Functional boundaries and communication. ICU Congress part 2

It’s the same issues and similar workarounds…in every ICU that I’ve ever worked.  Regardless of hospital, type of ICU, shift or time-lapse between shifts.

One of the biggest failures I’ve observed is the inability to communicate effectively across functions.  This is not restricted to Critical Care; it is a hospital phenomenon.  I think it’s just more obvious in the Critical Care Unit because of the patient acuity and intensity of care. The hospital system lends itself to poor communication via its strict traditional intra- and interdisciplinary lines, complex hierarchies and bureaucracies.  Role confusion and expectations around the behaviours of certain roles creates added inconsistencies to the system.

All of the above is maintained by the way things have always been done, beliefs about self and others, traditions, the stories told in the hospitals and so on.  In short our failure to communicate effectively in health care is due to our culture.  Our culture is created by the stories that we tell.

Each hospital system is divided into smaller, functional parts.  The real strength of the system lies in how these parts can connect seamlessly.  None of the parts can function in isolation.  Persons become trapped within the boundaries of their functions.  If we want to improve patient outcomes and reduce length of stay as a performance indicator, we need to readjust some of the functional boundaries.

How do we renegotiate the boundaries and change the culture?

Strengthening the multi-disciplinary team

In his book the Fifth Discipline, Peter Senge describes a team as:  “a group of people who function together in an extraordinary way- who trusts each other, who complement each other’s strengths and who compensate for each other’s limitations.  To have common goals that are larger than individual goals and who produce extraordinary results.”

I think that we often function as non-teams due to hierarchies and the value placed on autonomy in the health care culture; we prefer the culture of relying on individual expertise. We perform as groups of separate functions working side by side with no shared common goal.  Functioning as non-teams within the system is detrimental to the patient.

Pronovost et al (2003) did a study on the impact of daily patient goals in Critical Care Units.  They created a form that included basic information and questions such as what is the patients’ greatest safety risk today and how can we reduce it?  The form was completed during patient rounds, and signed by all health care workers involved with the patient’s care.  They established a relationship between daily communication and reduced patient length of stay.  Three years later this study was repeated in a paediatric ICU by Phipps and Thomas. They demonstrated that the utilization of daily goals improved the perception of communication and team work.

By applying short term daily goals, a common goal is created, crossing boundaries.  So why are we still so diligently doing separate sets of documentation, duplicating each other’s work and not speaking to each other?  Why are we not sharing daily goals across boundaries?

Team Communication

Effective communication is a prerequisite for team collaboration.  Pronovost et al (2003) estimated that 85% of errors across all industries result due to communication errors.  In health care, poor communication is associated with increased length of stay and error in patient care.

Communication is based on assumptions and we communicate in a way that is self-evident to us.  It might not be self-evident to the receiver.  The use of standardized communication tools can reduce some of the risks and assumptions.  A tool mentioned at the congress is the SBAR method.  (Situation, Background, Assessment, Recommendation).  This method originated in the US navy to provide critical information as fast as possible.  From a nursing perspective I think that often when we call physicians we make assumptions and the physician is left to mind read what exactly is happening. Using a standard tool can reduce the amount of assumptions made.

Summary

There was an underlying theme to inspiring ICU…and it was the need to change the culture to allow us to communicate better and work together across functions to improve patient outcome.

And to end with a Francis Peabody quote someone used at the congress:

“….for the secret of the care of the patient is in caring for the patient.”

References:

Phipps, L.M., Thomas, N.J.(2007). The use of a daily goal sheet to improve communication in the paediatric ICU.  Intensive and Critical Care Nursing. Vol. 23 pp. 264-271

Pronovost, P., Berenholtz, S., Dorman, T., Lipsett, P.A., Simmonds, T., Harden, C.( 2003). Improving communication in the ICU using daily goals. Journal of Critical Care. Vol. 18.  No.2. pp. 71 – 75

Senge. P., (1990).  The Fifth Discipline: The art and practice of the learning organization.  Doubleday, New York.

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