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How can administrators bring together physicians, advanced practitioners, and nurses, and create a culture of collaboration?
Team-based care has been linked to better access, higher patient satisfaction, and improved chronic care management. But it also opens the door to turf wars and friction - particularly among physicians and advanced practitioners who work together in the exam room. To keep care teams on task and preempt potential conflict, effective leadership is a must.
"The administrator is truly the kingpin of the practice," says Katrina Slavey, network executive for The Halley Consulting Group, a practice management consulting firm in Westerville, Ohio. "It's their job to create partnerships, not only between the physicians and providers, but with the entire staff. Synergy allows the practice to deliver the best possible care."
As practices transition to team-based delivery models, she says, either as a Patient-Centered Medical Home or Accountable Care Organization, the administrator, more than ever, must cultivate a collaborative culture, hold providers accountable, and communicate effectively with the staff.
The probability that providers will overstep their bounds, or under deliver, is drastically higher when roles are undefined. Such missteps fuel resentment and lower productivity. As such, every member of the care team must be crystal clear on what their job responsibilities entail. "It's amazing to see how many advanced providers, when put on a care team, aren't really sure what their roles are," says Elizabeth Woodcock, a practice management consultant with Atlanta-based Woodcock & Associates.
Job descriptions, she said, should include a detailed description of scope of service, some of which will depend on state guidelines. Physician assistants (PAs), for example, must practice medicine under the direct supervision of a physician, while nurse practitioners (NPs) may practice independently in 21 states, plus the District of Columbia. The remaining states restrict NP autonomy in some capacity.
That said, every care team is different. Some physicians want their advanced practitioners to copy them on every email to patients. Others want PAs to inform them of referrals for emergent patients only, or review their NP's responses when a patient calls in with a clinical query. Physicians and administrators should work together to clarify expectations, says Woodcock.
Likewise, office managers and administrators must hold every team member accountable for meeting quality and safety goals, including clinicians, and redirect those who perform tasks outside their defined job responsibilities, says Woodcock. Such dialogue should be viewed as a learning opportunity, not a slap on the wrist. By explaining how each role contributes to the mission of better care, that employee (or physician) gains a better understanding of where they fit on the care-team continuum and the value of their expertise.
HIGHEST LEVEL OF TRAINING
To optimize the care team, the administrator must also empower everyone on staff to work to the highest level of their licensure, says Halee Fischer-Wright, president and chief executive officer of the Medical Group Management Association. "Everyone plays a critical role in ensuring that patients receive excellent care and it's the administrator's job to be smart about how those resources are used," she says.
Advanced practitioners, for example, are excellent educators. They are able to spend time answering patient questions and provide resources on nutrition, community services, and chronic disease management, which leads to better outcomes. That, in turn, frees physicians to focus on more complex cases and diagnoses, which boosts job satisfaction and generates higher revenue for the practice. "I think it's important for office managers to have a good sense of what working to the top of your license means," says Woodcock. "That's where [advanced practitioners] get frustrated; when the practice doesn't support them and they're basically working as a glorified medical assistant or nurse."
At its core, team-based care hinges on trust. Physicians need to have confidence that the advanced practitioners with whom they work are competent and capable of meeting patients' needs. That takes time, but it starts with a robust recruiting program. "A lot of physicians talk about feeling uncomfortable with their NP or PA," says Woodcock. "They feel they need to supervise them too heavily, which breeds mistrust. It's critical to identify someone who is very good at their job, which leads back to good hiring practices."
Administrators, she says, should resist the urge to fill open positions quickly and instead hold out for a qualified candidate, especially in a team-based environment. "Don't ever hire in a panic," says Woodcock, noting it typically takes three to six months to find the right advanced practitioner.
In cases where providers are not up to par, or unable to embrace the team-based model, Fischer-Wright says don't delay - cut them loose. "The administrator has to be the leader and champion of organizational culture, whether it's a 20,000 provider health system or a five-provider practice," she says. "That can be as simple as hiring the right people for the job, or liberating former team members who haven't bought into the delivery model."
BE THE ARBITER
Personnel problems exist in every office, but infighting between clinicians creates a toxic environment for the staff. Effective administrators intervene when discord is detected in the ranks. "This is where the role of effective communicator comes in," says Fischer-Wright. "It's easy to come in and point fingers, but it takes a true administrator who understands the leadership role to sit back and say, 'What's the failure in the process?'" Successful administrators, she says, gather input from key stakeholders to identify the source of the problem and work together towards a solution.
Practices can preempt many of the biggest team-based challenges by training their troops to work collaboratively in the patient's best interests. Bellin Health, an integrated health system in Green Bay, Wis., spends months training individual care teams before transitioning to team-based care. "The key really is bringing in the administrator and key clinicians, including the physicians and advanced providers, to design the model together," says Kathy Kerscher, Bellin's operations and change leader. "Before our care teams go live, there is immense training, which involves the administrator of that clinic, so everyone understands their role in change management and team culture. There's much better buy in because they design it together so it's not the administration telling them what to do."
In addition to the weekly planning meetings Bellin Health holds on team-based care, individual care teams meet weekly to discuss lessons learned and opportunities for improvement. "Those meetings are led by the clinic's registered nurse, but the advanced providers, physicians, and other core team members are all in the room together talking about patient care and how to treat high-risk patients," says Kerscher. "That's where they get comfortable with each other in terms of who has what role."
Like a good coach, office administrators must know how to motivate, when to step in, and how to assemble a qualified team that gets the job done. They must also be the practice peacekeeper. "Effective administrators can really be the difference between an incredibly successful practice with patients who are satisfied and get good care, and a practice with frustrated patients who get poor care," says Fischer-Wright. "That all hinges on the administrator."
Shelly K. Schwartz,a freelance writer in Maplewood, N.J., has covered personal finance, technology, and healthcare for more than 17 years. Her work has appeared on CNBC.com, CNNMoney.com, and Bankrate.com. She can be reached via firstname.lastname@example.org.