The article in this issue by Benjamin Crabtree, PhD, and his colleagues points out a basic flaw in the organizational structure of many family medicine offices: the “dual organization,” with the clinical staff and support staff operating separately. Many practices could be characterized as having immature organizational structures and lacking a professional approach to the management of their finances, their personnel and their clinical quality. What these authors describe is simply a lack of optimal team functioning. Without teamwork, transformational change in office practice and patient outcomes will not occur.

I understand the importance of optimal team functioning firsthand, from a patient perspective. Two years ago, while speaking at a conference in Chicago, I began to feel flushed and nauseous, and I felt a dull pain in my left arm. Despite knowing better, I finished my talk before asking a colleague to take me to the hospital. In the emergency department, I described my symptoms to the clerk at the front desk, and he immediately picked up the phone, uttering only the words “chest pain.” Within seconds, a clinical team had responded and was ready to administer an EKG. When the results indicated the need for angioplasty, the team escorted me to the elevator, where one of the nurses took a key out of his pocket, inserted it into the slot and caused an elevator to be immediately available. I was taken directly to the cath lab, where the team was assembled and the cardiologist was waiting to perform the procedure. The time from check-in to angioplasty was just 34 minutes.

Clearly, someone had invested time in assembling this medical team. There was never discussion about what to do next. Everyone knew the process to follow. Everyone knew their role. And everyone knew who else to involve. In the end, my gratitude went to all the team members rather than just to the physician alone.

The habits of effective teams

Team development is an important early step for both clinical care and quality improvement work. High-functioning teams develop healthy habits of regular communication, agreement on an action plan and a collective approach to problem solving. There is no substitute for brief regular meetings where dialogue centers on how to deliver safe, reliable and consistent care. Getting to know other team members and their capabilities requires regular interaction and two-way communication. Discussions about roles, responsibilities, hand-offs and what to do in an unusual situation help to clarify expectations for all. These understandings also serve as a foundation for team accountability and a collective sense of responsibility for patient care.

Physicians, because of their education and the high value that has been placed on autonomy in medicine, often have to work hard at being good team players. Physician behaviors that model respect for others and acknowledge the important contribution of each team member are critical to success. Members of the best teams are constantly seeking ways to streamline the work by understanding the needs and capabilities of each other. Indeed, it is the quality of the interactions between team members that defines high-performing teams, not the presence of a star player.

What's in it for me?

This is certainly a legitimate question. Most of the family physicians and office personnel I talk to are feeling overworked and underappreciated and don't think they have time to build more effective teams or make other improvements. The reasons for this are multifactorial, and many involve payers or regulators: however, we should focus on the things we can do something about on the local level. Although it is easier to blame the outside environment for our problems, probably 80 percent of the reasons why we feel drained at the end of the day are related to inefficient office systems and processes that do not support the work we are expected to accomplish. Process mapping and a systematic look at how things are done in our practices will a long way toward relieving the daily stress for all.

Chronic disease management is a great example of an opportunity for improvement. Having a disease registry is essential for the optimal care of such conditions as diabetes and coronary artery disease. Knowing who has the condition allows the care team to manage these patients proactively and help them get what they need when they need it Managing the registry does not require a new employee or additional responsibilities for the physician alone. The care becomes a team responsibility in which each player has a specific role. Checklists, flow sheets and data collection are all part of this effort and serve to provide the physician with all the information he or she needs for the face-to-face encounter with the patient. Information is automatically recorded for quality improvement work and for programs such as the Physician Quality Reporting Initiative.

The most important result of great teamwork is better patient care with better patient satisfaction. The most satisfying result will be the positive work environment that develops. Working together is working smarter.