Table 5.

How Practices Overcame Challenges to Teamwork

Challenge	Solutions practices used to overcome challenges
Goals	“Once our priorities are clear, the plan for what we do follows.” (Physician)
Gaining provider and staff buy-in to teamwork	• Present data on results of changes in care processes to demonstrate merits • Encourage a culture where staff support one another • Engage the staff to identify best practices and optimal workflow
Need for effective leadership	• Leaders need to recognize & acknowledge problems in institution’s culture and to engage staff to address them • Recruit skilled leaders • Formal leadership training
Engaging patients in goal identification and achievement	• Care manager or physician outreach to patient to come for visit so all three can sit together to reinforce goals and discuss care plan • Encourage patient to use electronic portal to enter data (e.g. weight, blood pressures, glucose levels) and to access educational materials
Division of labor	“We can’t just go directly to the MAs and tell them what their new responsibilities are without involving them in that decision.” (Physician leader)
Physician reluctance to delegate	• Introduce delegation of tasks by provider to MA incrementally • Create electronic templates to help ensure appropriate information collection by MA • Outside team verifies competency of nurses to handle newly delegated tasks • Physicians more willing to delegate when team staffing is stable; e.g., informal agreements that MAs would stay at practice if they receive additional training
Poor role definition	• Pre-visit planning sheets to maximize visit efficiency & avoid missing issues • In an all-staff meeting, each person walks through their daily tasks to help one another understand respective roles & to identify areas for process improvement • Delegation of tasks to various staffs using task lists or “buckets”
Staff retention	• Fair distribution of tasks, including the more mundane tasks • Higher pay may be needed to retain effective and productive RNs, LPNs, or MAs
Communication	“In an average practice, there are often lines of authority rather than open communication.” (Primary care physician)
Communication breakdown	• “Having common goals facilitates structured communication” • Organize office space to co-locate MD/RN/MA for ease of live communication • Daily huddles to reinforce responsibilities and discuss patient-specific issues • Address communication problems in meetings • EHR as tool to help assign tasks to team members; e.g., electronic to-do lists or task lists (especially useful for part-time, off-site staff, e.g., nutritionists, care managers) • Create a “safe” environment for team members to ask questions • Nurse or practice manager as go-to person for communication gaps within team • Cross-pod and cross-site collaboration to share lessons • White board in hallway near nurses desk to indicate pending visit tasks
Initiating huddles & getting providers to attend	• Physicians/staff learn huddle process by observing others huddle • Allow teams flexibility on when they huddle (AM vs. PM vs. both) • Use populated pre-visit planning form to guide huddle
“Difficult personalities”	• Align team personalities & shifts that work well together • Teach providers to communicate in a nonjudgmental manner • If a person isn’t functioning well in a given role, try to repurpose that role • Evaluation, disciplinary action, and sometimes termination may be necessary • When hiring, emphasize that the person will be expected to act as team member
Risk of disrupting interpersonal continuity of care with patients as team grows	• With pre-visit data collection, most physicians felt that teamwork freed them to spend more of the visit discussing issues most important to the patient • Team hands patient a card with their team members’ names, titles, & roles • Pair same RN/MD or MA/MD in teams to allow them to learn one another’s styles and to ensure they are the key people interacting with the patient • Schedule patients with their PCP unless unavailable
Systems	“All the providers were just kind of sucking up the work themselves. They weren’t bouncing phone encounters back to us.” (Practice manager describing why they automated e-mail/phone appointment requests to go directly to front desk rather than to physician)
Sliding back to pre-team behaviors	• Build checks into system (e.g., practice manager tracks task completion in EHR) • Weekly staff meetings & daily huddles to address problems in a timely fashion
Protect physicians from non-clinical tasks	• Some practices assigned a front desk person per pod/teamlet • Establish rules and criteria for scheduling provider time
Limited resources for hiring	• Care managers focus on most at-risk patients • Most practices used their PCMH funding to hire a part-time care manager or RN
Fee-for-service emphasizes visit volume	• Large system switched to model where doctor was accountable for own expenses, including MA salaries, to allow allocation of funds to structure their team
Part-time staff, transitional staff, and different shifts	• Try to maintain consistency in leadership role • Maintain continuity between the longstanding staff (PCPs, nurses) and patients • Require team huddles to ensure rotating staff are on same page • Cross-train staff on tasks within their scope/skill level
Incorporating "shared" cross-practice staff	• Co-locate staff (e.g., shared care managers) when possible • If care manager can’t attend huddles, share relevant notes from huddles with them • If possible, replace the outside care coordinator with someone from within the practice
Volume of performance measures required	• Divide tasks, for example: 1) Front desk staff flags patients with diabetes or tobacco use on the schedule; 2) MA audits those charts, completes pre-visit planning forms, & gives to team; 3) clinicians do the tasks that MA cannot do • Larger entities (IPA) can help practices with reporting, data aggregation
Training	“The toughest thing is to avoid going back to old habits once training is done”
Finding time and resources	• Most common training was from within the practice by physician leaders • Key team members need to participate in training, not just the lead physician • Staff attend “super-user training to get clearance to create EHR templates.” • Some practices have been trained in teamwork by their larger system • Use of practice coaches, e.g., HealthTeamWorks, CO (www.healthteamworks.org)