplinary patient care meetings and their implications for the use of information technology. It examines the context, background, literature review, study approach, and observations of bullet rounds. The potential application of information technology and future work are also discussed.

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Communication Patterns in Interdisciplinary Patient Care Meetings

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  1. Patterns of Communication at Interdisciplinary Patient Care Meetings: Implications for the Use of Information Technology Vanessa Vogwill BA, BEd, MBA, PhD(cand) University of Toronto,Toronto,Canada vvogwill@mie.utoronto.ca

  2. Overview • Context of Study • Background • Literature Review • Study Approach • Observations of Bullet Rounds and Qualitative data • Quantitative analysis of data and results • Potential application of information technology • Future work

  3. Context of study • Medical error [(Institute of Medicine (IOM) Report; Corrigan et al 2000)] • Knowledge Translation Program at U of T • Knowledge Management framework • Multi/interdisciplinary patient care groups • Large teaching hospital • General Internal Medicine • How to improve the collaboration of healthcare professionals in such meetings? (aka can we make Bullet Rounds better?) • What are the issues around the use of information technology in such a context and how can it be used to improve collaboration?

  4. Background • Canadian Health Services Research Foundation (CHSRF) report - 2005 • “investigate the communication processes and information flow between providers “(pg 28). • understanding of these processes and flows is crucial to the effective implementation of information technology in healthcare settings. • Report findings • team as the “who” • team effectiveness ”how”: teamwork is defined as collaborative behaviours • report does not address the issue of information technology

  5. Literature Review (1) • IT necessary for information exchange • IT spending in the healthcare field in general is predicted to increase • Context of implementation. • Electronic medical records (EMRs) • Use of electronic spaces that function as meeting rooms

  6. Literature Review (2) • The Electronic Health Record (EHR) • Team Observation Protocol (TOP) • Information and collaboration needs of healthcare professionals • Few empirical studies

  7. Study Approach • Objective • Extend previous work done on the study of verbal exchanges in interdisciplinary team meetings • Understand the means by which knowledge is shared in Bullet Rounds, the knowledge management needs of such a group, and the potential role of information technology in them • Qualitative Data Capture • ethnographic study, unobtrusive unstructured non-participant observation of Bullet Rounds • Quantitative Data Coding • Team Observation Protocol (TOP) • VPA (Verbal Protocol Analysis) • Knowledge Management framework • Knowledge Management (KM) process through which organizations generate value from their intellectual and knowledge-based assets. • Distinguishes between information and knowledge: information is needed for building knowledge, but knowledge is associated with people (knower) while information is not (Brown, 2000). • Tacit v explicit knowledge • Assisted by new communication and information management technologies such as intranet resources, collaborative on-line technologies, and shared databases to support communities and project teams (Allee, 2000).

  8. Bullet Rounds • Bullet Rounds are multi/interdisciplinary group meetings of health care personnel engaged in patient care in General Internal Medicine (GIM) at a major teaching hospital in Toronto, Canada • Four mornings a week: attended by all or a subset of: • physicians (staff doctor, residents, and medical students) • nurse managers, charge nurse(s), emergency nurse (occasional), • occupational therapists • physical therapists • dietician (occasional) • social workers • pharmacist • speech/language therapist (occasional) • Goal: Establish a treatment program and discharge plan for the patients in GIM, with a focus on quality of care and efficiency. • Good example of the collaborative social interactions that lead to shared understandings: in Bullet Rounds group members exchange knowledge, and through socialisation of tacit knowledge the group as a whole increases its knowledge base

  9. Qualitative Data Capture • Goal of the initial phase of the Study • Ethnographic study • unobtrusive unstructured non-participant observation of Bullet Rounds, which were not taped. • Attended a total of 20 meetings over the course of 3 months in 2005. • Wards and patients in question were in GIM • Over 400 patient discussions documented. • Attended the full meetings which generally took between 1 and 1.5 hours in the morning, for an approximate total of 30 hours. • Extensive notes were taken by hand by the observer who did not participate in any way in Bullet Rounds • Notes transcribed the conversations that took place at Bullet Rounds and identified the role of the speaker (doctor, nurse etc). • Body of data has been transcribed into Field Notes, and is referred to as the Baseline Data

