team building in primary care mipct kick off—march 2012 kevin taylor md, ms associate medical...

Team Building in Primary Care

MiPCT Kick Off—March 2012

Kevin Taylor MD, MSAssociate Medical Director MiPCT

The Good, the Bad, The Ugly of Primary Care•http://www.youtube.com/watch?v=pOy5L

mp3qlQ&feature=related

http://www.youtube.com/watch?v=pOy5Lmp3qlQ&feature=related

http://www.youtube.com/watch?v=pOy5Lmp3qlQ&feature=related

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


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


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▫ Minimal Verbal exchange between physician and staff


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


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?”


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


Implications for Primary Care

•Scarcest resources are:▫TIME▫TEAMWORK


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?

• Providing all of the evidence-based preventive and chronic illness care to an average panel of patients would take a single primary care provider 18 hours a day.

• Most physicians only deliver 55% of recommended care and 42% report not having enough time with their patients

• Providers spend 13% of their day on care coordination activities and only 50% of their time on activities using their medical knowledge.

• Physicians spending 49% of the visit time at the computer and only 13% talking with the patient

Safety Net Medical Home Initiative August 2011 Issue

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

Improvements come from redesign of basic care delivery

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 Chronic conditions (Hypertension, diabetes and

hyperlipidemia)



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

What do they mean by Team Changes?

Changes to the structure or organization of the primary health care team, defined as present if any of the following applied:

Adding a team member or "shared care," Use of multidisciplinary teams, ie, active participation of

professionals from more than 1 discipline (eg, medicine, nursing, pharmacy, nutrition) in the primary, ongoing management of patients.

Expansion or revision of professional roles

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.

Shojania et al, JAMA 296:427, 2006

Redesigning of primary care for patients with chronic conditions

• Chronic Care team (Santa Clara Valley Health System)▫ RN and Pharmacist

Focus on patients with chronic illness, use registry, establish and conduct planned visits and provide medical management for HTN, DM and Hyperlipidemia following physician protocols.

• Team Nursing Pilot Project (Palo Alto Foundation)▫ In this pilot project, RN has

responsibility for assisting with the care of a distinct panel of patients.

▫ By doing so, the nursing team fosters continuity of care no only with the physician but also with the RN

▫ More efficient and effective than Advice Pool RN program

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Think about your favorite team…

Key Elements of Team Building

Defined Goals Systems Division of Labor Training Communication




Defined GoalsSystemsDivision of LaborTrainingCommunication



Overall Organizational Mission/Vision Statement

Specific Measurable operational objectives

Organizational Mission & Operational Objectives• HealthPartners in Minnesota

▫ Organizational wide campaign to redesign their primary care offices.

▫ Their goal was to move from physician care to team care

• “Right person do the right thing at the right time for the right patient”

• The Kaiser system adopted an ambitious goal to prevent cardiovascular events called the PHASE program—Prevent Heart Attacks and Strokes Every day.

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Clinical systems•Procedures for providing prescription refills

Administrative systems •Procedures for making patient appointments

“Standard Office Process” (SOP)





•We need to determine which people on the team perform which tasks within the clinical and administrative systems of practice.

•Clear definition of tasks•Clear assignment of roles

Roles on our Teams• Palo Alto Foundation

▫ Performed detailed time studies on the primary care teams 40-46% of RN functions

could be done buy a Medical Assistant

20% of physicians time (up to 1/12 hours per day) could be done by someone else.

▫ How do we divide up the work among our practice teams

• Clinica Campesina ▫ Pods that consist of 3 FTE

clinicians (physicians and APCs) and 3 LPNs or MA’s.

▫ The LPN plays a central role. Follow Standing Order

Protocols Serve as the pod coordinator

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Training and Cross-Training for the functions that each team member regularly performs

St. Peter Family Medicine Residency Program Olympia WA

•Medical Assistants become diabetes care managers:▫Follow Registry, Order appropriate labs, schedule planned

visits, Draw blood, Provide MA planned visit and Follow-up Phone call.

