1. Is the team (leader) getting it? Classically simple ways to create and sustain teams in primary care Anton J. Kuzel, MD, MHPE Virginia Commonwealth University Department of Family Medicine

2. The coming Tsunami OMG – 32,000,000 more people with insurance! Declining PC workforce! Massachusetts on a national scale!

3. 2014

4. The current reality Overworked, underpaid PCPs Tiny fraction of practices are at level 3 PCMH status No idea of how to get to an idealized model without special financing

5. What we really need FUNDAMENTAL REFORM THAT PAYS FOR VALUE, NOT VOLUME! Very tough to accomplish at the Federal level –One person’s waste is another person’s income –Independent voters swinging left and right Something to do in the meantime (Brace yourself for a little shameless self-promotion)

6. Practice redesign without special financing! Ten steps to a patient-centered medical home (Family Practice Management, November, 2009) How about just doing the first three steps – could have practices waltzing along (one-two- three, one-two-three, one-two-three)

7. Step 1: Documentation and coding Stop leaving money on the table 28% of FM established patient codes are level 4 60+% of FM established patient codes could/should be level 4 Using Medicare payment rates, this would generate about $50,000 per year per clinician in extra income (more if average payment exceeds Medicare rates) Little/no extra work/time from clinician Why not? Don’t know how, or afraid of audit Coding from the bottom up; memorize 99214 This is low hanging fruit!

8. Step 2: Add staff, with a purpose Clinicians are the ones generating income Clinicians should not be doing things that don’t require their expertise Nurses, other staff should take non-clinician work AWAY from the clinicians All people working to the top of their license Systematic attention to prevention, CDM Adds capacity (10-20% or more), increases quality, creates opportunity for increased income

9. Step 3: Rapid access scheduling Requires information system to know panel sizes Balance supply and demand Choose easier ways of working down the backlog Improves continuity, which supports coding to higher levels of care Do today’s work today Patients love it Can add capacity (about 10%)

10. If most primary care practices did these 3 steps Happier clinicians, staff, patients Improved quality of care –Systematic attention to prevention, chronic disease –Large gains possible without an EMR! 15-30% increase in capacity of existing practices! Talk about being ready for 2014!

11. So documentation/coding, teamcare, and advanced access scheduling – these three things abide AND THE GREATEST OF THESE IS TEAMCARE

12. Put more bluntly… It’s the economy, stupid! James Carville, Clinton campaign advisor team

13. So the greatest of these is teamcare And the hardest to achieve Accepted wisdom is that office culture is key, as lived by the leader(s) Culture trumps strategy, every time So how do you achieve a vibrant office culture? Maybe it’s as simple as…

14. Be the change you want to see in your practice.

15. Might work for some – epiphanies do happen Others might need more specificity Offer some behavioral prescriptions that can lead to better team function and morale Over time, repeated successful behaviors may lead to insights Maybe strategies can help establish culture

16. Since these are suggestions for self-help behaviors, let’s…

17. Real simple behavioral advice: Treat your co-workers the way you treat your patients (Assumes your patients experience you as a genuinely caring person who really listens to them) (Go ahead, say “Duh!”, but at least this is easy to remember)

18. More simple, classic advice By: Dale Carnegie

19. 1.Don’t criticize, condemn or complain 2.Give honest and sincere appreciation 3.Arouse in the other person an eager want Fundamental techniques in handling [interacting with] people:

20. Goal: What do you want? Reality: What is happening? Options: What could you do? Will: What will you do? (John Whitmore, Coaching for Performance: GROWing Human Potential and Purpose; one of my four must read books for leaders) GROW performance by enhancing awareness and responsibility

21. Team: a group of people that share common goals as well as the rewards and responsibilities for achieving them

22. (Another of my personal four must read books)

23. Consequences: Pretending to be competent Avoiding risks - Playing it safe “Look out for number one” “Don’t let ‘em see you sweat” #1: Absence of trust

24. Consequences: Leaderthink becomes groupthink Artificial harmony Stale patterns of behavior We’ve always done it this way If it ain’t broke, don’t fix it Arrested development or worse, regression #2: Fear of conflict

25. Consequences: Listless performance at work Resentment among those “carrying the load” #3: Lack of commitment

26. #4: Avoidance of accountability Consequences: Lack of critical feedback regarding behaviors Working in silos – holding team accountable creates incentive to understand how all the parts contribute to success

27. Consequences: Imagined accomplishment Mediocre performance Lack of ownership, and hence, meaning #5: Inattention to results What, me worry?

28. “Begin with the end in mind.” How to fix this?

29. Well, yes, but what end? How does the group decide what the end is – what their goals should be?

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35. How does a leader build a foundation of trust? Leader must: Risk being vulnerable Act in service of those on the team

36. “I was wrong” “I made a mistake” “I need help” “You’re better than I am at that” “I’m sorry” Get comfortable saying (when appropriate):

37. More constructive actions: Have regular team meetings (with staff on the clock) Ask your teammates what their goals are, how they see the current reality, what are their ideas about options, and which options they think should be tried Ask them what support they need, and make it your job to help them get it

38. They must have the liberty To pursue their own happiness If you want your team to have life

40. More practical things to do Celebrate successes great and small Have “why I came to work today” stories be part of your team meetings Let somebody else on the team lead some (maybe most) of the time – even if you are the owner, act like an employee some (maybe most) of the time Where are patients on your practice team? Consider a patient advisory panel (but choose members carefully)

42. It’s OK – try just doing better coding, basic team care approaches, and advanced access scheduling And remember, when it comes to your team… Still not feeling inspired?

43. Ask not what your team can do for you. Ask what you can do for your team.

44. The thing that really matters is sincerity. If you can fake that, you’ve got it made. George Burns (paraphrased)

45. Make someone happy Make just one someone happy And you will be happy, too.