NURS FPX 4005 Assessment 3 Interdisciplinary Plan Proposal
Student name
Capella University
FPX4005
Professor Name
Submission Date
Interdisciplinary Plan Proposal
Successful care transitions are vital in hospital settings in order to keep patients safe, prevent readmission to the hospital, and enhance health outcomes. Inadequate transitions can lead to problems with timely care, fragmented or repeated services, and/or confusion around care plans (Marsall et al., 2024). The purpose of this proposal is to tackle the problem of poor care transitions within the hospital departments and with external health care providers, which result in sub-optimal communication and patient dissatisfaction. The plan will be carried out in the coordination/discharge patient units of Riverstone Medical Center. The desired outcome is to have an improvement in interdisciplinary collaboration, continuity of care, and outcomes of patients during transition.
Objective
This plan’s goal is to standardize the care transition process at Riverstone Medical Center with structured interdisciplinary communication tools and regular team huddles. The idea is to minimize communication failures and delays in the passages of patients from one department to another and/or from one agency to another (Sheehan et al., 2021). This goal is in line with the hospital’s overall goal of improving the continuity of care and their patient centered outcome. Ultimately, if it is successful, the plan should result in increased patient satisfaction, fewer avoidable readmissions, and improved and more efficient use of resources. In the end, it will help foster a mindset of teamwork and responsibility among teams at Riverstone Medical Center.
Change Theories and Leadership Strategies
Lewin’s Change Theory is a change theory that will be used in this change plan at Riverstone Medical Center, which entails three sections: unfreeze, change, and refreeze. During the unfreezing, staff will be informed of the existing problems associated with the care transition (delay, communication problems, etc.) to give them an idea of what needs to be changed (Stanz et al., 2021). In the transition period, standardized transition procedures will be implemented, communication tools will be used in a structured manner, and interdisciplinary team huddles will be introduced to enhance communication. Reinforcement of these new practices will be done during the final refreezing stage, which is achieved via policy changes, continuous staff training, and examination of staff performance (Stanz et al., 2021). This theory offers a clear plan for change, and can make change more palatable for employees, who are more likely to embrace it if they feel engaged in and ready for change, which can improve their compliance with the new protocol.
Bornman & Louw (2023) will be implemented as a guiding strategy, Collaborative Leadership, to support this change. On the waterfront of teamwork, the charge nurse in the Riverstone Medical Center said there were instances of a lack of communication among team members and the daily use of teamwork. What charges the nurse said she saw in the Riverstone Medical Center could be addressed by collaborative leadership: “There are some examples of lack of team communication and lack of teamwork day to day.” This approach is focused on the management of the project, shared decision making, open communication, and multi-disciplinary accountability. Leaders will involve the nurses, physicians, case managers, and allied health professionals in creating and optimizing the care transition process (Geese & Schmitt, 2023). This builds trust and inclusiveness, leading to greater staff buy-in, cross-disciplinary collaboration, and making the new protocol a part of staff practice. In the end, it is consistent with the hospital’s mission to provide “patient-centred” care with good multi-disciplinary teamwork.
Team Collaboration Strategy
This plan will focus on a collaboration method that will include interdisciplinary team-based communication and strategies. It comprises standard handoff tools such as Situation, Background, Assessment, Recommendation (SBAR), frequent interdisciplinary team “huddles”, and has well-defined care transition strategies (Fernández et al., 2022). This ensures that all those within the care bubble (nurses, doctors, case managers, allied health workers, and others) remain informed and involved in the decision-making process related to patient transitions (Fernández et al., 2022). Last but not least, whenever care transfer came up in the discussion, Riverstone Medical Center described it as a murky process with room for misunderstandings.This structured ‘handoff’ can help to establish a strong framework for enhancing continuity and coordination across care settings.
