Team Care Starts at the Top

Team-based care at the bedside and beyond has become a goal as healthcare organizations seek to improve handoffs and care continuity. But to make that culture change stick, leadership needs to model team-based behavior and accountability.

This article first appeared in the May 2016 issue of HealthLeaders magazine.

Team-based healthcare doesn't work unless the leadership team also adopts that ethos.

So says Nancy Howell Agee, president and CEO of Carilion Clinic, a seven-hospital health system based in Roanoke, Virginia. She remembers that developing the health system's dyad leadership model, in which a physician leader and a nonphysician vice president work together to manage a group of departments, was only one part of a critical reorganization. The organization needed a hard turn toward integration of clinical, operational, financial, and strategic responsibilities as a down payment on a future where value is king. As important was recasting the way the leadership team interacts with those departments to achieve strategic and operational goals.

"We made a material change a couple of years ago wherein we divided into departments and created a physician leader (the chair) and a nonphysician leader (the equivalent of a vice president) together in a dyad leadership model," she says. "Those two-person teams are fully responsible for their individual departments across the geography of seven hospitals."

But that was only part of reengineering change management at the health system.

Words have meaning
Most every organization has a leadership team. But do the individuals really act as a team when managing the organization? Is the organization managed holistically, or does each department behave as a fiefdom?

Don't answer too quickly.

Agee says her leadership team tried not to ask others to work in ways the senior leadership team was not willing to buy into itself, so it was critical the leadership team modeled the kind of teamwork it wanted those leading the departments to display.

Solution: Include the executive team in the incentives that encourage teamwork and managing the organization holistically.

Although she didn't know exactly how critical it was at the time, that inculcation of team-based management principles at Carilion included a new way for the dyad department leaders to work directly with members of the C-suite through what Agee calls her "board of governors," which includes all the department chairs as well as the organization's executive team. That group meets every other week to discuss new metrics and evaluate progress on current ones and to hear presentations and distribute key lessons learned so other departments can avoid missteps and learn together what works to meet the metrics upon which they all will be judged.

"We make our decisions together, and we usually do it by consensus," she says. "Not that there's not controversy, but these regular meetings have considerably moved the needle in terms of integration and support for our decision-making, understanding the strategic needs of the whole and how each area can help us achieve."

Metrics for which the group is collectively responsible include a scorecard with five domains, and compensation is tied to whether those goals are achieved. So where does the teamwork come in? The incentives are all or none.

"We do that in a team-based way, too," she says. "Any one department can't achieve the scorecard bonus unless they all achieve it."

Agee says because pay is, in part, tied to meeting patient safety, satisfaction, and financial goals, teamwork has become ingrained as a clear expectation. That approach can take the form of a small concept like the daily huddle, where key managers of each department get together.

"This morning, we had a code yellow—we were clogged in the ED, and at 6 we called in a team to help the nursing units be aware of the need for discharges and to help facilitate them," she says.

Agee says teamwork is most evident when the senior leadership team helps facilitate close cooperation between departments that wouldn't normally happen. In the past year, such cooperation has been critical to the development of two institutes: an orthopedics and neurosciences institute and a cardiovascular institute.

Carilion's Institute for Orthopaedics and Neurosciences was "our first foray into multidisciplinary areas working together," Agee says.

In that case, Carilion repurposed an old shopping center. During its development and planning phase, disparate senior physicians and nonphysician managers in neurology, orthopedics, and medicine worked together to design workspaces in the institute. Leadership simply wanted those doing the work to organize it (with help from industrial engineers) so that clinicians could work together more effectively to treat patient conditions that involve all three disciplines.

The facility opened in early January, so results are only anecdotal, but Agee says its potential for better patient outcomes is huge.

"It's amazing," she says. "It's all designed around the needs of the patient."

Now the team can more effectively treat such maladies as movement disorders, for example, and all that the patient might need for such treatment—such as physical therapy, occupational therapy, or various specialties in orthopedics—is in one place.

Agee says physicians designed it with the patient in mind and even extended that to their own office spaces.

