Low-touch approach empowering clinical teams to improve the medical on-call communication experience

Abstract

Background/purpose

Team functioning is integral to providing high quality patient care. Improving communication during on-call medical coverage requires a level of individual engagement that can be challenging to achieve in large organisations, particularly in a climate of high population healthcare needs and health human resource limitations. This project represents a novel approach through engaging care providers in addressing on-call communication culture using a systems approach and quality improvement methodology.

Methods

Factors that influence the interdisciplinary experience of making, receiving and responding to calls about patient care were identified. An asynchronous action series addressed the key drivers of a good call experience.

Results

The Good Call Action Series was developed collaboratively by interdisciplinary teams. Six multidisciplinary teams across seven specialties participated over 5 months. A modified team effectiveness score demonstrated a 13% improvement on completion of the action series.

Conclusion

System thinking can be effectively applied to the complexity of the on-call experience for all members of the healthcare team. Clinical teams can develop team functioning skills and solve complex on-call communication issues with minimal support and without structured quality improvement training. Low-touch, time-efficient activities designed and delivered using quality improvement methodology can effectively address team-based care delivery challenges.

Introduction

Effective communication and teamwork between healthcare providers is an essential component of providing safe care for patients,¹ and continued efforts are required to learn more about feasible and efficient communication practices.² Increasing challenges of healthcare staff resourcing, increased occupancy and high acuity lead to an environment in which there is limited capacity for healthcare team members to spend dedicated time on professional development.³

There are many tools available to support communication among healthcare professionals⁴ and the on-call environment involves multiple situations, many healthcare providers and supporting team members, and often competing priorities within a complex adaptive system.⁵ The Stacey complexity matrix⁶ categorises tasks in four domains of simple, complicated, complex and chaos, and outlines the most appropriate response based on the level of complexity. On-call situations are often within the zone of complexity of the Stacey complexity matrix,⁶ challenging the application of a single approach across a large organisation.

We identified the on-call period, when a medical provider was providing cover for urgent and emergent patient care issues, to be a potential high-risk environment for communication breakdown and a challenging environment to address team functioning. Following a critical incident review of a patient safety event, we undertook a multiphased approach to address medical on-call communication, grounded in quality improvement methodology and resulting in the development and execution of an action series to improve team communication and effectiveness in clinical on-call situations. We describe the application of the ‘Probe-Sense-Respond’ approach of the Cynefin framework,⁷ in which complexity is addressed through a ‘probe’ phase to promote understanding of the current state, influencing themes are identified through a ‘sense’ or sense-making phase, before developing a ‘response’ in which change ideas are identified and implemented.

Methods

Probe

The first objective was to determine the experience of being on-call from the perspective of the team members involved. In April 2021, three quality improvement trained physicians were recruited into leadership roles in the project. After defining the project scope, the Physician Leads were tasked with seeking insight from their peers into the factors that influence in-person attendance when on-call and at which time points or phases in the on-call interactions they occurred. A prompting scenario was presented which highlighted competing priorities and included unclear information provided by phone outside of normal working hours.

Sense

Using the factors identified by the Physician Leads as a starting point, additional factors that influence the interdisciplinary experience of making, receiving and responding to calls about patient care were explored between June 2021 and March 2022. We hosted two virtual engagement events on the video teleconferencing software platform Zoom with the on-line collaboration platform Miro⁸ and distributed a survey.

The first event consisted of three parts designed to elicit collaboration and creative problem solving: an introduction to establish psychological safety and scope; a validation section to develop a comprehensive current state of the factors influencing call response; and an ideation component to create change ideas to address system level issues. The Disney Creativity Strategy⁹ is a brainstorming process that encourages teams to explore ideas in three distinct phases of Dreamer, Realist and Critic. This tool was used to provide a structured approach to ideation by separating analysis, divergent thinking, convergent thinking and critical review.

At the second event, an aim statement was co-developed which was specific, measurable, achievable, relevant and time-limited, and prioritised shared change ideas. Educational and engagement techniques to promote further participation were solicited. Physicians received a notional honourarium for participation in the virtual events.

Respond

In June 2022, a group of medical staff, nursing and allied health staff created a change package of tools and strategies designed to improve on-call communication culture using local-level quality improvement methodology. Each module consisted of self-guided asynchronous learning that promoted psychological safety and addressed the key themes through short videos, followed by in-person or virtual activities guided by an action period work sheet. Each module required a maximum of 1 hour of activity by each participant.

The Prosci ADKAR change model¹⁰ describes five steps for effective change at the individual level: awareness, desire, knowledge, ability and reinforcement. These change management principles were incorporated through the five modules. Videos included publicly available content related to the module as well as locally produced video content by a physician and multidisciplinary team member. Access to the module content was provided through the health organisation’s external website. Team members received regular email updates to a preferred email address.

