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8 System Strategies to Improve Patient Safety and Error Prevention System changes are needed in addition to enhanced supervision, workload adjustment, and fatigue prevention methods to enhance conditions for resident performance and patient safety. The committee recommends ways to make more effective handovers and error reporting an integral part of resident learning experiences to help achieve these goals. Teamwork co- ordination and clinical information technology can also foster increased learning, productivity, and patient safety. A transformation in the medical environment is needed so that a system-wide culture of safety develops and a system of blame is replaced with one of shared responsibility. The committeeâs examination of graduate medical education has re- vealed that duty hours represent only one among many factors in residentsâ experiences that may affect patient safety and resident learning. Although the committeeâs deliberations about recommendations to help mitigate and prevent resident fatigue were central to its charge, it became apparent that additional changes at the system level could also help improve patient safety, resident education, and the quality of care. The committee further recognized that redesigning hospital practices or system processes may be necessary to facilitate redesign of graduate medical education or implemen- tation of the proposed recommendations. The strategies discussed in this chapter and the recommendations of the committee are aimed at systems that not only improve resident work and learning, but also improve the delivery of care in teaching institutions by all staff. The need for these steps is apparent now, under the current duty hour limits, and will continue to be important after implementation of the committeeâs recommended changes to duty hours. 263
264 RESIDENT DUTY HOURS In order to implement such changes, an organization-wide approach is necessary to create an environment that involves all hospital workers in achieving the desired results of maximum safety and the provision of quality care. Adjustments that would assist in transforming the resident work environment, and the environment for all health workers, include improving communications skills among hospital staff, implementing team strategies to complete work more efficiently, and developing a safety cul- ture that extends across hospital settings. Therefore, this chapter discusses organizational and systems strategies that can help to (1) establish a culture of safety, (2) improve handover processes, (3) use adverse event and error- reporting systems for resident learning, and (4) develop a team culture to improve communication and task performance among residents. These ele- ments can both enhance a physicianâs education and contribute to patient safety. Learning IN a Culture of safety Creating a culture of safety and developing teamwork have been broadly addressed in previous Institute of Medicine (IOM) reports, namely the Quality Chasm series (IOM, 2000, 2003, 2004). The committee builds on those earlier reports, focusing attention on adopting strategies for team- work development and error reporting to better serve the educational needs of residents while fostering safe patient care. Culture of Safety and High Reliability Definitions of the concept of a culture of safety vary, but organizations that establish a safety culture generally demonstrate the following charac- teristics (Singer et al., 2003): â¢ Safety is considered the highest priority of the organization. â¢ There are strongly shared values and behavioral norms throughout the organization that are centered around safety. â¢ Resources and incentives are available for the organization to pur- sue and implement a safety commitment. â¢ There is non-hierarchical and open communication among Âworkersâ particularly in safety-related scenarios. â¢ There are rare occurrences of errors, but open recognition and reporting of them is accomplished without blame for individuals. â¢ Organizational learning is highly valued. High-reliability organizations (HROs) build on culture of safety ele- ments to go beyond the norm and approach their goals of zero errors
system strategies 265 and avoidance of potential disasters, such as multiple deaths (Weick and Sutcliffe, 2001). Businesses in particularly risky industries that could have a catastrophic impact on the public, such as military operations, commer- cial airlines, and nuclear power generation, were among the first to adopt the continual processes needed to achieve high-reliability operations while producing minimal errors. Although recognition of a safety culture and high-reliability compo- nents and practices (e.g., teamwork, blame-free error reporting) are becom- ing more common in health care, there has yet to be widespread adoption of these practices across the medical field (Patterson et al., 2004). Reasons for slow adoption by some institutions include resistance to organizational change (Carroll and Quijada, 2004) and insufficient resources to support safety culture practices (Patterson, 2007), although some experts note that a major investment of resources is not necessary (Hines et al., 2008). Ten- sion can exist between the goals of a safety culture and individual residents, program directors, or departments, which is why leadershipâat both the clinician and the executive levelsâis a critical component in overcoming any resistance and establishing the importance of high reliability through- out an organization (Roberts et al., 2005). Leaders in healthcare settings accomplish this by aligning incentives and encouraging the ideas that drive a culture of safety, promoting the continued progression of system redesign and eventually sustaining the developments made (Roberts and Perryman, 2007). Suggesting that they be more active in establishing patient safety standards for clinical performance and that such practices become part of medical training is in line with recommendations from the IOM report To Err Is Human (IOM, 2000). In an effort to take a lead in promoting a culture of safety for health- care settings, the Agency for Healthcare Research and Quality (AHRQ) now encourages hospitals to adapt the concepts of high reliability to their organizations, along with the previously mentioned elements of safety cul- ture (Hines et al., 2008). The introduction of high-reliability practices is still relatively new in the medical field, and the exact impact of the culture of safety on specific improvements in healthcare organizations has yet to be documented on a broad scale (Shojania, 2005). However, it is known that error rates in hospital care tend to be far greater than those associated with HROs in other industries (e.g., airlines). The 44,000-98,000 estimated deaths in the United States related to medical errors are just one component of risks to patients. Many more nonfatal pre- ventable events also harm patients, with impacts such as extended hospital stays, pain and suffering due to hospital acquired infections, or an adverse drug event. The frequency of such errors certainly indicates a need for improvement and is discussed in Chapter 6. In this chapter the focus is on organizational attitudes and culture: ensuring that safety is given the promi-
266 RESIDENT DUTY HOURS nence it requires for the provision of high-quality care, that residents and all other workers in the hospital are comfortable discussing errors, and that efforts are made to correct or prevent situations in which errors occur. To prevent such occurrences, hospital environments that promote com- munications by all levels and professions of workers should be supported. Encouraging questions about safety and blame-free reporting of errors would likely enhance the educational value of residentsâ training and their ability to learn from all of their colleagues and continuously improve qual- ity of care through cooperative teamwork (IOM, 2001). This does not ap- ply only to medical residents, but focusing attention on them may be a good place to introduce the culture change required for this shift to team mental- ity or shared responsibility and accountability in healthcare settings. Reducing Errors by Improving HANDOVERS Handovers, or transitions in patient care are an area of medical practice that is considered a substantial source of errors and risks to patients, but one that can benefit from immediate attention through processes improvement. More commonly referred to as âhandoffs,â âtransfers,â or âsign-outâ in the United States, the committee chose the term âhandoverâ for this report because it better encompasses the goal of these pivotal moments, suggesting that they are intended as a handing over of responsibility for a patient from one healthcare provider to another and not simply a quick transcription of patient information at the end of oneâs time on duty. Continuity of care as described in Chapter 4 refers primarily to relationship building between physician and patient, and gaining thorough knowledge of a patientâs con- dition in order to provide the best treatment. A residentâs familiarity with a patient and his/her care is important, and discontinuity of care due to handing cases over to other residents has been shown to result in increased levels of preventable adverse events (Laine, 1993; Petersen, 1994). However, to achieve stronger patient-physician relationships and serve its educational purpose, continuity of care relies heavily on the continuity of information itself. Information transferred during handovers may include a patientâs name, bed location, blood pressure, diagnosis, and other critical data on patient status or treatment plan. A service that must be available 24 hours daily, such as health care, requires transferring this information and responsibility of tasks from one team member to another at some point or points during the day. In a hospital setting, for example, where teams of physicians, nurses, and residents are all responsible for a single patient, continuity of care involves a comprehensive handover of patient information from one provider or team to another so that clinical care can be maintained successfully among a healthcare team. Handovers take place among teams of nurses, teams of physicians, and teams of residents, as well as between those teams and between integrated care teams consisting of various types of clini-
