Collaboration, multidisciplinary team, referral, handover and interdisciplinary practice

Overview

• The Collaborator domain in FRANZCOG training addresses the practical mechanics of working within and across professional teams to deliver safe, coordinated obstetric and gynaecological care.
• This learning outcome (COLLAB_S2) sits at the intersection of patient safety, professional accountability, and interprofessional respect.
• It is examined not as abstract theory but as applied clinical behaviour: what you actually say, to whom, when, and through what governance mechanism.

The foundational regulatory and quality frameworks underpinning this domain in Australia and New Zealand include:

• NSQHS Standards (3rd edition, ACSQHC): Standard 6 (Communicating for Safety) and Standard 1 (Clinical Governance) are the primary anchors.
• AHPRA Good Medical Practice: Shared-care expectations, duty to refer, and professional boundaries.
• RANZCOG College guidance on multidisciplinary team (MDT) care in high-risk obstetrics, maternal-fetal medicine, and gynaecological oncology.
• TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety): a US-origin but internationally adopted framework used in Australian hospitals for structured team communication.
• Crew Resource Management (CRM): adapted from aviation, applied in obstetric emergencies and theatre settings to flatten hierarchy and promote closed-loop communication.
• ISBAR (Identify, Situation, Background, Assessment, Recommendation): the standard handover tool mandated under NSQHS Standard 6, Action 6.9.
• Cultural Respect Framework for Aboriginal and Torres Strait Islander Health (Australian Government): relevant to collaborative practice in remote and Indigenous health settings.
• Te Tiriti o Waitangi principles (New Zealand context): partnership, participation, and protection underpin collaborative care with Maori patients and health workers.
• The Structured Oral examiner will probe whether you can describe specific behaviours, not just name frameworks.
• You must demonstrate that you understand the governance pathway when collaboration breaks down, the legal implications of inadequate referral, and the cultural dimensions of team function in Australian and New Zealand contexts.

Key Concepts

1. Positive Professional Relationships: What This Means Operationally

A positive relationship with a specialist colleague or allied health professional is not simply collegial warmth. It is a professional arrangement characterised by:

• Clarity of role and scope: Each team member understands what they are responsible for and what falls outside their scope. This is particularly important at the interface between O&G and anaesthetics, neonatology, urology, colorectal surgery, and haematology.
• Predictable communication patterns: Using ISBAR for handover, structured briefings before theatre lists, and documented case-conference outcomes.
• Psychological safety: Team members feel able to raise concerns without fear of hierarchy-based reprisal. This is a core CRM principle and is explicitly referenced in NSQHS Standard 1 (Clinical Governance), Action 1.27, which requires organisations to support a culture where staff can report concerns.
• Mutual respect for scope and expertise: A midwife's clinical assessment, a doula's knowledge of a patient's birth preferences, or an Aboriginal health worker's understanding of community context are forms of expertise that carry clinical weight.

2. Anticipating, Identifying, and Responding to Patient Safety Issues in Teams

• Patient safety failures in O&G frequently arise at team interfaces, not from individual clinical error alone.
• The ACSQHC's analysis of sentinel events in maternity care consistently identifies communication breakdown as a contributing factor.

Key mechanisms for anticipating safety issues:

• Pre-operative briefings (WHO Surgical Safety Checklist, Sign In / Time Out / Sign Out): Mandated under NSQHS Standard 5 (Comprehensive Care) and Standard 6. The Time Out is the moment to voice concerns about equipment, patient identity, antibiotic prophylaxis, and anticipated complications.
• Situation monitoring (TeamSTEPPS): Actively scanning the environment for changes in patient status, team workload, or resource availability. In an obstetric emergency, this means the team leader continuously reassessing who is doing what and whether the plan is working.
• Escalation pathways: Every maternity unit in Australia is required under NSQHS Standard 6 to have a documented escalation pathway for deteriorating patients. The Between the Flags / REACH / COMPASS systems (state-dependent) provide structured escalation. In obstetrics, the Modified Early Obstetric Warning Score (MEOWS) triggers escalation to the registrar or consultant.