  10. Analysis of Qualitative Data • Used to construct patient care and flow models, and outline of roles and responsibilities • Analysed using error concepts and verbal protocol

  11. Patient Centric Care Model

  12. Patient Journey

  13. Error Analysis • Anecdotally observed errors or near errors classified using Institute of Medicine classification system • Diagnostic • Treatment • Preventive • Other • Majority observed to cluster in Preventive ( “Inadequate monitoring or follow-up”) and Other (“Failure of communication”) types. • Handoffs between caregivers have inherent risks: loss of information through inadequate communication or monitoring/follow up, which may have potentially life-threatening consequences. • Documented instances of information loss identified during Bullet Rounds, and which as a consequence may not result in patient harm. • Identified losses may require follow up; at the time of the Bullet Rounds is assumed will take place but errors in follow up do occur. • Other unidentified and unknown information losses may exist that result in patient harm.

  14. Communication and Knowledge Management • Communication critical to ensure that correct information is available for the creation of knowledge its sharing and use.

  15. Quantitative Data Capture: Methodology • Field Notes were organized to enable coding. • Two approaches used for the coding process: • Using the categories from TOP without modification. • Breaking TOP categories into subcategories • Data coding for the first aproach involved the summation of statements according to category and participant through the use of a spreadsheet tool. • Data coding for the second aproach was done using a custom software tool called Verbal Protocol Analyzer (VPA) • VPA has been designed to assist in categorizing statements made in the context of software testing for usability. • Can be applied to other contexts where verbal protocols need to be categorized and allows the user to input their own analysis scheme and create subcategories as well • Modified version of the TOP Categories was used in this case: a subcategory “ Comments and Collaborative Behaviour” was added to the category ”Team” which enabled the documentation of non-verbal and non content-bearing communication which were indicators of team functioning. The category Information was refined to separate out ”Requests and Instructons” to add detail.

  16. Quantitative analysis of data and results: TOP Categories

  17. TOP Coding

  18. Examples of Coding Classification (1) • Category 1: Client (1%): There is only occasional discussion of social situation or personality as it relates to issues that may affect ongoing treatment. • Category 2: Team (3%):There are some comments on team functioning and processes, including other teams, but very few overt comments about individuals. Side conversations occur at times that preclude effective full group functioning. • Category 3: Questions (24%): Questioners are mainly doctors asking nurses, and nurses asking doctors.

  19. Examples of Coding Classification (2) • Category 4: Information (56%): This is the largest category of verbal exchanges, and involves all team members. • Category 5: Interpretation (5%): This category represents a small proportoin of the total verbal communicaton, includes expressions of opinion or uncertainty on the part of team members, and can relate to process or clinical issues

  20. Examples of Coding Classification (3) • Category 6: Alternatives (6%): The teams discuss possible alternatives in cases where the required information is available, but the percentage of verbal communication in this category is low because to do so the team generally requires outside information that is unavailable. • Category 7: Decisions (4%): The decision-making component of the meetings is very small and represents.only 4% of verbal exchanges. On any given day there are few discharges, and where a discharge is to take place, discussions around it are generally very brief. The group quickly move on to another patient unless the discharge is conditional upon further action being taken, because at patient discharge they have reached their collective goal, and need to move on to the “active” or “unsolved” cases.

