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Principles of Successful Partnerships Kara Mangold, MS, RN-BC, CCTN; Nancy J. Denke, DNP, FNP-BC, ACNP-BC, FAEN; Deb Gorombei, MS, RN, CFRN, LNCC; Tammy L. Ostroski, MSN, APRN, FNP-BC; Lynda Root, DNP, RN, PMHCNS-BC Health care providers must understand and value the unique contributions of all interdisciplinary professionals, with the goal of optimizing the wellness or illness needs of each patient. Work cannot be done in silos, and the ability to develop and sustain effective professional partnerships is essential. Health care teams must work within a complex environment that depends on the shared efforts of multiple professionals to successfully provide care in a fragmented, highly stressed system. Implementing partnerships that foster relationships through shared interests, vision, and values can aid in the coordination of resources to provide a more positive patient experience and outcome. The development of partnerships requires time and acceptance of shared risks and responsibilities. In return, involved parties will be able to build trust, share rewards, and expand the possibilities of what can be accomplished. The purpose of this review is to describe results-oriented partnerships, which include the attributes of collaboration, coordination, and communication. Essential concepts and practical tools for success are reviewed to offer new and existing partnerships a lens through which to view interdisciplinary interactions that can contribute to organizational success and longevity. Potential pitfalls that may impact patient services and organizational health are also discussed. Key words: collaboration, communication, coordination, multidisciplinary care team, professional partnership
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ROVIDING seamless, high-quality, affordable care to patients and families is a priority for health care leaders. The development and implementation of effective professional partnerships are essential in health care services.1 Patients often present with multiple problems requiring ongoing care from many disciplines. Health care teams must work within a complex environment that depends on collaborative and coordinated prac-
Author Affiliation: Arizona State University College of Nursing and Health Innovation, Phoenix. No funding was received for this article. The authors declare no conflict of interest. Correspondence: Kara Mangold, MS, RN-BC, CCTN, Arizona State University College of Nursing and Health Innovation, 550 N. 3rd St, Phoenix, AZ 85004 ([email protected]). DOI: 10.1097/NAQ.0000000000000034
tice. Health care delivery is moving toward the creation of Patient-Centered Medical Homes, the goal of which is to provide comprehensive, patient-centered care that is coordinated, accessible, high quality, and safe.2 The complexity of today’s working conditions often precludes a single provider from meeting all patients’ needs.3 Patient-Centered Medical Homes include interdisciplinary partnerships to more efficiently meet the needs of patients, families, and organizations and to improve patient outcomes by reducing fragmentation of care.4 Professional partnerships in health care are influenced by the context of the situation and the resources committed to the partnership. The nature of partnerships can vary and will likely change to adapt and meet the needs of patients and the health care system. Nursing and other health care leaders with knowledge
340 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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Principles of Successful Partnerships of the fundamentals of successful partnerships will be able to navigate through the dynamic challenges presented within the everchanging health care system. Therefore, the purpose of this review was to describe the fundamentals of successful health care partnerships. Essential partnership attributes of collaboration, coordination, and communication are explored in detail. Recommendations for developing and sustaining successful partnerships are examined. PARTNERSHIPS Partnerships are much more than an association of individuals; they are an interpersonal relationship between 2 or more individuals working toward a mutually defined goal.5 Shared knowledge and reciprocal respect are used to coordinate performance so that goals and objectives can be established, met, and sustained.5,6 All team members work together to effectively coordinate the operations, processes, and performances of the collective team. Individual strengths and abilities are optimized through careful coordination of multiple professional services and discussion of team interdependencies to ensure that the right team members are engaged and supported at the correct times.7 Nurses frequently use partnerships to coordinate patient care. A partnership is necessary when a mother has given birth and experiences unexpected cardiac complications. While the patient clearly needs nursing care provided by both obstetrical and cardiac nursing specialties, careful consideration and planning must be given to which nurse will provide what type of care and under what conditions. Establishing the rules of engagement and role delineation in this case is particularly important, as there will be overlapping scope of practice issues between the 2 nurses. A clear communication and handoff plan is essential for safe and effective delivery of care. Differing cultures, training, social status, and the use of language and jargon are challenges to any health care partnership.8 These challenges can be minimized with the identification of a common vision and the com-
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munication of a well-defined pathway to goal attainment.9 Alignment of priorities as well as communication and leadership styles will facilitate productive relationships and create a positive social context for interaction.8,10 Over the last decade, many initiatives have come forth to improve the quality and safety of patient care while attempting to reduce health care costs. To prepare health care professionals with the skills necessary to work in an environment that engages one another in collaborative patient-centered problem solving, an increased emphasis on interprofessional education (IPE) has emerged. With IPE, interprofessional learning activities are specifically developed to foster understanding of professional roles and the contributions of each discipline to patient outcomes. Ideally, IPE begins during initial preparation for practice and continues in professional practice settings by encouraging disciplines to learn “with, from, and about” each other.11(p212) Interprofessional education presents an opportunity to learn in an environment that embraces the reality of collaborative practice by bringing together multiple disciplines for training as well as nurturing the development of mutual respect. Effective partnerships exist when collaboration, coordination, and communication are present (Table).