system strategies 267 cians. Handovers occur between emergency departments, different inpatient settings from surgical to postoperative care, and different hospitals, not to mention transitions out of hospitals to nursing homes or home care settings (Patterson et al., 2004). The act of transferring responsibility for patient care is not inherently a negative practice. However with each additional handover per patient, there is more opportunity for dilution or omission of information, which can lead to inaccuracies that affect patient care and outcomes (Arora et al., 2005, 2007; Horwitz et al., 2008; Petersen, 1994). Such communication breakdowns result in information gaps that intensify discontinuity of patient care and the potential for errors. These factors make them pivotal moments in the care continuum and an important aspect of preventing medical errors and ensuring patient safety (Saultz, 2003). For residents, these exchanges are also opportunities for professional interaction, learning how to assess patient care situations, and problem solving. The next several sections discuss the role handovers play in the continuity of patient care, the impact they have on patient safety and resident education, how they are affected by the regulation of duty hours, and suggestions for rede- signing handover processes to optimize patient safety and resident education. Consequences of Transfers and Communication Failure for Patient Safety Several studies, not specific to residents, highlight observed patient cases that point out the errorsâat times fatalâcaused by poor commu- nication during handovers (Beach et al., 2003; Gandhi, 2005; Vidyarthi, 2004; Wachter, 2008; Wachter et al., 2006). An evaluation by the Joint Commission in 2005 of more than 3,000 root-cause analyses of reported error data revealed that nearly 70 percent of sentinel events in accredited healthcare entities result from communication failures (Joint Commission International Center for Patient Safety, 2006). The Joint Commission fur- ther stated that there is evidence that at least half of such communication failures occur during handovers. In a study by Gandhi and colleagues, poorly executed handovers contributed to 20 percent (36 of 181) of mal- practice claims that resulted in serious harm or death to patients (Gandhi et al., 2006). Additionally, poor handover and follow-up practices at dis- charge are particularly likely to increase safety risks for patients (Forster et al., 2003; Moore et al., 2003). Poor discharge practices have been associ- ated with higher readmittance rates or avoidable readmission of discharged patients (Halasyamani et al., 2006). Because this evidence is not specific to residents, it demonstrates the extent to which poor communication perme- ates the health system, posing safety risks to patients. Among residents, however, communication failures are among the most common factors contributing to adverse patient events (Sutcliffe et al., 2004), and handovers are just one form of communication between resi- dents and their medical team. In a study by Singh (2007), 19 percent (46)
268 RESIDENT DUTY HOURS of cases with errors made by residents (including interns and fellows) that resulted in malpractice claims and led to medical injury of patients were attributed to poor handoffs. Another study by Arora et al. (2007) in which 27 percent (1,876) of medication entries in sign-out forms from handover procedures by interns contained either omissions of or commissions from notations in the original patient chart, 54 percent of them had the potential to cause moderate or severe harm to patients. Reducing possible mistakes during these moments can be crucial, and residents can achieve this largely by improving their handover processes, especially with guidance from their attending physician on the critical clinical information that best prepares the next shift of residents to anticipate and respond to changes in patientsâ conditions. Variability of Handovers A likely contribution to errors during handovers is the variability of the handover process across settings without specification of the information that needs to be provided. Handover procedures and type of information transferred can vary from hospital to hospital and program to program within hospitals, and often are not structured or uniform between or among provider teams. Some use fax systems, others written tools, and others electronic tools, allowing handovers to take place either face-to-face, in written form only, in verbal form only, or in multiple formsâamplifying the variability of the process and information that gets transmitted across teams and care units. Solet and colleagues (2005) illustrate such variations in a single in- ternal medicine residency program that provides medical training across four different hospitals that each used different methods to transfer patient information. Three different computerized systems were utilized among the four institutions, and only two of the four used a computerized system for handovers. The other two hospitals conducted written handovers, one of which had a free-style form, using no templates or standard format, with residentsâ writing up or communicating their notes as they wished. Other studies describe additional variations in handover processes and their differ- ing degrees of effectiveness in communicating necessary patient information (Borowitz et al., 2008; Horwitz et al., 2006). Impact of Duty Hour Regulations on Handovers and Continuity of Care Although fewer duty hours or appropriately placed rest periods may help to reduce fatigue in residents, they raise serious concerns for continu- ity of care. Practice has shown that the number of hours worked and the number of handovers among patients are inversely related, meaning that the
system strategies 269 fewer hours residents spend in the hospital, the more often patient care has to be handed over to other residents (Horwitz et al., 2007b; Vidyarthi, 2004; Vidyarthi et al., 2006). Therefore, shorter shifts to comply with the 2003 duty hour regulations and periods of sleep within extended duty periods, as this committee recommends, can result in an increase of handovers. In light of the error rates associated with handovers (Arora and Farnan, 2008; Fletcher et al., 2005), increasing their frequency requires that hospi- tals improve the process in order to maintain or improve the quality of care. In the United Kingdom, this same trend of increased handovers (because of adherence to the European Working Time Directive) has led its Depart- ment of Health to emphasize the effectiveness of handovers as an area of improvement for patient safety (Sabir et al., 2006). Here in the United States, the Joint Commission has recently established a National Patient Safety Goal specific to improving handover practices (which apply to all healthcare professionals, not only to residents) as part of its accreditation process (Joint Commission, 2007). Experts in the field suggest that many errors stemming from poor handovers are preventable or can be made less severe if hospitals take steps to improve communication and coordination of care (Kripalani, 2008), create better opportunities for interaction, and provide better guidance for the process. Examinations of hospital systems and resident programs have shown that structured and supervised handover procedures can dramatically decrease the rates of errors associated with them (Catchpole et al., 2007; Horwitz et al., 2006). It has also been ob- served that implementing such processes is possible within current spending levels and without having to pass new legislation (Coleman and Berenson, 2004), thus building a case for improving quality of care through improved handovers. Instead of merely viewing more frequent handovers as an increased op- portunity for error, they can be viewed as another opportunity for resident learning. They represent a chance to develop macro cognitive skills such as recognizing and analyzing early warning signs or anticipating any problems that might arise for patients on the next shift, understanding warning signs in patientsâ response to treatment, better planning for the care of patients, and improving communication and teamwork skills. Handovers are par- ticularly crucial for all clinical staff to learn to navigate, and it is important that residents be familiar with effective strategies in order to apply them successfully in any setting. Suggestions for possible interventions and train- ing follow in the next section. Handover Interventions The attention that handovers have received as a target area to improve patient safety is exemplified by the Joint Commissionâs decision to issue