Responding to safety issues requires:

• Closed-loop communication: The person receiving an instruction repeats it back. This is a CRM standard and is particularly critical in theatre during major haemorrhage (e.g. "Give 1 gram of tranexamic acid IV" - "Giving 1 gram tranexamic acid IV now, confirmed").
• Assertive communication without insubordination: CRM teaches the "two-challenge rule": if a safety concern is raised and ignored, it must be raised a second time, more explicitly. If still ignored, the concern is escalated to the next level of authority.
• Incident reporting: NSQHS Standard 1 requires all healthcare organisations to have an incident management system. In O&G, this includes Riskman, IIMS, or equivalent state-based systems. Completing an incident report is a professional obligation, not optional.

3. Referral and Consultation: Sharing Expertise

The AHPRA Good Medical Practice framework states that doctors must refer patients when the care required is outside their competence, and must not allow financial, personal, or hierarchical considerations to delay referral.

In O&G, referral and consultation operate at several levels:

• The duty to refer is not discharged by simply writing a referral.
• You must confirm the referral has been received, communicate urgency clearly, and document the outcome.
• NSQHS Standard 6, Action 6.5 requires that clinical handover includes all relevant clinical information and that the receiving clinician acknowledges receipt.

4. Negotiating Overlapping and Shared Responsibilities

• Shared care creates ambiguity about who is responsible for what.
• This ambiguity is a patient safety risk.

Strategies to manage it:

• Shared care agreements: Formal documents specifying which clinician is responsible for which aspect of care. RANZCOG supports shared care models in antenatal care (GP shared care, midwifery-led care) but requires that the O&G specialist retains oversight for high-risk elements.
• Case conferences: Particularly in gynaecological oncology, high-risk obstetrics (e.g. placenta accreta spectrum, cardiac disease in pregnancy), and complex pelvic floor cases. RANZCOG guidance on gynaecological oncology MDT meetings specifies that all new cancer diagnoses should be discussed at a multidisciplinary meeting before definitive treatment.
• Documentation of agreed plans: When two specialists have discussed a patient and agreed on a management plan, that agreement must be documented in the medical record by both parties, or at minimum by the treating clinician with a note that the plan was agreed with the named colleague.

5. Respectful Shared Decision-Making with Colleagues

Shared decision-making in the interprofessional context is distinct from patient-centred shared decision-making. It involves:

• Presenting your clinical reasoning transparently: Not simply announcing a decision, but explaining the evidence base and inviting critique.
• Acknowledging uncertainty: Particularly relevant when consulting with a colleague who has more subspecialty expertise (e.g. MFM, urogynaecology, oncology).
• Managing disagreement professionally: If you disagree with a colleague's recommendation, the appropriate pathway is direct discussion first, then escalation to a senior colleague or department head, then formal second opinion. Bypassing a colleague to go directly to their superior without attempting direct discussion is a professional conduct issue under AHPRA Good Medical Practice.
• Documenting disagreement: If a management decision is made against your clinical recommendation, document your recommendation, the discussion, and the outcome. This protects the patient and protects you.

6. Contributing to Interdisciplinary Team Activities

This includes:

• Attending and contributing to MDT meetings (not passive attendance).
• Participating in morbidity and mortality (M&M) meetings and perinatal mortality review.
• Contributing to clinical audit and quality improvement cycles.
• Mentoring junior staff and students within the team.
• Participating in simulation training (obstetric emergency drills, PROMPT, ALSO).

Clinical Application

Scenario 1: Theatre Handover After Major Obstetric Haemorrhage

• A patient has undergone emergency caesarean section for placenta praevia with estimated blood loss of 3.2 litres.
• She is haemodynamically stable but has required 4 units of packed red cells and 2 units of FFP.
• She is being transferred from theatre to ICU.

ISBAR handover from O&G registrar to ICU team:

• Identify: "I am Dr X, O&G registrar. I am handing over Mrs Y, 34 years old, MRN 123456."
• Situation: "She has just had an emergency lower segment caesarean section for major placenta praevia with 3.2 litre estimated blood loss. She is currently haemodynamically stable, BP 105/70, HR 92."
• Background: "She is G3P2, known placenta praevia diagnosed at 20 weeks, admitted at 34+2 weeks with painless antepartum haemorrhage. She received antenatal corticosteroids. No other significant past history."
• Assessment: "She has received 4 units PRBC and 2 units FFP intraoperatively. Most recent Hb is 78. Coagulation results pending. Uterus is well contracted. No ongoing surgical bleeding identified. Baby is in NICU."
• Recommendation: "She needs ongoing haemodynamic monitoring, repeat FBC and coagulation at 2 hours, VTE prophylaxis to be reviewed given haemorrhage, and iron infusion to be planned. I have spoken with haematology who will review in the morning. Please call me if there is any concern about ongoing bleeding or haemodynamic instability."