COLLABORATION Successful partnerships require strong collaborative efforts from all members. Collaboration fosters a practice environment that brings people of diverse backgrounds and interests together to share ideas, risks, and responsibilities in order to build consensus and achieve a common goal.12 This collaborative practice environment allows for a “synergistic influence of grouped knowledge and skills” that provides the best care and outcomes.13(p3) A hallmark of successful collaboration is the presence of ongoing, dynamic communication that can increase not only accessibility to care but also lead to proactive and timely implementation of health care services.14,15
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Table. Key Attributes of Effective Partnerships Principals Collaboration
Coordination
Communication
Key Attributes Ongoing process and dynamic Provides for an understanding of health care roles Supports active participation in decision making Maintains shared responsibility for outcomes Increases outcome efficiency and effectiveness Decreases duplication of efforts Team performance is greater than the sum of it is parts Contributes to a shared mental model Critical to meeting goals Exchange of information for mutual benefits Shares critical and essential information Clarifies assumptions Produces positive outcomes, increasing patient well-being Increases knowledge Increases efficiency of information sharing
Challenges in collaboration should be recognized and may include disconnects in time and distance among members of a health care team, role and scope of practice confusion, lack of respect, and poor communication.16,17 Anticipating and working to prevent or minimize challenges are important. A clear definition of the problem is the first step in tackling challenges within collaboration.18 Understanding each team member’s role and scope of practice on a team is essential.19 In circumstances when roles or scope of practice overlap, clear communication, role delineation, and follow-through regarding responsibility are crucial. The essential elements for a successful collaborative practice can be used by health care teams to improve collaborative efforts.13 The first step toward collaboration is when team members actively participate in decision making and accept accountability by sharing responsibility for outcomes. Coordination of these collaboration efforts increases efficiency and effectiveness by fostering joint decisions. Duplication of effort is minimized, and care flows smoothly. Clear communication clarifies assumptions and potential misperceptions that can occur at any point during a collaborative effort.
Members of the health care team must relinquish “turf” wars and, instead, communicate information that is essential for positive outcomes, respecting each individual’s roles and responsibilities. A culture that values cooperation and respects professional opinions and viewpoints will have a positive impact on collaboration. Members of the team must feel comfortable speaking up in an assertive, respectful manner. A level of mutual trust and respect will bind the team together and allow for confidence in the autonomous decisions made by individual members.13 It is important to consider patterns of interaction between the physical environment, work processes, organizational culture, and technology and the roles that each of these elements play on the effectiveness of the health care team.20 Environmental factors, which include eco-diversity, spatial transparency, functional inconvenience, human scale, and neutral zones, should be considered when designing space for teamwork. Ecodiversity is when the layout and design of the workplace are set up in a way that allows for both spontaneous and planned interactions.20 Spatial transparency allows employees to have the ability to see and hear what others are doing, thus allowing for more
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Principles of Successful Partnerships opportunities to share information.20 The concept of functional inconvenience suggests that learning and interaction might be higher in organizations where employees do not have designated work spaces.20 This type of setup provides opportunities for chance encounters with a wider circle of people, opening up the possibility for increased collaboration. In addition, the opportunities for informal learning and interaction between team members may be higher when teams are organized into smaller spaces, a concept Becker20 identifies as human scale. The final element to consider is to establish neutral zones.20 These zones are established to eliminate environmental cues that convey hierarchal status of individuals and opens up barriers to free flow of information and interaction that will promote collaboration. An example of this element is a workspace that has private offices for physicians but shared workspaces for all other members of the health care team. Neutral zones serve to eliminate hierarchies and create an environment for open communication and chance encounters.20 While all of these suggestions may not be feasible considering the current physical space and availability of resources, health care teams striving for improved collaboration should consider ways to creatively incorporate some of these principles. COORDINATION The premise of coordination in professional partnerships is that the performance of the team is greater than the sum of individual members.21 Coordination is the act of working together to achieve a shared, mutual goal by orchestrating the sequence and timing of independent actions.22 Coordination requires adjustments be made to the environment (practice or administrative) and then organization of the sequence and timing of interdependent actions for common outcomes can occur.13 Partnerships that are well coordinated run smoothly and have the potential to increase the effectiveness and efficiency of health care delivery.
