Transforming Primary Care in
Teaching Practices
Kevin Grumbach, MD
UCSF Department of
Family and Community Medicine
“As “incorporating science into practice” was
the primary form that a new social need took for
Flexner, so should “incorporating system
improvement into practice” be the response to
the emerging social need 100 years later… The
new social context requires preparation of
physicians to thrive in systems of inescapable
interdependence.”
Don Berwick, Jonathan Finkelstein. “Preparing Medical Students
for the Continual Improvement of Health and Health Care:
AbrahamFlexner and the New ‘Public Interest.’” Academic
Medicine 2010
Berwick and Finkelstein:
A Proposed Core Competency
• “Leading, following, and making
changes in health care: Understanding
how to function in, and to lead, teams,
and to organize and participate in
intentional change.”
Primary Care Transformation and
the Imperatives of:
• Systems
• Teams
• Improvement
The Team Huddle
Swiss Clocks
Obtaining a Narcotic Refill in FHC
Chronic Pain Management
Triplicate Refill Process - Current Process
Part I - Initiation of Process and
Call-In Flow
09/2003
See Scheduled
Appt Flow
P at ient has a
pre-planned,
scheduled appt
Patient needs a
Refill
Patient calls the
clinic
Patient comes
into clinic
Primary's Voice
Mail
Patient Leaves
Message
Team Clerk
Contacts
Primary
Note in Mail
Box
Timeliness of
message and
retrieval
Completeness
of Information
See Drop-In
Flow
Consult
Attending
Schedule Appt
Pager
Refill Clinic
Primary
Message
Retrieved
Gathers
Information
See Scheduled
Appt Flow
Call Returned
Pages Primary
Reviews
Contract Book
Reviews LCR
Makes Decision
Based on Available
Informat ion
Refills
Medication
Does Not Refill
Medication
Requests Chart
How can change be created in
complex adaptive organizations?
It Takes a Team to Make Primary
Care Work
A primary care physician with a
panel of 2500 average
patients would spend:
• 7.4 hours per day to deliver all
recommended preventive care (Yarnall et
al. Am J Public Health 2003;93:635)
• 10.6 hours per day to deliver all
recommended chronic care services
(Ostbye et al. Annals of Fam Med
2005;3:209)
It Takes a Team
• Select the players and assign positions
• Design the plays
• Practice the plays
Share the Care
10 building blocks of high-performing primary
care
Tom Bodenheimer, MD, MPH
Center for Excellence in Primary Care (CEPC)
Department of Family and Community Medicine, UCSF
10 Building Blocks
10
Template of the
future
Patient-centeredness is not
one separate building block
Prompt access to
care
5
Patient-team
partnership
1
Engaged leadership
9
8
It infuses all the blocks
6
Population
management
2
3
Data-driven
improvement
Empanelment
Coordination of care
7
Continuity of care
4
Team-based care
Are we serious about teamwork?
"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 two hours on Sunday afternoon when their
teamwork really counts. Teams in organizations
seldom spend two hours per year practicing when
their ability to function as a team counts 40 hours
per week.”
Harold Wise et al. Making Health Teams Work.
Ballinger Publishing Co, 1974
Where Have I Heard This
Before…
• Systems?
• Teams?
What’s Different This Time?
• Business case and value proposition
• Reframing:
– From the fringe to the cutting edge
Evidence base on health care teams
Studies of general practices in England
demonstrated that better teamwork and team
climate are associated with better processes of
care for patients with diabetes, and better
continuity of care, access to care, and patient
satisfaction.
Stevenson et al. . Family Practice 2001;18(1):21-26.
Campbell et al. BMJ 2001;323:1-6.
Evidence base on health care teams
At Kaiser Permanente in Georgia, primary care
teams with higher “collaborative clinical
culture” scores had superior patient outcomes,
including better patient satisfaction and better
control of diabetes and hyperlipidemia.
Roblin et al. Presented at Academy Health Annual Meeting, 2002.
San Francisco Share the Care PC Model
Reform of SFGH FHC Model
• 4 geographic practice teams
– ~2,500-3,000 patients per team
– Residents on 3 of 4 teams
• New team leadership structure
– FM faculty + FNP/PA + RN
– Accountable for team performance
• Team level patient panel
• Team level PI metrics
– Stable faculty clinical supervision
Implications for Education
Challenge to the Medical Education
Culture
• Leaders!!!
• Followers
• Innovators!!! • Implementers
• Individualistic, • Team Players
Competitive
Brilliance!!!
Challenge to Family Medicine
Culture
George Saba et al. The
Mythology of the Lone
Physician: Towards a
Collaborative
Alternative. Ann Fam
Med (in press).
From “Me” to “We”
• “We will need to assemble systems in which
physicians can build satisfying work
relationships with staff and patients and feel
supported in sharing responsibility for health
outcomes. In place of the currently dominant
“silo” training, we will need to foster
interprofessional education about collaborative
communication and team building skills.
Expectations for role, competence,
satisfaction, and success will need to change.”
– G Saba et al., The mythology of the lone physician.
2005
AHRQ Report
• “The delivery of recurrent team training
across all segments of the health care
community is, at present, haphazard. Few
structural or procedural mechanisms exist to
ensure that it continues at regular
intervals…Simply stated, medical team
training must be instilled and reiterated at
every stage of a care provider's career.”
Who is way ahead of us in
investing in team training?
• Aviation industry
– Crew Resource Management (CRM)
• Military
– Tactical Decision Making Under Stress
(TADMUS)
– Team Dimensional Training (TDT)
• San Francisco 49ers
AHRQ Primary Teamwork
Competencies
Knowledge
Skills
Attitudes
Cue/strategy associations, shared task models,
familiarity with teammate characteristics,
knowledge of team mission, objectives, norms,
and resources, task-specific responsibilities
Mutual performance monitoring,
flexibility/adaptability, supporting/back-up
behavior, team leadership, conflict resolution,
feedback, closed-loop
communication/information exchange
Team orientation (morale), collective efficacy,
shared vision, team cohesion, mutual trust,
collective orientation, importance of teamwork
Resident Developmental Stages
and Share the Care Model
• Do you have to master it before delegating
it?
Competency:
Systems Based Practice
• Knowledge of systems
– “a set of interrelated elements or components,
interacting to achieve some shared goal”
(Berwick & Finkelstein)
• At many levels
–
–
–
–
–
Family systems
Microsystems
Health care system
Public health and community systems
Etc.
Competency:
Systems Based Practice
• Understanding how systems change
– Facilitators
– Barriers
Competence:
Practice-Based Learning
• More than just learning QI techniques
• Sustained relationship and engagement over
time with a practice and its workers and
patients
• Learners in authentic roles in care team
– Learn it to share it
One Proposed Notion
• Align UCSF Medical
Student education with
SF Share the Care
Teams delivery system
model
• Vice Dean Catherine
Lucey, FCM faculty
Margo Vener, Beth
Wilson, Bill Shore
Derek Siver’s Ted Talk on
the First Follower
• http://www.youtube.com/watch?v=fW8am
MCVAJQ