  21. VPA Coding: Code Definition

  22. VPA Report

  23. VPA Coding Results

  24. VPA Coding Results • More team interaction has been captured using the subcategory of comments and collaborative behaviours (4%) raising “Team” to 10% overall. Previously, using the original TOP categories, these behaviours were not recorded. • Information remains the highest category of types of statements at 46%, the additional subcategory of “Instructions and Requests” is 11% and provides additional description of the interactions in the teams. • Combined, the two results would provide a rating of 57% for information overall, similar to previous results. • Questions are reduced to 18% of the total, because where they represent requests for action they are coded under the new information subcategory

  25. Participation by Speaker

  26. Overall Findings Results of Coding Exercise show: • Dominant form of communication in Bullet Rounds is the sharing of information • Doctors and nurses are the participants who speak the most • Questioning component seeks further information that has not been made available or is unknown • Information provided by doctors is: diagnosis, background, and treatment plan/status, including general statements about what needs to be done • Doctors use the meetings for discussions amongst themselves • Physicians are responsible for the clinical diagnoses and the treatment protocol, other participants may get involved, or attempt to get involved, in clinical matters, especially the nurses.

  27. Information Categories

  28. Potential Application of Information Technology Discussion • Bullet Rounds meetings are a Community of Practice with the common goal of maximising the quality and efficiency of patient care • Great deal of time spent on information exchange, which through the process of socialisation is transformed into knowledge [Brown (2000)]. • Many handoffs between caregivers both within and outside the group, which carry inherent risks; instances of information loss may be the result of such handoffs. • Management and sharing of this knowledge is crucial to patient outcomes: there may be potential benefit to supporting this process. • Fact that doctors and nurses are the prime communicators in Bullet Rounds must be taken into account as background in the design of any supporting information technology.

  29. Potential Application of Information Technology Discussion (cont’d) • To an outsider the Bullet Rounds meetings appear chaotic and unstructured: communication hampered by noise, illegible writing and language issues. • Currently paper based records used as the basis for discussion. • Computer system into which doctors enter orders outside of Bullet Rounds, which links into the pharmacy system. • Potential for decision support in the form of electronic records for sharing updated information, to replace the paper records.

  30. Potential Application of Information Technology Discussion (cont’d) • Recurring themes in information technology implementation to support KM is the importance of focusing on the actual problems and issues faced by the people involved [Penuel (1999)]. • Knowledge exchange Bullet Rounds is tacit to tacit: in such cases Knowledge maps and Portals are the most appropriate [Carvalho (2001)]. • Knowledge maps work like yellow-pages that contain a "who knows what" list, and do not store knowledge. However, Bullet Rounds themselves to a large extent replace this function. • Portals can be used for many purposes: • publishing medium for explicit knowledge • support organizational communication and collaboration • facilitating information access and retrieval, negotiation of collective interpretations, development of shared meanings and the accomplishment of cooperative work [Carvalho(2001)].

  31. Potential Application of Information Technology Discussion (cont’d) • A Bullet Rounds portal may offer potential for support of the meetings by incorporating both repository, prompting and sharing functions. • Roles and responsibilites, processes. • Best Practices, FAQ and Lessons Learned • On-line Shift Notes. • Group review • Documentation for backup and training. • Reminder system • Virtual attendance at Bullet Rounds

  32. Issues • Currency of material: most technologies work best when users have time to assimilate information, which is not the case in Bullet Rounds where knowledge is constantly changing. This presents a challenge for both documenting and keeping records timely. • Maintenance: a Bullet Rounds portal would require constant updating • Central role played by nursing: this must be taken into account in the development of collaborative technology • Turnover and collaborative practice of participants at Bullet Rounds: the success or failure of information technology would depend on adoption. There is a wide and constantly changing array of healthcare professionals involved in Bullet Rounds and accomodation of user requirements may be complex. • The understanding of workflow and processes within hospital settings is not widely documented and is critical to the effective implementation of technology

  33. Future Work • Bullet Rounds Intervention as basis for potential information technology solution • Development of Measurement System for Pre-Intervention Data Collection • Delays? • Development of the Intervention Parameters, Measures and Toolkit • Focus groups • Domain expect interviews • Treatment Program scenarios • Collection of Quantitative Data (pre-Intervention) • Pilot Bullet Rounds Intervention • Qualitative Evaluation after Pilot Intervention

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