"Physician offices are small and in the back of the building because this is not about where the physicians are but how to best serve the patient," she says. "It was an opportunity to have a fairly clean slate, and bringing those folks together was challenging at first, but it is amazing what they came up with. Across disciplines is how the patient experiences us, so taking things from their point of view, as we did with this facility, is important and perhaps uncommon, regrettably."

Everyone's a change manager
What Agee and others are doing in integrating senior leadership into this teamwork philosophy is critical, according to Andrew Garman, PsyD, CEO of the National Center for Healthcare Leadership, a Chicago-based nonprofit, and professor of health system management at Rush University in Chicago.

Fully aligned leadership development means, at a minimum, that senior leadership has ownership of the process, even if implementation is a department-specific responsibility, he says. Ideally, however, leadership development should be something in which senior leadership actively participates, not just as agenda-setters, but also as mentors and learning facilitators.

"There's broad recognition that we need to move to a team-based care model, but you can't think it's the magic bullet," Garman says. "As soon as you have a team of managers, you run the risk of massively expanding cost. So figuring out that balance between providing that coordinated service on behalf of the healthcare consumer while at the same time maintaining efficiency is a big challenge."

At Penn Medicine's largest facility, Hospital of the University of Pennsylvania in Philadelphia, the burning platform was transitions in care, says Craig J. Loundas, PhD, associate vice president of the Penn Medicine Experience program, launched by Penn Medicine Academy. It's likely the same for many healthcare organizations, given the increasing level of penalties and incentives associated, in part, with poor transitions in care that may drive such negative outcomes as readmissions, for example.

About six years ago, Penn Medicine's leadership team wanted to focus on a so-called blueprint for quality, which included team-based approaches to improving quality: transitions in care, reducing variation, coordination of care, and increasing accountability.

"The leadership challenge was to develop skills that were in these silos—for example, the nursing or quality silos—and look at things from an interdisciplinary concept," says Loundas.

Under Penn Medicine's unit-based clinical leadership model, each unit is fully accountable to the chief medical officer and the chief nursing officer.

"They're rounding together, and there are frequent calibration meetings with those teams," he says. "It truly is looking at not just the process at the unit level but at the sponsorship at the senior leadership level."

Loundas says leadership involvement in the improvement teams emphasized the power of small wins. In other words, thinking of transformation as monolithic can lead to paralysis. It was the senior leaders' job to emphasize that no improvement in the target areas was too small to consider.

"One of the more important things that probably we would factor in as part of the CNO's and CMO's job under this type of organizational structure is being a change manager and inculcating that attitude into the multidisciplinary teams," he says.

Boiled down to its core, the need for such interdisciplinary change management came when senior leadership team members recognized about five years ago that the care of patients has become increasingly complex, and because of that, Penn Medicine needed a more collaborative approach framed initially around transitions in care, Loundas says.

"We added significant framework to have our leadership teams upskill around this work and, more importantly, how you manage a project," he says. "Now things are hardwired into our regular way of doing business. The CMO and CNO work together, and that trickles down to the unit."

Loundas says the collaborative approach has been incorporated into a balance of formal education and day-to-day behavioral expectations around the team, which Loundas helps organize.

"There's constant whitewater in healthcare, and what is really important is my role and how I as a leader manage change," says Loundas, describing the guiding philosophy for the multidisciplinary change management program.

A noble calling
None of this is magic, says Carilion's Agee.

"I personally think people who choose to be in healthcare generally choose it because it's a noble calling, and sometimes we force that out of people instead of nourishing and encouraging why we came to healthcare to begin with," she says. "Finding our way together makes us a lot stronger, and so by a thousand examples, we all come together and are stronger together."

Education plays a role. In addition to the formal structure of team leadership, many leaders are also involved in informal book clubs to help educate themselves about how best to reengineer care with the patient in mind.

Carilion also has a physician leadership academy and an annual leadership conference for the board as well as physician and nonphysician leaders.

"We're disciplined and focused around teamwork and integration," she says. "It starts with the dyad leadership model and is apparent to the whole organization."