Background:
Geographic localization of inpatient physician services to nursing units has been suggested to improve teamwork and patient safety among health care professionals, while perceived lack of collaboration has been associated with worse patient outcomes. On our inpatient oncology units, we previously found that large discrepancies exist in perceptions of teamwork and collaboration among professionals, with nurses perceiving teamwork as much worse than physicians. We hypothesized that one cause of perceived poor teamwork was dispersion of physician services across multiple units.
Methods:
Localization of all physician services on the inpatient oncology units proved complex, since nine distinct clinical oncology services had patients scattered across three different units. We focused on the least localized services, including three oncology hospitalist and two solid and liquid tumor teaching services. Complexity necessitated designating primary and secondary units for each service. We implemented localization in May of 2014. To determine impact, we surveyed nurses, residents, and hospitalists via email on perceptions of teamwork and collaboration during November 2014 to February 2015 using the same validated instrument (Safety Attitudes Questionnaire; scale 0-100) used prior to localization. Respondents also rated potential barriers to collaboration using a 4 point ordinal response scale (1=not at all a barrier; 4=major barrier).
Results:
Rates of localization for intervention services were 100% (91% primary unit, 9% secondary unit) for hospitalist, 100% (85% primary unit, 15% secondary unit) for solid tumor, and 100% (units unavailable) for liquid tumor services. Overall, 129 of 193 (67%) of eligible professionals completed the pre- and 58 of 99 (59%) completed the post-localization survey. The teamwork score among nurses improved (68.87 to 75.11, p=0.04). Teamwork scores were unchanged for hospitalists (84.33 to 80.36, p=0.52) and residents (81.9 to 76.47, p=0.24) (see Table 1). Nurses and hospitalists both perceived not having physicians routinely work with the same nurses as a barrier to communication, while nurses only perceived negative attitudes regarding the importance of communication, and not sharing the same office or medical records space as barriers to communication.
Conclusions:
Geographic localization of physician services on oncology inpatient units improved ratings of teamwork and collaboration among nurses, who previously felt it was poor; while high ratings of teamwork and collaboration among hospitalists and residents remained unchanged. Perceived barriers to collaboration indicate continued need for improvement. Next steps include additional interventions building on localization, and assessing impact on patient outcomes.