ms

• Principles and values of effective team-based health care

• Example: TBC and improving hypertension control

• Challenges to teamwork in clinical care

• What does "leadership" mean in a high-functioning team?

• What might a "trans-disciplinary" professionalism look like?

Discl osure and Discl aimer

Disclosure

• I have no personal financial relationships with any pharmaceutical

companies and none of my work is funded by pharmaceutical companies.

• The AMA receives some direct support for other projects and programs

from for-profit companies (<15% of total AMA budget).

Disclaimer

• The views expressed in this presentation are my own.

• Nothing I say should be construed as representing a policy of the AMA,

unless I specifically say otherwise.

.-L' i

I ,• I.

-.'

1.....

www.iom.edu/tbc

Characteristi cs

Facil it ators

Shared Goals...Work to establ ish shared goals that ref l ect patient and family pr iorities and that can be clearly articulated, understood, andsuppor ted by all members.

Clear Roles...Have cl ear expectations for eachmember's functions, responsibil ities, and accountabil ities.

• Patients and families as members of teams,

rather than recipients of team care

• Leadership in the context of team -based care

• Teaching and training for team -based care

• "External" factors that support or hinder

effective team-based care

(organizational, systemic, financing, legal,

etc.)

Preventable Deaths from Heart Di sease & Stroke

Cardiovascular disease and type II Diabetes

7

+ Diseases and

in juries

+ Risk factorsHigh blood p12Ssure•

+ Smoking-6

+ Alcohol

use+ IHD

s+ LRI +

HAP

Diet low in Fruit

•4 l.Dw ba d painI

+ Cerebrovasrular disease

3

• High BM I

+ FPGMalaria + Diarrhoea.

+ + Hr/COPD

/• ........_+ Road injuiy + +

PM H Amb.......... • lnactivit y tPret birth Undefweight + SahcomphcabonS

• , + Diet low in nuts and seeds•- Tuberculosis

Diabetes

2

+ Lung cancer

1

1610Deaths ( )

1 14 1 20

ffgt.re2:Compartson of the magnJ tudeof theten leadlngdlseases and lnJur1es and the ten leadlng r1sk factors based on the percentage of global deaths and the percentage of global DALYs, 2010

actors or poor ea t

1 Lower respiratory infect ions

2 Diarrhoea

3 Preterm birth

complications

4 lschaem i c heart disease

1 lschaemic heart di sease

·I2 Lower respiratory infections

3 Stroke

'14 [) iarr hoea I s HIV/A IDS

Communicable, maternal, neonatal, and nutritional disorders

1990 2010

I1 Childhood

underweight

1 High blood pressure

2 Tobacco smoking, excluding second-hand

smoke 3 Alcohol use

"14 Household air polluti on from solid fuel s

I2 Household air pollution from

solid fuels3 Tobacco smoking, excluding second-hand

smoke 4 Hi h blood pressure

IS Suboptimal breastfeeding

IS Diet l ow in fruits

- Ascending order in rank

3 Impr ovement Concepts

• Measure Accurately

• Act Rapidly

• Partner with Patients

& Families

Team -Based Care is a Potent Anti -hypertensive

•I

• •

-14.0

Allcom pan

sons (unadjusicd

, t\=33)

All Pro\•1der

l'rov1der compam ons education ( 1 1 )

reminder (6) (adjusccd forstud)

size & Difl'Prc: N

33)

l-'ac1l11.a1ed 1-'iment!-'anent

Self- Aud 11& Team Changerelay of ex:lucanon ( 18) management remmd ers I5) feedhock (3)

(20)infollllation

( 16)(9)

Qu a l i t y Im provement trategy

"Interventions that included team change as a QI strategy were associated with

the largest reductions in blood pressure outcomes. All team change studied

included assignment of some responsibilities to a health professional other than

the patient's physician."

Walsh et al 2006; Arch Intern Med

Cochrane Review, 2010MeJO Me;in

C>iffefma!

IVJ1>;ed.95% 0

St

°'Slbzl"CX.'P

Tre.:itrnent

N1"..'e:1.: ('SO)

Control

N

n(SD)

Dffermce

IV;R>af,95% Cl

Waz

Bogden 1998 49 -23 (226)

30 . (, ( 14.7)

345 6.8 (17.4)

349 -2 (14..1)

23 - 123 ( 1511)

I IO -<.. I (15.7)

63 -&2 ( 15.1)

1 18 l l 3 (17.l)

48 -24 (116)

29 -10 (8.7)

46 -11 (20)

34 -I (14.J)

338 3.5 (17)

280 -2 (10.7)

17 0.7 (18.B)

21 % -12 00 ( -2057, 143 ]

oe Cls:m 1006 3.1 %

-5..00 ( -1213, 21 3 1

GartiJ-R?n:i. 200 I

H:r.\. 1<;79

P.:lric 199(,

• l l 4 % -3.D ( 5.88, -On ]

4 1.4 %

0.0 [ -1.94, 1.94 1

1.7 %

-13.00 [ -2259, -141 1

Schroeder 2005 '94 . .. (18.3)

7.0 %

-1.70 [ 6..4J.,102 i

6..90 [ -12 7J., -1.08 ]

s.ro c -10.1a -1.11 1

-7.00 ( -13.45, -0.55 ]

Sdonxx 2001 70 -1.3 ( 19)

4.l. %

Soobnein! 2004

1 17

-176 (I B.l.)

