Interdisciplinary Plan Proposal

The proposal will contribute to the resolution of the issue of extended patient stay due to the inability of interdisciplinary communication in the acute care units of Riverbend Medical Center. Absence of cohesive work of nurses, physicians, case managers, and social workers commonly leads to late updates, insufficient responsibilities, and discharge bottlenecks. The plan will also implement interdisciplinary huddles daily, as well as the SBAR model of communication to support the exchange of information between the hospitals, improve discharge preparedness, and generally patient flow in the hospital.

Objective

The overall aim of this plan is to improve the process of interdisciplinary communication in the discharge planning process by integrating daily huddles and standardized Situation, Background, Assessment, Recommendation (SBAR) communication between teams involved in care. These tools will make the plan promote the exchange of information over time, describe the barriers to discharge, and synchronize the work of nurses, physicians, case managers, and social workers (Houte, 2024).

This will reduce the undue delays and enhance patient satisfaction as well as serve the overall organizational purpose of improving efficiency and timeliness of care in the hospital. Improved communication will also support decision-making, reduce the duration of hospital stay, and eradicate the disruptions in the workflow. The plan will help the organization to deliver more coordinated, safer, and patient-focused care through the establishment of stable and orderly communication channels.

Questions and Predictions

To ensure the success of this plan, the viability of the plan, the challenges that it may face, and the expected outcomes should be investigated. The use of the guiding questions will help the team to examine the potential of involving daily huddles and SBAR communication in the process of discharge and formulate the areas that may require refinement. This reflection analysis will make it possible to realize the long-term beneficial shifts in cooperation and adjust the initiative to the organizational goals. The following questions and predictions will be used in planning and help in the change that will be measurable and meaningful.

What is the impact of the introduction of daily interdisciplinary huddles and SBAR on discharge coordination?
Perhaps, it is essential to allow the staff time to become accustomed to the structured communication routines initially, yet with the consistency building up, the barrier of discharge will be identified earlier, the transfer of information will be delivered more consistently, and the patient throughput will expand.

What is the training and preparation required to be able to use SBAR and daily huddles effectively?
Short training, sample templates, and time constraints of practicing will be obligatory. It may have to make some time investments in the short term, but the long-term gain will override the short-term investment in terms of reduced delays and seamless coordination.

In what timeframe will discharge timeliness improvements be seen?
The first positive change can be noticed during the first several weeks, including more accurate updates and reduced miscommunication. It will occur that within two or three months of regular practice, significant changes in the discharge efficiency will be realized.

What difficulties can arise in the implementation process?
Common barriers might be the absence of continual attendance, an incompatible schedule, and a lack of desire to form new habits. Nonetheless, leadership support, responsibility in the huddles, and appreciation of progress will play a part in the acceptance and frequent use.

How will the continuous evaluation promote continuous improvement?
Review and an interdisciplinary check-in of feedback weekly will help identify the gaps, continue with the positive practices, and encourage the team members to stay on track with each other.

Change Theories and Leadership Strategies
This plan will be implemented through a long-term comprehensive shift of the staff to be assisted by the application of the Change Management Theory to Lewin. The unfreezing stage will be characterized by the leaders highlighting the current delays in discharges, making the data that illustrates their impact on patient flow, and creating a sense of urgency to make changes.

The changing phase will involve the introduction of daily huddles and SBAR training, its examples, and the desire to involve the team. The refreezing step will be achieved through the continuous evaluation and feedback on the new communication practices and integration into the routine unit procedures (Smoot, 2021). The systematic nature will be part of the effort to make sure that the changes in communication are sustainable, stable, and stable.

Transformational leadership will be used to facilitate the promotion of team commitment and the strengthening of collaboration during the implementation. Transformational leaders inspire employees through creating a shared goal to improve patient outcomes, setting a good example of effective communication skills, and creating a culture of trust and respect (Ystaas et al., 2023). The leader will facilitate open dialogue during the huddles, acknowledge the input of the team, and foster a feeling of ownership across disciplines as a nurse leader. This type of leadership will help to minimize resistance, encourage participation, and lead to trust in the new model of communication.

The plan creates a feasible and motivating structure for improving discharge communication, as the Lewin Change Theory and transformational leadership assist. The step-by-step procedure designed by Lewin ensures that the change is introduced gradually and reasonably, and the transformational leadership style makes the change emotionally conditioned, empowering, and inspires the workers to remain active in the team (Ahmed et al., 2022). All of them together contribute to the development of accountability, the work of the interdisciplinary team, and the organizational commitment to safe, efficient, and patient-centered care.

Team Collaboration Strategy
The well-defined responsibilities and high-order communication, as well as the mutual responsibility of the team members of various disciplines, will help to implement the plan successfully. The nurses will assess the readiness to discharge, complete SBAR reports at the end of each shift, and share the relevant information at daily huddles. Physicians in the electronic health record will clarify medical options, address outstanding issues, and have projected discharge times (Park, 2022).

