Challenges at the Intersection of Team-Based and Patient-Centered
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Insights From an IOM Working Group
Matthew K. Wynia, MD, MPH
Isabelle Von Kohorn, MD, PhD
Pamela H. Mitchell, PhD, RN
EAM-BASED HEALTH CARE MAY HELP THE UNITED STATES
achieve improved health and improved health care at asustainablecost.1 Itiscentraltomanyreformsofhealth care delivery, both actual and proposed. Team-based care can occur in many settings (eg, home, office, hospital); focus on different problems (eg, specific diseases); and include team members with a variety of backgrounds. Health care teams can be large or small, centralized or dispersed, virtual or faceto-face, and their tasks can be focused and brief or broad and lengthy. This extreme heterogeneity in tasks, foci, and settings presents a challenge to defining optimal team-based health care.
Recently, we led a working group—a team comprising a patient advocate, physician, registered nurse, physician assistant, social worker, and pharmacist—convened by the Institute of
care. The background work included structured discussions with high-functioning teams from a variety of settings, which revealed that such teams are guided by a set of shared principles and values that can be measured, compared, learned, and replicated (BOX).2
These principles and values are seemingly straightforward.
But considering the realities of implementation and spread of team-based care aligned with these principles and values raised difficult issues—3 of which deserve focused attention.
Patients on the Team
In high-functioning health care teams, patients are members of the team; not simply objects of the team’s attention; they are the reason the team exists and the drivers of all that happens.
The much-repeated phrase “nothing about me without me”4 conveys a powerful image of patients actively involved in care decisions. In team-based care, fulfilling this promise means integratingpatients,families,andcaregiversintohealthcareteams.
Having patients as members of teams is more than a shift in framing. One of the 5 principles of team-based care is that being clear about each team member’s role is critical. If patients are on teams, what, precisely, are their roles and those of their family members or caregivers? Although metaphors from sports
Author Audio Interview available at www.jama.com.
are used to describe team-based care, they are generally unhelpful. Is the patient the quarterback? The coach? What if a team has a different quarterback or coach every 15 minutes? How wouldthisvaryaccordingtotheteam’sparticularstructuresince, for example, teams for patients receiving surgical care vs primary care are dramatically different? Certainly, the role of patients on teams will vary with the focus of the activity.
Because many different patients and families interact with different sets of clinicians each day, team members must continually adapt as they form and reform teams. In addition, highfunctioning teams create, maintain, improve, and adapt formal and informal rules and customs over time. For patients entering such a team, there must be structured processes to both introduceandrefinetheroles,expectations,andnormsoftheteam to meet the patient’s needs. High-functioning teams also communicate well; effective communication requires transparency and a common language. Thus, integrating patients and families into teams requires consistent use of plain language, methods to ensure understanding,5 and systems that provide open access to information. Perhaps new metaphors are needed that look beyond competitive sports to describe teams with patient members. One possibility is an orchestra with individual patients as soloists, entering, leaving, and making unique contributions, always supported by the larger ensemble.6
Accountability and Flexibility on Teams
Providing patient-centered care in teams raises operational