October 2008 Volume 34 Number 10 The Joint Commission Journal on Quality and Patient Safety 614 View the World T hrough a Different Lens: Shadowing Another Provider Tool Tutorial T he delivery of health care is specialized, with multiple professionals representing different disciplines caring for the patient. Although specialization is intended to provide higher-quality care from each provider, the compilation of providers into an interdisciplinary team can increase the potential for communication, collaboration, and teamwork breakdowns. In addition, while each health care provider is an expert in his or her discipline, very few providers understand the daily responsibilities, needs, communication, and team- work issues of other disciplines. Communication is an impor- tant thread that weaves the various disciplines into an effective interdisciplinary team. When communication is ineffective, collaboration and teamwork fail, and patients are at increased risk of medical mistakes, sentinel events, or even death. 1–3 In September 2004, we developed Shadowing Another Provider (SAP) as a structured tool to help health care providers identify the teamwork, communication, and collaboration issues that affect patient care delivery from the perspective of other professional disciplines. T he goals of this tool are two- fold, as follows: 1. To identify the defects in communication, collaboration, and teamwork between the different disciplines 2. To identify methods to resolve these problems to optimize patient care delivery. To do this we ask the person shadowing to see things from the perspective of the person being shadowed. Tool Description T he relationship of two disciplines working together to provide clinical care is the focus of the interaction, and the shadowing tool prompts the person who is shadowing to focus on team communication, collaboration, and teamwork and their impact on patient care delivery. T he tool also provides an opportunity for the person shadowing to view a clinical area from another’s perspective and to make recommendations to improve multi- disciplinary interactions. T he tool encourages the shadower to ask questions about the impact on patient care delivery, primar- ily focusing on defects in the system in which the provider works, often related to communication between two different disciplines. T he shadowing tool includes a one-page instruction guide and a two-page shadowing process divided into four sections. ■ In Section I, observers describe the interactions that occurred between providers through the eyes of the providers they shadowed. ■ Section II provides a framework of questions to help observers identify and assess communication and teamwork issues that affect teamwork climate and, ultimately, patient care in the unit. ■ On the basis of their observations, the person shadowing describes what he or she will do differently in clinical practice to communicate more effectively in Section III. ■ Finally, the observer makes recommendations for improv- ing communication and teamwork in Section IV. The observer then discusses findings and proposed solutions with adminis- tration to determine whether any action is needed to address the recommendations. Tool Application to Quality and Safety Effective communication and teamwork are the foundation for quality and safety in patient care. T he shadowing tool allows a provider to observe and better understand the tasks and respon- sibilities of another discipline, thereby enabling the shadower to identify how teamwork and communication can be improved, with the goal of improved patient care delivery. Shadowers get a “behind the scenes” look at another discipline’s issues relative to oral and written communication, collaboration and team- work, and how problems can affect patients. Two examples illustrate situations that might have been avoided if the shad- owing tool had been used to highlight such issues. ■ An inpatient with a neurologic injury needed a feeding tube. However, tube insertion was delayed because the consult team’s recommendation was not verbalized directly to the pri- Readers may submit Tool Tutorial inquiries and submissions to Steven Berman at sberman@jcrinc.com. Tina Maund, R.N., M.S., serves as Tool Tutorial edi- tor. David A. Thompson, D.N.Sc., M.S., R.N.; Christine G. Holzmueller, B.L.A.; Lisa Lubomski, Ph.D.; Peter J. Pronovost, M.D., Ph.D. Copyright 2008 Joint Commission on Accreditation of Healthcare Organizations