This handover satisfies NSQHS Standard 6, Action 6.9 (structured clinical handover) and documents the inter-specialty communication with haematology.

Scenario 2: Mandatory Reporting of Suspected Child Abuse in Antenatal Clinic

• A 17-year-old presents at 28 weeks gestation.
• She discloses that her partner, aged 32, is the father and that she has been living with him since she was 15.
• She describes controlling behaviour and occasional physical violence.

Team collaboration required:

• Social worker referral: immediate, documented in the medical record.
• Aboriginal health worker or cultural liaison: if the patient identifies as Aboriginal or Torres Strait Islander, involve the health worker before any mandatory reporting discussion to ensure culturally safe communication.
• Mandatory reporting obligations: in all Australian states and territories, a doctor who suspects on reasonable grounds that a child is at risk of harm has a mandatory obligation to report to child protection services. The unborn child is not a "child" under most state legislation, but the existing children in the household may be. The registrar must know their state-specific legislation (e.g. Children and Young Persons (Care and Protection) Act 1998 in NSW; Children, Youth and Families Act 2005 in Victoria).
• Domestic violence documentation: use the SAFE questions or a validated screening tool. Document verbatim disclosures where possible.
• Safety planning: in collaboration with social work and, if available, a domestic violence specialist.
• The registrar does not make mandatory reporting decisions in isolation.
• The decision is made in consultation with the social worker, senior medical staff, and, where available, a child protection liaison officer.
• The report is documented in the medical record.

Scenario 3: Working with Aboriginal Health Workers in Remote Antenatal Outreach

• A FRANZCOG trainee is participating in a remote outreach antenatal clinic in a community in the Northern Territory.
• The Aboriginal health worker (AHW) has a longstanding relationship with the community and has identified that a patient with gestational diabetes is not attending for glucose monitoring because of concerns about being sent away from country for delivery.

Collaborative approach:

• The AHW's knowledge of the patient's context is clinical information. It should be documented and incorporated into the care plan.
• The Cultural Respect Framework for Aboriginal and Torres Strait Islander Health (Australian Government) requires that health services respect and incorporate Aboriginal and Torres Strait Islander peoples' cultural values and beliefs in care delivery.
• The registrar should not override the AHW's assessment of the patient's priorities. The appropriate response is to ask the AHW to facilitate a three-way conversation with the patient, with the registrar explaining the clinical risks of poorly controlled GDM and the AHW helping to contextualise the patient's concerns.
• The care plan should document the agreed compromise: for example, more frequent outreach visits, telehealth glucose review, and a clear threshold for transfer that the patient has agreed to.
• In New Zealand, the same principle applies under Te Tiriti o Waitangi: the Maori health worker or kaiawhina is a clinical team member whose input carries weight in care planning.

Scenario 4: Second-Opinion Conflict in Gynaecological Oncology

• A patient with a 6 cm adnexal mass and elevated CA-125 has been discussed at the gynaecological oncology MDT.
• The gynaecological oncologist recommends primary debulking surgery.
• The medical oncologist at the MDT recommends neoadjuvant chemotherapy based on imaging suggesting unresectable disease.
• The registrar is asked to counsel the patient.

Collaborative obligations:

• The registrar must not present one opinion as "the" recommendation if there is genuine clinical disagreement at MDT level.
• The patient must be informed that there are two evidence-based approaches and that the team has discussed both.
• The registrar should facilitate a joint consultation with both the gynaecological oncologist and medical oncologist present, or at minimum ensure the patient has access to both opinions.
• The MDT outcome must be documented, including the nature of the disagreement and the plan for resolution (e.g. further imaging, second MDT review, referral to another centre).
• RANZCOG guidance on gynaecological oncology MDT meetings supports this model of documented deliberation.

Pitfalls

1. Treating handover as a formality rather than a safety-critical communication.

• Incomplete ISBAR handovers are a leading cause of adverse events.
• In the Structured Oral, if asked about handover, name the specific NSQHS Standard 6 action (6.9) and describe what information must be included.