270 RESIDENT DUTY HOURS a âPatient Safety Goalâ (effective January 1, 2006) requiring hospitals to standardize their handover approaches and communications as components of improving continuity of care (see Box 8-1) (Joint Commission, 2007). It is generally believed that providing some structure for handover procedures is the appropriate solution for improving outcomes. Other industries in high-risk or high-reliability environments have already identified aspects of BOX 8-1 National Patient Safety Goal 2: Improve the Effectiveness of Communication Among Caregivers Requirement 2E â Implement a standardized approach to âhand offâ communications, including an opportunity to ask and respond to questions. Rationale for Requirement 2E â The primary objective of a handoff is to provide accurate information about a patientâs care, treatment, and services; current condition; and any recent or anticipated changes. The information communicated during a handoff must be accurate in order to meet patient safety goals. â In health care there are numerous types of patient handoffs, including but not limited to nursing shift changes; physiciansâ transferring complete responsibility for a patient; physiciansâ transferring on-call responsibility; temporary responsibility for staff leaving the unit for a short time; anesthesiologistâs report to post-anes- thesia recovery room nurse; nursing and physician handoffs from the emergency department to inpatient units, different hospitals, nursing homes, and home health care; and critical laboratory and radiology results sent to physiciansâ offices. Implementation Expectations for Requirement 2E â The organizationâs process for effective handoff communication includes the following: â¢ Interactive communications allowing for the opportunity for questioning between the giver and receiver of patient information. â¢ Up-to-date information regarding the patientâs care, treatment and services, condition, and any recent or anticipated changes. â¢ A process for verification of the received information, including repeat-back or read-back, as appropriate. â¢ An opportunity for the receiver of the handoff information to review relevant patient historical data, which may include previous care, treatment, and services. â¢ Interruptions during handoffs are limited to minimize the possibility that information would fail to be conveyed or would be forgotten. SOURCE: Joint Commission, 2007. Â© The Joint Commission, 2008. Reprinted with permission.
system strategies 271 handover processes, and several of their lessons or techniques are applicable to hospital settings (Patterson et al., 2004). Examples from such industries were indeed drawn upon to help formulate the Joint Commission require- ments for these procedures. Improving handovers provides an opportunity to restructure the way residents learn, possibly leading them to greater collaboration with peers and supervisors and helping them to build new skills that promote qual- ity care. One-size-fits-all interventions or complete standardization of the process across all settings, however, is not feasible in a highly variable and complex system such as health care; therefore flexibility in adopting any suggested handover method would be crucial to its success (Patterson, 2008). Application of core components should be evaluated for each set- ting and care scenario to ensure that they are not used superfluously and do not hinder existing effective transfer methods (Patterson, 2008; Perry et al., 2008). It is expected that handover practices would be tailored somewhat to accommodate the differing needs of intensive care units compared to emer- gency rooms, surgical and internal medicine disciplines (Arora and Johnson, 2006), or outpatient and inpatient settings, but that core components would be instituted within a basic framework with consistent principles. Therefore, the basic elements that may help improve current medical han- dover processes presented in the following section are general suggestions. Limited data are available on the implementation of handover guidelines or their effectiveness, but the existing evidence suggests that following a some- what structured protocol does improve resident communication (Chung and Ahmed, 2007) and patient outcomes (Catchpole et al., 2007). General Guidance for Improving Handovers One of the factors most consistently found in the research to help en- sure successful handovers for residents is face-to-face interaction (Horwitz et al., 2007a; Parke and Mishkin, 2005; Solet et al., 2005). Solet et al. (2005) suggest that the combination of oral and written handoff is the most effective for transmitting patient information. Most residency programs do solely written sign-outs, and there are times when physicians can be avail- able only via phone or e-mail to exchange crucial information. However, direct face-to-face communication enhances the comprehension of written orders and allows for greater expression of what points need emphasizing and those that are less urgent (Solet et al., 2005). This approach also al- lows residents to ask questions and clarify instructions, interactions that are helpful for learning and avoiding errors. Face-to-face communication also creates clearer transitions of responsibility and authority on a case, which some believe is equally important to recognize during the handover process (Behara et al., 2005). Because of the benefits of face-to-face interactions,
272 RESIDENT DUTY HOURS finding locations in which they can occur with limited distractions or inter- ruptions may be helpful (Perry et al., 2008; Singer and Dean, 2006). For example, some advocate going to a patientâs bedside to perform transfers, which may have additional benefits associated with patient centeredness. Building in overlap time between shift schedules also helps set aside the time for this type of interaction, improving handover processes and increasing their educational value by providing the opportunity to ask questions and clarify treatment plans or other pertinent information (Afessa et al., 2005; Goldstein et al., 2004; Landrigan et al., 2004; Volpp and Landrigan, 2008). Each of these actions is very team oriented and often requires training be- cause they are not easily instituted by written standards alone. The literature further suggests that structuring the content of what is exchanged during handovers and using uniform language or terminology to communicate information assist in preventing omission of necessary information and help reduce confusion about what tasks are to be com- pleted (Arora et al., 2005). To aid in this process several studies recommend framing content by using written checklists such as âI pass the batonâ or âSignout,â created by TeamSTEPPSâ¢ (2007) and Horwitz et al. (2007a), respectively. These checklists outline specific information to exchange dur- ing handovers such as patient name, diagnosis, pending tests, allergies to medications, and so forth. Ideally, they would be as concise as possible without omitting relevant information. More advanced tools that achieve this same goal are electronic sign-out systems. Electronic systems can improve handover content by providing structured, easy-to-access databases of patient information and creating for- matted checklists of tasks that need to be considered for patient treatment. When residents record information electronically, they reduce paperwork and duplication. Electronic systems can also enhance the uniformity of ter- minology and procedures if multiple departments or an entire hospital uses the same electronic program, much like the Department of Veterans Affairs (VA) does with the system it recently adopted (Carpenter, 2008). The VA system combines sign-out strategies by importing patient data electronically but also includes a free-text entry segment that allows users to personally add treatment plans or anticipated tasks (Solet et al., 2005). Together, these factors can increase handover efficiency, reduce instances of content omis- sion, and help resident and integrated teams have consistent and up-to-date information about their patients and care schedules. Although electronic systems have demonstrated improved resident performance and patient outcomes by reducing rates of adverse events and allowing residents more time to spend on direct patient care (Petersen et al., 1998; Van Eaton et al., 2005), very few residency programs or hospitals actually employ electronic sign-out systems. There are reports that roughly 18 percent of large resi- dency programs have some form of electronic sign-out, as do 3 percent of