Horizontal collaboration of staff within the same level – e.g., across different shifts, across departments – is one type of collaboration and teamwork that will support this plan. It also involves vertical coordination among staff across different roles and departments, such as between the nursing staff, case management, and rehabilitation staff (Baek et al., 2023). Regular (daily or shift-based) interdisciplinary huddles will help to build a sense of shared understanding of patient care plans and provide for real-time communication. Further, by taking staff on board to co-develop and improve transition procedures, processes, and pathways, this fosters ownership and accountability, which ensures continuity of staff engagement (Bhati et al., 2023). Team members will also be able to better understand each other’s job roles with the assistance of cross-functional training sessions, which will minimize friction and increasingly effective handoff.
The partnership is a direct result of the challenges Riverstone Medical Center faced with regard to teamwork, as a value they already know and consider important to implement, but in practice, it is lacking. The plan prioritizes communication skills and habits, as well as facilitating routine and inclusive collaboration – all the things that are missing from the care transitions process today. In the end, these are the main strategies that will lead to a more uniform interdisciplinary environment and, subsequently, safer, more efficient patient transfers, along with better organizational outcomes.
Required Organizational Resources
The protocol for care transitioning is a standard protocol that will need to be implemented at Riverstone Medical Center and will require several resources in the organization. An interdisciplinary or daily huddle will require staffing to accommodate the time for nurses, physicians, case managers, and supportive allied health professionals to participate in daily training. Staff training will be required in the initial implementation process, and is estimated to be 3-5 hours per staff member. Also, it may be necessary to have a care transition coordinator or quality improvement nurse to monitor the protocol implementation, adherence to the protocol, and results. These roles can be existing staff, but they will have to drop other duties, which could involve overtime and/or temporary staff.
There are some key pieces of equipment and supplies that are required for the plan: (1) access to Electronic Health Records (EHR) systems, (2) standardized handoff tools (e.g., SBAR templates) that can be used in print or electronically, and (3) space for team meetings and huddles (Cobrado et al., 2024). Riverstone Medical Center already has an EHR system in place, meaning that big technology acquisition savings can be achieved. Optimizing the EHR for smoother and more optimized records to document care transitions will, however, require a bit of software tweaking and/or technical support, which is estimated to cost between $5-10,000. The costs of printing hand-off tools or creating or embedding them in current electronic tools would be minimal ($1,000 or less). An extra $3,000-$5,000 could be spent on staff training materials or those developed in-house or through external staff training modules.
Implementation of the plan requires a multi-departmental approach and access to various patient care units, including medical, surgical, rehabilitation, and discharge planning units (Patel & Bechmann, 2023). This isn’t anticipated to have any direct costs as it’s an internal coordination. But if there are set times dedicated to cross-department collaboration that may temporarily impact the workflow of departments, as it will need to be carefully scheduled. In total, the costs associated with this plan proposal would be the training time, minor changes in software/IT (these are estimated at $1000-$2000), and staff coordination costs (estimated at $5-$10,000), for full implementation.
The potential cost of ongoing inadequate care transitions – if the proposed plan is not implemented – could be much more substantial. Such as higher readmission rates, longer stays, waste from performing duplicate tests, and negative patient satisfaction scores, all of which have a detrimental effect on the rate of reimbursement and the reputation of the hospital (Dhaliwal & Dang, 2024). Moreover, an inability to successfully solve interdisciplinary communication problems can result in staff burnout, staff turnover, and ineffective utilization of clinical resources. These consequences would put a much greater strain on Riverstone Medical Center’s finances and operations in the long run than the initial cost it will take to implement the Care Transition Plan.
Conclusion
The interdisciplinary care transition plan that is being proposed at Riverstone Medical Center (RMC) will address some of the key issues of communication gaps and delays in care transition. The plan involves utilizing structured communication techniques, frequent interdisciplinary huddles, and Lewin’s Change Theory and collaborative leadership to foster teamwork, continuity of care, and better patient care. The key is to horizontally and vertically collaborate on the strategy, understanding and realistically estimating the resources required, from staff training, through minor IT updates and coordination efforts. If it proves to be successful, it will improve the safety, satisfaction, and efficiency of patients. On the other hand, if the strategy fails to be implemented, then it may lead to higher readmission rates, resource wastage, and other demoralization of staff, which will lead to more costs in the long term.
