Redesigning Systems to Enhance Teamwork and Outcomes for Medical Patients (RESET for Medical Patients)

Despite significant investments to improve the quality of care for hospitalized patients, the existing evidence suggests that progress has been slower than desired.1-6 Most adults requiring hospitalization are admitted for medical conditions,7,8 yet the optimal model of care for these patients is yet to be determined.9 Teams caring for medical patients are large, with membership that continually evolves because of the need to provide round-the-clock care. Physicians are often spread across multiple units and floors and have little opportunity to develop relationships with other professionals who work on designated units (e.g. nurses). Patients and family members are generally poorly informed and lack opportunities to engage in decision making. As a result, medical services lack the structure and shared accountability necessary to improve performance over time. A growing body of research has tested interventions to redesign aspects of care delivery for hospitalized medical patients. These interventions address the challenges mentioned above and include geographic localization of physicians to specific units,10-13 unit co-leadership,14,15 and inter-professional rounds.16,17 The evidence that these interventions improve outcomes is equivocal, but most studies have reported their effect in isolation. These interventions may be better conceptualized as complementary components of a redesigned clinical microsystem. A clinical microsystem is defined as the small group of people who work together in a defined setting on a regular basis to provide care. Effective clinical microsystems have clinical aims, linked processes, a shared information environment, and measure performance outcomes. High-value organizations deliberately design clinical microsystems to optimize their performance.18,19 Members of our research team previously implemented a set of complementary interventions, redesigning clinical microsystems across 7 medical units at Northwestern Memorial Hospital. The interventions included geographic localization of physicians, unit nurse-physician co-leadership, unit-based quality performance tools, and Structured-InterDisciplinary Rounds (SIDR).12,20,21 With AHRQ funding, we studied these interventions and found significant improvements in teamwork climate and a reduction in adverse events.22,23 Though limited, research by other investigators has also shown that combinations of similar interventions appear to improve patient outcomes.24,25 Our long term goal is to discover and disseminate the optimal model of care to improve outcomes for medical patients. Our specific objective for this proposal is to implement a set of complementary interventions across a range of sites, identify factors and strategies associated with successful implementation, and evaluate the impact on teamwork climate and patient outcomes. We will enroll 6 hospitals in this quality improvement mentored implementation study. Our hypothesis is that uptake of the complementary components of the intervention set will result in improvements in teamwork climate and patient outcomes. Our research team consists of physician and nurse leaders who are national experts in inter-professional teamwork, quality improvement, and implementation science. We will leverage the expertise of professional organizations including the Society of Hospital Medicine (SHM), the American Nurses Association, the American Society of Health-Systems Pharmacists, and the Institute for Patient- and Family-Centered Care, Specific Aims of the RESET for Medical Patients study: AIM 1. Conduct a multi-site mentored implementation quality improvement study in which each site adapts and implements complementary interventions, redesigning the clinical microsystems delivering care for hospitalized medical patients. Hypotheses? AIM 2. Assess the effect of the intervention set on teamwork climate and patient outcomes related to safety, patient experience, and efficiency. AIM 3. Conduct rigorous program evaluation to determine the influence of contextual factors and strategies associated with successful implementation.