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Coordination requires a shared mental model, closed loop communication, and mutual trust. A shared mental model exists when formal or informal relationships are able to synchronize operations or activities to make services more accessible and less redundant.23,24 Closed loop communication ensures that all are operating under the same goals and plan, balancing conflict and cooperation to achieve overall goals. It also serves to manage interdependencies between activities performed to achieve a goal.25 As tasks become more complex and the number of team members increase, the coordination of efforts is increasingly critical to meet goals.26 Achieving a well-coordinated team can be difficult. Obstacles to coordination efforts include poor planning, lack of leadership, role uncertainty, lack of interpersonal links between team members, conflicting professional values, competing demands, lack of trust, and lack of commitment by team members.23,25,27-29 However, wellfacilitated coordination is worth the effort. Well-coordinated teams can mitigate the effects of high workloads and stress by fostering adaptability and event management.27,28,30 Effective working relationships that exhibit sound communication, role clarity, adaptive behaviors, social connectedness, and professional knowledge facilitate coordination.21,27,28,31,32 The facilitation of coordination is impacted by health care leaders. Leadership that is able to organize and synchronize member efforts is essential for coordination to be successful.21,32 Leaders must promote team learning and understand the goals of the team in relation to the larger organization.13 Teams with strong coordination exchange information and modify activities for mutual benefit to achieve a common purpose; in health care, this translates to the delivery of safe and optimal patient care.23 Coordination is critical for optimal performance, resulting in the efficient use of resources and practice standardization.21,31 Coordination improves health care outcomes
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and decreases adverse events, resulting in fewer errors and more timely care delivery.28,33 In well-coordinated partnerships, decision making requires less time and there is a reduction in nonproductive downtime, as there is more concise communication between team members.28,33 The concept of primary care teams is critical to primary care practices’ coordination efforts. While most teams are somewhat informal, a clinic in Colorado has demonstrated how an organized coordinated team approach to care can improve outcomes and patient satisfaction. Clinica Campesina has organized into pods. These pods consist of a smaller group of clinical and administrative individuals with designated patient panels. Assigning patients to a pod increases continuity, and consistency of care to a set of care providers improves the ability to foster mutual relationships and accountability in care. This coordinated team approach improves outcomes, patient satisfaction, continuity, and coordination of care.34 An additional example of exemplary coordination occurs in primary care practice. A patient comes to the clinic to follow up on recent changes made to his diabetic and hypertension regimens. The patient reports a recent onset of painful, burning urination to the receptionist. Knowing that a nurse practitioner other than the one the patient is scheduled to see, but familiar to the patient, just had a schedule cancellation, the receptionist instead has this nurse practitioner see the patient. The nurse practitioner evaluates the patient and orders a urine culture. The results are ready to review with the patient when meeting with the nurse practitioner the appointment was initially scheduled with. This coordinated effort between the receptionist and 2 nurse practitioners in the practice ensured more efficient and timely provision of care. COMMUNICATION The concept of communication is an integral component of successful partnerships and is clearly interwoven throughout the con-
cepts of collaboration and coordination. Communication must be meaningful and timely, serving to increase knowledge and/or influence behavior.35,36 Communication functions to exchange information, respond to emotions, manage uncertainty, foster relationships, and make decisions.37 A variety of communication tools are available. It is important that all individuals in a partnership come to an agreement about which tools to use as well as how and when to use them in a professional manner. This includes establishing expectations and enforcing guidelines for the use of the electronic medical record, e-mail, cellular telephones, text messages, paging systems, and medical imaging technology. Professional partnerships must strive for high-quality, time-efficient communication. Efficient sharing of information allows for synchronization of work by coordinating schedules and availabilities.33,38 Characteristics of high-quality communication include the ability to see others’ points of view, use of language that is understood by all, and speech clarity appropriate for the situation. Silence and listening are also integral to effective communication.39 Effective 2-way communication using a feedback loop enhances a patient’s understanding of care and improves satisfaction, rapport, and trust with health care team members. More importantly, it allows the patient to feel acknowledged and to have a voice in health care decisions. Organizations that support ongoing patient communication facilitate increased access to care, as well as appropriate social and psychological support, and are better equipped to enable patients to learn and practice self-care skills. Ultimately, these can result in improved patient wellbeing, increased functional ability, vitality, and survival.37 Obstacles to honest communication include a desire to appear “good” and avoid criticism. As a result, positive actions and outcomes can be overreported and negative actions can be underreported.40 Electronic medical record templates may trigger the documentation of standard information but may overlook other rich information that could
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Principles of Successful Partnerships be used to enhance comprehensive care.40 Fast-paced, resource-limited, and timeconstricted settings can all impair effective communication; however, the appropriate use of technology and coordination efforts may help automate processes and ease the burden of limited resources and high patient volumes.41 It is imperative that leaders cultivate an organizational climate and culture valuing strong communication.41 Resources must be devoted to education and training that not only focus on the technical and clinical aspects of health care but also emphasize human interaction, communication techniques, and the development of team cognition in decision making.3 Communication techniques that are brief, yet cover comprehensive information and follow a consistent format, increase the likelihood of high-quality, effective communication.40,41 An example of this is the use of the SBAR (situation, background, assessment, recommendation) format. A failure in communication and coordination can lead to delay or omissions in decision making and poor patient outcomes.3 It is paramount that leadership prioritizes and provides tangible resources that foster quality communication, such as appropriate funding for the use of communication tools and technology. As new technologies or challenges are presented, leaders must continually evaluate and embrace methods that can be implemented to sustain effective communication in a complex health care environment.23,33 Although procedures, staffing numbers, and high patient volumes contribute significantly to an organization’s bottom line, advanced practitioners must work to shift the focus on nonbillable constructs such as communication planning and monitoring as well as measuring team communication effectiveness and efficiency. Communication must be seen as a critical factor to facilitate complex and comprehensive patient care and outcomes, achievement of bottom line targets, and a high-quality, sustainable organization.