Registration for the action series, titled ‘Good Call’, began in November 2022, targeting multidisciplinary teams of three to seven participants. The action series ran from January 17 to June 20 2023.

Physicians engaging in the action series received up to 6 hours of funding over the 5-month period.

An evaluation tool was developed by adapting eight questions from Beckhard’s Goals, Roles, Processes and Interpersonal Relationships (GRPI) model of team effectiveness¹¹ for a clinical setting, which describes four key elements of effective team functioning—goals, roles, processes and interpersonal relationships. Teams completed the short questionnaire immediately before, on completion and at 6 months after completion of the action series.

The project was led by a team of medical educators with a primary focus on teaching quality improvement to physicians, in collaboration with health organisation quality and patient safety consultants. The project champions were physicians who had completed quality improvement training in Model for Improvement¹² along with multidisciplinary team members, representing a range of clinical services across 25 specialties.

Patients were not involved directly in this study.

Results

Probe

During the initial environmental scan, common factors were identified across sites and specialties at three different time points or phases in the on-call interactions: receipt of the call, understanding the evolving clinical situation and the decision to attend in person. Four influencing factors emerged: system and process opportunities or constraints impacting the on-call experience (situational and environmental); how information is shared and what information is shared (communication); the influence of prior experiences with multidisciplinary team/physician colleagues and the patient (relationship and trust); and physical requirements impacting the on-call experience (technical).

Sense

The June 2021 virtual sense-making event was attended by 15 physicians representing 10 specialties and 4 communities. The first three influencing factors were validated through broader engagement and five broad categories for improvement were identified: establishing communication tools and checklists, establishing on-call triage process, addressing system-level bias and stigma, improving psychological safety and establishing feedback loops for learning. Technical factors were determined to be out of scope for the project team.

Affinity mapping, cause/effect matrix and dot voting were used to identify and prioritise participants’ change ideas as the basis for a change package. The relationship between the call response phases, influencing factors, categories for improvement and change ideas, as identified by the participants, is presented in figure 1.

Figure 1. Relationship between the call response phases, influencing factors, categories for improvement and change ideas identified through sensing.

Five physicians and six multidisciplinary staff (registered nurse, allied health, leadership, other), representing 5 communities and 10 clinical care areas, identified the aim statement: to achieve a 20% improvement in scores of team effectiveness in on-call communication by team members, within 80% of participating teams, by December 2023.

Participants identified process elements for success to include peer-to-peer communication; a focus on patient safety and why the initiative was relevant; recognition of the resource challenges and low energy levels; easy access to materials; having something fun to unite around a common cause; asynchronous activities; and showing recognition of all team members.

Respond

Over five modules, the action series directed teams to explore the impact of systems and human factor thinking, understand team roles, use tools to support communication in clinical scenarios and team communications, identify and implement high impact-low effort processes to enhance call experiences and explore how the team will continue to lead change for improvement in their area. The Good Call Action Series modules are presented in figure 2.

Figure 2. Good Call Action Series modules. CUS, Concern-Uncomfortable-Safety issue; SBAR, Situation-Background-Assessment-Recommendation; STOP, Summarize the case-Things that went well-Opportunities to improve-Points to action and responsibilities.

Six teams enrolled in the action series. Five teams completed the series, and one team withdrew after the first three modules. 34 participants included 19 physicians from 7 specialties and 15 non-physicians covering 7 roles: clinical nurse educator, clinical nurse leaders, clinical coordinator, nursing unit assistant, booking clerk and registered nurse. 28 out of 30 modules were completed across the 6 teams. 22 participants (64%) completed the initial team effectiveness score; 21 participants (62%) completed the post-series survey. Combined team effectiveness scores increased from 75% to 88%, with all six teams showing an increase by the end of the action series. All four domains increased: goals by 12.6%, roles by 12.7%, processes by 20.3%, interpersonal relationships by 9.8%. Three teams (50%) demonstrated a 20% increase or greater in overall scores. All teams achieved an increase in the four domains of the evaluation tool. Of the 34 participants, 10 (29%) responded with an average score of 89.5% at 6-month follow-up.

Limitations

The Good Call Action Series recruited teams who self-identified and hence were motivated to find solutions and make changes. The teams participating in the action series were limited to seven members who participated in on-call exchanges together and not entire call groups or unit staff. The ability of the innovators and early adopters¹³ to scale and spread has not been examined. The responses to the evaluation tool were unpaired and fell from a high of 64% for the pre-series evaluation to a low of 29% 6 months post completion of the series. Patient partners were not involved in developing this action series.

Discussion

In the changing healthcare environment with human health resource pressures and high acute care occupancy, the need for a safe, supportive environment and clear communication was identified as a priority. One team expressed this as ‘I cannot express the incredible value in getting together with your colleagues and finding common ground. This work needed to be done and Good Call gave us a platform to get started’. Spending time to build the team around a common goal was identified as a key element of success in the action series: ‘I am glad we slowed down and took the time to get to know each other and set common goals instead of jumping straight into our ideas. I won’t underestimate the value of that again’. Informal feedback highlighted an appreciation of the limited time commitment required. Seeing physicians and staff from their organisation in the videos enhanced the construct validity of the content.

