SaferPatients

At Brigham & Women’s Hospital in Boston, team-based inpatient care has resulted in dramatic reductions in inpatient mortality, significantly lower lengths of stay, and higher satisfaction for physicians and nurses.

Team-based care dissolves the hierarchical, traditional structure that exists among nursing, physical therapy, pharmacy and medical staff, social work staff and others to empower individual members of the team to contribute equally to the optimal outcomes for the patients.

At Brigham & Women’s Hospital and its sister Faulkner Hospital, a team-based model of care has been adopted for almost all general medicine units. This system replaces the “chaotic model,” in which residents, attending physicians and interns rotated on different cycles; physicians and nurses did not know one another; and the admissions department assigned patients to whatever beds were available.

Each unit now has a team made up of attending physicians, residents, interns and medical students, pharmacy students and a faculty supervisor, nurses, a social worker, an RN care coordinator and a physical therapist. All members of the team are assigned to work together on a specific unit for at least four weeks at a time.

Two other key changes were instituted: The admissions department assigns a patient to an intensive care unit team only if there is a bed available on its unit and interdisciplinary rounds are structured sequentially by nurse, rather than by room number.

Also, under a team-based care model the expectation is that you don’t discuss a patient until the nurse is present, Another expectation is that before a physician articulates the [patient's care] plan that you get the nurse’s input. The physician team leader will always address the nurse and ask, “Do you have anything to add about this patient?”

The perspective of other team members is equally valued, depending on the patient’s diagnosis and care plan. Sometimes the most important clinician is the physical therapist. The physician may be writing the orders and doing some of the direction, but under the team-based care model the physician does not work alone, but as part of a team.

This approach requires new standardized processes, extensive teamwork and communication training, and strong support and leadership action from top administrators.

Watch a Three-minute movie about LifeWings

We hear a lot about disruptive physicians and Disruptive Physician Policies these days.

As Seth Godin points out in his blog, bad behavior and irrational decisions are almost always caused by fear. If you want to change the behavior, address the fear.

I don’t see that approach to changing behavior much.

In my previous work with airline safety systems, I used to lead what we called “Mediated Debriefs” for cockpit crews that had a total meltdown in teamwork and could no longer fly together safely. Usually the meltdown was caused by disruptive behavior - which can be deadly when experienced in a confined metal tube with wings hurtling through the air at 500 MPH.

After scores of sessions with totally dysfunctional crews, I realized most of the bad behavior stemmed from some sort of fear. That discovery transformed my ability to help the crews get to the root cause of the meltdown and, more importantly, plot a way forward to change behavior.

I wish more folks would try that tactic.

Instead, we ban someone, or we put a letter in the permanent file, or put the employee on a performance improvement plan.

Sometimes asking “What are you afraid of?” is the shortcut in understanding what motivates the behavior you are seeing. Fix the fear - change the behavior.