Team Building in Primary Care March 13 th, 2012 Kevin Taylor MD, MS Associate Medical Director MiPCT

Team Building in Primary Care

March 13th, 2012

Kevin Taylor MD, MSAssociate Medical Director MiPCT

A Brief History of Primary Care Teams

The general practitioner of the early 20th century was a lone ranger. Black bag in hand.

California HealthCare Foundation

Building Teams in Primary Care: Lessons Learned

1915 – 1960

In 1915, teams of physicians, health educators, andsocial workers were created at MassachusettsGeneral Hospital’s outpatient department.

Primary care team models were developed at New York’sMontefiore Hospital in 1948 and at Yale in 1951.

The Neighborhood Health Center program of the 1960s developed.

California HealthCare Foundation

Building Teams in Primary Care: Lessons Learned

Research on Structure and Culture in Modern Primary Care

•Practices are highly individual and personality driven enterprises▫Split deeply between physicians and staff

•Embracing Radical Changes (PCMH or EMR)▫No fundamental redefining of roles or creating different

hierarchy within practice

Health Affairs 29,No. 5 (2010) 874-879

Field Study of Three Primary Care Practices-2010•Observations and Structured Interviews by

Professional Anthropologist▫A solo Practice▫A certified PCMH▫A multi-physician academic practice

How Teams Work-Or don’t-In Primary Care

Benjamin J. Chesluk and Eric S. Holmboe

Health Affairs 29,No. 5 (2010) 874-879

Study Results

•Practice team operates in separate social silos▫Different experience of time, space, and work within

the practice▫Isolates Physicians from staff▫Disorients patients

Health Affairs 29,No. 5 (2010) 874-879

Physicians—The Frantic Bubble•Series of non-stop, one-on-one interactions with a stream

of patients, • “Fictive Schedule”

▫ The”real” schedule in physicians’ heads was informed by their knowledge of the actual patients.

•Not nearly enough time during office schedule to do routine documentation ▫ Several hours in evening to catch up

•Extraordinary diversity of patients and complaints▫ Physicians presented calm, friendly faces to all patients

•Handled each visit essentially alone▫ Quick handoff of instructions for follow-up tests or next appointments▫ Verbal exchange between physician and staff was minimal

Health Affairs 29,No. 5 (2010) 874-879

Practice Staff—The Flexible Team

•Practice Staff work in more flexible and collaborative manner▫Collective work ebbed and flowed

•Staff would “team up” in groups▫Handle a host of jobs

Greeting patients Answering phones Scheduling visits Preparing charts Rooming patients

Health Affairs 29,No. 5 (2010) 874-879

Patients—In Limbo

•Even more isolated than the physicians•Long wait times

▫Unpredictable, open-ended periods of waiting In designated public areas, In cold, sparse exam rooms, Sometimes partially clad in thin gowns

•Left confused and disoriented at the end of visit▫Left to sort things out for themselves▫“Where do I go now?”

Health Affairs 29,No. 5 (2010) 874-879

Meetings

•Physician meetings▫Discuss practice from clinical and business standpoint▫How to tweak flow of patients and information▫Non-physicians absent from meeting

•No regular meetings with staff and physicians

Health Affairs 29,No. 5 (2010) 874-879

Implications for Primary Care

•Scarcest resources are:▫TIME▫TEAMWORK

Health Affairs 29,No. 5 (2010) 874-879

Common Culture undermines Teamwork in Primary Care

•Physicians’ hectic routine forces them to work in a manner that inhibits reflection and collaboration

•Professional and administrative staff cannot step in to collaborate with physicians the way they do with each other

•Team focus around physicians and facilitating their schedules, rather than around patients and their experiences

Health Affairs 29,No. 5 (2010) 874-879

Think about your favorite team…

Common goals Great leadership Esprit de corps Loyal Common values Have fun together Share the wins and the losses Play nice together Dress code????

© Tantau & Associates

A simple definition of “team”

“A team is a group with a specific task ortasks, the accomplishment of which requires theinterdependent and collaborative efforts of itsmembers.”

California HealthCare Foundation

Building Teams in Primary Care: Lessons Learned

Why teams?

Health care is most effectively delivered by a team of providers with multi-dimensional skill sets Places patient at the center - MD not center of staff

attention Entire staff know and own the care of the patient Work is distributed according to level of staff training (e. g.

RNs more free to do RN level tasks) Improves quality and efficiency of care Makes providing good primary care more possible

Cambridge Health Alliance

InformedActivatedPatient

ProductiveInteractions

PreparedProactivePractice Team

Improved Outcomes

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System

Resources and Policies

Community

Health Care Organization

Chronic Care Model

Outcomes

Benefits of Teams in Primary Care

Clinical Outcomes

Multidisciplinary clinical teams produce clinical outcomes superior to those achieved by “usual care” arrangements.

Performance in diabetes care Overall patient satisfaction Continuity of care Access to care Better control of diabetes and hyperlipidemia

California HealthCare Foundation

Building Teams in Primary Care: Lessons Learned

Shojania et al, Effects of Quality Improvement Strategies for Type 2 Diabetes on

Glycemic Control. JAMA 296:427, 2006.

Effects of Quality Improvement Strategies for Type 2 Diabetes on Glycemic Control

Effects of Quality Improvement Strategies for Type 2 Diabetes on Glycemic Control

Team changes and case management showed more robust improvements.

The most effective team changes included routine visits with personnel other than the physician and expansion of professional roles (e.g. RN, pharmacy) to include an active role in patient monitoring or adjustment.