This initiative demonstrates the complexity of the on-call experience for all members of the healthcare team and highlights the system-level factors that contribute. This includes, but is certainly not limited to, the patient population, patient morbidity, patient location, staff experience, communication skills, technology, support systems, competing priorities and the call schedule. We were able to leverage the expertise of clinical care providers trained in quality improvement methodology including system thinking, change management and team building. The recognition of a complex issue where there was a lack of agreement on what needed to change and a lack of certainty on how the changes would impact the outcome required high levels of innovation and creativity at the team level. Vision clarity was fundamental¹⁴ for multidisciplinary team members to unite around a common goal before embarking on changes: ‘The action series gave us a reason to get together and start talking about the current state and what we could do to change it’.

Several teams were eager to move directly to implement change ideas and were initially reluctant to spend time creating a shared vision and values and role clarity. Qualitative feedback identified modules 1 and 2 as the most valuable, and potential change ideas that had been considered before beginning the action series were discarded by individuals once they built rapport with their team and developed a shared mental model.¹⁵ The action series approach provided the tools and environment to improve psychological safety within the group,¹⁶ addressing one of the key factors identified to enhance on-call communication. While several on-call communication support tools were provided, team ownership of solutions allowed customisation for each of the clinical groups. Using foundational change management principles, success was demonstrated while balancing the extremely limited capacity of clinical staff to undertake new training.

In the context of on-call communication, the GRPI model of team effectiveness¹¹ aligns with the influencing factors and key change ideas identified through multidisciplinary engagement. As the action series was developed, the four key elements of the model—goals, roles, processes and interpersonal relationships—were addressed. Using a simplified version of this evaluation tool, we were able to obtain team functioning scores for all teams both before and at the end of the action series. Initial team effectiveness scores were high, which may reflect the tendency to overestimate behaviour and performance¹⁷ or the engagement of innovators and early adopters.¹³ The initial high scores may have impacted the ability to achieve the aim of 20% increase by 80% of teams. We made the decision to maintain the original aim statement for this cycle of the action series; however, in subsequent cycles, we have adapted the aim and have set the target as 80% of teams to increase their score over 90% to accommodate teams with a high initial score.

Use of the Cynefin framework⁷ to probe, then sense before developing a response was highly effective in engaging care providers in a potentially challenging subject area. It promoted the development of a product that allowed a common issue to be addressed by varied teams across different geographies and clinical care areas, which was led by clinical care staff and achieved an organisation-level objective. In contrast to a traditional QI approach using Model for Improvement,¹² the action series allowed teams to use quality improvement methodology without the requirement for formal training in QI and to adapt the change ideas to their individual setting based on shared vision and understanding of the roles within their team. We did not use formal Plan- Do-Study-Act (PDSA) cycle labels or cycle-specific measures and used a low-touch approach to ensure that teams simply tried an idea, explored the impact and made a decision to adopt, adapt or abandon. This allowed the teams to be nimble and reduced the time commitment to test and measure change ideas.

The most significant challenge of the Good Call Action Series was the forming of the teams themselves. We developed online video information to address frequently asked questions and provided individualised consultations. Initial concerns regarding the time commitment were unfounded as the suggestions obtained during the ‘probe’ phase guided the development of an approach which required minimal time commitment with synchronous and asynchronous components.

Change ideas took two forms—structural and behavioural. The teams that made structural changes to their processes were successful in embedding new workflows and these were maintained. Changes to team culture are potentially more challenging to maintain as team membership changes over time. Some teams have enrolled in subsequent cycles of the action series with new team members to support sustainability and spread. Once developed, the action series approach has been low effort to run subsequent cycles using the same materials.

Conclusion

We explored the factors that influence the interdisciplinary experience of making, receiving and responding to calls about patient care and developed an asynchronous action series to address the key drivers of a good call experience. Participants explored the impact of systems and human factor thinking, team roles, communication tools, high impact-low effort change ideas and developed a sustainability plan. There was high demand to see change in on-call communication patterns and behaviours to reduce adverse patient safety events and improve effectiveness and efficiency.

We demonstrated that team effectiveness could be enhanced by employing a team-based approach to generate grass-root level changes, developing an interdisciplinary coalition of engaged clinical care teams, improving psychological safety and local team culture and using data-driven improvement methods. We confirmed that changes to culture-driven practices are effectively approached through team building, and that addressing psychological safety and trust is at the core of patient safety and quality improvement.

Implication

This was a novel approach that used the probe-sense-respond framework to address a complex healthcare communication challenge. The action series approach places confidence in teams to build psychological safety, trust and team effectiveness in a variety of settings.