The practice of medicine often conjures up the image of talented, intelligent, hardworking doctors making life-or-death decisions about patients, with hardly a consideration for the execution of those decisions. In popular culture, the predominant images are of the cantankerous but brilliant doctor who connects the dots to solve an otherwise inscrutable mystery (à la House), or unflappable surgeons removing bullets from brains, unaffected by any chaos surrounding them (as in ER or Code Black). These images push aside the reality that doctors today are not silos of knowledge and experience; rather, they are members of an increasingly intricate medical system—a system that requires coordination, communication, and teamwork.¹

It is an understatement to say that medicine has become more complex. Since the day when antibiotics were first added to the physicians tool-belt. With over 25,000 articles published on the PubMed site,² over 1000 medications in use, and countless medication interactions,³ it is difficult for one physician to understand the state of medicine as it currently stands, let alone keep up with the pool of knowledge that is exponentially expanding.⁴

As a result of the increasing complexity of healthcare delivery, more and more errors are occurring in patient care. This is not because of gaps in knowledge by their providers or the inefficacy of procedures, but rather due to the intricacy of delivering the care needed in a multifaceted medical system. While it may have been possible in the past for a patient to be treated by one family physician, one recent study showed that today, a patient over the age of 65 has seen, on average, more than 28 physicians during their lifetime.⁵ Another study estimated that up to 400,000 deaths occurring in the hospital were related to errors, making this the third-leading cause of death in the United States.⁶

One approach to handling this staggering amount of information, dynamics, and complexity is to disperse the responsibility among several members of a care team. However, this cannot be done without significant foresight and training. Unfortunately, training in shared responsibility and high-quality teamwork is frequently lacking for many physicians, resulting in a significant number of medical errors pertaining to that lack of training.⁴

In an effort to improve not just outcomes for patients, but value in medicine and physician satisfaction, significant thought has been given to how team-based care can help. We will explore in this chapter the reasons behind team-based care, the principles underlying it, how it may be implemented, and examples where it has been employed successfully in the hospital to improve clinical outcomes.

In the quest to improve outcomes in the hospital, it comes as no surprise that numerous methodologies have been implemented, including morbidity and mortality reviews, grand rounds, and even the often-difficult transition to electronic medical records (EHRs). Of the various approaches, team-based care has garnered the most interest recently, as numerous studies have demonstrated its efficacy. In addition, there exists great potential to improve not just the value of care, but also physician satisfaction. Being able to affect so many elements of medical care is likely a driver in encouraging people to consider this methodology as a way to help improve outcomes in their own institutions.⁷

Team-based care is necessary going forward due to the increasing complexity and cost of healthcare. There is an overwhelming amount of care to coordinate, which is both difficult and expensive for physicians and patients. The increased cost, according to one program director at a national health policy think tank, is the central driving force behind team-based care.⁷ A team can save costs by using less expensive providers and increase the quality of care by using practitioners who are properly suited for specific tasks. In addition, by having several practitioners together in one location or in one system, the barriers to access for patients using that system are lowered.

While potential benefits exist, there is no consensus about best practices in today’s team-based care, and an old-school, hierarchical system continues to dominate the medical landscape. Therefore to overcome the barriers that hierarchical structures sometimes erect, training for team-based care need to start early in the education process.

Since today’s medical schools place little emphasis on team-based care, before implementing this form of care, it is important to consider the basic tenets and principles behind it. An understanding of these concepts is essential to build a functional team that will succeed in implementing changes based upon team-based care. It is with this in mind that a committee proposed to articulate the core principles of team-based care and build upon these principles to develop team-based strategies.¹ During this discussion, five key elements were identified as important values that were necessary for building a team: honesty, discipline, creativity, humility, and curiosity. These will be detailed next:

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  Honesty: When care for a patient gets distributed, it is essential that the team members are able to accurately communicate complex information to one another. While this value appears to be self-evident and surely is universal among healthcare providers, there are numerous pressures that sometimes work against people’s better natures, such as punishment, uncertainty, and even the feeling that one’s opinion is invalid. By explicitly understanding that honesty is paramount for a group to be successful, one can reinforce error reporting, feel comfortable contributing ideas, and clarify the uncertainties that can exist.

  
  
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  Discipline: Although new methods can be exciting to implement in a practice, they often come with increased burdens of effort. In addition, disturbances to the workflow during transitioning will lead to decreased productivity, even if the ultimate result leads to increased productivity. When implementing a new methodology, it is important to be diligent and disciplined, while continuing to work out problems and stick to the action plan rather than reverting to old habits.

  
  
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  Creativity: Errors and barriers inevitably plague every new undertaking. Anticipating these errors and developing nontraditional workarounds are essential when confronting new challenges. An environment of creativity needs to be fostered to help develop new, original solutions and prevent shoehorning old solutions into new problems.

  
  
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  Humility: Teams will be comprised of people from various professional backgrounds, and while a hierarchy may be in place within a team, it remains essential to have a universal understanding that no single training or perspective is superior to the training or perspective of another. This is vital for all team members to contribute equally to a task and take equal ownership in the success of a team project.

  
  
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  Curiosity: While a team may be able to develop a successful intervention, ongoing improvement is always necessary in the ever-changing healthcare system. Curiosity about how to improve further can make the difference between being good enough and true excellence.

These elements are important for each individual member of the team. In addition to each member of the team needing to demonstrate these values themselves, these values must be reinforced regularly during the process of team building. Once these values are accepted by each member of the team, the following elements should be pursued to shape the team as a whole:

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  Shared goals: Buy-in to a team’s plans is essential to their success. Each team member must be able to articulate the goals of a project and be able to support each other.

  
  
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  Clear roles: Each member of the team must understand what her or his personal responsibilities are. Clarity of roles does not mean that the roles must not overlap, though; indeed, to ensure that mistakes are prevented, often multiple people performing different roles may be responsible for the same task (e.g. ensuring consent for a procedure has been granted by both physicians and nurses). However, with complex and integrated teams, efficiency can best be achieved by having all the players fully understand their own responsibilities, even when they overlap with other people’s.

  
  
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  Mutual trust: Along with sharing responsibilities, it is essential that team members understand that they can trust that other members will work in good faith to achieve their goals. This trust is independent of profession and is best built over time or through reliable training.

  
  
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  Effective communication: Stable communication channels must be established that are not just available for members to use, but their use is encouraged and even incentivized.

  
  
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  Measurable processes and outcomes: Without reliable performance markers, it is difficult to measure the success of any new process. When developing a workflow, it is important to incorporate metrics that can help identify what works and what doesn’t.