Team training strategies to promote quality and efficiency Larry Mauksch, M.Ed Consultant and Trainer Clinical Professor Emeritus, Department of Family Medicine University of Washington Editor, Families, Systems, and Health

Objectives Identify core elements of team effectiveness Learn a model blending communication training and team  development Plan ways to incorporate video creation and review into training Larry Mauksch, M.Ed University of Washington Department of Family Medicine

Team Training: Sports versus Healthcare and use of Practice Larry Mauksch, M.Ed University of Washington Department of Family Medicine

Time Demands in Primary Care Am J Public Health Time Demands in Primary Care Am J Public Health. 2003;93:635–64; Ann Fam Med 2005;3:209-214. 2500 patients Conservative time estimates Ten most common Chronic illnesses Well controlled 3.5 hrs/day Poorly controlled 10.5 hrs/day Preventive care Level A and B recommendations 7.4 Hours per day Add the 60 % of patients with acute problems, plus paper work, phone calls and charting = 24 hours / day Cut panel size to 1250 = 12 hours / day

Estimating Panel Size in Primary Care with Team-Based Task Delegation Ann Fam Med 2012 10(5) 396-400

Why Are High-Functioning Teams Essential To Primary Care Too much work for one person Collaboration produces better outcomes Effective teams help sustain healthy behaviors in their members Fewer errors

Transdisciplinary Functions and Roles in Primary Care PCP Nurse LPN Front Desk Behavioral health Care Management Relationship 5 Agenda setting and activation 4 3 Self management-simple 2 Self management-complex 1 Primary care counseling Plan confirmation and care integration Proactive follow-up and stepped care Intensity: 5 =always; 4= often; 3 = periodic; 2 = support; 1 = reinforce and connect Larry Mauksch, M.Ed UW Family Medicine

Levels of MA/LPN(RN?) Activity Limited Warm Engaged Activating Relationship/Empathy X Vitals/ Visit prep Update Meds/ check refills Agenda/Priority/Organize Activate / Questions? Prev/HCM/screening Initial history (Scribe) SMS: goal/action plan Proactive f/u (registry mgmt) Closure/navigation Frequency ++ +++ +

Critical Considerations for Teamwork Salas et al, Human Resources Mangmnt, 2014 Conditions Culture Context Composition Cooperation Coordination Communication Coaching Cognition Conflict

Primary Care Team Building Activities Huddles & Debriefs Team Training Peer Coaching Video Creation Role Modeling X XX Cognition Cooperation Coordination Conflict Communication

Big Five Teamwork Behaviors Leasure et al “No I in Teamwork” Acad Med Leadership Mutual performance monitoring Backup behavior Adaptability Team orientation

Phases of Teamwork Planning (Huddles) Action (The provision of care) Debriefing (Reviewing the experience, celebrating success, and planning change and learning)

TEAM COMMUNICATION TRAINING Team members reinforce use of communication skills in one another Shared learning of skills builds team function

Common Training Sequence Introduction to PCOF Group rating and discussion of C/B Videos Teamlet members observe each other using extended appointment slots Groups meet to share learning and set goals Within teamlets Across teamlets Recurrent observations and team meetings for reinforcement Do the cycle again to learn more skills and achieve more goals Larry Mauksch, M.Ed University of Washington Department of Family Medicine

Giving Feedback It is timely and requested Kind Honest Provisional and curious Specific Not judgmental About something that the receiver can change

Direct observation: Logistics Orienting patients Activity in the room Feedback and Reflection

Orienting patients Example: I have a colleague observing me today. We do this in our clinic to help one another maintain high standards of patient care and team work

Patient Template: Teamlet training 8:30-8:40 discuss needs of first three patients 8:40-8:45 MA bring patient to exam room and explains teamlet training- at some point is joined by MD, ARNP or PA 8:45 -9:30 8:45 to 9:00 MA interview patient and MD observes 9:00 to 9:30 MD interviews patient and MA observes 9:30 to 9:40 debrief encounter 9:40 MA gets next patent and repeat cycle two more times Larry Mauksch, M.Ed University of Washington Department of Family Medicine

Activity in the room-Seating Counter MA/RN MD B Exam table This is an animated slide showing where the observer should sit if the patient sits in chair B, chair A or if both chairs are taken. A Door

Observer behavior during interview Avoid upstaging interviewer with eye contact or non verbal behavior, e.g., head nodding, non verbal empathy If patient speaks to you, look at” the other” or at the floor, and then to your paper to avoid reinforcing being included in the conversation Never interrupt person being observed OK to plan ahead to invite observer in to help If interviewer leaves the room: Engage patient in brief conversation or respond to patient questions but be careful not to undermine the interviewer, or Leave with interviewer

Observer Foci 1) Skills on the PCOF 2) Overlap with Lean approach Those done well Wonder about doing something differently 2) Overlap with Lean approach Going where the action is Value stream thinking- study the present, plan the future Standard work Raising skills to the ceiling of role capacity Work supported by coaching Reveal waste Change designed by folks who do the work

Common and Better Video: Faculty development primer Common Missing core skills Should not be bad caricature Better if observer rates it and doesn’t see much to improve Better Re-create the scenario but with core skills Should be better, but not perfect Make both videos the same length

Toward Patient-Centered Teamwork: Promoting Cultural Change Educational Goal Understand core concepts (Facts; Knowing) Skill learning (Knowing; comprehension ) Enhance self awareness (Doing; application) Team ownership and reinforcement (Doing; analysis) Cultural change (Synthesis) Educational Strategy or Tool Read to create vocabulary Group discusses “Common” and “Better” Video with vocabulary tutoring Rate video with PCOF, Online training to increase vocabulary and skill recognition Maximize structured direct observation: Observe others, be observed Video and rate self Team critique of video Follow patients across team encounter Share learning and establish goals Leaders as video role models, champions System wide training Inter-system sharing

FILL IN ONE OR MORE OF THE PRACTICE CHANGE OPTIONS BELOW Practice Reflection and Commitment to Change Tool JOUR OF CONTIN EDUC IN HEALTH PROFESSIONS, 35(3):166–175, 2015 The most useful information for me was: This highlighted the following gap in my practice: FILL IN ONE OR MORE OF THE PRACTICE CHANGE OPTIONS BELOW I will change my current practice in the following way: Barriers I anticipate: What changes to my current practice am I considering? What would enable me to change What confirmed my current practice? What supports my current practice? I am not convinced there is a need to change my current practice because: