Collaboration and Teamwork Between Program Roles and Individuals
Teamwork at El Rio: Formal and Informal
Teamwork was described as both formal and informal in the PBDMP at El Rio.
Formal teamwork (e.g. CPAs) was described as containing a structured team created for a specific purpose. The formal working relationships identified by the upper level
management, were defined by job description and patient care coordination. Informal teamwork (e.g. informal check-ins about individual patients and their needs) did not include a set structure and tasks were interoperable between staff members. Informal teamwork described communication between employees of the PBDMP and the
relational coordination between work practices.
Formal Teamwork
At the PBDMP, formal teamwork was identified in the CPA signed by the participating physicians, pharmacists and clinical team members. The CPA outlined the formal working agreement behind the program and specific function of the clinical pharmacist. Setting a CPA for structured work outlined the working relationships between key PBDMP staff members. Clinical pharmacists’ patient care services, including those provided through CPAs, can reduce fragmentation of care and improve health outcomes.(59) Moreover, job descriptions and divisions of labor regarding patient care were identified in work contracts and departmental agreements within El Rio. The CDTM was pre-identified by El Rio leadership before hiring a team of clinical
pharmacists. Importantly, all participating clinicians contributed to the CDTM model before implementation. El Rio management tailored the CPAs and CDTM model to foster an environment of collaborative and functional teamwork under the auspices of mutual agreed upon contracts.
Formal teamwork was most articulately described in the brainstorming group diagrams as “cycles of care coordination.” For example, teamwork was noted as the set of “cycles” taken by a patient as they progressed through the different areas of the
PBDMP. An example cycle of care was described in the data: after a patient was seen by the pharmacist, the patient entered into a state of care with referrals to specialists, the primary care physician, and then back to the pharmacist. This formal cycle of teamwork identified in detail in the Pharmacist Group 3 Map, addressed the needs of the patient at
all stages of care identified the coordination necessary for program success. This formal cycle of care was developed over time and through active reflection in the PBDMP through direct oversight by the El Rio Program Director. The PBDMP arrived at the current structure after a series of trials and changes to the program’s teamwork structure.
Another example of this formal cyclic care was described in the Pharmacist Group 1 process map, described in detail in Appendix D. As presented in the diagram, the medical assistants checked the patient’s blood sugar levels, took vitals, completed a foot exam, and then sent the patient to the primary care provider. The primary care provider then sent the patient back to the pharmacist or to other clinical referrals leading the patient back into the program cycle. While each brainstorming session perceived the order of the teamwork process steps somewhat differently, the formal work cycles remained consistent. Data presented in the key informant interviews described how this type of patient hand-off and teamwork directly correlated to improved patient outcomes in the PBDMP.
Interviewee 2 from the Tucson, Arizona ACO described the importance of formal teamwork during the key informant interview, “care coordination is either an embedded component, like at El Rio for example, has embedded care coordinators [sic] they hire their own people to help identify high-risk people. Folks that are either at high risk for readmission, or admission in the first place, we can also call people on, you know, train wrecks, people that you know that something’s going to happen.” Interviewee 2 pointed out the utility of the formal job descriptions that the El Rio leadership had created—
Registered Nurse Care Coordinators (RNCC)s—specifically for patient continuity and
team coordination. This foresight on the part of El Rio to identify a need within the PBDMP directly addressing coordination and teamwork was notable.
The Administrative Group RCA diagram described the formal teamwork of CPAs during the brainstorming session. The group noted that the “pharmacist-inclusive
practice: CPAs” was a success of the PBDMP. This recognition of the existence of CPAs within the structure of the program pointed to both the leadership’s deep knowledge of the inner workings of the program, but also to the success of the formal CPAs
themselves.
Informal Teamwork
Formal teamwork identified each individual team members’ role and function. In contrast, informal teamwork was not formulated or codified by clinic leadership. The ways that employees related to each other informally to understand each other’s skills was reflected in multiple data sources. The key informal teamwork practices included team communication and affiliation to identify the best individuals for a specific task.
Allowing health care providers to interpret details of the CPA to best fit the group dynamic was also an important feature of informal teamwork at the PBDMP.(59)
The Program Director of the UNC program described this informal understanding between pharmacists and physicians, “I think our physicians have always felt like we have functioned very much as a team, so, we’re helping. They recognize us as part of that team and they recognize how we can contribute to the goals of an ACO and so we’re very team-based. And, so if the patient is seeing me and I can address some of those issues then I should be held accountable to try to meet some of those while the physician
if they are meeting with the patient then they should be responsible.” This collaboration surpassed typical clinical roles and expectations by arriving at a place of mutual respect between physicians and pharmacists. In many cases, identifying a team leader at the outpatient clinical pharmacy programs was a simple process due to the small number of team members and division of labor. Data showed that delineating formal team
responsibilities was identified upon team formation, and informal working relationships developed over time.
