ms

• Principles and values of effective team-based health care• Example: TBC and improving hypertension control

• Challenges to teamwork in clinical care• What does "leadership" mean in a high-functioning team?

• What might a "trans-disciplinary" professionalism look like?

Discl osure and Discl aimer

Disclosure• I have no personal financial relationships with any pharmaceutical

companies and none of my work is funded by pharmaceutical companies.• The AMA receives some direct support for other projects and programs

from for-profit companies (<15% of total AMA budget).

Disclaimer• The views expressed in this presentation are my own.• Nothing I say should be construed as representing a policy of the AMA,

unless I specifically say otherwise.

.-L' i

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www.iom.edu/tbc

Characteristi cs

Facil it ators

Shared Goals...Work to establ ish shared goals that ref l ect patient and family pr iorities and that can be clearly articulated, understood, andsuppor ted by all members.

Clear Roles...Have cl ear expectations for eachmember's functions, responsibil ities, and accountabil ities.

• Patients and families as members of teams,rather than recipients of team care

• Leadership in the context of team -based care• Teaching and training for team -based care• "External" factors that support or hinder

effective team-based care (organizational, systemic, financing, legal, etc.)

Preventable Deaths from Heart Di sease & Stroke

Cardiovascular disease and type II Diabetes

7

+ Diseases and

in juries+ Risk factors

High blood p12Ssure•

+ Smoking-6

+ Alcohol use

+ IHDs

+ LRI +

HAP

Diet low in Fruit

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3

• High BM I+ FPGMalaria + Diarrhoea.

+ + Hr/COPD

/• ........_+ Road injuiy + +

PM H Amb.......... • lnactivit y tPret birth Undefweight + SahcomphcabonS

• , + Diet low in nuts and seeds•- Tuberculosis

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2

+ Lung cancer1

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ffgt.re2:Compartson of the magnJ tudeof theten leadlngdlseases and lnJur1es and the ten leadlng r1sk factors based on the percentage of global deaths and the percentage of global DALYs, 2010

actors or poor ea t

1 Lower respiratory infect ions

2 Diarrhoea

3 Preterm birth

complications4 lschaem i c heart disease

1 lschaemic heart di sease

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'14 [)iarr hoea I s HIV/A IDS

Communicable, maternal, neonatal, and nutritional disorders

1990 2010

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1 High blood pressure

2 Tobacco smoking, excluding second-hand

smoke 3 Alcohol use

"14 Household air polluti on from solid fuel s

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smoke 4 Hi h blood pressure

IS Suboptimal breastfeeding

IS Diet l ow in fruits

- Ascending order in rank

3 Impr ovement Concepts

• Measure Accurately• Act Rapidly• Partner with Patients

& Families

Team -Based Care is a Potent Anti -hypertensive

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Qua l i t y Im provement trategy

"Interventions that included team change as a QI strategy were associated with the largest reductions in blood pressure outcomes. All team change studied included assignment of some responsibilities to a health professional other than the patient's physician."

Walsh et al 2006; Arch Intern Med

Cochrane Review, 2010MeJO Me;in

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• Overcome therapeutic inertia• Improve adherence to evidence-based guidelines

• Streamlined care processes• Teams give explicit thought to process issues

• Increased 'dose' of health information/ advice• More points of contact• More time spent with health professionals• Additional types of information provided

• Better interpersonal connections with patients

There are al ways tensions that come up . Part of working isdealing with tensions. If there's no tension, then you're not serious about what you're doing.

Wynton M arsalis

Hot Button Terms• Scope of practice• Independent practice• Supervision• Physician-l ed• Doctor• Mid-level• Allied health• Collaboration

... the nuanced nature of "Leadership" within teams carrying out complex or innovative work...[requ ires] Leadership from all members of the team...

"Physician-Led" Teams

Leadership is nota clinical skill

We need a new metaphor ...

The Power of Teams

Leadership in TeamsTechnical Problems

• Problem is clear• Expert/leader provides

solution• Solutions easy to

accept

Adaptive Challenges• Problem hard to

acknowledge• The team must

provide the solution• Solution requires

difficult change

The most common fail ure inleadership is produced by treating adaptive chal lenges as if they were technicalproblems

Ronald Heifetz, Marty Linsky & Alexander Grashow, The Practice ofAdaptive Leadership: Tools and Tactics for Changing Your Organization and the World (Boston: Harvard Business Press, 2009), 19; 23-24.

TRIP/CUSP Models

1. Summarize the evidence in a behavioral checklist

2. Identify local barriers to implementation

3. Measure performance

4. Ensure all patients get the evidence

• Engage• Educate• Execute• Evaluate

Measure Accurately Act RapidlySupport Patient s and Their Families

1. Educate staff on science of safety

2.

Identify defects

3. Ass ign executive to adopt unit

Learn from one defect per quarter

Implement teamwork tools

. . . The danger of any care model in which the caregiver is broadly conceived as a team rather than as an individual is the possible dilution of responsibility assumed by individual caregivers. Without safeguards, no individual member of the team may feel compelled to go the extra mile to ensure the delivery of necessary care.

. . . Given the breadth of primary care, licensure and regulation cannot restrain nonphysician primary caregivers from offering primary care services that they are not qualified to provide.Only professionalism will keep such caregivers operating within their sphere of competence- as is the case for all clinicians, including primary care physicians.

Tom Huddle, Annals of Internal M ed icine, September 2013

ProfessProfession Professional Professional ism

Definitions

Unidisciplinary - One group working alone Multidisciplinary - Multiple groups working individually on a shared issueInterdisciplinary - Multiple groups working together toward a common goal (AKA "interprofessional") Transdisciplinary - Multiple groups working together to develop a new, shared model and common language

"Transdisciplinary professionalism could be defined as 'an approach to creating and carrying out a shared social contract that ensures multiple health disciplines, working in concert, are worthy of the trust of patients and thepublic in order to improve the health of patients and their communities.' "

Institute of Medicine of the National Academy of Sciences Global Forum on Innovation in Health Professional Education

A New, Shared Social Contract

• Social contracts spell out the relations between individuals,groups and society

• Gain coherence, smooth function, reliability, safety.. .• ... at the expense of some individual liberty (agree to play by

the rules)

"The sum total of medical knowledge is now so great and wide-spreading that it would be futile for any one man... to assume that he has even a working knowledge of any part of the whole... It has become necessary to develop medicine as a cooperative science; the clinician, the specialist, and the laboratory workers uniting for the good of the patient, each assisting in elucidation of the problem at hand, and each dependent upon the other for support."

William Mayo, 1910

Special thanks to Shahid Chaudhry, PhD for assistance in devel oping this presentation