▫Require 40 hours of training 8 hours are for basic orientation to diabetes including

pathophysiology, complications, treatment, practice guidelines. Also include training in behavior change, goal setting with action

plans, use of the registry, conducting planned visits and SMAs

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Communication structures•Routine communication•Minute-to-minute communication•Team meetings

Communication processes•Huddles (Briefings)•Assertion (SBAR)•Feedback•Conflict resolution

Team Time• Cambridge Health Alliance

▫ Developed a team role called the Planned care site coordinator. To assist with the

implementation of this new role, the CHA office sites conduct a retreat to discuss importance in primary care team cohesion and to clarify how the planned care site coordinators will work with the sites.

• HealthPartners Medical Group▫ Adopt a new culture in which

non-clinicians have greater responsibility and new job descriptions and clinician give up autonomy Informal Team building

Lunch, B-Days, Holidays Formal Meetings

Encourage team members to bring into the open conflicts or behaviors that are seen as dysfunctional to the team goals

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Team Building

Team Building Tools

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http://va.gov/ (search TDM)www.teammeasure.org

http://va.gov/

http://www.teammeasure.org/

TEAM DEVELOPMENT 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?

Teamwork components

•Cohesiveness (a sense of “oneness” or working well together),

•Communication (including participation, problem-solving, and decision-making),

•Role clarity (understanding the roles of each team member),

•Goals and means clarity (agreement on the team’s goals and the strategies to achieve them).

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Stages of Team DevelopmentStage Score Range Components

present**Pre-Team 0-36 Any team elements are

accidental

1 37-46 Building Cohesiveness

2 47-54 Building Communication

3 55-57 Building Clarity of Roles

4 58-63 Building Clarity of Goals and Means

5 64-69 Cohesiveness Establish

6 79-77 Communication Established

7 78-80 Role Established

8 81-86 Goals and Means Established

Fully Developed 87-100 All Team Attributes Firmly in Place

IMPLEMENTING THE TEAM DEVELOPMENT MEASURE SURVEY• STEP 1. INITIATE THE TEAM DEVELOPMENT SURVEY (10 Minutes, 31

questions)▫ Online www.teammeasure.og or http://va.gov/

• STEP 2. DISTRIBUTE TEAM REPORT IN PREPARATION FOR MEETING

• STEP 3. HOLD A MEETING TO REVIEW TDM REPORT (60-90 minutes)▫ Use Facilitator Guide http://va.gov/

• Step 4. CONDUCTING A BRIEF TEAM REVIEW▫ What do you consider to be the team's two or three greatest strengths? ▫ What are two or three things that the team should change or improve

immediately that will make it more effective?

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http://www.teammeasure.og/

http://va.gov/

http://va.gov/

TIPS FOR SUCCESSFUL TEAMWORK

http://va.gov/

Adapted from The Team Handbook®, Third Edition, Scholted, Joiner and Streible, Oriel Incorporated, 2003

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Tips for Improving:•Cohesion•Communication•Roles•Goals & Means

http://va.gov/

Change Management

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DANGEROPPORTUNITY

CRISIS

TransforMED Recommendations

•Medical home requires more than just the four pillars and technological support ▫(four pillars: access, comprehensive care, coordination of care,

relationships over time) • In addition, it requires a strong organizational core (material

and human resources, organizational structure, clinical process) and adaptive reserve (healthy relationship infrastructure, an aligned management model, facilitative leadership). Crabtree et al, Summary of the National Demonstration Project and Recommendations for Patient-Centered Medical Home.Ann Fam Med 2010: 8 (Suppl

1) S80 – S90

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What have we learned?

•Practices that never get started have leadership that is either ineffective or opposed to change.

•Practices that transformed have Adaptive Reserve – the ability to learn and change.

•Key feature of adaptive reserve is unified leadership that can:▫envision a future,▫have a strategy for getting there,▫facilitate staff involvement, and▫devote time to make and evaluate changes

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Crabtree et al, Summary of the National Demonstration Project and Recommendations for Patient-Centered Medical Home.Ann Fam Med 2010: 8 (Suppl 1) S80 – S90

Set Up for Change—Clarify the Vision • Communicate to all staff-- make a

compelling case • Describe how it will be better • Describe the plan for making the

change happen • Contributions and expectations

from all • Welcome open and constructive

“resistance” • Create a solid and realistic plan

“The culture of an organization is a reflection of the values of its leaders. Thus, cultural transformation begins with the personal transformation of the leaders”

From “Building a values-driven organization” Richard Barrett

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Is There Alignment in Vision?

