18 August 2017
Dr Ayman Shenouda
Most will agree that high quality care in general practice relies on effective teamwork. There are some good studies providing insights into the key features of effective primary health care teams confirming a strong correlation between a good team climate within the practice and a range of aspects of high quality care. [i] A stronger focus on research within general practice, in my view, would provide more quantitative studies detailing the effects of integrated multidisciplinary teams from within the practice setting for differing health populations and geographic regions.
From a broader health system perspective, there is currently strong interest on the efficiencies of multidisciplinary teams and their effectiveness in improving health outcomes and lowering costs. The role of the team in supporting integration between services and in enabling a shift from episodic to continuous care at a whole of system level. Driving this interest is also the need to develop new models of care in addressing increased demands associated with an ageing population and as the disease burden increases.
The multidisciplinary team is best defined by Cohen and Bailey (1997) as ‘a collection of individuals who are independent in their tasks, who share responsibility for outcomes, who see themselves and who are seen by others as an intact social entity embedded in one or more larger social systems and who manage their relationships across organisational boundaries’.[ii] Therefore, ‘teamwork’, in this context, is the product of interactions between healthcare professionals in a team.[iii]
Teamwork starts at the practice level
My focus here is in establishing structures to support effective team interactions within your own practice first, providing ways to evaluate or measure success, which can then build toward broader integration aims.
In measuring practice-level performance, teamwork in the primary care setting is often determined through a focus on a specific disease area such as effectiveness in terms of management of chronic diseases. Organisational capacity within general practice can also be tested through quality improvement measures such as through clinical audit.[iv] In my experience, clinical audit provides an effective way to measure the effectiveness of multidisciplinary teams in a value driven hole practice approach that aims to deliver quality patient care with clear achievable outcomes. Its participatory structure also allows you to ensure involvement from the full team in finding practical solutions.
We know a much broader funding focus is required in terms of driving more effective ways to manage the increased complexities and costs associated with the new patient norm of multiple comorbidities and chronic diseases. Structural and system supports are required to enable coordination and collaboration across boundaries – primary, secondary and tertiary care. In order to truly tackle and address fragmentation and achieve a more seamless service for patients throughout their disease trajectory much more focus is required on ensuring the required supports at the practice level.
Effective team characteristics
Collaborative teamwork provides a link between efficient organisational practice and high-quality patient care.[v] A large cross-sectional study of Australian general practices undertaken in 2007 showed that team climate was important for patient and staff satisfaction. Interestingly, this study also found that in terms of large general practices, that separate sub-cultures may exist between administrative and clinical staff, which has implications for designing effective team interventions.[vi]
But how much do we know around the qualitative aspects of what makes for a well-functioning multidisciplinary team in the practice setting?
One key study identified 10 characteristics underpinning effective interdisciplinary team work which is useful in terms of guiding a practice redesign. [vii]
The 10 underlying characteristics of an effective team.
I agree that all these aspects are important to a well-designed and high functioning team. From my own practice perspective, I would attribute the most reliant performance factors around good practice governance and business management systems including clinical information systems in supporting integration. But a great deal of focus for us also lies in providing a supportive team environment and in strengthening the capacity of the team.
Role utilisation and supports
A practice can make a significant difference for its patient population by using the team to their full capacity. Greater use of the primary care practice nurse through nurse-led clinics has provided significant benefits in my own practices. Our nurse-led diabetes clinic is proving very effective in delivering this care. As are our COPD and other chronic disease nurse-led clinics through offering enhanced patient management of chronic and complex conditions by helping patients in managing their conditions.
Nurse-led clinics not only lead to improved health care but can lead to patient empowerment as well as nurse empowerment. These models do not impact on continuity of care and instead provide a sustainable practice model enabling constant monitoring and management. Time intensive tasks such as data extraction, data management and patient recall systems in coordinating aspects of care are just a few examples which can be shared across the team.
Exposure to the full workings of the multidisciplinary team can enhance the training experience for the medical student, prevocational doctor or registrar in the general practice environment. A culture of teamwork needs to be instilled early and can only enhance the learning experience for the trainee. They need to be immersed in this structure and fully exposed to the workings of the multidisciplinary team. It helps to improve their understanding of others’ roles and builds respect and understanding.
Broader benefits for the entire patient population are achieved through stronger utilisation of the full practice team. Time efficiencies and cost benefits can be realised through increased throughput of patients. Patient booking can be made for both doctor and nurse, each with their own specific caseload and role but with a shared focus on enhanced patient care. The GP can then be better utilised in their specialist capacity to focus their expertise on more complex areas of care.
Primary care service delivery models that optimise the performance of the full multidisciplinary team should underpin future funding decisions. This is a key requirement to shifting care to the more cost-effective sector of primary care and out of hospitals. Increased costs in addressing demand must be met through flexible funding solutions to help meet the additional cost burden for private practices. The effective use of skills to optimise the full practice team is key to providing patient centred collaborative care but the funding must now follow.
[i] Campbell S M, Hann M, Hacker J, Burns C, Oliver D, Thapar A et al. Identifying predictors of high quality care in English general practice: observational study BMJ 2001; 323 :784
[ii] Cohen, SG and Bailey, DR (1997). What makes teams work: group effectiveness research from the shop floor to the executive suite. Journal of Management 23: 238–90, DOI: https://doi.org/10.1177/014920639702300303
[iii] Van Dijk-de Vries AN, Duimel-Peeters IGP, Muris JW, Wesseling GJ, Beusmans GHMI, Vrijhoef HJ. Effectiveness of Teamwork in an Integrated Care Setting for Patients with COPD: Development and Testing of a Self-Evaluation Instrument for Interprofessional Teams. International Journal of Integrated Care. 2016;16(1):9. DOI: http://doi.org/10.5334/ijic.2454
[iv] Amoroso C, Proudfoot J, Bubner T, Swan E, Espinel P, Barton C et al. Quality improvement activities associated with organisational capacity in general practice. Australian Family Physician Vol. 36, No. 1/2, January/February 2007 8-84.
[v] Mickan S, Rodger S. The organisational context for teamwork: comparing health care and business literature. Aust Health Rev 2000;23:179–92.
[vi] Proudfoot J, Jayasinghe UW, Holton C, Grimm J, Bubner T, Amoroso C, Beilby J, Harris MF. Team climate for innovation: what difference does it make in general practice? International Journal for Quality Health Care. 2007 Jun;19(3):164-9. Epub 2007 Mar 2.
[vii] Nancarrow SA, Booth A, Ariss S, Smith T, Enderby P, Roots A. Ten principles of good interdisciplinary team work. Human Resources for Health. 2013;11:19. doi:10.1186/1478-4491-11-19.
[viii] Nancarrow SA, Booth A, Ariss S, Smith T, Enderby P, Roots A. Ten principles of good interdisciplinary team work. Human Resources for Health. 2013;11:19. doi:10.1186/1478-4491-11-19.
Dr Ayman Shenouda