team building in primary care march 13 th, 2012 kevin taylor md, ms associate medical director mipct
TRANSCRIPT
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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