Collaboration and Leadership

Good afternoon everyone and welcome to my Collaboration and Leadership Reflection Video for : Leading People, Processes, and Organizations in Interprofessional Practice. My name is Michelle Taylor.
During this video I plan to:
• Reflect on an interdisciplinary collaboration experience noting ways in which it was successful and unsuccessful in achieving desired outcomes.
• Identify how poor collaboration can result in inefficient management of human and financial resources supported by evidence from the literature.
• Identify best-practice leadership strategies from the literature, which would improve an interdisciplinary team’s ability to achieve its goals
• Identify best-practice interdisciplinary collaboration strategies to help a team to achieve its goals and work more effectively together.
• I’ll make mention of authors from the literature.
First let me provide some background
The experience I will share tells the story of the interdisciplinary collaboration that occurred during my hospital’s monthly electronic medical record down time planning. I’ll refer to the electronic medical record as an EMR.
As a health care informatics analyst, my job is to serve as a liaison between the clinical and information technology (IT) teams. The IT team has asked me to help identify an appropriate time for the EMR to be taken off line in order to perform mandatory software and hardware updates. The EMR is used to enter orders, allocate medications, document patient care activities, generate lab and other diagnostic results, perform allergy and drug-drug interaction checking, monitor for fall, infection, and sepsis risks. While the EMR is “down” or off-line none of these functions are available and clinicians need to rely upon paper-based down-time procedures. Needless to say, clinicians are dependent upon the EMR for all their patient care activities, and any gap in its availability causes anxiety, frustration, and has the potential to impact patient safety. Because of this, clinicians want the EMR to always be available, and operating at peak performance. The IT team, on the other hand, are required to conduct periodic software and hardware updates in order to maintain system reliability and performance.
The IT team advised my manager that an EMR down time was needed to apply required security patches and upgrade the server operating system. The team anticipated that the entire EMR, including labs and the diagnostic imaging system known as the PACs system, would need to be taken down to apply the patches and perform the upgrades. If these tasks were not performed there was a great risk that the security of the EMR would be jeopardized, and the database corrupted, ultimately resulting in the inability to utilize the EMR or access any patient information. The IT team would need approximately four hours to complete the updates. My manager tasked me to work with the clinicians and IT team to determine a date and time for the down time, create the down time plan, identify resources to provide support pre, during, and post down time, provide down-time related education, and conduct post-down time interviews to identify opportunities for improvement.
After thanking my manager for the opportunity, and taking a deep breath I started to work. Given the fact that all departments would be impacted by the down time for at least four hours, I realized that I would need to engage all of members of the interdisciplinary teams(physicians, nurses, laboratory staff, radiology technicians, patient access teams, IT staff, emergency room staff, etc.) to determine a date and time for the EMR down time. The objective was to identify a four-hour block of time where the least amount of patient care activities would be impacted by the lack of access to the EMR. What a great opportunity to see interprofessional collaboration in action!
The published evidence would support my idea. Quoting from a 2015 publication the Center for Applied Research:
• Effective interprofessional collaboration promotes the active participation of each discipline in patient care, where all disciplines are working together and fully engaging patients and those who support them, and leadership on the team adapts based on patient needs.

