Principles of Collaboration
Partners: Patients, Physicians, Nurses, Community Health Center Administration and Staff, Boston Community Medical Group, Physician Assistants, Consulting Services, Students, Nursing Education, Pharmacists, Physical and Occupational Therapists Environmental Services, Nutrition and Dietary and Community-based providers including rehab units and SNFs
Our Mission: To provide safe, high quality, evidence based, efficient, patient centered care at all times in an environment of collaboration and team work.
Team Focused
- Responsibility for care rests with a team of in and outpatient professionals rather than just a single provider.
- Goal: Implement Teams training
Clarity of Responsibility At All Times
- The identity of the provider and the team responsible for each case will be evident.
Citizenship
- Vigilant team physical presence on 6W will promote respectful, collaborative communication.
High Efficiency
- Promote early discharge and minimize redundancy.
- All clinicians and staff are encouraged to work at the highest level for which they are qualified.
Evidence-Based Care
Care provided will be:
- Based on the current best practices.
- Standardized among all providers.
- Informed by a rigorous CQI process.
Timely, High Quality Communication to Support Safe Provision of Care
- Participative a.m. and p.m. team board rounds
- Communication with primary care team and among providers for change in plan or patient transfer
- Use of a standardized tool for handoffs
- Use language that patients understand
Acceptable Case Load and Daily Work Load
- To provide safe care there must be well rested providers responsible for a reasonable number of patients
Patient and Family Satisfaction
- Is a responsibility of all team members
- Is a key metric for quality
Safe Transitions at Discharge
- All patients and/or families will be knowledgeable about their care
- Goal: Implement Re-Engineered Discharge
Maximize Continuity
- Communicating with PCP is a priority
- Smooth information flow among pre and post hospital care providers from admission to discharge.
Excellence in Education
- All team members have responsibility for:
- Education of residents, students and other trainees
- Orienting new members of the team
- Nurses will receive education from Family Medicine team and Clinical Nurse Educator
Clear, Comprehensive, Consistent Documentation of All Care Provided, including:
- Medication Reconciliation
- Health proxy and end of life care