Chapter 9: Scenario
Jan slowly began to realize that most
of the care offered on her unit was predominantly incremental and
compartmentalized. The physicians did their diagnosis and treatment; the
pharmacy, physical therapy, social work, and other professional services
intervened in the patient care periodically as required or requested to meet
specific needs. While all of these professional services were offering their
best care, their efforts were largely uncoordinated and not specifically
integrated around the unique and individual needs of each patient. Much of the
work of the disciplines had become ritualized and routine without much team
planning, interaction, or face-to-face time between providers.
Jan wants to change this model of
care to more strongly emphasize the integration of clinical services, and more
specifically intersection care, in a well-communicated interdisciplinary plan
of care that involves increased interaction, relationship, and engagement
between the disciplines around individual patient needs. Furthermore, she wants
to more fully engage patients in these dialogues so the care offered by the
team can be more specifically aligned with the unique individual needs of each
patient. Jan is not sure where to begin, but she knows it is important to begin
this work soon.
Discussion Questions
1.
With whom does Jan needs to discuss
this situation first, and what should be the content of this dialogue?
2.
Who is the stakeholder community
here, and how should they be gathered around this issue?
3.
What would be some of the first
elements of discussion and dialogue with the stakeholder group? Are the
questions and issues that the group should initially concern itself with more
about the group’s interactions or the group’s relationship to the care of the
patient?
4.
For
this interdisciplinary relationship to work and integration to
interdisciplinary care to thrive, which three or four principles must all the
disciplines agree upon as a way of guiding their work together?
5.
W
ith
the colleagues on your learning team, develop a plan for this interdisciplinary
group as its members begin the work of building their relationships with one
another and implementing an interdisciplinary approach to managing and
integrating patient care.