• Effective interprofessional collaboration enhances patient- and family-centered goals and values, provides mechanisms for continuous communication among caregivers, and optimizes participation in clinical decision-making within and across disciplines. It fosters respect for the disciplinary contributions of all professionals.
I’ll now go step by step through the Plan-Do-Study-Act process. I’ll refer to that as the PDSA.
Let’s start with Plan
PDSA as advocated by Donnelly and Kirk —- (writing in 2015) — as a foundation, I met with the nursing, physician, lab, radiology, health information management, emergency department, and IT stakeholders to plan the down time. During these meetings the IT team leaders explained the need and reason for the down time, underscoring the long-term benefits, despite the short-term “pain.” Other stakeholders shared critical patient care activities that occurred in their areas during a 24-hour period. Clarke (writing in 2013) would call such activities as collaborative learning, a demonstrated method for achieving shared successes. The stakeholders explored the pros/cons of a variety of days/times for the EMR down time. As expected, no one day/time was optimal, but realizing the long-term importance of the event, the stakeholders agreed that the EMR down time would occur on Tuesday from 1:00 a.m. to 5:00 a.m. This selection was made for the following reasons: allow end of day billing transactions to be completed; permit the phlebotomy team to begin their morning rounds on time; had a historically low volume of emergency department visits; a radiologist was available to be on site to read imaging studies; and nursing unit staffing was acceptable.
Now I’ll look at the ‘Do’ phase of the PDSA
On Tuesday at 1:00 a.m. the IT team implemented the plan and “took the EMR down.” During this time, the clinical teams resorted to their down-time procedures to request, document, and monitor patient care activities. From 1:00 a.m. to 4:45 a.m. the IT team rebooted 64 servers, applied 14 security patches to the software, installed the new version of the operating system, and tested the updates to make sure there were no negative impact on the EMR. The clinical teams could access the EMR at 4:55 a.m.
Now let’s explore the Study phase
At Tuesday 8:00 a.m. the organization’s stakeholders met to review (“or study”) the down time events. This activity is supported by 2018 guidance from the Institute for Healthcare Improvement support the value of PDSA cycle as a scientific method. We demonstrated this best practice when the stakeholders identified what worked well during the down time, listed opportunities for improvement, and summarized and reflected upon lessons learned.
Last, but not least, let’s explore the Act phase
The stakeholders identified the following as lessons learned:
• Tuesdays from 1:00 a.m. to 5:00 a.m. was an optimal time to take the EMR offline
• Downtime procedures need to be reviewed with all nursing staff as several units did not know how to obtain down time forms
• Additional phlebotomy staff are needed to help with first round lab draws in order to minimize delays in lab result processing
• The PACs administrator needs to be on site to assist radiologists with down time processes
• The clinical informatics staff needs to round every hour to support staff pre, during, and post down time
• Providing an explanation of the importance of the down time was critical to the success of the event
• There was no delay in critical test result notification or medication errors during the down time
• Future down time events will be communicated at least two weeks in advance; all stakeholders will meet two days before the event to review down time plan.
When you think about it, the PDSA process is a way to lead an interdisciplinary team through effective change. This is part of being a high reliability organization
Planning and implementing an organization-wide EMR down time provided an opportunity to demonstrate the impact of interdisciplinary collaboration. Poor collaboration and incomplete planning could have resulted in delays in communicating critical test results, medication errors, and potential patient harm. Stakeholder engagement is identified as one of the foundations to the achievement of a high reliability organization. High reliability organizations according to the Agency for Healthcare Research and Quality are those that “operate in complex, high-hazard domains for extended periods without serious accidents or catastrophic failures. The concept of high reliability is attractive for health care, due to the complexity of operations and the risk of significant and even potentially catastrophic consequences when failures occur in health care” (AHRQ, 2019, para 1). Patient safety should always be the focus of any interdisciplinary collaboration. “ The Joint Commission suggests that hospitals and health care organizations work to create a strong foundation before they can begin to mature as high reliability organizations. Quoting 2019 guidance from the Agency for Healthcare Research and Quality : Such foundational work includes developing a leadership commitment to zero-harm goals, establishing a positive safety culture, and instituting a robust process improvement culture”.
So, upon reflection, I am happy to say that I survived this experience. I learned a lot about myself as a result of the project. I actually thanked my manager for the opportunity; and told her I would be happy to do it again. Without the support and engagement of the department directors, and the cooperation and partnership of the front-line teams the EMR down time could have been a chaotic event, creating opportunities for medication and diagnostic errors, resulting in patient harm. Through this experience I discovered the power of collaboration, and the critical role of leadership in organization-wide project implementation.

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