The challenges and pay-offs of growing your team and infusing QI at its core 

By Dr. Cole Stanley

Foreword: Here I try to pull together my thoughts on the importance of a team-based care approach in primary care, and what conditions we need for our teams to thrive. I’m learning this with my team as we go, including from mistakes I make along the way. I hope this may serve as a resource for those wanting to set up a team or improve team functioning. I erred on the side of being inclusive so that I could refer people back to a single article later, thus explaining the more comprehensive read (~15min). I’ve added headings so that it may be consumed in bite-sized fashion. I first review why we even need to shift to teams in the first place, and how this isn’t as simple as co-locating people in a workspace. I then highlight the widespread support for this shift from other healthcare professionals and patients’ perspectives. If you are already sold on this idea, then feel free to skip ahead – Next comes the How, where functional and cultural changes are necessary, and embedded QI is central. I then explain what happened when I made a big mistake along the way and conclude by highlighting some of the payoffs when things do start going right.

If you’ve perused any of my previous articles or heard me talk about quality improvement (QI) at all in recent years, you know how much I love to rave about working in my team-based primary care setting. I suspect at times I sound a touch pollyannaish, so today I’ll start by stressing that it’s not all sunshine and lollipops. There are tense moments and stressful days, some uniquely tied to the complexities of working in a growing team. Mistakes are made, feelings get bruised, and sometimes I am to blame.   

On one occasion, my colleague and Medical Director for our clinic called me in for a 1:1 chat. In his caring and gentle way, he led by highlighting some of the unique contributions I brought to the clinic. Though nice to hear, part of me was alerted that I might be in for a compliment sandwich. Then came the meat – two nurses on our team felt that I was being overly critical and judgmental of their work. This stemmed from a few iterations of clinic in which we were trying out some new patient check-in/triage templates and processes. With my QI hat on, I had thought my short discussions with them in between seeing patients were along the lines of “what if we try this”, “how else could we do this”, or sussing out what ideas they had for improving our check-in process. Instead, my comments landed as critical, judgmental, and directive. Not what I was going for! I could start to guess where I had faltered (more on what I was in for later).   

Why the shift to teams? 

We’ve reached the limits of what individual physicians can do to improve healthcare for our populations, and many are overstretched and burning out as they attempt to do this. The amount of knowledge relevant to patient care is ever expanding and far exceeded the capacity of a single individual long ago. And even if we could download this vast wealth of knowledge to one person (or large language model like OpenAI’s GPT-4), we haven’t solved how this translates into meaningful change for patients (see previous article where I discuss the Know-Do gap). Even worse, we could be contributing to burnout as this knowledge feels “locked in”. For instance, I may know the evidence that different housing and increased social connections (decreased loneliness) are likely to improve my patient’s condition, but I feel relatively powerless to change this for them on my own.  

In talks from prominent public health physicians and in books on the matter, I’ve noticed a recurring narrative: they started off in primary care but then switched careers as this sense of powerlessness grew in the face of the most important challenges for their patients (often the social determinants). They then go on to make important findings on what matters in health and healthcare on a population level, and feel they are able to extend their reach with public health initiatives. But here I get a sense that something may have been lost, and wonder about a world where these folks had stuck it out with primary care. Does team-based primary care with embedded QI afford an alternative path? Along with our team, can we measure how we are doing and progressively feel more effective in our efforts to improve our patients’ lives?   

Easy as 1, 2, Team? 

To make breakthrough improvements in healthcare, we need to now turn to a division of the knowledge work, where specialized team members can come together to create a product that is greater than the sum of its parts. This is a hard shift to make given our culture’s focus on individual achievement above all else, where those at the top get to conduct and others simply need to follow instructions. In her book The Extended Mind, Annie Murphy Paul advises that we can extend the reach of our knowledge by thinking in groups, and that the quality of our thinking is improved when it is done out in the open with a team. There are of course pre-requisites to this – team members need to feel safe in voicing their opinions, giving feedback, and asking clarifying questions so that the exercise doesn’t turn into a “follow the leader” groupthink. In essence, there is far greater potential in a team approach, but we need specific methods to unlock this (see Team Exercise Vignette below).  

