My goal as a physician is to deliver superb care in a vital and sustainable practice. Some may say it is a lofty goal, but it gets to the root of why I chose to become a physician. For years I thought I could achieve this level of care if I had exactly the right information technology. Over time, I came to realize that while the technology was definitely helpful, I was more likely to achieve my goal with a team effort.
The concept of working as a team seems logical. Superb care is made up of many activities, and only some of these activities require a medical degree. But delegation carries risk. Will the tasks be completed? Will they be done well? Will patients view the process as seamless or disjointed?
These issues face our practices every day. We work alongside people, but we probably never think of ourselves as a “care team.” Once we recognize that we are part of a clinical team, we can begin our pursuit of the outstanding care we know we are capable of delivering.
Forming your game plan
This article explores the behaviors of highly functional clinical teams. This insight comes from personal experience in practice, from work as faculty in various improvement collaboratives with the Institute for Healthcare Improvement and from the developing research into why certain clinical teams excel. The findings suggest that successful teams employ the following steps:
Collect feedback on performance. I am in solo practice with one nurse, Judy Zettek, RN, and we have an excellent working relationship. We communicate well and often, and I used to think this was all that was necessary to achieve our desired results. However, once we started to regularly gather data on our patients’ experiences with the practice, we found unexpected gaps between what we had assumed and what was actually transpiring.
Patients with chronic conditions reported excellent experiences regarding access, efficiency and continuity, but they reported surprisingly low scores on the quality of information they received on their conditions. At the same time, an insurer’s chart review found deficiencies in documentation of HIPAA authorizations, health care proxy discussions and adult immunizations.
We had to accept the fact that our professionalism and dedication were not sufficient to achieve the results we would like for our practice, and that regular feedback and performance measurement would be necessary for us to become a highly functional team.
We now have several ways of obtaining feedback from patients. First, we ask them informally to tell us what they think about how our office works. Second, we ask those who participate in our group visits to offer us feedback, similar to how a focus group would operate. Finally, we formally collect specific data by surveying patients through the Web site http://www.howsyourhealth.org.
Conduct regular meetings. Our next step was to meet regularly to discuss goals and processes. We had discussed these in an ad hoc manner, but phone calls and patient arrivals often brought our conversations to an abrupt end, and over time we found that our improvement efforts didn’t always move ahead as quickly as we would have liked. For example, when we stopped to talk about adult immunizations, we would agree we needed to improve our outcomes, but we would not always have time for an explicit discussion of how we would get there or how we would recognize when our intentions were leading to improvement.
Judy determined that we needed a scheduled, uninterrupted meeting to address these issues properly. She started scheduling an hour every few weeks for us to discuss our goals and what we were doing to improve. Our personal experience mirrored research by John Wasson, MD, of Dartmouth Medical School (unpublished data, 2000–2005) that regular all-staff meetings – even in the context of a practice with little to no staff – are a critical time of reflection that allows for planning and improvement. Once Judy and I began our meetings, we developed a better understanding of our improvement efforts.
Clarify goals and roles. Ambiguity in roles is not unusual in medical practices. Sometimes we work on tasks that should be handled by someone else. Sometimes the physician and nurse both take vitals on the same patient. Sometimes we forget to ask the right questions of the patient, such as whether his or her history of gastrointestinal cancer or colon polyps has changed. The greater the number of individuals involved in the work, the greater the chances for uncertainty, error, rework and potential patient harm.
Even a practice the size of ours can suffer from ambiguity. To help us avoid errors of omission or rework, Judy and I created a checklist to clarify who does what. During the course of each patient visit, we check off the following tasks as we perform them:
Obtained HIPAA signature,
Took vital signs,
Asked about smoking status and readiness to quit,
Documented health care proxy discussion,
Reviewed changes to personal or family history of GI cancer or polyps,
Referred patient to howsyourhealth.org.
The check-in checklist has lead to a dramatic surge in our delivering tetanus and pneumovax vaccines as well as in obtaining HIPAA authorizations and referring patients for appropriate cancer screening. We have continued to discuss how well the tool and our process is working and what we can do to reach our goals, and we have made modifications as appropriate.
Act on ideas. When we decide to change the way we work, we do it right then. It’s more effective to test a new tool or approach that same day than to plan a grandiose implementation over the course of several meetings. (For more information on rapid cycle improvement, see http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/HowToImprove/.)
Immediately following the meeting where we developed the checklist, we created a mock-up on paper and tried it with the very next patient. We quickly realized that we could use the visit template function in our electronic health record, which would make it easier to incorporate age- and gender-specific information.
As you begin to work toward your goals, your team will identify gaps in the tools you have – things that don’t support the work as well as they should or things that are missing entirely. For instance, if you’re going to track a number of important clinical parameters, you’re going to need a clinical registry. Be sure you supply yourself with the proper tools to bring your ideas to fruition.
Keep it simple. Your processes must be easy to understand. Because our checklist is part of the note for the visit, when Judy and I have a handoff in the process, we can see exactly what is happening, pick up where the other left off and follow through to completion. We have the same goals for processes like handling incoming paperwork, managing referrals and using tickler files. They must be straightforward and transparent enough that even temporary staff could step right in and make them work.
Everyone’s a winner
A high-performing clinical team is achievable in any practice. It takes a group of individuals working closely to serve patients and a willingness to follow the steps outlined in this article. Teams that implement these behaviors are likely to achieve better health outcomes with less effort than teams that do not. Our team has achieved a very high score for team satisfaction as well as patient satisfaction with the care we deliver. By setting clear goals, defining roles, holding regular meetings, having the right tools to do our work and ensuring transparency and simplicity in the work itself, you can do the same.