Building the Successful Transformation Team

1. Building the Successful Transformation Team R. Scott Hammond, M.D., FAFFP Chair, CAFP PCMH Task Force Medical Director, SOC-PCMH Initiative, Colorado Associate Clinical Professor, Dept. of Family Medicine UCHSC Westminster Medical Clinic, Westminster, Colorado --PCMH Level 3 shammond@evcohs.com

2. Building a Transformational Team • Why a team? • What does a team look like? • Types • Dysfunction • Team roles • Trust • Self efficacy • Team meetings • How start? • Leadership

3. Why?

4. Day in the life of Primary CareTyranny of the urgent Mid afternoon. Running behind. Seen 20 patients. 55 y.o. DM requesting refills and routine visit. Not seen for 9 months. Also has dizziness, a rash and knee pain No recent labs for over a year Med list not up to date Does not know last retinal exam You evaluate dizziness, look at the rash, briefly discuss arthritis, order labs, refill meds, discuss OTC meds. No diabetic education or foot exam. Not sure when you will see him again.

5. Reality of Care Delivery “Comprehensive high-quality management of 10 common chronic diseases requires more time than primary care physicians have available for all patient care.”Annals of Family Practice May 2005 Yarnall. Prev Chronic Dis 2009;6(2)

6. Up to 40% of the work we do is re-work: Hand-offs Repetitive patient calls & messages Staff salary & benefits makes up 70% of overhead Realty of Teams

7. “An ideal team is everybody doing what I tell them to do.” Quote from a cardiac surgeon What’s the Big Deal?Aren’t we a team already?

8. Day in the Life of a PCMH • The MA checks the next day’s schedule at 4 PM and identifies chronic care patients. • Mr. DM is 55 years old with uncontrolled diabetes with renal manifestations • Recently was seen for dizziness, arthritis and she noted that he needed a Pneumovax and lipids test, retinal exam. She made referral for eye exam, ordered tests. • Now returning for a planned care visit. She prints his flow sheet and notes if he is up-to-date with USPSTF recommendations.

9. Day in the Life of a PCMH • During morning huddle, MA discusses her action plan and Mr. DM’s specific needs. • MA pre-visit: assesses BP, foot exam, depression screening, gives injection per Standing Orders. • PCP performs assessment according to guidelines, engages patient in self-management, agrees on goals, and pre-plans next visit. • MA post-visit: • Instructs on medication and TLC change • MA calls patient in 2 weeks to see if he has questions or needs assistance in problem solving.

10. “It is naïve to bring together a highly diverse group of people and expect that, by calling them a team, they will, in fact, behave as a team. It is ironic indeed to realize that a football team spends 40 hours a week practicing teamwork for the 2 hours on Sunday afternoon when their work really counts. Teams in organizations seldom spend 2 hours per year practicing when their ability to function as a team counts 40 hours a week”. Harold Wise, Making Health Teams Work Team Building takes Work

11. “Primary Care is a Team Sport” Bruce Bagley, M.D.Medical Director of Quality, AAFP

12. The Perfect Team

13. The Perfect Medical Team Fortunately, we find examples scattered throughout the country where up-to-date science, not shop-worn habit, is the basis for clinical decisions, where learning is constant and purposeful, and where errors are discovered early and prevented. Patients are the center of care rather than bystanders on whom medicine is practiced. Professionals and patients work together to decide on a treatment plan, and medical care is coordinated and integrated for the benefit of each patient. David Lawrence, M.D. From Chaos to Care: The promise of Team-based Medicine

14. Operational Definition of a Medical Team • Traditional practice Everyone works for the doctor • Transformational practice Everyone works for the patient

15. NCQA PPC-PCMH Standards and Scoring 15 **Must Pass Elements

16. Models of Team-Based Care • Parallel: Independent providers, separate “Silos” in same organization • Consulting-expert advice from 1 provider to another • Collaborative/Coordinated-independent providers share information • Multidisciplinary-different disciplines, hierarchical organization, one leader • Interdisciplinary-shared leadership Boon H Et Al. From parallel practice to integrative health care: a conceptual framework. BMC Health services Research 2004; 4:15-20.

17. Teams Gone Wrong

18. 5 Dysfunctions of a Team

19. Shared goals Clear expectations and roles Available tools Easy to understand and discuss processes of care Effective, timely and consistent communication Practice standardization Information and training is available when needed Everyone on the staff is valued; Respect and trust Feedback of performance and opportunities to grow Positive attitudes of co-workers; solution oriented; modeling Public celebration Characteristics of a High Functioning Team So how do I do this?

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21. Types of Change • Learn new skills • Implement new policies • Physician centric Developmental • Process change • Team building • Physician centric Transitional • Behavior and culture shift • New paradigm • Patient centric Transformational R. Scott Hammond, M.D., Primary Care Consultants

22. Becoming a PCMH Requires Transformation PCMH • Attitude & Cultural Changes Process & Structural Changes • Asynchronous communication • Care that is: • Team-based • Population-based • Proactive • Patient-centered Open access Electronic medical records Group visits Quality-improvement initiatives PCMH=patient-centered medical home

23. Building Teams • Guiding Coalition • 3-4 key practice leaders with shared vision • Practice Team • All staff • Transformation Focus Group • 5-8 committed staff with complimentary skills • Clinical Teamlet • 2-3 persons who know the current health goal of the patient

24. Building Practice Teams • Find your vision and learn leadership skills • Create your Guiding Coalition • Communicate and share vision (PCMH) • Find common ground (quality patient care) • Establish common goals and team tools (access policy) • Create transformational focus team and meet regularly • Spread to teamlets • Measure and respond

25. Team Play vs Record Setting Player • Team member self-efficacy • Check lists • Standing Orders • Patient Educator • Care coordinator • Patient-Centered Medical Home

26. Traditional Team Meetings

27. Team Development Stages • Forming: • New group. • Superficial relationships, politically correct • Size things up, guarded • Conflict suppressed • Telling/asking, 1-way communication • Leader-expert directs decision-making • Storming: • Overt conflict • Power struggle for leadership • Factions & polarization

28. Stages of Development, continued • Norming: • Attempt to establish deeper relationships, negotiate • Goals • Ground rules • Leadership functions • Cohesion • Performing: • “Flying Circus”-free expression of ideas & feelings • Understanding of roles • Trust • Shared decision-making, informal leadership • Conflict is OK, not personal, used to advance mission & problem solve

29. Stages of Development, concluded • Adjourning or Leaving: typically personnel turnover (may be team dissolution) • Team members may be at different stages • May cause regression to earlier developmental stage • Thus, teams may oscillate through stages, not always linear progression

30. Leadership “Once you have them by the gonads, their heart and minds will follow.” Lyndon Johnson

31. Leadership “As for best leaders, people do not notice their existence; The next best, the people honor and praise; The next, the people fear; And the next, the people hate. When the best leaders work is done, the people say, ‘we did it ourselves’.” Lao Tsu

32. Leadership Download Automated Medicine, by Guy Billout, 2000

33. Leadership, Teams and Change • Leadership is a Learned Skill. Taylor, R. FPM, October 2003 (www.aafp.org/fpm) • Creating a High-Performing Clinical Team. Moore, G. (www.aafp.org/fpm/20060300/38crea.html) • 7 Habits of Highly Effective People, Stephen Covey • The Speed of Trust: The One Thing that Changes Everything, Stephan M.R. Covey • Leading Change, John Kotter • The Improvement Guide: A Practical Approach to Enhancing Organizational Performance, Gerald Langley

34. Transformational Change Model

35. Teaming Up to Launch Your PCMH

36. WMC Team