Collaborative practice model took years to implement

Before Hoag Memorial Hospital Presbyterian in Orange County, CA, started its collaborative care initiatives for case management and social work, the two disciplines often were at odds with each other.

"Historically in our organization, the RNs have complained to other RNs about the social workers and the social workers have complained to other social workers about the RNs. It was like the two different groups were warring with each other," says Theresa Thomsen, LCSW, manager of the social work department.

One of the goals of the initiative was to eliminate the backbiting and complaining about the other disciplines and to improve communications between the two disciplines.

"Over a period of time, people started being team members and were going to the people with whom they had issues instead of going through the boss. We felt we were breaking down barriers and opening up lines of communication," Thomsen adds.

The case managers and social workers have learned to recognize that they have accountability to the other disciplines on their team and a responsibility to work together, says Paula Griego, BSN, manager of the case management department.

"They can’t just pull back and say they won’t deal with something. There is accountability and teamwork," she says.

Designing the collaborative model and making it work was a long, and sometimes difficult process, according to Thomsen and Griego.

It coincided with a hospital initiative to improve employee morale. Part of the process was to build "Just Do It" groups in every department. The groups were to identify goals and barriers to reaching the goals and then work toward overcoming the barriers.

"It’s a very powerful tool, but it takes a couple of years. It doesn’t just happen overnight," Griego says. When Hoag instituted its hospitalwide program, some of the staff went through training to learn how to get the ball rolling in the groups.

"Part of the training is to set ground rules. Every-body has to understand that there are no bad questions and no bad ideas and that the team should be serious about the change," Griego says.

The Just Do It groups are made up of the team on each unit who work together every day and includes RN case managers, social workers, and case management assistants. Everyone in the department is assigned to a group. The groups meet monthly and focus on improving communication and team work. "The groups in our departments became a little competitive. The rest of the department would see how one team was really getting along and they’d try something else as well," Thomsen says.

The groups began by outlining barriers that were problematic. For instance, the social workers complained that the RN case managers sometimes dumped cases on them, and the case managers complained that the social workers didn’t always order the equipment the patient needed in a timely manner. "Their comments can be stinging, and we sometimes had to tease out some of those whispering comments that go on behind the other people’s backs," Thomsen says.

The group leader took the complaints that each discipline had been making about the other for years and put them on a blackboard, saying, "this is part of what the unspoken communication has been, what the tension and resentment is all about."

The group took up the comments one by one and talked about what they could do to make things better. For instance, in the case of complaining about other disciplines behind their backs instead of tackling the problem head-on, the groups established a hard-and-fast rule: If someone has a gripe or a problem, they talk to their colleague first without going to the manager.

Now the team members seldom go to their managers with problems, but when it happens, she tells them to talk to their colleague and come back if they can’t solve the problem. Very few people ever come back, Griego adds.

"We’re really consistent with the direct communication approach. It took a couple of years before the culture took hold, but we kept working at it," says Thomsen.

The case managers and social workers look at each other as customers as well as colleagues and work together to keep each other happy.

"Keeping the satisfaction level and communication levels between teammates of different disciplines is as important as keeping patient satisfaction and communication high," she adds.