References
Baek, H., Han, K., Cho, H., & Ju, J. (2023). Nursing teamwork is essential in promoting patient-centered care: A cross-sectional study. BioMed Central Nursing, 22(1), 433. https://doi.org/10.1186/s12912-023-01592-3
Bhati, D., Deogade, M. S., & Kanyal, D. (2023). Improving patient outcomes through effective hospital administration: A comprehensive review. Cureus, 15(10), 1–12. https://doi.org/10.7759/cureus.47731
Bornman, J., & Louw, B. (2023). Leadership development strategies in interprofessional healthcare collaboration: A rapid review. Journal of Healthcare Leadership, 15(1), 175–192. https://doi.org/10.2147/JHL.S405983
Cobrado, U. N., Sharief, S., Regahal, N. G., Zepka, E., Mamauag, M., & Velasco, L. C. (2024). Access control solutions in electronic health record systems: A systematic review. Informatics in Medicine Unlocked, 49, 101552–101552. https://doi.org/10.1016/j.imu.2024.101552
Dhaliwal, J. S., & Dang, A. K. (2024). Reducing hospital readmissions. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK606114/
Fernández, M. C. M., Martín, S. C., Presa, C. L., Martínez, E. F., Gomes, L., & Sánchez, P. M. (2022). SBAR method for improving well-being in the internal medicine unit: Quasi-Experimental research. International Journal of Environmental Research and Public Health, 19(24), 1–13. https://doi.org/10.3390/ijerph192416813
Geese, F., & Schmitt, K.-U. (2023). Interprofessional collaboration in complex patient care transition: A qualitative multi-perspective analysis. Healthcare, 11(3), 1–14. https://doi.org/10.3390/healthcare11030359
Marsall, M., Hornung, T., Bäuerle, A., & Weigl, M. (2024). Quality of care transition, patient safety incidents, and patients’ health status: A structural equation model on the complexity of the discharge process. BioMed Central Health Services Research, 24(1). https://doi.org/10.1186/s12913-024-11047-3
McGilton, K. S., Krassikova, A., Wills, A., Bethell, J., Boscart, V., Pinol, E. A., Iaboni, A., Vellani, S., Maxwell, C., Keatings, M., Stewart, S. C., & Sidani, S. (2023). Nurse practitioner-led implementation of huddles for staff in long-term care homes during the COVID-19 pandemic. BioMed Central Geriatrics, 23, 713. https://doi.org/10.1186/s12877-023-04382-3
Patel, P., & Bechmann, S. (2023, April 3). Discharge planning. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK557819/
Sheehan, J., Laver, k, Bhopti, A., Rahja, M., Usherwood, T., Clemson, L., & Lannin, N. (2021). Methods and effectiveness of communication between hospital allied health and primary care practitioners: A systematic narrative review. Journal of Multidisciplinary Healthcare, 14(14), 493–511. https://doi.org/10.2147/JMDH.S295549
Stanz, L., Silverstein, S., Vo, D., & Thompson, J. (2021). Leading through rapid change management. Hospital Pharmacy, 57(4), 422–424. https://doi.org/10.1177/00185787211046855
FAQs
1. How much time will it take staff to get used to using the new standardized care transition protocol?
Staff might need an extra 15-20 minutes per shift to get up to speed, document, and huddle with staff. As more and more people become aware of the protocol, however, the additional time should continue to decrease and be less than 5 minutes per shift.
2. Will the new protocol significantly reduce delays in patient transfers between departments or to external providers?
By cutting down on delays in transferring patients between locations and roles, it is expected that the protocol will help decrease this delay by at least 25% in the first 3 months of its implementation.
3. How will this plan affect patient satisfaction scores at Riverstone Medical Center?
Within the next 6 months, it is expected that patient satisfaction scores will increase 10-15% (esp. communication and continuity of care) due to better coordination between the two and reduced delays in care transitions.
What is the main focus of NURS FPX 4005 Assessment 3?
The assessment focuses on creating an interdisciplinary plan proposal to solve a healthcare problem through teamwork and collaboration.
Why is an interdisciplinary plan important in healthcare?
- An interdisciplinary plan helps healthcare professionals work together efficiently to improve patient care and organizational outcomes.