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PUTTING IT ALL TOGETHER An interprofessional collaborative practice partnership is defined as “a partnership between a team of health professionals and a patient in a participatory, collaborative, and coordinated approach to shared decisionmaking around health and social issues.”31(p58) The Patient-Centered Medical Home model is just that type of health care partnership. Patient-Centered Medical Homes are a promising way to improve the United States health care system by changing how care is organized and delivered. This would not be possible without effective professional partnerships that involve not only health care teams within a single organization or group but also the ability to connect externally, reaching beyond professional and organizational boundaries to provide requisite patient resources and quality care. In addition, a tandem collaborative management team can be beneficial to patients and their families in the delivery of patient care.14 Patient-oriented, holistic care not only strengthens the care provided but also supports self-care in preventive and chronic illness. As health care professionals, we must ensure that this comprehensive care takes place while working in coordinated partnerships that communicate and address these complex and challenging issues and needs. CONCLUSION As the health care environment becomes increasingly complex, it is imperative that professional partnerships be formed and sustained to meet the needs of patients and an overstressed health care system. Attributes of successful professional partnerships in health care include collaboration, coordination, and communication. An exploration of these concepts, along with strategies for success, was reviewed in an effort to equip health care leaders and practitioners with the knowledge needed to establish and sustain effective partnerships. Health care leaders must ensure that
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comprehensive care is practiced to meet the outcomes and goals of patients. This compre-
hensive care requires coordinated, collaborative practice.
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13. Way D, Jones L, Busing N. Implementation Strategies: Collaboration in Primary Care—Family Doctors & Nurse Practitioners Delivering Shared Care. Toronto, ON, Canada: The Ontario College of Family Physicians; 2000:1-10. 14. Herrmann LL, Zabramski JM. Tandem practice model: a model for physician-NP collaboration in a specialty practice, neurosurgery. J Am Acad Nurse Pract. 2005;17(6):213-218. 15. Salas E, Goodwin GF, Burke CS. Team Effectiveness in Complex Organizations: Cross-disciplinary Perspectives and Approaches. New York, NY: Psychology Press; 2009. 16. Hallas DM, Butz A, Gitterman B. Attitudes and beliefs for effective pediatric NP and physician collaboration. J Pediatr Healthc. 2004;18(2):77-86. 17. Stamps J, Lipnack J. Communicate, collaborate, coordinate, decide: how IT achieves strategic leadership. Cutter IT J. 2008;21(11):21-28. 18. Von Korff M, Gruman J, Schaefer J, Curry SJ, Wagner EH. Collaborative management of chronic illness. Ann Intern Med. 1997;127(12):1097-1102. 19. Bridges DR, Davidson RA, Odegard PS, Maki IV, Tomkowiak J. Interprofessional collaboration: three best practice models of interprofessional education. Med Educ Online. 2011;16:6035. doi:10.3402/meo.v16i0.6035. 20. Becker F. Organizational ecology and knowledge networks. Calif Manage Rev. 2007;49(2):42-63. 21. Kolbe M, Grande B. Team coordination during cardiopulmonary resuscitation. J Crit Care. 2013;28(4):522-523. 22. Marks MA, Mathieu JE, Zaccaro SJ. A temporally based framework and taxonomy of team processes. Acad Manage Rev. 2001;26(3):356-376. http:// login.ezproxy1.lib.asu.edu/login?url=http://search .proquest.com/docview/210978387?accountid=4485. Accessed February 4, 2014. 23. Himmelman AT. Collaboration for a change: definitions, decision-making models, roles, and collaboration process guide. http://depts.washington.edu/ ccph/pdf files/4achange.pdf. Published 2002. Accessed February 4, 2014. 24. Gardner DB. Ten lessons in collaboration. Online J Issues Nurs. 2005;10(1). doi:10.3912/OJIN .Vol10No01Man01. 25. Malone TW, Crowston K. The interdisciplinary study of coordination. ACM Comput Surv. 1994;26(1):87119. doi:10.1145/174666.174668. 26. Espinosa A, Lerch J, Kraut R. Explicit vs. implicit coordination mechanisms and task dependencies:
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one size does not fit all. In:Salas E, Fiore SM, Cannon-Bowers JA, eds Team Cognition: Process and Performance at the Inter- and Intra-individual Level. Pittsburgh, PA: Carnegie Mellon University; 2002. http://kraut.hciresearch.org/sites/kraut.hci research.org/files/articles/Espinosa03-Explicit VsImplicitCoordination.pdf. Abbasi A, Owen C, Hossain L, Hamra J. Social connectedness and adaptive team coordination during fire events. Fire Saf J. 2013;59:30-36. Entin E, Serfaty D. Adaptive team coordination. Hum Factors. 1999;41(2):312-325. Hall WA, Long B, Bermbach N, Jordan S, Patterson K. Qualitative teamwork issues and strategies: coordination through mutual adjustment. Qual Health Res. 2005;15(3):394-410. doi:10.1177/1049732304272015. McCarthy D, Ellison E, Venkatesh A, et al. Emergency department team communication with the patient: the patient’s perspective. J Emerg Med. 2013;45(2):262-270. Orchard CA, King GA, Khalili H, Bezzina MB. Assessment of interprofessional team collaboration scale (AITCS): development and testing of the instrument. J Contin Educ Health Prof. 2012;32(1):58-67. doi:10.1002/chp.21123. Fernandez Castelao E, Russo SG, Riethm¨ uller M, Boos M. Effects of team coordination during cardiopulmonary resuscitation: a systematic review of the literature. J Crit Care. 2013;28(4):504. doi:10.1016/j.jcrc.2013.01.005. Zorich DM, Waibel G, Erway R. Beyond the silos of LAM: collaboration among libraries, archives and museums. http://www.oclc.org/content/dam/