Case management was defined as any system for coordinating diagnosis, treatment or ongoing patient management by personnel working in collaboration with the primary care physician. Protocols to guide pharmacologic management were particularly effective.

Shojania et al, JAMA 296:427, 2006

Conclusions

There is good evidence from a variety of analyses that performance on biological outcomes measures will be impacted by high leverage interventions including

Delegation of work away from the physician to non-physician providers

Use of clinical protocols which drive changes in treatment until goals are reached

Increased frequency of contacts as treatment is changed to reach goals

Patient activation

The Good, the Bad, The Ugly of Primary Care•http://www.youtube.com/watch?

v=pOy5Lmp3qlQ&feature=related

Optimal Care TeamsGolden Rule Number 1:

Move work away from the constraint in the system.

© Tantau & Associates

Goal: Right Person, Right Care, Right Place, Right Time• “Patients want care to be there when they want it and they

want a care plan to revolve around their needs.”• Delegate work away from the physician is a key

component of the most robust changes in delivery system design for improving biological outcomes

• Reorganize care so it is provided to patients by a team of professionals with diverse skills and talents, rather than by a single provider (MD, NP, PA)

Optimal Care Teams

Golden Rule Number 2:Elevate all members of the team to the highest level their education, training, and experience will allow.

© Tantau & Associates

Team-based care model

•All care team members contribute to the health of the patients by working at the top of their licensure and skill set. ▫Nurses can conduct complex care management,▫Front desk staff can call patients who need evidence-

based care and invite them in, ▫Medical assistants can provide patient self-management

support, ▫Pharmacists can support complex medication

reconciliation.

Key Elements of Team Building

Defined GoalsSystemsDivision of LaborTrainingCommunication

California HealthCare Foundation

Building Teams in Primary Care: Lessons Learned

The Team Measure

How do you know whether you are working as a team or not? How much “teamness” is present in your clinic or workgroup? What are the attributes of effective teamwork and how can

you improve them?

www.teammeasure.org

Stages of Team DevelopmentStage Score Range Components

present**Solidification

Pre-team 0-36 None to Building Cohesiveness

----------------------

1 37-46 Cohesiveness

In Place

2 47-54 Communication

3 55-57 Role Clarity

4 58-63 Goals and Means Clarity

5 64-69 Cohesiveness

Firmly in Place

6 79-77 Communication

7 78-80 Role Clarity

8 81-86 Goals and Means Clarity

Fully Developed 87-100 Everything

www.teammeasure.org**Within each stage the more the team score is toward the higher score in the range, the more of those components that are present

TransforMed ExperiencePractice Change is Hard

“The magnitude of stress and burden from the unrelenting, continual change required to implement components of the PCMH model was immense.”

Nuttinget al. Ann FamMed. 2010

Practice Characteristics Supportive of Transformation• Can the practice function adequately in times of stability?

▫Sound Financial Systems▫Stable leadership and staff▫Stable IT

• Can the practice change to adjust or improve?▫Facilitative Leadership▫Effective Relationships▫Learning Culture▫Group Time

• Message: If a practice is broken, it may not be able to make meaningful change unless it is repaired.

Core Structure

Adaptive Reserve

Joy in Work

Improving staff satisfaction appears to be a powerful motivator for change.

If staff perceive their work life to improve, it invigorates QI efforts.

We should re-orient QI efforts to focus more on its impacts on staff.

Transformation: A new way of thinking… Physicians will need to move towards facilitated

leadership skills and away from authoritative ones

Physician-patient relationship will need more emphasis on partnership to achieve patients’ goals

Practice will need to change from a machine that processes patients for the doctors to a team that proactively manages a population of individual’s health

Facilitating Change: Lessons from the TransforMED National Demonstration Project, AHRQ 2009 Annual Conference, Sept. 14, 2009, Elizabeth E. Stewart, PhD, Independent Evaluation Team from Center for Research in Primary Care & Family Medicine

Team Care Medicine

•http://www.youtube.com/watch?v=CvBoVJYkMPg

http://www.youtube.com/watch?v=SII1EU3huuE&feature=related

Tools

• Clinical Microsystems

http://www.clinicalmicrosystem.org/

The Dartmouth-Hitchcock Medical Center offers free tools, including a great quick team assessment, to help pinpoint areas of improvement in team functioning.

• Improving Chronic Illness Care

http://www.improvingchroniccare.org/downloads/ICIC_Toolkit_Full_FINAL.pdf

  ICIC developed a free, step-by-step toolkit called “Integrating Chronic Care and Business Strategies in the Safety Net” that provides tools for practices as they work to improve quality.

• Institute for Healthcare Improvement

http://www.ihi.org/Pages/default.aspx

IHI provides free guidance an tools around forming the team and using team huddles to improve communication.

• Iowa Chronic Care Consortium

http://www.iowaccc.com/programs-and-projects/clinical-health-coach/index.aspx

  This group offers training for health professionals interested in becoming leaders in improving chronic illness care in their practice. Training focuses on self-management support and panel management skills among others.

• Integrating Chronic Care and Business Strategies in the Safety Net

http://www.safetynetmedicalhome.org/safety-net/empanelment.cfm

Group Health’s MacColl Institute for Healthcare Innovation, RAND and the California Health Care Safety Net Institute have published a toolkit which provides a step-by-step practical

approach to guide teams through quality improvement, focused on the chronically ill in safety net populations.

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