system strategies 273 smaller residency programs (Horwitz et al., 2006), and that less than 5 per- cent of U.S. hospitals have adopted such procedures (Okie, 2007). At least one study has shown that if electronic sign-out systems are cumbersome, residents may find ways to work around them or discard them altogether (Landrigan et al., 2004). Furthermore, if implemented or used improperly, electronic systems can have unintended consequences that undermine cli- nician communication or patient care (Ash et al., 2007; Campbell et al., 2006; IOM, 2006), making the need for training in these systems an im- portant one. Further discussion of electronic system use among healthcare staff is addressed in more detail later in this chapter. In addition to the identified key components of tested handover meth- ods mentioned thus far, results from an observational study of residents dur- ing sign-out by Horwitz et al. (2007a) also illuminated the importance of residentsâ having supervision available during the process and having time to formulate clear plans to carry out their assigned tasks. Opportunities for learning could be increased by the presence of appropriate supervisors during the handover process. Learning how to hand over responsibility and information is important, as is learning what patient signs to look for and what types of information are critical to forward to another caregiver. A supervisor can help new residents anticipate a patientâs future care needs. All together, the above results fall in line with a 2005 study that in- terviewed 26 interns from a university teaching hospital. These interns suggested improvements in handover practices to help them make more informed and accurate decisions about patient care and reduce duplicative or unnecessary work. The recommendations included a request for face-to- face interactions; reviewing anticipated areas for care or troubleshooting; and having an accurate, updated, legible, written worksheet that includes standard patient content and medical information (Arora et al., 2005). Since these were the suggestions of first-year residents, it may be that having the structured format is more beneficial to residents as they first learn these processes (rather than after several years of experience), which underlines the educational benefits of using these methods for handovers. Other components that can add structure to handover processes in- clude agreeing on an end-of-shift time that allows for an overlap of shifts, establishing pre-handover routines, determining a set location for transfers to take place, requiring that outgoing residents inform incoming residents of all patients in the department, and conducting joint bedside visits (Singer and Dean, 2006). Innovative Handover Strategies A number of handover strategies currently being developed and prac- ticed incorporate several of the components addressed above. A particular
274 RESIDENT DUTY HOURS handover strategy used to improve patient care and help residents learn patient-centered techniques is bedside handover. Bedside strategies establish patient centeredness and visible continuity that reduces patient confusion or anxiety (Singer and Dean, 2006). For example, a pilot study in Ontario, Canada, involving nurses showed that implementing bedside handover helped catch incorrect patient armbands or intravenous solutions (via the bedside safety checks that were part of the handover intervention), prevent- ing possible harm to the patient and helping to reach established patient safety goals. Patients seem to appreciate this approach and acknowledge that âthey are reassured by knowing information about their care require- ments has been communicatedâ (Alvarado et al., 2006, p. 78), promoting a culture of patient safety and team integration. Another suggestion to promote team structure and shared information through bedside handover strategies is to share the care responsibilities of specific teammates more regularly with patients. For example, introductions of the care team at the bedside could indicate not only the names of the team members but their titles or roles on the team. If staff shifts change at times when no patient visits are planned, a record could be kept in the ward (or a note in each patientâs record) to indicate which resident and attend- ing are responsible for each patient at a particular time. Also, a schedule could be kept in the ward of when patient rounds with the attending phy- sician could reasonably be expected, so patients and their families can be informed (Simmons and Gonzalez del Rey, 2008). These changes, suggested by patients, would be relatively easy to implement in facilities that do not already follow such protocols. Integrating patients more openly into the care team allows team culture to extend beyond the resident or integrated teams, adding a more personal view of the patientâs perspective to the team. Patients familiar with this handover practice also suggest that hospital staff introduce themselves, use an understandable vocabulary when speaking to them, and include patients in discussions to maximize the value to patient and to promote team thinking (Simmons and Gonzalez del Rey, 2008). As previously noted, handovers that occur at discharge create substan- tial risk to patients. Also known as a type of âcare transition,â âtransfer of care,â or âtransitional care,â these types of transfer have been defined as âa set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care in the same locationâ (Coleman and Berenson, 2004). Often they are transfers of patients to somewhere outside the hospital setting, usually to home settings or home care facilities where regular monitoring of a patientâs condition is not necessarily possible. A number of strategies have been shown to be effective in increasing patient centeredness and reducing the occurrence of errors, such as Dr. Eric Colemanâs Care Transitions Program and the Transforming Care at the Bedside program launched by the Robert Wood Johnson Foundation and the Institute for Healthcare Improvement
system strategies 275 (Care Transitions Program, 2008; IHI, 2007). Since information in these cases passes from health professionals to patients or their families (instead of to other health professionals), residents need special training in how to present the information adequately and appropriately in a way that patients will understand, which is what the mentioned programs aim to do for all health professionals. Handovers, from the perspective of patients, can appear to be a confus- ing interruption or discontinuity in their care, as responsibility for their care shifts from physician to physician. Lessons learned from the above studies could decrease the discontinuities that the patient experiences with hando- vers, regardless of their frequency. Likewise, applying some of the suggested methods can also help residents learn what information is most pertinent for quality care and patient safety during handovers and how to handle both the clinical and the relationship side of the process by interaction with their peers and supervisors as well as patients. Creating a formal protocol to transfer clinical information and patient care thoroughly and accurately, in any setting, can go a long way to help prevent or intercept errors, enhance workforce communication, provide educational opportunities for residents, and possibly assist to minimize the negative effects of increased shift work. The committee concludes that whichever method or combination of methods is used to improve handovers, the key factor is that handovers be structured, while also conforming to the needs and capacity of particular departments or settings. Residents and all other participants in handover processes should be trained in how to perform effective handovers. Training other hospital staff in addition to residents will be particularly important for those who work on integrated care teams and those who hand over to other units. Establishing some basic, facility-wide principles and structures should assist all teams to work more seamlessly together and foster more open communication and accurate transfer of information and responsibil- ity across hospital settings. Both clinical and executive leaders can help promote these system-wide practices. Successful handover processes should try to include the following components: â¢ Face-to-face interactions (whenever possible), â¢ A set location and time for handovers to occur, â¢ Minimal interruptions, â¢ Structured content (e.g., use of checklists) to ensure that all relevant information is transmitted, â¢ Uniform language or terminology, â¢ Sufficient time to interact and clarify questions or concerns (e.g., overlap in shift schedules), and â¢ Presence of a supervisor to oversee the process and answer addi- tional questions.
