Theme | Subthemes (associated knowledge, skills and attitudes) |
---|---|
Patient-centred care: a common concern Being able to work together with the same patient-centred goals | Work from a common patient centred framework |
Respect and understand the patients’ view | |
Know the background of the patient | |
Set shared goals | |
Shared care thinking | |
Collaborative attitude and respect Being able and willing to work together with respect for partners in collaboration | Respect each other |
Respect each other’s roles, expertise and task distribution. Do not re-refer, do not retain | |
Respect each other’s values related to the patients’ outcome | |
Be willing to cooperate, be open-minded | |
Look beyond one’s own position and task | |
Accept limitations to autonomy | |
Roles and responsibilities Being able to know, make arrangements about, work in and follow up on a clear division of tasks, roles and responsibilities | Understand, make arrangements about and cooperate in a clear division of tasks, roles and responsibilities |
Share responsibility for (continuing) care | |
Give and receive feedback and address conflicts | |
Be (directly) accessible and available | |
Use consultation as an educational opportunity | |
 ° Recognise moment, learning needs and sufficiency moment | |
 ° Use and provide appropriate means | |
 ° Deliver valuable information in a tactful way | |
Specific responsibilities for PCD | |
 ° Provide appropriate, timely referral | |
 ° Follow up advice | |
 ° Prepare the patients for the hospital visit | |
Specific responsibilities SCD | |
 ° Have clear referral requirements | |
 ° Provide consultation | |
 ° Include the PCD in important decision-making in the hospital | |
 ° Guarantee that appropriate follow up is arranged | |
 ° Confirm appropriate treatment plan, matched to the patient | |
 ° Display interest in the patient and look for additional pertinent information | |
 ° Take into account the referrer’s characteristics | |
 ° Invite requesters for informal consultation | |
Mutual knowledge and understanding Being able to identify, know about and understand partners in collaboration | Know your own limitations |
Know each other, doctors, personally | |
Know the training, workplace and resources of the other | |
Know the referral and communication system | |
Understand the profession and perspective of the other and be able to match expectations | |
Understand team dynamics and power relations | |
Communication Being able to communicate well in the right way on the right moment | What should be communicated |
 ° Physical symptoms and medication: new, dose, duration, changes | |
 ° Communicate only appropriate and essential information | |
 ° Communicate the ending of consultation | |
 ° Good request: states the urgency, a clear question and includes all the necessary information, including psychological information when relevant | |
 ° Good reply: addresses the question asked, is prompt, adequate, detailed, shows understanding of the patient, includes prognosis, a treatment plan, future steps and follow up | |
When should communication take place | |
 ° Timely: sometimes this means quick, other times this means knowing when to communicate based on the medical situation | |
 ° Immediate and direct in emergency situations | |
 ° At admission, at major decision-making points and at discharge | |
How should communication take place | |
 ° Way of communication depends on urgency request | |
 ° Communicate concise | |
 ° Communicate without condescension | |
Good oral communication | |
 ° Communicate friendly, clearly (tone, pace, accent) and listen open and active | |
 ° Ensure that it’s heard and understood | |
 ° Communicate diplomatic with patients about colleagues | |
Good written communication | |
 ° Well-structured written communication by PCD: Provide referral reason and clinical information in the referral letter | |
 ° Well-structured written communication by SCD: Summarise findings, assessment and management plan in a comprehensive non-discourteous letter, with bulleted recommendations at the bottom of response | |
Leadership Being able to show leadership to facilitate collaboration | Manage persons (mediate, motivate, influence, build teams and relationships) |
Manage processes to facilitate collaboration (coordinate, organise well-functioning systems for collaboration, plan collaboration processes) | |
Show leadership on organisational level and beyond to support collaborative practice |