2. Failing to document inter-specialty communication.

• Verbal agreements with colleagues are not legally or professionally sufficient.
• If you have discussed a patient with a haematologist, cardiologist, or anaesthetist, document the name of the person you spoke to, the date and time, and the agreed plan.

3. Conflating referral with transfer of responsibility.

• Referring a patient to another specialty does not remove your responsibility for that patient's care until the referral is accepted and a care plan is in place.
• This is an AHPRA Good Medical Practice principle.

4. Hierarchy-based communication failure.

• Junior staff not feeling able to escalate concerns to consultants is a CRM failure.
• As a senior registrar, you are responsible for creating an environment where midwives, nurses, and junior doctors can raise concerns.
• If a midwife raises a concern about a CTG and you dismiss it without review, you have created a patient safety risk and a professional conduct issue.

5. Ignoring cultural safety as a clinical competency.

• Failing to involve an Aboriginal health worker, Maori health worker, or cultural liaison in a case where cultural context is clinically relevant is not just a cultural oversight.
• It is a clinical error that may result in the patient disengaging from care.

6. Bypassing direct professional communication.

• Going to a colleague's supervisor before attempting direct discussion is a professional conduct issue.
• The exception is when patient safety is at immediate risk and direct discussion has failed or is not possible.

7. Passive MDT attendance.

• Attending an MDT meeting without contributing is not sufficient.
• The examiner will ask what you contribute, how you prepare, and what you do when you disagree with the MDT recommendation.

8. Mandatory reporting without team consultation.

• Making a mandatory report without consulting social work, senior medical staff, and (where relevant) a cultural liaison is poor practice.
• The report may still be legally required, but the process should be collaborative.

Examiner Expectations (Structured Oral)

The Structured Oral examiner in this domain is assessing whether you function as a senior clinician who actively manages team dynamics, not just as an individual practitioner who happens to work near other people. The following behaviours distinguish a passing from a failing response:

Passing responses will:

• Name specific frameworks by name: ISBAR, NSQHS Standard 6, TeamSTEPPS, CRM, RANZCOG MDT guidance, AHPRA Good Medical Practice.
• Describe concrete behaviours: "I would use ISBAR to hand over to the ICU team and document the handover in the medical record."
• Acknowledge the limits of individual authority: "If I disagreed with the consultant's plan, I would first discuss it directly with them, document my concern, and if unresolved, escalate to the department head."
• Demonstrate cultural safety as a clinical skill: "I would involve the Aboriginal health worker before discussing mandatory reporting with this patient."
• Show awareness of governance pathways: incident reporting, M&M review, formal second opinion processes, mandatory reporting obligations.
• Distinguish between types of professional relationships: the relationship with a midwife in a shared care model is different from the relationship with a subspecialist consultant, and the communication strategies differ accordingly.

Failing responses will:

• Speak only in generalities: "I would communicate well with the team and make sure everyone is on the same page."
• Fail to name any specific framework, standard, or governance mechanism.
• Treat cultural safety as an add-on rather than a core clinical competency.
• Describe bypassing direct professional communication as a first-line response to disagreement.
• Conflate patient-centred shared decision-making with interprofessional shared decision-making.
• Fail to mention documentation as a component of every collaborative interaction.

Likely Structured Oral question stems for this LO:

• "You are the registrar on call. A midwife calls you about a CTG she is concerned about. You review it and think it is normal. She calls again 20 minutes later. What do you do?"
• "You are handing over a patient with postpartum haemorrhage to the incoming team at the end of your shift. Walk me through your handover."
• "You are at an antenatal outreach clinic in a remote community. The Aboriginal health worker tells you the patient does not want to be transferred to the regional hospital for delivery. How do you manage this?"
• "The gynaecological oncology MDT has recommended primary surgery, but you believe the patient is not fit for surgery. What do you do?"
• "A patient in your antenatal clinic discloses domestic violence. What is your immediate response and who do you involve?"
• In each of these scenarios, the examiner is looking for a structured, specific, governance-aware response that demonstrates you understand the professional and legal obligations of collaborative practice, not just the interpersonal skills.
• Cite the framework, name the standard, describe the documentation, and identify the escalation pathway.
• That is what distinguishes a Fellowship-level response from a registrar-level response.