276 RESIDENT DUTY HOURS Teaching the Handover Process A lack of standard educational practices for teaching how to do hando- vers is another factor contributing to the degree of variability in conducting them. Evidence suggests that a formal curriculum including sessions on handovers does not exist in 92 percent of medical schools and that most medical students and residents alike learn handover procedures informally from other residents (Solet et al., 2005), highlighting the lack of atten- tion this matter receives. A later study found that 60 percent of medical training programs (not including those of New York State) provided no lectures or workshops on sign-out skills (Horwitz et al., 2006). Therefore, the committee agrees with suggestions to improve handover education that include providing standard instructional materials, training faculty leaders to encourage shared responsibility and effective handover, encouraging or requiring faculty or resident leaders to properly supervise handover pro- cedures, and teaching residents formal communication techniques (Solet et al., 2005). Additionally, materials on handovers could give case examples of how the type of information transferred can influence the outcomes of patient care. Because in addition to providing basic patient information, handovers âsupport macrocognitive functions, such as problem recogni- tion, problem analysis, sensemaking, and planningâ (Perry et al., 2008, p.Â 2), where residents have to determine future actions for a patientâs care, anticipate any problems that might arise, and adequately communicate these things when necessary. Training materials that teach residents how to approach these actions would highlight the clinical lessons that can be gained from good handovers. Hospitals should consider each factor for incorporation into new education strategies for the improvement of han- dovers by residents. Examples from the literature of effective curricula for training health- care professionals in handover practices vary from providing a compre- hensive series of classes over time to providing a one-time instructional conference (Alvarado et al., 2006; Horwitz et al., 2007a). When introduc- ing new training or a new curriculum, however, the already extensive na- ture of residentsâ workload must be considered thoughtfully. Some studies found that programs had difficulty finding a time when sufficient numbers of residents were available to attend the proposed conferences (Horwitz et al., 2007a). As a result, only a small number of residents trained on the handover process. Given that resident schedules and workload are already so demanding, it is important either to find a time that works with their schedules (e.g., during orientation) or to make this lesson a priority and place it in the regular curriculum where appropriate. Education about these methods should also occur in real time, with patients under the residentâs care to reinforce the lessons learned in general orientation on systems. For
system strategies 277 example, attendings could incorporate the discussion of what should be in each patientâs sign-out during rounds and the nature of errors (omission or commission) that might occur without vigilance during these interactions. Alternately, computer-based or simulated lessons could be designed so that residents could learn whenever convenient. Recommendation 8-1: Teaching hospitals should design, implement, and institutionalize structured handover processes to ensure continuity of care and patient safety. â¢ Programs should train residents and teams in how to hand over their patients using effective communications. â¢ Programs should schedule an overlap in time when teams transition on and off duty to allow for handovers. â¢ The process should include a system that quickly provides staff and patients with the name of the resident currently responsible in addition to the name of the attending physician. Because of widespread concern across medical specialties that increasÂing handoversâa necessary consequence of restricting resident duty hoursâwill result in decreased continuity of care and increased risk to patient safety, systematic research is required on the effects of different handover tech- niques designed to prevent loss of continuity of care and risks to patients. Currently, we do not know if the relative risk of resident duty hours and fatigue mitigation as recommended by the committee, combined with good handover practices, results in better or worse patient safety outcomes. There should be detailed examination of specific elements of handoversâfor ex- ample, the optimal time(s) required by residents for handovers of a specific number and severity of patients, when joint bedside visits would be recom- mended, minimum information transfer needed for all patients, availability of supervisors at handovers, the impact of face-to-face handovers and how handovers can be opportunities for intercepting errors. Training Doctors and Error Reporting In addition to the latest, evidence-based best practices for patient care and structured handover procedures, new physicians must also learn and practice safety and quality improvement principles and methods. Through- out medical centers or hospitals there should be encouragement for resi- dents to participate in ongoing quality improvement efforts and support for them to learn from constructive feedback. As part of its six core competen- cies the Accreditation Council for Graduate Medical Education (ACGME) requires residency programs to teach about quality improvement practices
278 RESIDENT DUTY HOURS and produce residents who can âsystematically analyze practice using qual- ity improvement methods, and implement changes with the goal of practice improvement,â and âparticipate in identifying system errors and imple- menting potential systems solutions,â to improve care based on an under- standing of resource allocation and integration of care delivery systems as well as individual patientsâ clinical needs (ACGME, 2007, pp. 1, 3). Some health researchers are finding that educating residents on quality improve- ment methods for patient care can have a beneficial effect on the outcomes of patients that they treat during training (Stevens et al., 2008; Warm et al., 2008). If the quality of education that residents receive during training affects the quality of care they give to future patients once they are working independently, then learning from their mistakes or those of others as part of that education can be valuable for future patient safety. Teaching hospitals typically have error-reporting systems (as ACGME states they should in its competency requirements), but residents are often not fully integrated into the hospitalâs culture of safety and either do not know how to report errors or do not see the value of doing so. A serious barrier is that residents, regardless of whether they see the value of report- ing errors, are often reluctant to report them because they fear retribution for asking questions, displaying ignorance, or facing legal consequences (Hines et al., 2008; Kaldjian et al., 2008). The Joint Commission recently issued a Sentinel Event Alert concern- ing âintimidating and disruptive behaviors [that] can foster medical errors .ââ.ââ. and preventable adverse outcomesâ that indicates that such Âdisruptive behavior is not unusual (Joint Commission, 2008, p. 1). The Joint Com- mission mentioned examples of intimidating behavior, such as âreluctance or refusal to answer questions, return phone calls or pages; condescending language or voice intonation; and impatience with questions. Overt and passive behaviors undermine team effectivenessââ.ââ.ââ.â (Joint Commission, 2008, p. 1). The alert states that several surveys have found that a major- ity of healthcare workers have seen or experienced such behavior and one study found that â40 percent of clinicians have kept quiet or remained pas- sive during patient care events rather than question a known intimidatorâ (Joint Commission, 2008, p. 1). Likewise, an AHRQ database comprised of voluntary survey responses by hospital staff on the efforts to create a patient safety culture in their institutions revealed that only 44 percent of respondents agreed that their hospital had a nonpunitive response to er- rors (AHRQ, 2008). Among the core concepts of HROs is a perception of errors or near misses not as an occasion to point blame, but as an opportunity to improve system design and performance to achieve an even safer environment (Hines et al., 2008). This leads to creating a blame-free environment through a