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Nurs Admin Q Vol. 38, No. 4, pp. 340–347 c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright
Principles of Successful Partnerships Kara Mangold, MS, RN-BC, CCTN; Nancy J. Denke, DNP, FNP-BC, ACNP-BC, FAEN; Deb Gorombei, MS, RN, CFRN, LNCC; Tammy L. Ostroski, MSN, APRN, FNP-BC; Lynda Root, DNP, RN, PMHCNS-BC Health care providers must understand and value the unique contributions of all interdisciplinary professionals, with the goal of optimizing the wellness or illness needs of each patient. Work cannot be done in silos, and the ability to develop and sustain effective professional partnerships is essential. Health care teams must work within a complex environment that depends on the shared efforts of multiple professionals to successfully provide care in a fragmented, highly stressed system. Implementing partnerships that foster relationships through shared interests, vision, and values can aid in the coordination of resources to provide a more positive patient experience and outcome. The development of partnerships requires time and acceptance of shared risks and responsibilities. In return, involved parties will be able to build trust, share rewards, and expand the possibilities of what can be accomplished. The purpose of this review is to describe results-oriented partnerships, which include the attributes of collaboration, coordination, and communication. Essential concepts and practical tools for success are reviewed to offer new and existing partnerships a lens through which to view interdisciplinary interactions that can contribute to organizational success and longevity. Potential pitfalls that may impact patient services and organizational health are also discussed. Key words: collaboration, communication, coordination, multidisciplinary care team, professional partnership
P
ROVIDING seamless, high-quality, affordable care to patients and families is a priority for health care leaders. The development and implementation of effective professional partnerships are essential in health care services.1 Patients often present with multiple problems requiring ongoing care from many disciplines. Health care teams must work within a complex environment that depends on collaborative and coordinated prac-
Author Affiliation: Arizona State University College of Nursing and Health Innovation, Phoenix. No funding was received for this article. The authors declare no conflict of interest. Correspondence: Kara Mangold, MS, RN-BC, CCTN, Arizona State University College of Nursing and Health Innovation, 550 N. 3rd St, Phoenix, AZ 85004 ([email protected]). DOI: 10.1097/NAQ.0000000000000034
tice. Health care delivery is moving toward the creation of Patient-Centered Medical Homes, the goal of which is to provide comprehensive, patient-centered care that is coordinated, accessible, high quality, and safe.2 The complexity of today’s working conditions often precludes a single provider from meeting all patients’ needs.3 Patient-Centered Medical Homes include interdisciplinary partnerships to more efficiently meet the needs of patients, families, and organizations and to improve patient outcomes by reducing fragmentation of care.4 Professional partnerships in health care are influenced by the context of the situation and the resources committed to the partnership. The nature of partnerships can vary and will likely change to adapt and meet the needs of patients and the health care system. Nursing and other health care leaders with knowledge
340 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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Principles of Successful Partnerships of the fundamentals of successful partnerships will be able to navigate through the dynamic challenges presented within the everchanging health care system. Therefore, the purpose of this review was to describe the fundamentals of successful health care partnerships. Essential partnership attributes of collaboration, coordination, and communication are explored in detail. Recommendations for developing and sustaining successful partnerships are examined. PARTNERSHIPS Partnerships are much more than an association of individuals; they are an interpersonal relationship between 2 or more individuals working toward a mutually defined goal.5 Shared knowledge and reciprocal respect are used to coordinate performance so that goals and objectives can be established, met, and sustained.5,6 All team members work together to effectively