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Nurses and physicians in General Internal Medicine (GIM) work in a complex environment where patients present with complex (co)morbidities; management of such patients requires input from a full range of medical disciplines. In addition, there is regular resident physician changeover every 8-9 weeks in this teaching environment, and patient “flow” problems caused by overcrowding and placement issues. This complexity causes difficulties in the information exchange between nurses and physicians necessary to manage patient care. Multidisciplinary team meetings have been suggested as helpful to interprofessional communication, and in General Internal Medicine these take place in the form of daily “Bullet Rounds”. More recently the use of process engineering approaches has been suggested as a way to increase efficiency in healthcare; this dissertation evaluates its impact on communication between nurses and physicians. The initial observational field study showed that information exchange was the main focus of dialogue in Bullet Rounds, and identified information gaps between nurses and physicians. Script Theory (Schank and Abelson 1977) was used to propose that information gaps in Bullet Rounds are caused by different knowledge and goals, which result in inconsistent scripts. A process engineering intervention took place in General Internal Medicine. Process engineering methods have been proposed as being helpful in process design and improvement in healthcare but have not been systematically evaluated. The researcher conducted a pre and post intervention study of Bullet Rounds in order to identify and analyse the impacts of a process engineering intervention on information exchange between nurses and physicians. The results showed that information loss decreased after the intervention but that resident physicians were not satisfied with the nurses-physician information exchange. The staff and resident physicians appeared to have distinct and different information needs and perspectives, while the nurses felt that the Bullet Rounds process had improved, but that it needed revisiting, and were not aligned with staff physicians on respective roles and responsibilities. The overall results suggest that even after the process engineering intervention, there was still misalignment of goals and scripts between the two groups of physicians and between the physicians and nurses, and strategies for addressing these gaps are proposed.

Nurses and physicians in General Internal Medicine (GIM) work in a complex environment where patients present with complex (co)morbidities; management of such patients requires input from a full range of medical disciplines. In addition, there is regular resident physician changeover every 8-9 weeks in this teaching environment, and patient “flow” problems caused by overcrowding and placement issues. This complexity causes difficulties in the information exchange between nurses and physicians necessary to manage patient care. Multidisciplinary team meetings have been suggested as helpful to interprofessional communication, and in General Internal Medicine these take place in the form of daily “Bullet Rounds”. More recently the use of process engineering approaches has been suggested as a way to increase efficiency in healthcare; this dissertation evaluates its impact on communication between nurses and physicians. The initial observational field study showed that information exchange was the main focus of dialogue in Bullet Rounds, and identified information gaps between nurses and physicians. Script Theory (Schank and Abelson 1977) was used to propose that information gaps in Bullet Rounds are caused by different knowledge and goals, which result in inconsistent scripts. A process engineering intervention took place in General Internal Medicine. Process engineering methods have been proposed as being helpful in process design and improvement in healthcare but have not been systematically evaluated. The researcher conducted a pre and post intervention study of Bullet Rounds in order to identify and analyse the impacts of a process engineering intervention on information exchange between nurses and physicians. The results showed that information loss decreased after the intervention but that resident physicians were not satisfied with the nurses-physician information exchange. The staff and resident physicians appeared to have distinct and different information needs and perspectives, while the nurses felt that the Bullet Rounds process had improved, but that it needed revisiting, and were not aligned with staff physicians on respective roles and responsibilities. The overall results suggest that even after the process engineering intervention, there was still misalignment of goals and scripts between the two groups of physicians and between the physicians and nurses, and strategies for addressing these gaps are proposed.

Purpose: The United State health system is fractionated: most patients travel from location to location to see various clinicians about specific aspects of their health. The poor outcomes and high cost we currently see in the United States health system has challenged clinicians to explore better processes. This study sought to identify the potential impact of utilizing interprofessional transitional care (IPTC) teams in the primary care setting following hospitalization. One outcome measured was the relationship between pharmacist’s participation and number of medications a patient was taking after their IPTC visit. Electronic Health Records were utilized to extract patient data and it was analyzed using SPSS and R programming to examine relationships between patient populations, disease states, number of medications, and pharmacist intervention. This study was conducted as part of an overall investigation into benefits of IPTC teams in Primary Care. We expect that the number of the medications to be reduced for patients that had a pharmacist involved in their transitional care visit.

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京都大学 / 0048 / 新制・課程博士 / 博士(人間健康科学) / 甲第20058号 / 人健博第39号 / 新制||人健||3(附属図書館) / 京都大学大学院医学研究科人間健康科学系専攻 / (主査)教授 桂 敏樹, 教授 任 和子, 教授 川村 孝 / 学位規則第4条第1項該当 / Doctor of Human Health Sciences / Kyoto University / DFAM

This thesis portrays a research study undertaken to explore the unknown concept of electronic interprofessional documentation. Academic literature largely centers on multidisciplinary electronic documentation yet clinicians provide care using an integrated interprofessional model. Current design of electronic health records (EHRs) continue to propagate a deluge of data resulting from disparate siloed documentation. End users report challenges with finding data. Additionally, care planning and decision making are delayed. To bridge the gap between electronic design and interprofessional delivery of care, more understanding of shared documentation is required. The provenance of the design of this study is based on the concept of common ground and the framework for complex diverse data. Common ground is a shared communication space within a team with a shared purpose (Cioffi, Wilkes, Cummings, Warne, & Harrison, 2010). The framework for complex diverse data posits that data must be linked to other interconnected data; linked data enables connection of diverse pieces and insight-sharing within a team. A descriptive qualitative study was designed to answer the research question: What are the common data elements between disciplines? A case scenario of a patient with a fractured hip was created; participants generated clinical notes based on the video and patient record. The clinical notes were coded and results indicated numerous diverse common data elements. These were analyzed and major findings such as categories appropriate for use by all disciplines on admission and design implications for care planning throughout an acute care stay were identified. Further, as disciplines and care team members do have different documentation patterns, it is suggested attendance to differences in the entry of data yet maintaining a common ground in the display of patient information is vital. Finally suggestions such as duplicate checking for documentation through a common care plan that tracks assessments and completed interventions alongside planned interventions are made. Creation of a standardized interprofessional terminology is key in building the road leading to interprofessional electronic documentation. / Graduate

Training interprofessional healthcare teams continues to advance practice for patient-centered care. Empathy research is also advancing and has been explored in social work, psychology, and other healthcare areas. In the absence of understanding empathy in an interprofessional setting, educators are limited in preparing teams to develop empathy as part of core competencies This grounded theory study explored for a theory of how interprofessional healthcare teams conceptualize and operationalize empathy in their practice. Azjen's theory of planned behavior and Barrett-Lennard's cyclical model of empathy framed the study. Data were collected using 6 focus groups and 24 semistructured interviews of varied healthcare professionals working in an interprofessional setting in Ontario, Canada. Systematic data analysis utilizing Auerbach and Silverstein's (2003) approach revealed participants engaged in and valued empathy as a team. Empathy was identified as purposeful and intentional behaviors believed to be meaningful for positive patient outcomes. In addition, professionals identified the role of genuine intent in the practice of empathy. As a result of this study, a grounded theory of interprofessional intentional empathy centered care explains the conceptualization and operationalization of empathy in practice. Collective empathy in an interprofessional team model contributes to improved patient outcomes. The work of this study ascertains that empathy is not accidental; it should be cultivated in the form of intentional and genuine team experiences. This study advances social change by further identifying how the practice of empathy can be integrated into interprofessional healthcare education and praxis.