A great way to flounder or fail in system change is to avoid relationship development between team members. When we examine efforts to integrate collaborative designs, relationship development is often given short shrift or completely overlooked. For example, the recently published initial evaluation results from the medical home National Demonstration Project found team function suffered (Nutting et al, Ann Fam Med 2009;7:254-260). One way to build teamwork is to use direct observation of day-to-day practice. I have been experimenting with this strategy for 15 years and below I will share some experiences.
Since we began the mental health internship in collaborative care within our Family Medicine Residency in 1996, the first month for the new intern is spent shadowing residents and faculty. Observing helps the intern learn about the challenges of family practice and it spawns many new relationships. Our residents and medical students observe one another regularly as well.
In 1998 I was invited to spend a year training providers, serving patients and designing a system of care in an indigent primary care clinic. During the first half of the year I regularly observed the primary care providers, teaching them interview and primary care psychotherapy skills and forming relationships. My behavioral health practice grew rapidly. A few years before I arrived a local agency had placed a counselor in the clinic. Six months later the counselor was withdrawn due to lack of referrals despite being in a clinic where 50% of the patients had one or more mental disorders. Looking back, it appears that little was done to create relationships with this new team member.
In my work with health care organizations to train primary care teams to be more efficient and effective in communication with patients, a standard portion of training is peer observation. When the lack of team coordination between medical assistants and physicians became a common theme, I began asking physicians how often they had observed their medical assistants or if medical assistants had observed them. The answer was almost always the same—team observation had never occurred. I began having these dyads observe one another and discuss how to increase the quality and efficiency of patient flow. These primary care dyads or “teamlets” (see Bodenheimer, Ann Fam Med, 2007, 5:547-461) immediately began dissecting day-to-day processes to improve systems of care.
Collaboration is hard won without adequate relationship development. One way of forming relationships is to curiously watch each other provide patient care. It takes time. Trainees need to be sensitive to how feedback is delivered and remember that watching someone else promotes observation of one’s self.
Many of you have other strategies to promote team development or perhaps use similar approaches. What experiences have you had where team development went really well or stumbled?