coordinate the operations, processes, and performances of the collective team. Individual strengths and abilities are optimized through careful coordination of multiple professional services and discussion of team interdependencies to ensure that the right team members are engaged and supported at the correct times.7 Nurses frequently use partnerships to coordinate patient care. A partnership is necessary when a mother has given birth and experiences unexpected cardiac complications. While the patient clearly needs nursing care provided by both obstetrical and cardiac nursing specialties, careful consideration and planning must be given to which nurse will provide what type of care and under what conditions. Establishing the rules of engagement and role delineation in this case is particularly important, as there will be overlapping scope of practice issues between the 2 nurses. A clear communication and handoff plan is essential for safe and effective delivery of care. Differing cultures, training, social status, and the use of language and jargon are challenges to any health care partnership.8 These challenges can be minimized with the identification of a common vision and the com-
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munication of a well-defined pathway to goal attainment.9 Alignment of priorities as well as communication and leadership styles will facilitate productive relationships and create a positive social context for interaction.8,10 Over the last decade, many initiatives have come forth to improve the quality and safety of patient care while attempting to reduce health care costs. To prepare health care professionals with the skills necessary to work in an environment that engages one another in collaborative patient-centered problem solving, an increased emphasis on interprofessional education (IPE) has emerged. With IPE, interprofessional learning activities are specifically developed to foster understanding of professional roles and the contributions of each discipline to patient outcomes. Ideally, IPE begins during initial preparation for practice and continues in professional practice settings by encouraging disciplines to learn “with, from, and about” each other.11(p212) Interprofessional education presents an opportunity to learn in an environment that embraces the reality of collaborative practice by bringing together multiple disciplines for training as well as nurturing the development of mutual respect. Effective partnerships exist when collaboration, coordination, and communication are present (Table).
COLLABORATION Successful partnerships require strong collaborative efforts from all members. Collaboration fosters a practice environment that brings people of diverse backgrounds and interests together to share ideas, risks, and responsibilities in order to build consensus and achieve a common goal.12 This collaborative practice environment allows for a “synergistic influence of grouped knowledge and skills” that provides the best care and outcomes.13(p3) A hallmark of successful collaboration is the presence of ongoing, dynamic communication that can increase not only accessibility to care but also lead to proactive and timely implementation of health care services.14,15
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Table. Key Attributes of Effective Partnerships Principals Collaboration
Coordination
Communication
Key Attributes Ongoing process and dynamic Provides for an understanding of health care roles Supports active participation in decision making Maintains shared responsibility for outcomes Increases outcome efficiency and effectiveness Decreases duplication of efforts Team performance is greater than the sum of it is parts Contributes to a shared mental model Critical to meeting goals Exchange of information for mutual benefits Shares critical and essential information Clarifies assumptions Produces positive outcomes, increasing patient well-being Increases knowledge Increases efficiency of information sharing
Challenges in collaboration should be recognized and may include disconnects in time and distance among members of a health care team, role and scope of practice confusion, lack of respect, and poor communication.16,17 Anticipating and working to prevent or minimize challenges are important. A clear definition of the problem is the first step in tackling challenges within collaboration.18 Understanding each team member’s role and scope of practice on a team is essential.19 In circumstances when roles or scope of practice overlap, clear communication, role delineation, and follow-through regarding responsibility are crucial. The essential elements for a successful collaborative practice can be used by health care teams to improve collaborative efforts.13 The first step toward collaboration is when team members actively participate in decision making and accept accountability by sharing responsibility for outcomes. Coordination of these collaboration efforts increases efficiency and effectiveness by fostering joint decisions. Duplication of effort is minimized, and care flows smoothly. Clear communication clarifies assumptions and potential misperceptions that can occur at any point during a collaborative effort.
