Multidisciplinary care refers to the active collaboration between various members in the health care system to deliver optimal care for every hospitalized patient. Successful teamwork is a core competency that can be taught and incorporated into patient care processes. The Association of American Colleges (AAMC), the Accreditation Council for Graduate Medical Education (ACGME), and the Society of Hospital Medicine (SHM) require specific teamwork-related competencies for medical students, residents, and hospitalists. Hospitalists can improve multidisciplinary care of hospitalized patients by demonstrating group dynamic skills, conducting effective multidisciplinary team rounds, evaluating performance, providing feedback, teaching about error and how teamwork and communication can reduce error, and by leading quality improvement initiatives.

The U.S. health care system is a highly organized and complex system. Over the last three decades of the public safety movement there have been landmark studies and published reports about individual and systemic failures that have not only cost lives but wasted billions of U.S. dollars while delivering unsafe care. Although different solutions may be debated, it is clear that the U.S. health care system will need to be redesigned to deliver the highest quality of care possible. Sweeping change requires effective teamwork on every level, hospital networks, hospital, hospitalist service, and direct multidisciplinary patient care.

In general, most physicians have little formal training relating to complex hospital systems or human error and lack insight into their own limitations during conditions of stress, lack of sleep, or conflicting demands. Strong hierarchy, power differentials, lack of clarity requiring specific tasks and roles, and lack of coordination are common teamwork and communication failures in health care. Lessons learned from the aviation industry can be applied to the delivery of hospital care, and hospitalists can take steps to reduce the likelihood of (1) individual error resulting from physiological and psychological limitations of human beings and (2) team errors resulting from failure to act or deviation from established standards. Although it is not possible to eliminate individual error, systems can be designed that reduce the likelihood of error and make hospitals a safer environment for patients. Working in teams and serving as the hub of communication network in the hospital, hospitalists are ideally poised to change the culture of “how we do things around here” by serving as clinical role models and as leaders of patient safety on the multidisciplinary care team. Without effective teamwork and medical leadership, however, these complex systems have been shown to be less effective in producing quality outcomes.

The hospitalist team is a unit of professionals that directly provides care and so most directly impacts the patient experience and the quality of care. Composition of the team varies, but a team typically may include a hospitalist, consulting physician(s), nurse, case managers or a social worker, and a pharmacist.

Individuals have particular tasks based on their particular specialties, but the hospitalist team depends on each other for situational awareness and goal success strategies. Situational awareness is a common, accurate understanding of the patient’s condition, needs, clinical trajectory, and feelings based on the multiple perspectives of team members. The team only obtains situational awareness when these perspectives are communicated within the team. Without the perspectives of team members, no individual-including the hospitalist-truly has situational awareness. Decisions made, orders written, even conversations with patients without the perspectives of others on the team are less likely to promote coordinated, high quality care.

Goal success is an optimal patient experience. The team relies on each other to provide best practice care by limiting unnecessary variation in practice, enhancing patient satisfaction with the hospitalization experience, and discharging the patient as safely and as soon as possible. Variability in performance can be reduced by using appropriate protocols, order sets, checklists, and institutional processes to address a patient’s problems.

Limiting the risks associated with prolonged unnecessary hospitalization should be a stated goal of the hospitalist team. In support of that goal, each team member – as they round on their patients and decide whether to discharge now or not – must determine whether the benefits of continued hospitalization outweigh the inherent risks of continued hospitalization. Each team member should be encouraged to articulate the rationale for their decision to the rest of the care team.

A hospitalist typically leads the inpatient care team. As the leader, the hospitalist is responsible for goal clarity, role clarity, communication, and team cohesiveness. Effective teamwork requires the willingness of the team members to work toward a shared goal. Goal clarity requires explicitly stating what defines success for the team and a quality outcome for the patient.

• What medical conditions are or are not being treated as an inpatient?
  
• What is the goal of treatment?
  
• What is the endpoint of hospitalization?
  
• What is the reason for each test, intervention, change?

Role clarity requires explicitly identifying who will do what on the team.

• Who on the care team is responsible for which aspects of care?
  
• Who is discussing which issues with the patient?
  
• Which consultant is managing which problem?
  
• Who is writing orders for what?

Effective communication requires fostering the sharing of essential information across the hospitalist team. The team leader is responsible for demonstrating techniques that encourage specific teamwork behaviors that ensure that roles are clearly defined, timely and accurate information is shared, and plans are discussed and mutually agreed upon. Effective teamwork can reduce the number of medical errors through improved communication and better coordination of care.

• What method will the team use to communicate, the chart, phone, or face to face; for example: by reading each other’s chart notes, by phone, face-to-face
  
• How often will members communicate; for example: during rounds, only as needed, every afternoon before going home?
  
• What tone and language will be used to decrease barriers and misunderstandings?

Cohesiveness requires recognition of a shared purpose, defined roles, and task interdependence. As the facilitator of optimal team function, the leader limits disruption and fragmentation of the team that can occur with any dynamic and complex process. This requires active listening and frequent communication with all members of the team, sharing decision-making responsibilities, and proactively providing opportunities for everyone to contribute according to their abilities, including patients and families.