Full Answer Section

Summary of Interview Findings:

Sarah highlighted a recurring issue: ineffective communication and coordination during patient transitions from inpatient to outpatient care. She described frequent instances where:

• Lack of Timely Communication: Discharge summaries were often delayed, leading to outpatient providers receiving crucial information late or not at all.
• Inadequate Information Sharing: Important patient information, such as medication changes, follow-up appointments, and specific care instructions, was often missing or incomplete.
• Poor Coordination of Services: Patients frequently experienced delays in accessing necessary outpatient services, such as home health care or physical therapy, due to communication breakdowns between inpatient and outpatient teams.
• Lack of Follow Up: There was little to no follow up after discharge to ensure that patients were following their care plans.
• Patient confusion: Due to the lack of clear instructions, many patients did not understand their follow up care.

Sarah noted that these issues often resulted in patient readmissions, increased healthcare costs, and decreased patient satisfaction. She attributed these problems to a lack of standardized communication protocols, inadequate use of technology, and limited face-to-face interaction between inpatient and outpatient teams.

Identified Issue: Ineffective Patient Transition Communication

The interview revealed that ineffective communication and coordination during patient transitions represent a significant issue that would benefit from an evidence-based interdisciplinary approach. The current system lacks standardized protocols, timely information sharing, and coordinated service delivery, leading to adverse patient outcomes.

Change Theories and Leadership Strategies:

To address this issue, Lewin’s Change Management Model could be applied. This model involves three stages: unfreezing, changing, and refreezing.

• Unfreezing: This stage involves recognizing the need for change and creating a sense of urgency. This could be achieved by presenting data on readmission rates and patient satisfaction scores to stakeholders.
• Changing: This stage involves implementing the proposed changes, such as developing standardized communication protocols and utilizing electronic health record (EHR) systems for seamless information sharing.
• Refreezing: This stage involves reinforcing the changes and ensuring they become part of the organization’s culture. This could be achieved through ongoing training and monitoring of performance metrics.

A transformational leadership approach would be beneficial in driving this change. Transformational leaders inspire and motivate their teams, fostering a shared vision and promoting collaboration (Bass & Riggio, 2006). This leadership style would encourage interdisciplinary team members to actively participate in developing and implementing solutions.

Collaboration Approaches:

To establish or improve an interdisciplinary team, several collaboration approaches from the literature could be relevant:

• TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety): This evidence-based framework emphasizes communication, teamwork, and patient safety (Agency for Healthcare Research and Quality, 2023). It provides tools and techniques for improving team communication and coordination.
• Interprofessional Education (IPE): IPE involves healthcare professionals from different disciplines learning with, from, and about each other to improve collaboration and patient outcomes (World Health Organization, 2010). Implementing IPE initiatives can enhance understanding and respect among team members.
• Shared Decision-Making: This approach involves patients and healthcare professionals working together to make informed decisions about care (Elwyn et al., 2012). Implementing shared decision-making can improve patient engagement and adherence to care plans.
• Utilizing technology: Implementing a secure, easy to use, communication platform can greatly increase communication between inpatient and outpatient care teams.

Conclusion:

The interview with Sarah Jenkins highlighted significant challenges in interdisciplinary collaboration during patient transitions. Addressing these challenges through an evidence-based interdisciplinary approach, utilizing change theories and effective leadership strategies, and implementing appropriate collaboration approaches can improve patient outcomes and enhance the quality of care. The next steps will involve developing a detailed interdisciplinary plan proposal that outlines specific interventions and evaluation methods.