Department of Health Care Quality, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
Center for Health Care Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
JAMA Netw Open. 2022 Apr 1;5(4):e228867. doi: 10.1001/jamanetworkopen.2022.8867.
Inpatient subspecialty consultations, a common and expensive practice within inpatient medicine, do not always go well; however, little is known about the failure modes of consultation, thus making it difficult to identify interventions to improve consultation quality.
To understand how stakeholders envision the ideal inpatient consultation and identify how and why consultations commonly fall short of this ideal.
DESIGN, SETTING, AND PARTICIPANTS: This qualitative study used in-depth, semistructured interviews collected from April to October 2017 and analyzed from January 2018 to February 2020 using conventional content analysis. The setting was a single academic medical center in Boston, Massachusetts. Participants were hospitalists and specialists who had requested or performed a consultation for a non-intensive care unit patient in the previous 4 months, patients who had received a consultation while hospitalized at the medical center in the previous 15 months, and family members of such patients.
Consultation experiences reported by participants. Clinicians were asked about characteristics of the ideal consultation, positive and negative consultation experiences, costs and benefits, and suggested improvements. Patients and family members were asked about their consultation experience, changes in care, communication preferences, and suggested improvements.
The study included 38 participants: 17 specialists, 13 hospitalists, 4 patients, and 4 family members. More than half (21 of 38) of the participants were female. There were 11 key information exchanges identified that occur among the specialist team, primary team, and patient/family during an ideal consultation. These exchanges are time sensitive and primarily carried out through unwritten protocols. We also identified 6 defects (process failures) that commonly derail information exchanges (complete omission, exclusion of a key stakeholder, poor timing, incomplete or inaccurate information, and misinterpretation) and 5 contextual factors (roles and boundaries, professionalism, team hierarchy, availability, and operational know-how) that influence how information exchange unfolds, making some consultations more prone to defects.
Successful inpatient consultation requires a complicated, sequenced series of time-sensitive information exchanges that are highly vulnerable to failure. Maximizing the benefit of consultations will likely entail not only minimizing low-value consultations but also actively preventing defects, such as information inaccuracies and misinterpretation, that commonly derail the consultation process.
住院患者专科会诊是住院医学中常见且昂贵的做法，但会诊并不总是顺利进行；然而，对于会诊失败的模式知之甚少，因此难以确定可以提高会诊质量的干预措施。
了解利益相关者如何设想理想的住院会诊，并确定会诊通常如何以及为何达不到这一理想。
设计、地点和参与者：这项定性研究使用了 2017 年 4 月至 10 月收集的深入、半结构化访谈，并于 2018 年 1 月至 2 月使用常规内容分析进行分析。研究地点是马萨诸塞州波士顿的一家学术医疗中心。参与者包括在过去 4 个月内为非重症监护病房患者请求或进行会诊的住院医师和专家、在过去 15 个月内在该医疗中心住院期间接受过会诊的患者以及此类患者的家属。
参与者报告的会诊经验。临床医生被问及理想会诊的特征、积极和消极的会诊经验、成本和收益，以及改进建议。患者和家属被问及他们的会诊经验、护理的变化、沟通偏好和改进建议。
该研究包括 38 名参与者：17 名专家、13 名住院医师、4 名患者和 4 名家属。超过一半（38 名中的 21 名）参与者为女性。在理想的会诊中，专家团队、初级团队和患者/家属之间有 11 个关键的信息交流。这些交流是时间敏感的，主要通过未成文的协议进行。我们还确定了 6 个缺陷（流程故障），这些缺陷通常会破坏信息交流（完全遗漏、排除关键利益相关者、时机不佳、信息不完整或不准确以及误解），以及 5 个背景因素（角色和边界、专业性、团队层级、可用性和运营知识），这些因素会影响信息交流的展开方式，使某些会诊更容易出现缺陷。
成功的住院会诊需要一系列复杂的、时间敏感的信息交流，这些交流非常容易失败。要最大限度地提高会诊的效益，可能不仅需要尽量减少低价值的会诊，而且还需要积极防止缺陷，例如信息不准确和误解，这些缺陷通常会使会诊过程脱轨。