• 7.4 %

Tobe 2006

47 - 17 (18.1)

3.7 %

To n 2007

18 -10 -1) 5...5 %

0.0 [ -S3Q 5JO 1

Total (95% CI)H e t e r o Ctt:?

116423.46. df 9 (P =

0.0 I

107 1 100 .0 % -2.52 [ -3.77, -1.27 ]P.?

=62%lest for O\oer.i effett Z = 3.96 (P = 01Xl0075)

Test foc subf;rc:x:i:> cfr!fcrmces: Not ;!ppra l:ie

0 5 0 0

r>Min 'e:l! rcrt r:MU'.l cxx-t'."CI

• Overcome therapeutic inertia

• Improve adherence to evidence-based guidelines

• Streamlined care processes

• Teams give explicit thought to process issues

• Increased 'dose' of health information/ advice

• More points of contact

• More time spent with health professionals

• Additional types of information provided

• Better interpersonal connections with patients

There are al ways tensions that come up . Part of working isdealing with tensions. If there's no tension, then you're not serious about what you're doing.

Wynton M arsalis

Hot Button Terms• Scope of practice• Independent practice• Supervision• Physician-l ed• Doctor• Mid-level• Allied health• Collaboration

... the nuanced nature of "Leadership" within teams carrying out complex or innovative work...[requ ires] Leadership from all members of the team...

"Physician-Led" Teams

Leadership is nota clinical skill

We need a new metaphor ...

The Power of Teams

Leadership in TeamsTechnical Problems

• Problem is clear

• Expert/leader provides

solution

• Solutions easy to accept

Adaptive Challenges

• Problem hard to

acknowledge

• The team must

provide the solution

• Solution requires

difficult change

The most common fail ure inleadership is produced by treating adaptive chal lenges as if they were technicalproblems

Ronald Heifetz, Marty Linsky & Alexander Grashow, The Practice of

Adaptive Leadership: Tools and Tactics for Changing Your Organization and the World (Boston: Harvard Business Press, 2009), 19; 23-24.

TRIP/CUSP Models

1. Summarize the evidence in a behavioral checklist

2. Identify local barriers to implementation

3. Measure performance

4. Ensure all patients get the evidence

• Engage• Educate• Execute• Evaluate

Measure Accurately Act RapidlySupport Patient s and Their Families

1. Educate staff on science of safety

2.

Identify defects

3. Ass ign executive to adopt unit

Learn from one defect per quarter

Implement

teamwork tools

. . . The danger of any care model in which the caregiver is

broadly conceived as a team rather than as an individual is the

possible dilution of responsibility assumed by individual

caregivers. Without safeguards, no individual member of the

team may feel compelled to go the extra mile to ensure the

delivery of necessary care.

. . . Given the breadth of primary care, licensure and regulation

cannot restrain nonphysician primary caregivers from offering

primary care services that they are not qualified to provide.

Only professionalism will keep such caregivers

operating within their sphere of competence-as is the

case for all clinicians, including primary care physicians.

Tom Huddle, Annals of Internal M ed icine, September 2013

ProfessProfession Professional Professional ism

Definitions

Unidisciplinary - One group working alone

Multidisciplinary - Multiple groups working individually

on a shared issue

Interdisciplinary - Multiple groups working together

toward a common goal (AKA "interprofessional")

Transdisciplinary - Multiple groups working together to

develop a new, shared model and common language

"Transdisciplinary professionalism could be

defined as 'an approach to creating and carrying

out a shared social contract that ensures

multiple health disciplines, working in concert,

are worthy of the trust of patients and the

public in order to improve the health of patients

and their communities.' "

Institute of Medicine of the National Academy of Sciences Global Forum on Innovation in Health Professional Education

A New, Shared Social Contract

• Social contracts spell out the relations between individuals,

groups and society

• Gain coherence, smooth function, reliability, safety.. .

• ... at the expense of some individual liberty (agree to play by

the rules)

"The sum total of medical knowledge is now so great and

wide-spreading that it would be futile for any one man...

to assume that he has even a working knowledge of any

part of the whole.. . It has become necessary to develop

medicine as a cooperative science; the clinician, the

specialist, and the laboratory workers uniting for the good

of the patient, each assisting in elucidation of the problem

at hand, and each dependent upon the other for support."

William Mayo, 1910

Special thanks to Shahid Chaudhry, PhD for assistance in devel oping this presentation