Team Exercise Vignette: There’s a great teamwork simulation exercise I had a chance to participate in a few years ago that illustrates this well. Imagine you are on a small plane flying back over Northern Canada and you need to make a crash landing on the snowy tundra. Luckily there are no fatalities, but a few passengers suffer some significant cuts and bruises. You and the group of about ten others need to prioritize a list of items to salvage from the wreckage, from most to least useful (eg. matches, water purification tablets, metal pot, etc). In the first stage, you write down your own ranking of the items and get a score based on comparison to an expert consensus ranking. Then you have time to deliberate with your team and come up with a team ranking of the items. The point here is that an effective team should be able to come up with a ranking that scores higher than any individual in the group. This exercise taught me two key lessons– first, it seems that my upbringing in snowy rural Ontario gave me an advantage over my other international team members for this online (mid-COVID) simulation. Second, it’s easy for the group to be swayed by loud voices and fail the exercise without proper facilitation. Debriefing after revealed that we had left many valid rationales for prioritization unheard, including my own. Since then, I’ve paid more attention to facilitating group conversations so that we don’t leave valuable knowledge or perspectives on the table, which often happens for the introverted or more junior team members.  
Studies also indicate that the benefits of a team are challenging to unlock among healthcare professionals. This was the case in a study by Pfeiffer et al of “mixed-status clinical teams”, where each member received partial information on a clinical case and then were to come together to reach a diagnosis. The teams often failed to reach the most accurate diagnosis when only some of the team members were able to contribute their information.

Who’s with us? 

There is growing agreement among physicians that a shift to team-based care is needed, and provincially Patient Medical Homes (PMHs) and Primary Care Networks (PCNs) are in different stages of development. Along with this, other healthcare professionals are eager to join teams and can bring their specialized perspectives. I spoke with NNPBC’s Dr. Eliza Henshaw about this. She’s an excellent NP I’ve had the pleasure of working with, and is now the Executive Director for NP Provincial Initiatives and Programs. She and her team have successfully advocated to get some funded time for NPs to participate or lead QI efforts. She fully agrees that health care quality and provider resilience can be improved with a shift to team-based care and embedded QI, offering these comments:   

“Nurse practitioners are uniquely positioned to contribute to this shift. Nursing theory is grounded in patient centered approaches to delivering care. In addition, nursing education values places tremendous value on the role that the social determinants of health play in contributing to individual and population level health. Poverty and Covid-19 for example have created worsening health inequities across our province. These complex problems can only be addressed at a patient level by high functioning teams with multiple perspectives and skill sets. A steady and relentless commitment to patient centered, team-based care, with a focus on embedded quality improvement as part of the work culture is the only pathway to improved health equity. Nurses and nurse practitioners are eager and ready to step up to the plate to contribute to this important shift.”  

There are also other professions strongly advocating for inclusion in our teams. A prime example of this is recent work by the BC Psychological Association. I caught up with Drs. Simon Elterman and Lesley Lutes as they were touring my team-based care clinic just last week (pictured left to right: me, Dr. Elterman, Dr. Lutes).

Dr. Elterman is a psychologist and behavioural health consultant and has been working with his association to advocate for inclusion of psychologists in primary care networks (their PCPsych Program is currently under review at the Ministry of Health). Dr. Lutes is the head of Public Advocacy for their association, and was recently President of the Canadian Council of Professional Psychology Programs (CCPPP). They both agreed that team-based care is what is needed, but this isn’t as simple as throwing different professions together in a room. We discussed some of the challenges, and the importance of having dedicated time for team reflection and improvement based on data. Dr. Elterman later summed this up as follows:

“The most common and easy way for team-based care to fail is for providers to become siloed. Primary care, with a broad range of presenting concerns, has a fast pace and complex environment for care. This often naturally leads to a slow drift in practice where clinics focus on individual clinicians and burnout recovery (rather than prevention). What happens when teams shift to focus on being a team and improving as a team based on quantifiable data is that overall practice improves. As a psychologist who works in the primary care field, I have seen that teams who spend time on quality improvement tend to provide better services. This is not only by purely data-driven improvements, but because creating these goals cooperatively creates a system that reinforces teamwork and mutual support. We know from decades of research that creating superordinate goals helps teams communicate and improve. Creating higher order goals in addition to data-driven quality improvement to actualize those goals is a recipe for success. By utilizing the whole team to create QI workflows, overall communication improves and team resilience improves as a result. After experiencing this type of team environment, I do not think I would go back to working at a clinic that does not weave quality improvement and team building practices into the fabric of the clinic culture and workflow.”

Patients are also accepting (and likely expecting) this transition to team-based care. A 2022 online survey of over 9000 Canadians (Our Care) showed that most respondents were comfortable with receiving care from other team members besides their primary provider.