The UNC Program Director identified coordinated care through informal
teamwork as the preferred model for outpatient clinical pharmacy, “I think that’s the best model—to have coordinated care. Because everybody brings their strength to the table.”
The Clinical Group RCA diagram described “communication and affiliation” as a success of the PBDMP reflecting this coordination of care between employees. In addition, the Pharmacist Group RCA diagram specified “team-approach” and “group dynamic” as a success of program delivery. This group dynamic was reflected in the group’s
identification of the fact that “everyone is included in different projects.” During the brainstorming sessions, these self-identified groups and affiliations were described as informal teamwork, pointing to the importance of program communication to achieve a common goal.
While the data described the positive attributes informal team dynamics brought to the PBDMP, there were barriers identified relating to program consistency and
expectations between employees. The Pharmacist Group RCA diagram reflected both the necessity for better provider-to-provider communication as well as patient to provider
communication. The data reflected that the need for “more communication between providers.” The lack of this communication between providers described a potential breakdown in some team communication.
Culture of Teamwork
Creating a team-driven environment with mutual understanding took time for the outpatient clinical pharmacy programs. The Program Director at MHC reflected on the struggle to create shared work practices between clinicians, “For us, I really believe it is still really a work in progress. We’re always talking about it in senior staff meetings.
We talk about it between me and my medical director and other providers. And, part of my goal, I’m not getting ahead of myself, is the development of our clinical pharmacy practice to coincide with the medical group so that we can work as a cohesive unit—
pharmacy to medical and back and forth and share the same stories and report data that we collect in pharmacy back to medical through our EMR system. So, it’s still in development. There’s a lot more to put together.” The goal to achieve collective work between practitioners at MHC showed a desire for a culture of teamwork and
cooperation.
Work culture as it related to teamwork was described by a respondent from the Tucson, Arizona ACO as fiefdoms, “But, medicine tends to be a bunch of tribes. And, so if they practice tribal medicine, in isolation, what I call—a consensus of one—then that isn’t going to work.” The ACO Interviewee 2 noted the importance of teamwork, both formal and informal, since a consensus of one does not create the best patient outcomes.
The respondent continued to describe the types of work cultures present within a clinic
and how teamwork reflected the organization’s attitude toward inclusion, “This is all important when it comes to team-care. And, so, I think El Rio does [team-care] so don’t be afraid to interview or start to interview all the members of a team because I think you miss some of the sub-culture stuff that goes on there.” These fiefdoms were not as present in the key informant interview with the Program Director at UNC, “…and it [the UNC program] really is to enhance the care of patients in a team-based approach. So, we’re not here to take the care away from the physicians, we’re here to augment that care.” The augmentation rather than the replacement of care was a common theme throughout the interviews with outpatient clinical pharmacy programs.
Clear communication leading to positive teamwork was discussed in multiple brainstorming sessions. The data pointed to bilingualism as a key element of teamwork throughout the brainstorming sessions. Importantly, lack of complete bilingualism among staff members could hinder patient visits.
The presence of bilingual staff who could communicate with Spanish-speaking patients was highlighted as a strong and positive characteristic of the employees in the PBDMP. The independent characteristic of bilingualism itself did not lead to successful teamwork, but the clear communication between patients and providers and also from providers to other providers led to better teamwork. However, the lack of bilingual staff was also specified as a barrier to program success in the Clinical Group’s and
Administrative Group’s RCA Diagrams. While a number of reasons could lead to this dissonance in the data, it is noteworthy that the vast majority of the PBDMP staff was bilingual.
Conclusion
Teamwork took two main forms informal and formal in the PBDMP and other outpatient clinical pharmacy programs. Cohesive health care teams not only have clear and measurable outcomes, but also have successful division of labor and effective communication.(52) The El Rio leadership created the PBDMP with clinical teams and measurable goals. Together, the formal and informal teams created by BDMP leadership contributed to the success of the program. The communication between team members supported collaboration and positive patient health outcomes. Teamwork was repeatedly cited as the backbone of the program structure which directly led to the successful implementation of the PBDMP and the other outpatient clinical pharmacy programs.