system strategies 279 systemic response to errors, which could help reform the punitive culture often observed in healthcare settings that tend to inhibit open communica- tion and, thus, learning. The careful design of an error-reporting system, analyses resulting from it, and feedback to those involved and to others who can learn from error-related events are critical to the success of the system (Kaplan and Rabin Fastman, 2003). An understanding of the errors in a system is the foundation for building a strong culture of safety. Infor- mation from error reporting and root-cause analyses of critical cases could also contribute significantly to residentsâ education. Since the focus of most hospital error-reporting programs has been on system-wide problems rather than on the individual, and they frequently guarantee confidentiality, they often do not note characteristics of the in- dividual who was involved in the event, such as profession, discipline, and training status. Without data on error patternsâincluding what type of caregiver was involved, at what training level, and whether there were errors of omission, commission, misdiagnosis, or work-aroundâit is more diffi- cult to address educational deficiencies (Battles and Shea, 2001). However, if data were available on when during a work period the event occurred, it might show that events happened most frequently at the end of an extended work period and were possibly an indication of decreased attention due to fatigue. Error reports indicating the time and other specific circumstances of events might reveal patterns related to work shifts of individuals or teams, the transitions from team to team, and whether fatigue or communications failures were a significant factor. Currently, reporting does not capture such information in hospitals for use in residency programs. While most individual institution reporting systems would have a lim- ited volume of reports and insufficient power to draw statistically valid conclusions about certain events, they could be valuable to management and educators by identifying any problem. Just one report of a near miss could identify a critical situation in need of redesign and lead to significant quality improvement. Residents in particular can play an important role in improving health systems in this regard. Acting as the âspackleâ in the busy training settings of the health profession, they know where gaps ex- ist in the system, and helping to identify them can be an asset in any care setting as well. Not only would residents be a part of the solution to these problems, they would benefit from the educational benefits these systems can provide. If more hospitals had robust error-reporting systems with sufficiently detailed data reported, and an atmosphere that encouraged all workers to participate, and if such data were consistently recorded from hospital to hospital and could be aggregated to a national level, or if there were an ef- fective national reporting program in place, it might have been possible for
280 RESIDENT DUTY HOURS this committee to assess whether errors by residents were a serious threat to patients and to what extent those errors could be attributed to fatigue and long work hours. However, data at that level do not currently exist. The issues surrounding error-reporting systems are not new and are of much broader relevance than just the training of physicians. In fact, earlier IOM reports, including many in the Quality Chasm series, contain exten- sive discussions of these issues and recommendations on how to develop an effective error-reporting and learning system. This report does not repeat those discussions, but rather turns the focus toward residents. Healthcare organizations have been responding to these reports and pressures from the Joint Commission and public bodies. Both the public and healthcare pro- fessionals are growing more aware of the importance of identifying errors in understanding how to improve the quality of services and the safety of patients and workers. However, progress in reporting and reducing errors has not been uniform (ACGME, 2008; Hines et al., 2008; Kaldjian et al., 2008). At the hospital level, to learn from mistakes in patient care involving residents and to prevent similar events in the future requires an error-report- ing system with a common set of data standards and a broader definition of what information should be collected that could, perhaps, contribute to the training of doctors. The error-reporting system would have to include train- ing for all residents in what should be reported, how to report incidents, who should report, and how to analyze the reported errors to understand the root causes of the error and the changes needed to prevent future harm to patients (Garbutt et al., 2008). Support and encouragement from execu- tive leadership, methods for reporting errors anonymously, and a feedback loop to the residents, caregivers, and especially the graduate medical faculty are all important elements of the reporting system for promoting its use. Knowledge that the reported information will be used to enhance patient care is critical to motivate doctors and other caregivers to make the effort to report an incident. The perception that there is no follow-up can be a deterrent to reporting (Evans et al., 2006). The use of such reported infor- mation to enhance resident training would also be a benefit. Recommendation 8-2: Graduate medical education-sponsoring institu- tions should fully involve residents in their safety reporting, learning, and quality improvement systems, and this should become an impor- tant part of the residentsâ educational experience. Health Information Technology for Clinical Decision Support Todayâs residents face a rapidly expanding knowledge base while serv- ing in a learning environment with a growing focus on patient safety mea-
system strategies 281 sures. As mentioned, fostering relationships between residents and other hospital staff provides important clinical support to residents as they learn to make decisions about patient management. Yet other forms of support can aid them in their clinical decision making as well. Besides seeking help from their peers and supervisors to reduce uncertainty and prevent errors, residents can use an array of information technologies to assist them. Health information technologies include up-to-date patient-specific data in electronic medical records, clearly documented handovers from other team members, and diagnostic support systems that offer clinicians opportunities to avoid reaching premature closure on diagnoses. Informa- tion technology (IT) support systems have been shown to enhance care and reduce errors by alerting patients to drug interactions and providing access to clinical guidelines (Bates et al., 1998; Garg et al., 2005; Petersen et al., 1998). Various studies show that electronic medical records have been ob- served to help in documentation, thus preventing errors and reducing test ordering by residents (Hier et al., 2005; Keenan et al., 2006; OâConnell et al., 2004; Stair and Howell, 1995). IT solutions can also enhance communication for supervision in the event that attendings are unable to be on site. Remote access can help attendings monitor the activities of residents as well as patient progress through review of online records. Greater accountability is being required of residency program directors (e.g., monitoring resident hours, privileges for clinical and surgical procedures, workflow management) that require documentation for accreditation purposes and to enhance patient safety (Afrin, 2006). Despite all the benefits electronic tools can provide, if they are ill suited to an organizationâs needs or are not used appropriately, unintended or adverse consequences are possible, requiring ongoing maintenance and attention to business processes to prevent such occurrences (IOM, 2006). Not all electronic medical systems are created equally; some are quite ad- vanced while others are more rudimentary, ranging in degrees of content or flexibility of integration with other systems. Those that integrate poorly with other information systems may be more time consuming to use or may create duplicative efforts instead of reducing them (Campbell et al., 2006). Heavy reliance on electronic systems can also decrease general communica- tion skills and the occurrence of face-to-face interactions among clinicians (Ash et al., 2007). In some cases, electronic medical systems can contribute to errors by new users who are learning to navigate these systems and in- correctly fill out information or accidentally press wrong functions, or by program formats that are too cumbersome to enter information in a timely manner (Campbell et al., 2006). For these reasons, training staff in how to use any electronic system is critical to their effectiveness and efficiency (Arora et al., 2007).
282 RESIDENT DUTY HOURS Health IT will likely continue to advance and come to be a more widely used tool in hospitals and training facilities. As more residents are exposed to these systems they may be in an ideal position to provide necessary feedback on how to improve their functionality for clinical use. Currently, however, it is beyond the scope of this report to evaluate specific models of electronic medical records or decision support systems for residents. The committee recognizes the potential usefulness of these systems for informa- tion transfer, supervision, workload reduction, and enhanced education in the pursuit of patient safety and urges their continued evaluation and adoption. Adoption of these systems can have value to all staff on patient care teams and is not resident specific. Developing A Team culture It has been recognized that healthcare structures are complex, âcharac- terized by competing responsibilities and an evolving perception of patient care as a collective responsibilityâ (Park et al., 2007, p. 111). Residents are increasingly trained and expected to practice in models of integrated care, which rely on the coordination of different services, clinicians, and teams all working together to provide comprehensive care for patients. Facilitat- ing this coordination requires effective communication skills and strategies across and among all unitsâa fundamental trait of teams and teamwork. A team is defined as a distinguishable set of two or more people interacting toward a common goal with specific roles and boundaries on tasks that are interdependent and are completed within a larger organizational context (Kozlowski and Bell, 2003; Salas et al., 1992). The tasks that teams work on tend to require (1) dynamic exchange of team member resources (in- cluding information), (2) coordination of activities, (3) adaptability to task demands, and (4) an organizational structure that coordinates members (Salas et al., 1992; Swezey et al., 1994). Team-based work is an effective strategy not only for combating errors, but also for mitigating the negative impact of high workloads, fatigue, and stress, especially when team members become aware of their own respon- sibilities in addition to the responsibilities of others (Salas and Cannon- Bowers, 2000b; Salas et al., 2005; Smith-Jentsch et al., 1996). Using a team-based approach for resident work and patient care could suitably address concerns of both continuity and fatigue, reducing potential threats to patient safety. A study by Singh and colleagues, analyzing malpractice claims in which residents were identified as playing a role in harming patients, concluded that residents âare particularly vulnerable to medical errors owing to team- work failuresâ (Singh et al., 2007, p. 2030). From among 240 cases result- ing in patient injury, teamwork breakdowns were a factor in 70 percent of
system strategies 283 them (errors in judgment were a factor in 72 percent and lack of technical competence was a factor in 58 percent) (Singh et al., 2007). It was also found that âlack of supervision and handoff problems were the most preva- lent types of teamwork problems [in the malpractice cases], and both were disproportionately more common among errors that involved trainees than those that did notâ (respectively, 54 percent vs. 7 percent, p = .001, and 20 percent vs. 12 percent, p = .009) (Singh et al., 2007, p. 2032). Such data suggest that residents could greatly benefit from a reinforced team structure and training in communication and team practices to prevent patient harm, where supervision is readily available to provide necessary guidance. Shared Responsibility For team structures to develop and thrive, it is important to transform the culture of care. By introducing such culture change into residency programs, researchers have noted that âthe real challenge of the 80-hour workweek is that it demands a psychological transformationâ (Mukherjee, 2004, p. 1824), one that allows residents to tone down expectations of su- perhuman resistance to long hours and continuous care, and give in to the flexibility of team systems. Residents will continue to strive to be indepen- dent practitioners, but given their time constraints and the content of their work, distributing workload among colleagues can help them collectively better manage their time and alleviate demands while on duty. In this way, a team dynamic lends itself to better organization, which has the potential to better sustain continuity of care among multiple health practitioners and, in turn, help improve overall patient care. There is general agreement among systems experts that a mentality of âshared responsibilityâ is necessary to successfully adopt interventions for any specifically team-centered goal (Arora et al., 2008). Mutual trust and shared mental models are key components to successfully achieving these goals. Shared mental models refer to an organized knowledge structure among a team for a particular task in which the team is engaged and how team members will interact. This interaction includes anticipating and predicting each otherâs needs, identifying changes in the team task or team- mates, and implicitly adjusting strategies as needed (Salas et al., 2005). A challenge in adopting this shared mentality is that a variety of team structures exists in hospitals of which residents are a part or with which they need to communicate. Nursing teams, physician teams, resident teams, lab clinicians, pharmacists and other healthcare professionals all exist inter- dependently with one another and combine into integrated teams to provide comprehensive and continuous care to any given patient. Furthermore, each type of professional (e.g., nurses, doctors) is trained to communicate differ- ently, creating discrepancies in expectations when exchanging information
284 RESIDENT DUTY HOURS (Leonard et al., 2004). Targeting residents is a good way to introduce team- work and shared accountability across these interdependent teams, which can help develop structured communication among all healthcare workers and ultimately reduce gaps or errors in patient care. Teamwork and Task Performance The focus of teamwork for residents is individual performance in a team environment; helping each resident perform to his or her fullest capacity, most effectively and efficiently, while creating more learning op- portunities. Teamwork is defined as a set of interrelated behaviors, cogni- tions (thoughts), and attitudes (feelings) held by each team member that combine to facilitate adaptive, coordinated performance (Morgan et al., 1986; Salas et al., 2004). Learning and using the five core components of teamworkâspecifically, leadership, mutual performance modeling, backup behavior, adaptability, and team orientation (Box 8-2)âcan lead to more effective work processes. Box 8-2 The Five Core Components of Teamwork 1. Team leadership: The ability to direct and coordinate the activities of other team members; assess team performance; assign tasks; develop team knowl- edge, skills, and abilities; motivate team members; plan and organize; and establish a positive atmosphere. 2. Mutual performance monitoring: The ability to develop common under- standings of the team environment and apply appropriate task strategies to accurately monitor teammate performance. 3. Backup behavior: The ability to anticipate other team membersâ needs through accurate knowledge of their responsibilities. This includes the ability to shift workload among members to achieve balance during periods of high workload or pressure. 4. Adaptability: The ability to adjust strategies based on information gathered from the environment through the use of backup behavior and reallocation of intrateam resources. Altering a course of action or team repertoire in response to changes in conditions (internal or external). 5. Team Orientation: The propensity to take othersâ behavior into account dur- ing group interaction and the belief in the importance of the teamâs goals over individual membersâ goals. SOURCE: Salas et al., 2005.