Members of the health care team must relinquish “turf” wars and, instead, communicate information that is essential for positive outcomes, respecting each individual’s roles and responsibilities. A culture that values cooperation and respects professional opinions and viewpoints will have a positive impact on collaboration. Members of the team must feel comfortable speaking up in an assertive, respectful manner. A level of mutual trust and respect will bind the team together and allow for confidence in the autonomous decisions made by individual members.13 It is important to consider patterns of interaction between the physical environment, work processes, organizational culture, and technology and the roles that each of these elements play on the effectiveness of the health care team.20 Environmental factors, which include eco-diversity, spatial transparency, functional inconvenience, human scale, and neutral zones, should be considered when designing space for teamwork. Ecodiversity is when the layout and design of the workplace are set up in a way that allows for both spontaneous and planned interactions.20 Spatial transparency allows employees to have the ability to see and hear what others are doing, thus allowing for more
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Principles of Successful Partnerships opportunities to share information.20 The concept of functional inconvenience suggests that learning and interaction might be higher in organizations where employees do not have designated work spaces.20 This type of setup provides opportunities for chance encounters with a wider circle of people, opening up the possibility for increased collaboration. In addition, the opportunities for informal learning and interaction between team members may be higher when teams are organized into smaller spaces, a concept Becker20 identifies as human scale. The final element to consider is to establish neutral zones.20 These zones are established to eliminate environmental cues that convey hierarchal status of individuals and opens up barriers to free flow of information and interaction that will promote collaboration. An example of this element is a workspace that has private offices for physicians but shared workspaces for all other members of the health care team. Neutral zones serve to eliminate hierarchies and create an environment for open communication and chance encounters.20 While all of these suggestions may not be feasible considering the current physical space and availability of resources, health care teams striving for improved collaboration should consider ways to creatively incorporate some of these principles. COORDINATION The premise of coordination in professional partnerships is that the performance of the team is greater than the sum of individual members.21 Coordination is the act of working together to achieve a shared, mutual goal by orchestrating the sequence and timing of independent actions.22 Coordination requires adjustments be made to the environment (practice or administrative) and then organization of the sequence and timing of interdependent actions for common outcomes can occur.13 Partnerships that are well coordinated run smoothly and have the potential to increase the effectiveness and efficiency of health care delivery.
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Coordination requires a shared mental model, closed loop communication, and mutual trust. A shared mental model exists when formal or informal relationships are able to synchronize operations or activities to make services more accessible and less redundant.23,24 Closed loop communication ensures that all are operating under the same goals and plan, balancing conflict and cooperation to achieve overall goals. It also serves to manage interdependencies between activities performed to achieve a goal.25 As tasks become more complex and the number of team members increase, the coordination of efforts is increasingly critical to meet goals.26 Achieving a well-coordinated team can be difficult. Obstacles to coordination efforts include poor planning, lack of leadership, role uncertainty, lack of interpersonal links between team members, conflicting professional values, competing demands, lack of trust, and lack of commitment by team members.23,25,27-29 However, wellfacilitated coordination is worth the effort. Well-coordinated teams can mitigate the effects of high workloads and stress by fostering adaptability and event management.27,28,30 Effective working relationships that exhibit sound communication, role clarity, adaptive behaviors, social connectedness, and professional knowledge facilitate coordination.21,27,28,31,32 The facilitation of coordination is impacted by health care leaders. Leadership that is able to organize and synchronize member efforts is essential for coordination to be successful.21,32 Leaders must promote team learning and understand the goals of the team in relation to the larger organization.13 Teams with strong coordination exchange information and modify activities for mutual benefit to achieve a common purpose; in health care, this translates to the delivery of safe and optimal patient care.23 Coordination is critical for optimal performance, resulting in the efficient use of resources and practice standardization.21,31 Coordination improves health care outcomes
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and decreases adverse events, resulting in fewer errors and more timely care delivery.28,33 In well-coordinated partnerships, decision making requires less time and there is a reduction in nonproductive downtime, as there is more concise communication between team members.28,33 The concept of primary care teams is critical to primary care practices’ coordination efforts. While most teams are somewhat informal, a clinic in Colorado has demonstrated how an organized coordinated team approach to care can improve outcomes and patient satisfaction. Clinica Campesina has organized into pods. These pods consist of a smaller group of clinical and administrative individuals with designated patient panels. Assigning patients to a pod increases continuity, and consistency of care to a set of care providers improves the ability to foster mutual relationships and accountability in care. This coordinated team approach improves outcomes, patient satisfaction, continuity, and coordination of care.34 An additional example of exemplary coordination occurs in primary care practice. A patient comes to the clinic to follow up on recent changes made to his diabetic and hypertension regimens. The patient reports a recent onset of painful, burning urination to the receptionist. Knowing that a nurse practitioner other than the one the patient is scheduled to see, but familiar to the patient, just had a schedule cancellation, the receptionist instead has this nurse practitioner see the patient. The nurse practitioner evaluates the patient and orders a urine culture. The results are ready to review with the patient when meeting with the nurse practitioner the appointment was initially scheduled with. This coordinated effort between the receptionist and 2 nurse practitioners in the practice ensured more efficient and timely provision of care. COMMUNICATION The concept of communication is an integral component of successful partnerships and is clearly interwoven throughout the con-
