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