2. 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?

4. 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-L' i I,I, I.-.-.'.' 1.....

6. www.iom.edwww.iom.edu/tbc

7. Characteristi cs

8. Facil it ators

11. Shared Goals... Work to establ ish shared goals that reflect patient and family pr iorities and that can be clearly articulated, understood, and suppor ted by all members.

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

15. 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-basedcare (organizational, systemic, financing, legal, etc.)

18. Preventable Deaths from Heart Di sease & Stroke Cardiovascular disease and type II Diabetes

19. 7 + Diseases and injuries + Risk factors High blood p12Ssure + Smoking- 6 + Alcohol use +IHD s + LRI + HAP Diet low in Fruit 4 l.Dw bad pain I + Cerebrovasrular disease 3 HighBMI + FPG Malaria + Diarrhoea. + + Hr/ COPD /........_+ Road injuiy + + PMHAmb..........lnactivityt Pret birth Undefweight + Sah comphcabonS,+ Dietlow innuts and seeds - Tuberculosis Diabetes 2 + Lung cancer 1 1616 10 Deaths () 1 14 1 20 ffgt.re2: Compartson of the magnJ tudeof theten leadlngdlseases and lnJur1es and the ten leadlng r1sk factors based on the percentageof global deaths and the percentage of global DALYs, 2010 actors or poor ea t 1Lower respiratory infections 2 Diarrhoea 3 Preterm birth complications 4 lschaem i c heart disease 1 lschaemic heart di sease ·I 2 Lower respiratory infections 3 Stroke '1 4 [)iarr hoea I s HIV/A IDS Communicable, maternal,neonatal,and nutritional disorders 1990 2010 I 1Childhood underweight 1 High blood pressure 2 Tobacco smoking, excluding second-hand smoke 3 Alcohol use "14 Household air polluti on from solid fuel s I 2 Household air pollution from solidfuels 3 Tobacco smoking, excluding second-hand smoke 4 Hi h blood pressure IS Suboptimal breastfeeding IS Diet l ow in fruits -Ascending order in rank

24. 3 Impr ovement Concepts Measure Accurately Act Rapidly Partner with Patients & Families

26. Team -BasedCare is a Potent Anti -hypertensive I -14.0-14.0 All com pan sons (unadjusicd, t\=33) All Pro\1der l'rov1der compamons education ( 1 1 ) reminder (6) (adjusccd for stud) size & Difl'Prc: N 33) l-'ac1l11.a1ed 1-'iment!-'anent Self- Aud 11& Team Change relay ofex:lucanon ( 18) management remmd ers I 5) feedhock (3) (20) infollllation (16) (9) Quality 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

27. Cochrane Review, 2010 Me JO Me;in C>iffefma! IVJ1>;ed.95% 0 St °' Slbzl"CX.'P Tre.:itrnent N 1"..'e:1.: ('SO) Control N n(SD) Dffermce IV;R>af,95% Cl Waz Bogden 199849-23 (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 18ll3 (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 %-1200 ( -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(, ll4 %-3.D ( 5.88, -On ] 4 1.4 %4 1.4 %0.0 [ -1.94, 1.94 1 1.7 %1.7 %-13.00 [ -2259, -141 1 Schroeder 2005 '94... (18.3) 7.0 %7.0 % -1.70 [ 6..4J.,102 i 6..90 [-127J., -1.08 ] s.ro c -10.1a -1.11 1 -7.00 ( -13.45, -0.55 ] Sdonxx 200170 -1.3 ( 19) 4.l. % Soobnein! 2004 1 171 17-176 (I B.l.) 7.4 % Tobe 2006 47 -17 (18.1)3.7 % Ton 20071818 -10 -1) 5...5 %0.0 [ -S3Q 5JO 1 Total (95% CI) Hetero Ctt:? 1164 23.46. df 9 (P = 0.0I 10711071 100.0 %100.0 % -2.52 [ -3.77, -1.27 ]-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 ;!ppral:ie 050500 r >Min 'e:l! rcrt r :MU'.l cxx-t'."CI

29. 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

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

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

34. ...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 not a clinical skill

35. We need a new metaphor...

37. The Power of Teams

42. Leadership in Teams Technical 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

43. The most common fail ure in leadership is produced by treating adaptive chal lenges as if they were technical problems 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.

45. 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 Rapidly Support Patients and Their Families 1.1. Educate staff on science of safety 2.2. Identify defects 3. Ass ign executive to adopt unit Learn from one defect per quarter Implement teamwork tools

46. ... 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 professionalismwill 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

48. Profess Profession 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

49. "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

50. 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)

52. "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

53. Specialthanks to Shahid Chaudhry, PhD for assistancein devel oping this presentation