system strategies 285 Research by Jung and colleagues has demonstrated that as teams work together applying these components, they can increase their productivity and build shared ideas of how to accomplish a task (Jung et al., 2002). Teamwork depends on each team memberâs ability and willingness to coop- erate toward achieving shared goals. For residents, these goals are providing effective patient care, maximizing learning, and minimizing errors. An example of using team efforts to achieve these goals is a general medicine residency program that recently developed a team-based teaching program to determine the effects of reducing workload and providing more supervision and teaching upon the quality of resident education and patient care. This was accomplished by creating integrated teams of two attendings (one a primary care physician and the other a hospitalist or subspecialist), two residents, three interns, and two medical students. The team remained together for 2 weeks or more at a time completing daily work and teaching schedules with a cap of 15 patients at any time, who were divided equitably among the interns. Compared to the traditional general medicine resident team, patients treated by the integrated team had a lower mortality rate (1.4 percent vs. 2.4 percent, p = .053) and significantly shorter length of stays (LOSs) (4.2 vs. 4.7 days, p < .01) (McMahon, 2008). The quality of discharge communications was also higher for the integrated team, and members managed to double their amount of time spent in educational sessions (McMahon, 2008), demonstrating that improved patient care and resident learning can both be facilitated by team structures. Other efforts incorporating interdisciplinary or multidisciplinary team rounds had very similar results of reduced LOS and improved core knowledge and team skills (Curley et al., 1998; OâMahoney et al., 2007). Training Residents in Effective Teamwork Strategies Teamwork skills often need to be learned and numerous reports and publications highlight the importance of team training in realizing goals to enhance patient safety and clinical communication (Barach and Small, 2000; Barach and Weingart, 2004; Jeffcott and Mackenzie, 2008; Leonard et al., 2004). The skills acquired through resident team training can be taught using various techniques (Klein et al., 2009; Rosen et al., 2008; Salas and Cannon-Bowers, 2000a, 2001; Salas et al., 2008; Smith-Jentsch et al., 1998), including simulation strategies that can measure team competency (Zheng et al., 2008), and are valuable because they are applicable to many facets of resident work. Since there are multiple forms of team structures and methods in which teams can be trained, a straightforward way of introducing team-centered activity and skills into healthcare settings is by training residents as a team around completing specific tasks. Also referred to as âtask-tailored train-
286 RESIDENT DUTY HOURS ing,â this type of training can be effective for several processes that take place in hospitals (e.g., surgical procedures, handovers, clinical rounds). For example, a study by Chung et al. (2007) applied a task-tailored team approach to the rounding process (a substantial part of some handover pro- cesses) performed by general surgical residents, specifically morning rounds. The strategy focused residentsâ work during their rounds on three distinct tasks: detecting postoperative complications early or conducting orderly preoperative workup; informing patients of the agenda for the day; and answering patient questions and complaints. In addition to having them focus exclusively on these tasks, the members of the rounding team (nine members: one PGY-5 and eight PGY-1 to PGY-4s) were assigned specific roles. With this direction, residentsâ work became more purposeful and e Â fficient, and they completed rounds and associated work in 1 hour (Chung and Ahmed, 2007). After a year of implementation, attendings on duty ob- served substantial increases in resident professionalism and communication, demonstrating the positive effects of team structure and culture, not only on workload but on general attitude as well. Such structure also automated team continuity of care, increasing patient awareness of the resident team and satisfaction with care received (Chung and Ahmed, 2007). Whichever methods of handover intervention or error reporting are used, residents will have to be trained in the team components of coordi- nation, communication, and cooperation to conduct them most effectively and efficiently. In some facilities, faculty or supervisors may also have to be trained in these matters in order to ensure their organizational adoption and most effective implementation. conclusion Redesigning any part of the resident learning process is a challenge. To eliminate preventable adverse events and intercept other errors before they harm the patient, it is important to have in place an environment that is both mindful of errors and nonpunitive, as well as leaders willing to consider redesign of the institutionsâ systems and processes as necessary to reduce risks. The emphasis on handovers, blame-free error reporting, and teamwork does not mean that individual residents are not expected to develop a sense of loyalty or personal responsibility for individual patient care, but it helps ensure that the best information is available at all times for patient care given that a resident or any caregiver cannot be at the bedside 24 hours a day, 7 days week. It may not be possible to eliminate discontinuity altogether in healthcare settings, but the training system can strive to minimize its effects by enhancing the quality of handovers and error reporting, promoting patient-centered approaches, and improving physician relationships by facilitating communication through team struc-
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