▫It is easy to create a vision ▫It is harder to create a shared vision that individuals

actively engage in. ▫It is harder still to have deep shared understanding of

what the vision means for the future. ▫It is even harder to move individuals from compliance

(will do what’s expected) to commitment (will do all they can to make it happen)

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VisionProject Aims

Clear Picture of reality

GAP

Feelings + Perceptions + Context

Emotional tension

ReactivityResistance

Creative tension

ReflectionResilience

OutcomesRevised vision and picture of reality

Adapted from Senge, The Fifth Discipline

Waterline Model: A Diagnosis Tool• The Waterline Model is a useful

diagnostic tool for when: Teams seem to be working as

hard or even harder than normal, yet the tasks and goals of the team are not being met as quickly or efficiently as the team envisioned

There is some dissonance within the team membership that is leading to inefficiency and dysfunction.

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http://web.uvic.ca/hr/managertoolkit/buildingtools/waterlinemodel.html

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http://web.uvic.ca/hr/managertoolkit/buildingtools/waterlinemodel.html

Building Cohesive Teams

•Group Health Cooperative▫Building cohesive teams is primarily a function of

defining who does what and making sure all team members are well trained to carry out their responsibilities.

▫Teams also need to work on interpersonal issues that can hamper teams from optimal functioning

Use Team-Building techniques called Courageous Conversations (www.courageousconversations.net)▫Train team members to speak honestly with each other

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VisionProject Aims

Clear Picture of reality

GAP

Feelings + Perceptions + Context

Emotional tension

ReactivityResistance

Creative tension

ReflectionResilience

OutcomesRevised vision and picture of reality

Adapted from Senge, The Fifth Discipline

Responding Skillfully to Resistance• Establish understanding: their view

▫ Use active listening and empathy to understand the resistance (and confirm it)▫ Get in their shoes

• Establish understanding: alternative views▫ Bring in new data and alternative views as information for consideration▫ As indicated, assert authority or explain leadership decisions

• Find mutual goals▫ Find the connection between the vision and what is important to the

person/group▫ Elicit pros/cons of doing and not doing the change

• Stay in Dialogue▫ Free flow of information dependent on:

Mutual Purpose and Mutual Respect

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Motivational Model

1. It’s possible to do.(Yes or No)2. I have the capability. (high, medium, low)

▫ Capability means skills, time and resources▫ Are you capable now? Can you learn it in time?

3. It’s worthwhile for me personally?▫ “What is most important to me personally in this situation”?

Copyright 2010 Mindtech, Inc. Manny Elkind

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Kenmore Site—Harvard VanguardRedesigning Teams—Toyota Management Approach

Essence of Toyota Method“Respectfully seeing employees as

quality improvement experts and creative front line employees to improve their own work process”

Three Principles in Team Formation▫ Respect each other and the

patients▫ The management team supports

the staff “What resources and training do you need to achieve your job?”

▫ Set Expectations for excellence!

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Kenmore Leadership—“Operationalzing” Respect• Team members meet regularly to listen

to their colleagues describe their workday in detail▫Stimulate listening, understanding

and coordination• Team members are encouraged to talk

about what they believe in, how they feel helping their patients and what challenges come up during their day

• Team members ask patients “What does it feel like to receive care here?”▫Share these stories at the team

meetings

• Clinical team felt empowered to change the way they worked

• Clinicians and staff members began to embrace change

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Successful Practice Transformation For MiPCT Practices—Embrace Change! Recognizes its difficulty and

prepares practices for it.

Assure that routine care delivery is different.

Involve staff and patients in continuous process of change.

WE CAN DO IT!

WE CAN MAKE CARE BETTER!

WE ARE MiPCT!

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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team building in primary care mipct kick off—march 2012 kevin taylor md, ms associate medical...

Documents

primary care practices

primary carebenjamin

staffhealth affairs

physicianshealth affairs

practicehealth affairs

holmboehealth affairs

timeteamworkhealth affairs

single primary care