Tasks that will be performed by case managers are the assessment of post-acute care needs, the arrangement of services, and the communication with other partners. The social workers will also identify social or financial barriers that determine transitions and will communicate with the case managers to remove them. The nurse leader will monitor the process and will be a problem solver of new challenges, as well as leading weekly interdisciplinary reviews.

The collaborative methods that will facilitate the timely communication and effective organization of the efforts will be the daily interdisciplinary huddles and shared EHR tools. The huddles will be a brief yet intensive form of discussing discharge barriers in real time, which will result in the team members prioritizing their activities and collaborating to resolve the issues (Park, 2022). The similarity in utilizing EHR will permit homogenous updates, access to proper information by all fields, and a reduction of duplication of work or insufficient communication. The approaches will promote transparency, reduce disunity, and streamline operations at care environments.

Free communication promotion within the team will result in the creation of psychological safety and the promotion of a proactive approach to the issues. As soon as their members realize that they are heard and respected, they will be more eager to communicate their concerns, to offer an insight, and engage in shared decision-making (Jasubhai, 2025). As the communication between interdisciplinary teams will be more effective, the time loss during the discharges will decrease, the rotation of patients will become more efficient, and the labor efficiency will be enhanced. The collaborative culture of responsibility and respect will remain to ensure team unity and strengthen the goals of the hospital to improve patient-centered outcomes.

Required Organizational Resources
The successful implementation of this plan will be associated with the distribution of certain resources (training, staff time, communication tools, etc.). Two-hour SBAR and huddle-training session will be introduced to all the members of the team, and the overall estimated cost per interdisciplinary group is approximated at around 2,000 dollars. The nurse leader will spend about three hours per week overseeing, following up, and monitoring the progress (Park, 2022).

The process of taking updates, their contribution to the communication, and their subsequent documentation will be implemented using the available EHR systems without having to make any additional technological purchases. Low costs will involve minimum costs, such as printed SBAR templates and educational resources, whose cost will amount to approximately cost of 200. This will be a good starting point for consistent communication and improved coordination of discharge activities.

Without this plan, Riverbend Medical Center will continue to experience ineffective discharge processes that have contributed to the lengthy hospital stay, poor patient satisfaction, and enormous expenses. Delays in the patient throughput may bring about overcrowding, work stress, and a drop in the capacity of accepting new patients. Such inefficiencies can result in higher costs of operation, burnout of the staff, and potential patient safety comorbidities in the long term (Sartini et al., 2022). This type of investment in planned communication practices will therefore become cost-efficient and will play a central role in enhancing productivity, security, and sustainable interdisciplinary collaboration.

Conclusion
The proposal of the interdisciplinary plan is aimed at improving the discharge coordination process in Riverbend Medical Center, which is conducted by applying daily huddles and SBAR communication resources. The plan relies on the Change Theory by Lewin and the rules of the transformational leadership practices, which promote planned change, cooperation, and long-term improvement. It is estimated that this effort will make the discharge and patient satisfaction more efficient as it will enhance the regularity of communication, joint responsibility, and mutual respect between nurses, physicians, case managers, and social workers.

This is possible by effective utilization of resources, continuous feedback that is continuous and as well as leadership that will provide successful implementation and long-term effects. Lastly, this plan will assist the organization in meeting its objectives of offering safe, effective, and patient-centered care through effective interdisciplinary cooperation.

References for NURS FPX 4005 Assessment 3
Ahmed, A., Kassem, A., & Sleem, W. (2022). Applying Lewin’s change management theory to improve patients’ discharge plans. Mansoura Nursing Journal (MNJ), 9(2), 2022. https://journals.ekb.eg/article_295591_2e01c440a7769101b9fd53066f06f65c.pdf

Houte, A. G. V. (2024). SBAR in long-term care: A quality improvement initiative. https://scholarworks.montana.edu/server/api/core/bitstreams/5fbcfbf9-a994-4131-970f-d5ee47a9bddd/content

Jasubhai, S. (2025). Leadership dynamics: The interplay of cognition, emotion, and resilience. International Journal of Research in Medical and Clinical Science, 3(01), 134–140. https://doi.org/10.70829/

Park, R. D. (2022). Educating nurses on SBAR tool implementation for end-of-shift reporting. ScholarWorks. https://scholarworks.waldenu.edu/dissertations/13728/

Sartini, M., Carbone, A., Demartini, A., Giribone, L., Oliva, M., Spagnolo, A. M., Cremonesi, P., Canale, F., & Cristina, M. L. (2022). Overcrowding in emergency department: Causes, consequences, and solutions—a narrative review. Healthcare, 10(9), 1625. https://doi.org/10.3390/healthcare10091625

Smoot, S. (2021). Emergency department to inpatient admissions: An evaluation of a transfer protocol in decreasing adverse patient events. https://www.doctorsofnursingpractice.org/wp-content/uploads/project_form/complete_080222045105.pdf

Ystaas, L. M. K., Nikitara, M., Ghobrial, S., Latzourakis, E., Polychronis, G., & Constantinou, C. S. (2023). The impact of transformational leadership in the nursing work environment and patients’ outcomes: A systematic review. Nursing Reports, 13(3), 1271–1290. https://doi.org/10.3390/nursrep13030108