cepts of collaboration and coordination. Communication must be meaningful and timely, serving to increase knowledge and/or influence behavior.35,36 Communication functions to exchange information, respond to emotions, manage uncertainty, foster relationships, and make decisions.37 A variety of communication tools are available. It is important that all individuals in a partnership come to an agreement about which tools to use as well as how and when to use them in a professional manner. This includes establishing expectations and enforcing guidelines for the use of the electronic medical record, e-mail, cellular telephones, text messages, paging systems, and medical imaging technology. Professional partnerships must strive for high-quality, time-efficient communication. Efficient sharing of information allows for synchronization of work by coordinating schedules and availabilities.33,38 Characteristics of high-quality communication include the ability to see others’ points of view, use of language that is understood by all, and speech clarity appropriate for the situation. Silence and listening are also integral to effective communication.39 Effective 2-way communication using a feedback loop enhances a patient’s understanding of care and improves satisfaction, rapport, and trust with health care team members. More importantly, it allows the patient to feel acknowledged and to have a voice in health care decisions. Organizations that support ongoing patient communication facilitate increased access to care, as well as appropriate social and psychological support, and are better equipped to enable patients to learn and practice self-care skills. Ultimately, these can result in improved patient wellbeing, increased functional ability, vitality, and survival.37 Obstacles to honest communication include a desire to appear “good” and avoid criticism. As a result, positive actions and outcomes can be overreported and negative actions can be underreported.40 Electronic medical record templates may trigger the documentation of standard information but may overlook other rich information that could
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Principles of Successful Partnerships be used to enhance comprehensive care.40 Fast-paced, resource-limited, and timeconstricted settings can all impair effective communication; however, the appropriate use of technology and coordination efforts may help automate processes and ease the burden of limited resources and high patient volumes.41 It is imperative that leaders cultivate an organizational climate and culture valuing strong communication.41 Resources must be devoted to education and training that not only focus on the technical and clinical aspects of health care but also emphasize human interaction, communication techniques, and the development of team cognition in decision making.3 Communication techniques that are brief, yet cover comprehensive information and follow a consistent format, increase the likelihood of high-quality, effective communication.40,41 An example of this is the use of the SBAR (situation, background, assessment, recommendation) format. A failure in communication and coordination can lead to delay or omissions in decision making and poor patient outcomes.3 It is paramount that leadership prioritizes and provides tangible resources that foster quality communication, such as appropriate funding for the use of communication tools and technology. As new technologies or challenges are presented, leaders must continually evaluate and embrace methods that can be implemented to sustain effective communication in a complex health care environment.23,33 Although procedures, staffing numbers, and high patient volumes contribute significantly to an organization’s bottom line, advanced practitioners must work to shift the focus on nonbillable constructs such as communication planning and monitoring as well as measuring team communication effectiveness and efficiency. Communication must be seen as a critical factor to facilitate complex and comprehensive patient care and outcomes, achievement of bottom line targets, and a high-quality, sustainable organization.
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PUTTING IT ALL TOGETHER An interprofessional collaborative practice partnership is defined as “a partnership between a team of health professionals and a patient in a participatory, collaborative, and coordinated approach to shared decisionmaking around health and social issues.”31(p58) The Patient-Centered Medical Home model is just that type of health care partnership. Patient-Centered Medical Homes are a promising way to improve the United States health care system by changing how care is organized and delivered. This would not be possible without effective professional partnerships that involve not only health care teams within a single organization or group but also the ability to connect externally, reaching beyond professional and organizational boundaries to provide requisite patient resources and quality care. In addition, a tandem collaborative management team can be beneficial to patients and their families in the delivery of patient care.14 Patient-oriented, holistic care not only strengthens the care provided but also supports self-care in preventive and chronic illness. As health care professionals, we must ensure that this comprehensive care takes place while working in coordinated partnerships that communicate and address these complex and challenging issues and needs. CONCLUSION As the health care environment becomes increasingly complex, it is imperative that professional partnerships be formed and sustained to meet the needs of patients and an overstressed health care system. Attributes of successful professional partnerships in health care include collaboration, coordination, and communication. An exploration of these concepts, along with strategies for success, was reviewed in an effort to equip health care leaders and practitioners with the knowledge needed to establish and sustain effective partnerships. Health care leaders must ensure that
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comprehensive care is practiced to meet the outcomes and goals of patients. This compre-
hensive care requires coordinated, collaborative practice.
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