Upload
rosa-benson
View
216
Download
0
Tags:
Embed Size (px)
Citation preview
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
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▫ Minimal Verbal exchange between physician and staff
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
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)
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
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
17
Think about your favorite team…
Key Elements of Team Building
Defined Goals Systems Division of Labor Training Communication
California HealthCare Foundation
Building Teams in Primary Care: Lessons Learned
Key Elements of Team Building
Defined GoalsSystemsDivision of LaborTrainingCommunication
California HealthCare Foundation
Building Teams in Primary Care: Lessons Learned
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.
21
Key Elements of Team Building
Defined GoalsSystemsDivision of LaborTrainingCommunication
California HealthCare Foundation
Building Teams in Primary Care: Lessons Learned
Clinical systems•Procedures for providing prescription refills
Administrative systems •Procedures for making patient appointments
“Standard Office Process” (SOP)
Key Elements of Team Building
Defined GoalsSystemsDivision of LaborTrainingCommunication
California HealthCare Foundation
Building Teams in Primary Care: Lessons Learned
•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
24
Key Elements of Team Building
Defined GoalsSystemsDivision of LaborTrainingCommunication
California HealthCare Foundation
Building Teams in Primary Care: Lessons Learned
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
26
Key Elements of Team Building
Defined GoalsSystemsDivision of LaborTrainingCommunication
California HealthCare Foundation
Building Teams in Primary Care: Lessons Learned
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
28
Team Building
Team Building Tools
29
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).
32
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?
34
TIPS FOR SUCCESSFUL TEAMWORK
http://va.gov/
Adapted from The Team Handbook®, Third Edition, Scholted, Joiner and Streible, Oriel Incorporated, 2003
35
Tips for Improving:•Cohesion•Communication•Roles•Goals & Means
Change Management
36
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
37
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
38
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
39
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)
40
41
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.
42
http://web.uvic.ca/hr/managertoolkit/buildingtools/waterlinemodel.html
43
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
44
45
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
46
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
47
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!
48
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
49
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.
52