Bringing teamwork into primary care

CHICAGO—“If we have any hope to prevent index hospitalizations from occurring, we have to improve the quality of care and the extent to which coordinated care depends on teamwork,” said Ann O’Malley, MD, MPH, senior fellow at Mathematica Policy Research, Washington D.C., speaking at the Healthcare Leadership Forum on Sept. 29.

O’Malley discussed the findings of two qualitative studies conducted in 2013 and 2009. Both involved in-depth phone interviews of about one hour each. The 123 respondents came from 53 practices that ranged in size and ownership. All had EHRs in place for several years.

The 2013 study focused heavily on primary care teamwork and how to maximize the extent to which they function as teams. The National Committee for Quality Assurance has a domain on teamwork and the study focused on those practices that scored 100 percent of that teamwork element and those that did poorly.

The 2009 study focused on primary care practices and specialty care providers to learn more about how they communicated with each other and how EHRs either supported or challenged that communication.

O’Malley said that if the primary care teamwork piece isn’t working, “it’s hard for the practice to interact with patient needs outside of that setting.”

Large practices divide into smaller teams, or core clinical units to effectively function as teams. Those that do well, she found, tend to arrange their office and staff in a system of one physician to two medical assistants using three exam rooms.  

The five elements of teamwork, she found, include: common goals, clear division of labor, communication, systems and training.

One of the biggest challenges is physician buy-in. They are not trained to be good team members because they are trained to trust no one and to verify everything for themselves. Leadership is important because leaders need to recognize and acknowledge problems in their culture and engage staff in changing practice.

Practices can achieve staff buy-in by engaging staff to identify and refine optimal workflow. “Make one small change without rattling everyone’s world but improves care and then they will be much more open to more changes.”

To better engage patients, the nurse care manager role is critical. They can help with phone calls, home visits and encouraging patients to sign up for the patient portal.

Physicians are reluctant to delegate tasks, O’Malley said, so they should start by incrementally creating delegation tasks to other members of the care team. If they start with safe standing orders, such as pneumococcal vaccination and other similar simple things, all clinicians are more likely to feel comfortable.

Staff meetings in which everyone discusses their role can help build empathy as well as identify duplication in roles and identify possible opportunities to streamline work processes. “Clarifying upfront who does what is critical to teamwork.”

O’Malley said the studies found that daily huddles—quick debriefings—to assign responsibilities and discuss patient-specific issues that arise are very valuable once practices learn how to properly conduct the meetings. “It sounds like a simple concept but it’s not that simple and you have to be patient. You can’t try it once. It took most practices months to refine this process. You really have to keep working on it.”

There is a strong likelihood that practices will slide back to pre-teamwork behaviors, O’Malley noted. Those successful at preventing that built checks into their systems so practice administrators could track task completion in EHRs. “That is incredibly effective at seeing when people finish what they’re supposed to do. Weekly staff meetings and daily huddles can avoid slideback because you can catch things right then. And, systems can be designed to support delegation.”

Another challenge is the fact that EHRs predated the care manager role so care management software does not integrate with EHRs. To manage that, some practices have created templates and macros. Patient registries also are not integrated with EHRs. “There are lots of ways this is being handled as health IT evolves but users want this to be more seamless and they want it to be actionable.”

Training was “sadly, the thing we heard the least about,” O’Malley said. “There is a need for more training, specifically on primary care teamwork. The more that can happen, the happier people are.”