COLLABORATE UNIFY HEAL
( continued from page 9)
is measured by compliance with a checklist, whereas loyalty and trust are built in the in-between moments a checklist cannot capture.
This frames the map almost perfectly onto interdepartmental and physician collaboration. The moments patients remember, and the moments that determine whether a handoff goes well or badly, rarely happen inside a department’ s own four walls. These moments occur in the doorway between departments, the discussion between nurses from the ED to the floor, the consultation call, the disposition conversation. If we measured and rewarded what happens in the doorway or on the phone call the way we measure the metrics inside each unit, many of these“ communication failures” would surface as the process gaps they actually are, one hopes, before the fallout reaches the patient.
This is where places like the Cleveland Clinic and the Mayo Clinic excel, and why they have the reputation of being the best. It’ s in that doorway, when a patient’ s family member can’ t find where they were transferred, the environmental service employee will walk them to the department and hand them off with a nurse or unit secretary. It’ s when the plastic surgeon heading to the cafeteria takes the time to take a lost patient back to their bed on the Med Surg. It’ s when the security guard at the metal detectors asks,“ Who’ s your loved one?” instead of“ What’ s the patient’ s name?” Here we move from my department and my patients to our hospital and our patients.
What Actually Rebuilds Trust
None of this is solved by a memo about communication or a module on culture. The departments that collaborate well with the emergency department share a few concrete habits: they answer in the way they’ d want a page answered back, they call instead of messaging when something is urgent or ambiguous and they assume good faith. The emergency physician who is calling at 2 a. m. isn’ t trying to dump a patient or forgot to call earlier, she just finished telling a family that their 15-year-old child was shot and killed in a violent matter, and despite our best efforts, we were unable to revive them. On the other hand, the hospitalist pushing back on an admission isn’ t trying to be difficult. What the emergency department may not see is the inpatient challenges: the nine admissions pending with a flood of orders, followed by a family meeting in 40 minutes. Both are usually right about their own piece of the picture and missing the others. gets tense; and that kind of trust is a lot harder to erode than to build, when the system is under immense pressure or stretched thin.
What Should We Ask For?
If we want better collaboration as departments, hospitals and communities under pressure, the honest ask isn’ t just“ communicate better,” though it helps. It’ s structural: motivated individuals who are given the resources to build processes and rehearse those processes before the pressure hits, not improvised in the middle of it; phone systems and protocols that get the right two people talking in one call instead of four; and a shared understanding, at a system level, that the handoffs among departments, physicians and nurses, nurses and nurses, etc., deserve the same design attention as anything that happens inside those departments.
The trauma bay gets the credit for teamwork because it’ s dramatic, and it usually works, largely because someone designed it to. The quieter collaboration, the 2 a. m. phone call, the resolved disposition disagreement in two extra minutes of conversation instead of two more chart notes, deserves the same kind of deliberate design as the trauma bay. It’ s a systems problem worth solving on purpose and a collaboration issue worth rectifying.
Dr. Kuzel is an Assistant Professor of Emergency Medicine at the University of Louisville School of Medicine and Director of Observation Medicine at University of Louisville Hospital. Dr. Kuzel also serves as the Medical Director for Okolona Fire and Rescue, Spencer County EMS and Bullitt County EMS.
The other thing that improves trust, unglamorously, is proximity. The best working relationships I have are with people I’ ve stood next to during a hard shift; it is true there is camaraderie in the trenches. It is not the people I’ ve only ever reached through a phone extension. When you’ ve watched someone handle a tough case well, you begin to extend to them the benefit of the doubt the next time a conversation
10 LOUISVILLE MEDICINE