Key Driver 4: Create and Support High Functioning Care Teams to Deliver High-Quality Evidence-Based Care

Given the demands of primary care practice, no clinician can single-handedly incorporate new evidence into all aspects of practice. Care teams blend a complementary set of skills and expertise and take joint responsibility to give patients the highest quality care possible. Each team member knows his or her job and is empowered to get it done. All the moving parts come together because the team communicates well. Creating an environment in which teams can succeed in keeping up with the ever-changing evidence base involves developing a culture of cooperation and shared accountability for outcomes, embracing learning about new ways of doing things, and engaging teams in the quality improvement endeavor.

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Change Strategies

Assign patients to clinicians and teams to create accountability and a sense of shared responsibility among the team for their patient panel
Assigning patients to clinicians and teams, a process known as empanelment, is the basis for population health management. Team members share responsibility to make sure that all patients in their panel receive care that is consistent with current evidence, whether or not those patients regularly come in for visits. Empanelment also helps create stable patient-care team relationships, which build trust and make it more likely that patients will follow recommendations for evidence-based care. The process of empanelment, however, can be complex. Even in solo practices it is important to identify who are the practice’s active patients.  In larger practices, empanelment also includes determining the size of each team’s panel, which may involve projecting the intensity and type of services each patient requires and soliciting and respecting patient preferences. (Go to Key Driver 3: Optimize health information systems to extract data and support use of evidence in practice for information about linking patients with care teams in clinical information systems.)

Empower team members
In order to apply new evidence effectively and efficiently, all members of the team need to have the authority and skill to accomplish their responsibilities. Practices can explore delegating to other team members some tasks that the primary care clinician has traditionally performed. Practices may find that team members are capable of taking on more complex tasks because they have skills that the practice is not aware of. In other cases, practices will need to provide additional training. Everyone will need to have confidence in each team member’s competence and respect their ability to execute their duties autonomously. At the same time, team leaders cultivate an environment where everyone takes on shared responsibility for delivering high quality care. Practices empower team members by creating a culture that emphasizes collaboration, celebrates each team member’s unique contribution, and makes it easy for anyone to identify obstacles, offer improvement ideas, or speak out if there is a safety issue or other concern.

Support care team learning about new evidence
Practices may have to augment in-service training to address the constantly evolving nature of evidence. Ongoing education informs care team members about new evidence as it emerges, and training can help team members incorporate new processes involved in implementing the new evidence. Approaches to team learning include lunch and learn sessions, shadowing, mentoring, consultation with experts, in-service training and online learning modules, among others.

Establish care teams and delineate team roles for clinical and non-clinical staff
There are two aspects to establishing high functioning teams: deciding who is on each team and agreeing on what each team member does. No one team size or structure will work for all practices. Consistency of team composition and roles throughout a practice, however, can make it easier to function when there are staff absences or departures. Team members need to understand not only their own responsibilities, but also those of others on the team. Written job descriptions can document these responsibilities, and training can help bring clarity to each team member’s understanding of how the team gets its work done. New evidence can mean that both clinical and non-clinical team members have to take on new tasks. If someone changes positions or shifts roles, it is important that everyone in the practice be notified and adjust their expectations accordingly. 

Optimize care team communication
Working well as a team requires good communication, which can take many different forms. One way is holding regularly scheduled team meetings to address team and practice functioning and opportunities, challenges, and priorities related to implementing evidence. Another form of team communication is the team huddle during which the team addresses daily opportunities and challenges, sets priorities, and prepares to meet the needs of scheduled patients. A shared expectation that each team member will keep their colleagues informed and involved in changes to their workflow or responsibilities is fundamental to good communication. Practices can enhance team communication by providing training in communication techniques and co-locating team members in the same physical space.

Make reviewing their performance and participating in quality improvement (QI) activities part of everyone’s roles and responsibilities
Quality improvement is part of each team member’s job and each care team is collectively accountable for its performance. While the QI team may pull the data and produce the reports, practices will want each care team to review its own data and compare its performance with that of others in the practice, and other benchmarks. When a team realizes there are opportunities for improvement, it can learn from higher performers and test possible solutions to improve results. Sharing performance data with care teams also creates opportunities for practices to celebrate improvement together.

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