Self Directed Work Teams in Primary Care

In the early 20th century Frederick Taylor set out the principles of efficient work made famous on the Ford Motor Company production line.  This system was based on a large and uneducated work force whose individual inputs were largely the same and individually of relatively low value.  Moving forward 50 years and a couple of world wars we see the mechanical model was still very much alive and well, but the education and expectations of people were clearly changing.  By the early 1950’s thought leaders were regularly publishing new ideas about respect, accountability, and authority.

Finding ourselves in the midst of the knowledge age both our ability to do the work and the expectations of employee and customer have changed dramatically.  Self directed work teams (SDWT) are an evolving solution to those changing abilities and expectations.

SDWT are built upon the principles of empowered knowledge workers who have both the personal and professional skills to function largely independently.  They are characterized by a common goal, clear interdependent roles, power to carry out their work without additional permissions, a high level of competence (personal and professional), and a strong culture of accountability, transparency, and generosity.  In other words the team has the authority, resources, information, and accountability to get the common goal accomplished.  Team members with an internal locus of control seem to be most effective; meaning those who believe they are responsible for their success or failure, instead of outside forces controlling their fate.

In this setting the role of the leader changes dramatically, from one of authorizer to one of a caring coach, facilitator, and communicator.  Instead of day to day decision making, developing action plans, or giving orders – these responsibilities rest with the team.  Team leaders help team members develop their unique abilities and talents, encourage an environment of trust, model group communication, team based problem solving, and lead by example.

A customer focused team is ideal, as this mental model provides the common goal or purpose around which the teams individual members perform their work.  These teams have become increasingly common in many industries, but have lagged in health care.  There is a lot of rhetoric around teams, but few SDWT as described above.

A significant reason for this lag has to do with the professional guilds that have evolved in health care.  The traditional model has advocated for respect and autonomy of those professionals, who were primarily independent contractors or in small groups by sub-specialty.  Large multi-specialty groups evolved according to market forces and concentrations of populations but largely functioned as independent knowledge workers within those large economically oriented groups.

Team based care, and SDWT are a completely different paradigm to the guild based paradigm.  That is a primary reason it has been so slow to be adopted.  Our terminology is a good indicator of the challenges implicit in truly team based care, and patient focused care.  Well published studies indicate that for most chronic conditions social determinants are the primary factors in health.  Yet our models are called “medical homes” and respected organizations like the American Academy of Physicians advocate that the physician is always the team leader.  For good reason there is a lot of fear amongst physician organizations about anything that diminishes control of the individual practitioner over “their” practice.  It is unfortunate that this fear retards progress to a more effective model.  It should be clear that on a real team there are distinct roles, each is to be carried out with maximum competence, good judgment, and respect of and for the other team members.

In a modern health SDWT physicians are team members.  They have a unique role, and in an efficient practice they will primarily carry out that role they are uniquely suited to fill.  Likewise, other team members have a unique role and their efforts are primarily focused on that role.  The physician could be the team leader, but not necessarily, and their might not even be a formal team leader.  There does have to be a coordination role, however, and many teams rotate that role.  It should be provided by the team member(s) who has the greatest aptitude for coordination, which has nothing to do with the most formal education or unique technical competence.  The power of the SDWT is in the composition of the team members and the focus provided by a customer/patient orientation.

I like the term “patient focused health home” because it recognizes the goal of health and the predominant role of the patient.  We check our ego at the door and work together as a team with the patient as full partner on the team.  This health home will look and feel very different from a typical medical practice.  The composition of the team members will vary depending upon the needs of the patient.  Core members include medical, nursing, support, and behavioral.  Common members might include pharmacy, addictions, home health, therapist, and community health worker.

In the most effective care settings we not only require highly competent individuals in their standard skill set, but additional training and tools are necessary.  Even in a highly functioning team if we must employ active and empathic listening, motivational interviewing, SBIRT (Structured Brief Intervention and Referral to Treatment), PHQ-2 (9), health literacy, and other skillful communication tools and best practices.  The consistent and competent use of these tools will both improve our effectiveness and our ability to measure that effectiveness.

If our goal is health, we have to include many more pieces of the puzzle than medicine alone.  The SDWT paradigm is uniquely suited to success, particularly when applied in a profoundly patient focused team that includes the patient as a full partner.  The primary care practice is particularly suited to this model as they are the foundation that all people should have access to.  This represents a huge and necessary leap forward from a traditional medical practice.  It respects the value adding role of medicine, and other key partners in the nurturing of health.  It is foundational to achieving the triple aim of better outcomes, lower costs, and a better patient experience.

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