More than just a group of individuals

So in sum, there is broad support for this shift towards team-based care, and we’re learning about some of the challenges as we go along. At the core, shifting to team-based care means that the physician’s workday can look starkly different than before, and requires a fundamental shift in mindset. In his book The Power of Teamwork, Canadian physician and radio host Dr. Brian Goldman reminds us that “A group of individuals is not a team”. We can find many examples of this in healthcare, where different professions are co-located and appear to be a team on paper, but their day-to-day work remains siloed. Many of these on-paper groups meet very rarely if at all, making it almost impossible to satisfy this definition Dr. Goldman provides:

“To be a team, these individuals must be interdependent in terms of knowledge, abilities, and the materials they work with. And they must work together to achieve a shared goal.”

I’m reminded of a W. Edwards Deming’s quote here: “Eighty-five percent of the reasons for failure are deficiencies in the systems and process rather than the employee”. We need to apply this principle and set up the right system and processes for our team to come together and grow (writing down a list of names, putting those people in the same building, and calling them a “team” is NOT enough). Leaders have tough decisions to make here, as it usually means pulling the team members back from direct patient care and affording dedicated protected time to meet and develop together, ideally as a continuous process. I personally like the 80% “do the work”, 20% “improve the work” heuristic, though in true QI fashion I advise starting small.

Setting the stage for your team

So what’s important to consider in setting all this up? Singer et al looked at these processes in a 2019 mixed methods study on effective transition to team-based care, and broke these down in Table 2 below. This can serve as a checklist for those setting up or growing a team. They looked at 12 different teams participating in a learning collaborative to set up team-based care and found that high-performing teams needed both functional and cultural change.

Table 2 (adapted from Singer et al): Functional and Cultural Change Processes Characteristic of Practices’ Approach to Transformation, by Domain of Change

Domain of Change Functional change process Cultural change processes
Team formation Role revision: Formalized reallocation of tasks and responsibilities

Team time: Shared time (huddles) and/or space (team sits together) to work as a team.
Access to clinical data: Electronic records give all team members access to patient records and ability to take action.

Sharing authority: Devolve and share power, dialogue and two-way feedback.

Staff engagement: Communicate transformation plans and encourage staff participation from the start.

Physician leadership: As highest status personnel, unique role in modeling egalitarian behavior and tackling resistant peers

Capacity for continuous improvement Improvement skills: Training, for example, Plan-Do-Study-Act, which enable staff to undertake improvement activities.

Meeting structures: Systematic communication from teams to practice leaders and vice-versa.

Data collection capacity: Mechanisms for tracking progress towards goals, for example, clinical registries.

Openness to experimentation: people seek out opportunities to test ideas, comfort with a state of continual change.

Willingness to fail: View failures as learning experiences rather than threats.

Data as a valued tool: Feedback is sought out and viewed as a tool of empowerment rather than a mechanism for punishment.

Here are several relevant observations emerging from this paper:

On cultural and functional change:

  • Prioritization of both change types in team formation and improvement capacity building engendered a virtuous cycle: both were necessary ingredients for successfully creating effective team-based care.

On task sharing and “role blurring”

  • This task-shifting relieved some of the burden on physicians and felt rewarding to nonphysicians, contributing to a culture of mutual regard and respect, which in turn reinforced confidence in, and reduced discomfort with, the redistribution of tasks and responsibilities.
  • Giving nonphysician team members greater responsibility for certain elements of patient care (e.g., routine screenings, between visit calls, introduction as “your” nurse) created opportunities for more staff to form meaningful relationships with patients.

I’ve seen the benefits of this first-hand in our clinic. As an example, our peer support workers primarily handle text appointment reminders for clients, but other team members are there to help out as back-up, thus ensuring this improvement that’s greatly helped with client engagement is reliably completed. This affords more team members direct contact with clients, and we’ve been able to celebrate our data demonstrating sustained reductions in client disengagement rates.

And with respect to data

  • Data became a tool that enabled individuals and teams to make sense of their work and practice environment, visualizing successes, and locating barriers.
  • More perniciously, when cultural change processes were overlooked, practices were more likely to view data with suspicion—it was perceived as a threat rather than helpful feedback.
  • To use data constructively, functional changes need to be supported by cultural changes that enable data to be understood as a tool facilitating experimentation and learning, sometimes through failure.

These ideas of needing a trusting environment and of using data primarily as a tool for improvement are central to what we do at HDC, and we’ve shared several examples of our data being used to visualize successes through our Bright Spots articles, with more to come.

