Assignment: Barriers To The APN Roles

INTERDISCIPLINARY collabora-tion is an emerging mandateto decrease fragmentation ofcare delivery in U.S. hospi- tals. Higher mortality rates (Estabrooks, Midodzi, Cummings, Ricker, & Giovannetti, 2005) and longer lengths of hospital stay (Zwarenstein, Goldman, & Reeves, 2009) have been found in environ- ments where collaboration is lim- ited or not present. As many as 98,000 people die in hospitals each year as a result of medical errors which may be traced to lack of collaboration and disjointed care. Beyond the cost of human lives, billions of dollars are spent annually for additional care re – sulting from medical errors (Kohn, Corrigan, & Donaldson, 2000). The aim of this study was to determine if a care delivery model based on collaboration and coordination of care using the CareGraph® would improve patient outcomes.

To provide high-quality care and meet public expectations with limited resources, collaboration has become a necessity. In a land- mark study, Knaus, Draper, Wagner, and Zimmerman (1986) found that hospitals where collaboration was present reported a mortality rate 41% lower than the predicted number of deaths. Hospitals where there was little to no collaboration exceeded predicted mortality by as much as 58%. Collaborative

relationships have also been tied to reduced costs for the health care system (Zwarenstein et al., 2009). Although empirical evi- dence in support of collaboration in the health care environment is available in the literature, there is little evidence on how to create this environment (Tschannen, 2004). The main structural ele- ments necessary for collaboration in an acute care environment in – clude a culture where relation- ships are valued, health care pro- fessionals communicate effective- ly, and respect is shared among all parties. A model of care delivery consistent with these cultural val- ues and focused on patient safety is paramount.

A Midwestern health care sys- tem designed an innovative model of care delivery where collabora- tion was purposefully woven into the structures and processes to effect positive change in patient and organizational outcomes. Called the Clinical Integration Model (CIM) (Zander, 2007), sev- eral of the health system hospitals adopted it while others chose to stay with a traditional primary care model. Comparing hospitals within the health system provides an opportunity to determine if there is a difference in survival, length of stay (LOS), and cost for patients receiving care in facilities utilizing the CIM and those receiv-

EXECUTIVE SUMMARY The current lack of collabora-

tive care is contributing to high- er mortality rates and longer hospital stays in the United States.

A method for improving collabo- ration among health profession- als for patients with congestive heart failure, the Clinical Integration Model (CIM), was implemented.

The CIM utilized a process tool called the CareGraph® to priori- tize care for the interdisciplinary team.

The CareGraph was used to focus communication and treat- ment strategies of health pro- fessionals on the patient rather than the discipline or specific task.

Hospitals who used the collab- orative model demonstrated shorter lengths of stay and cost per case.

Cheryl McKay K. Lynn Wieck

Evaluation of a Collaborative Care Model for Hospitalized Patients

CHERYL McKAY, PhD, CNS, RN, com- pleted this work as part of her doctoral education at the University of Texas at Tyler. She is presently Nurse Executive, Healthier Populations, OrionHealth, Santa Monica, CA.

K. LYNN WIECK, PhD, RN, FAAN, is Mary Coulter Dowdy Distinguished Nursing Professor, University of Texas at Tyler.

249NURSING ECONOMIC$/September-October 2014/Vol. 32/No. 5

ing care in facilities utilizing a pri- mary care model.

Collaboration in Health Care Collaboration, as defined by

the American Nurses’ Association (ANA) (2010), is a partnership based on trust with shared power, recognition, and acceptance of separate and combined practice spheres of activity and responsi- bility. Collaboration also includes mutual safeguarding of the legiti- mate interests of each party and a commonality of goals. The key components of shared power, recognition and acceptance, and common goals are relevant to many of the definitions found in the literature (Fewster-Thuente & Velsor-Friedrich, 2008; Petri, 2010). These components are essential for a collaborative process and can be operationalized in an acute care setting.

A number of factors have affected the ability of health care organizations to provide a collabo- rative environment including the educational system and profes- sionalization of health care practi- tioners. Studying determinants of successful collaboration, San Martin- Rodriguez, Beaulieu, D’Amour, and Ferrada-Videla (2005) found health care practitioners develop a strong professional identification through education. This strong profession- al identification often limits know – ledge of other professionals within the team and is considered a main obstacle to collaboration. The dynamics of professionalization lead to further differentiation of health care professionals (D’Amour & Oandasan, 2005) and potential conflict hindering the develop- ment of true collaborative rela- tionships.

Collaboration in health care affects patient survival and de – creases adverse patient outcomes. Knaus and colleagues (1986) found hospitals where collabora- tion was present reported a signif- icant decrease in mortality rates (Chi square=62.9, df 12; p<0.0001, r=0.83). Hospitals where there

was little to no perceived collabo- ration exceeded predicted mortal- ity. Positive collaborative relations have also been tied to a decrease in failure to rescue. Boyle (2004) evaluated unit-level characteris- tics and the impact on patient out- comes and found a negative corre- lation between collaboration and failure to rescue (r= -0.53). High levels of perceived collaboration were linked to early detection of change in clinical condition and appropriate intervention leading to a decrease in failure to rescue.

Collaborative environments can positively affect health system outcomes. Ovretveit (2011) evalu- ated the impact of clinical coordi- nation and collaboration and found when collaboration and coor – dination were present, patients ex – perienced a shorter LOS with lower costs to the health care insti- tution. Additionally, Zwarenstein and co-authors (2009) evaluated multiple studies to determine the impact of interprofessional collab- oration and found 80% of the stud- ies demonstrated decreased LOS and cost savings to the health care institutions.

Barriers to Collaboration in Health Care

The barriers to collaboration are rooted in the hierarchal and long-established structures of most health care organizations and are difficult to change. The nurse- physician relationship is one example of an established hierar- chal relationship that has been a barrier to true collaboration in health care facilities. Hojat and colleagues (2001) conducted a cross-cultural study evaluating nurse-physician attitudes toward collaboration and found nurses in both the United States and Mexico expressed more positive attitudes toward collaboration than their physician counterparts (p<0.01). As a possible solution, the authors recommended inter-professional education to improve nurse-physi – cian collaboration.

Empirically the link between collaboration and improved pa – tient and system outcomes has been demonstrated, but there re – mains a gap in the literature on how to create a collaborative envi- ronment. This study begins to fill the gap by looking at a large scale change of care delivery based on essential collaborative structures and processes and its impact at the patient, hospital, and system levels.

Theoretical Framework The Donabedian Model (1966)

is proposed as a way of providing essential structures and processes for collaboration in the health care setting. The model was used to provide a comprehensive struc- ture to move from inputs through the process of care delivery, and conclude with the outcomes for this study.