Care Teams and Workforce Guide

Building capacity for quality improvement into the team through a quality improvement lead and quality data analyst as outlined in Care Team and Workforce Guide Resource 1: Core and Expanded Care Team Functions, Team Members and Roles enables your organization to be ready to take on the work of improving patient-centered population-based care.

1. Recognize care team expertise to identify and solve problems.

The core and expanded primary care teams are the heart of population health management. In partnership with patients, care teams create health through compassionate clinical interactions. Each day, the team sees what is working for them and for patients. As such, they have a unique and powerful perspective for understanding what can be improved and how to improve it. Too often, health systems rely on centralized quality improvement infrastructure with little relationship to the care teams who identify and address operational, clinical or questions related to patient experience. As care teams become established, clarify their roles and workflows, and build trust and communication among one another, they can also start to play a key role in clinical quality improvement.

2. Create a structure, including a time to meet, to optimize team performance and address patients’ needs.

Start by identifying which members of the care team will be regularly engaged in the quality improvement (QI) team. Though everyone has a role to play, identifying representatives from different roles to participate on a defined QI team with regular meeting times and activities can help keep momentum going. Participants on the QI team may attend meetings based on which improvement activities you are undertaking, or may rotate over time. The clinical quality lead and data analyst for the expanded care team will be important roles, as will providers, nurses, front desk staff and others who have interest and ideas in improving operational and clinical activities.

Define shared goals and aims.

When teams define their own clinical improvement goals and aims they are taking the first steps in improving patient health and bolstering their own feelings of agency and empowerment along the way. No matter how high-performing, practices always have an opportunity to improve. Reviewing the metrics described in the Data Quality and Reporting Guide is a good place to start for ideas. Getting crisp by defining specific, measurable, actionable, reasonable and time-bound goals can clarify team priorities and cultivate buy-in.

Try small tests of change.

The QI team may suggest plan-do-study-act (PDSA) cycles, which involve developing an idea of something to improve, testing a new way of working for a few days with a few patients, collecting data and reflecting on the results, and then modifying actions as necessary. Once several PDSA cycles have been run, you will have a good sense for if and how a larger scale implementation would work in your site. When you’re ready, convene the whole team for staff training when implementing major workflow or protocol changes.

Engage often in training and educational opportunities.

Ideas for improvement may come from the QI team, but they can also bubble up from many other sources. Educational material is provided frequently through conferences, live or virtual training, and via learning collaboratives. As staff learn and try new skills, try these approaches to spreading best practices.

• Have one staff member who attends a conference or webinar report back and teach the materials to others.
• Have staff spend a half-day “shadowing” their counterparts at clinics that have successfully adopted specific team-based population health management practices.
• Create opportunities for regular cross-training of staff in standardized protocols and workflow processes across related job roles to ensure consistent provision of care and thorough documentation.

Use data to regularly assess team progress and performance.

Regularly evaluate team progress and look for opportunities for improvement. Clinical data is a great place to start, and teams can also reflect on patient, provider and staff experience data to generate new ideas to try.

Celebrate your successes by sharing learning with other care teams across the organization and at other practices. If you find something that works, share widely!

• Post run charts and other summaries of performance in a shared area for all staff to review.
• Present at an all-staff meeting at the practice, or in the quality committee across a multisite organization.
• Share at regional or statewide learning collaboratives.