A key ingredient: embedded team-based QI

Let’s talk about the centrality of embedded QI in all of this. This is widely recognized as a building block for effective primary care, and so needs to be embedded in the regular work of the team- a principle central to recommendations coming from the National Academies 2021 document: Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. In addition to improving quality of care for patients, as Dr. Elterman alluded to above, regular quality improvement can provide lasting effects on team performance across a wide range of dimensions (BMJ Open Quality article). Teams participating in QI Collaboratives also experience lasting benefits on team functioning (BMJ Open Quality article). Here’s a couple observations from the teams who had dedicated time to do QI:

  • Some practices cited more effective communication channels within their practices, incorporating regular team meetings, as a positive outcome of the [Australian Primary Care Collaboratives] program.GP007. “Previously, we had one, between one and four (meetings) a year, after Collaboratives we had more. Since last year we have them fortnightly”. (Brown et al 20)
  • A common narrative was that QIC [QI collaborative] participation helped team members to get to know each other. Better understanding of each other’s roles led to increased trust. This empowered different members, including non-clinical staff, to work to their scope, develop as leaders and take on redistributed tasks.

All of this makes me think that team-based QI needs to be the primary mechanism for building our teams. If we think back to the definition of the team above, this fits well. In QI, we sit together and come up with a shared purpose (improvement goal), then share resources and work together. This will take significant effort and investment, as many of us will need to learn new ways of working together. We’ll need dedicated time together as a team with proper QI training and facilitation, and we’ll need to get comfortable making mistakes (as I have) along the way.

Learning from mistakes

Concerning that mistake I told you about at the start of this article, I’m thankful that the nurses felt comfortable meeting with me to debrief. Following my apology for coming off this way, we had what I’d call a learning conversation, where we homed in on the root of the problem. I’d assumed that our conversations were taking a QI lens and that we were working in a non-hierarchical team, whereas from their perspective there was still a sense that I was “the boss” and that my suggestions were directions, things they needed to do despite some of the demands being unreasonable. I assured them that I felt that I did not know “the right answers”, and instead wanted to bounce ideas off them and hear their own unique perspectives about how to improve as a team. We talked about how this is not the norm in our medical system, where nurses are explicitly and implicitly ordered to do things by physicians, and there is often fear of blaming and shaming if things go awry. We agreed that this was not the type of system we wanted to work in at our clinic, and that we needed to have a team discussion about our approach.

Since that time, I’ve tried to be more mindful about framing discussions with a QI lens before I launch into sharing what is sometimes a flurry of ideas (many of them bad ones, surely). As a team, we’ve also been more intentional about discussing and documenting some of the basics of how we work together (I plan to share more about these “team agreements” in future writings). We make more of an effort to not forget the “cultural change processes” like “sharing of authority” and “willingness to fail”. We make more of an effort to get new hires up to speed, especially where our team approach differs significantly from the norm.

The payoffs

All these extra efforts to change and grow as a team really pay off. A high-functioning team who works together on shared QI goals yields more resilience, social connection, and I would just say it’s just much more fun. I like to think that by allowing time for things like QI and for the team to check in with each other at the start of each day (often with a random check-in question on an endless variety of topics – from favourite TV shows to ideal superhero traits to worst musical genres and so on), and by saving a few minutes at the end of the day to discuss Team Wins and Improvements, we create a system in which trust and social connection can flourish.

I like to think I am seeing evidence of this (exhibit A pictured below from our recent team trip to Pender Island). Here’s a partial menu of some of the wide range of activities team members are doing together outside of work hours: trivia nights, book club, hockey games, drag shows, The Sun Run, and an aerobic boxing workout with the alluring motto “where fight club meets nightclub”. The Good Life, a book about Harvard’s longest running study states that a significant contributor to happiness and well-being in life is dictated by having close relationships with those you work with. We can embed QI and design our team processes to make this easier to attain, and at the same time expect that happier team members will deliver higher quality care as a result.

Photo: “Now do a wacky one” – some of our Hope to Health clinic team on route to our Pender Island weekend retreat (May 2023)

Are you interested in learning more about team-based care, data-driven improvement, or how HDC Discover has been used by teams to improve care? There are several provincial resources that can help you and your team on a journey to high functioning with embedded QI. At HDC, we’re happy to help you navigate this challenge, so please contact us here.

And check out these resources:

Practice Support Program

Physician Quality Improvement

Health Quality BC – Team-Based Care BC