Editors' Comments

Changes in Caregiving: Transitioning from Working Independently to Working Together. E-mail your testimonies to me: Lee.Jacobs@kp.org. Lee Jacobs, MD, Associate Editor, Health Systems

Change has been the elemental constant of medicine since the days of Hippocrates; historically it has taken place in scientific advances. Today change occurs more than ever in the realm of how care is delivered to the patient. From a new specialty to team-based care, Kaiser Permanente is an active agent in creating positive change.

Dr Diane Craig's report in this edition of The Permanente Journal on the national Kaiser Permanente Hospitalist meeting demonstrates how rapidly the changes in health care have occurred over the past few years. For generations primary care physicians have been responsible for hospitalized patients, dividing their time and focus between the office and hospital rounds. Today, the new specialist area of Hospitalists has emerged to fill a growing need. Isn't is amazing how readily and quickly a new process of care is accepted?

I believe the transition of many health care organizations, including Kaiser Permanente, to team-based care will impact ambulatory care just as dramatically as the Hospitalist programs have impacted hospital care. (I define "team-based care" as a small unit of caregivers including receptionists, medical assistants, nurses, associate providers, and physicians working together to care for a definable population of patients.)

It is my opinion that the extent to which the health care team works together will correlate directly with how much improvement in service, quality, and professional satisfaction the team will attain. How each discipline contributes to the patient's care experience and how interdependent the team members are when it comes to patient flow (not practicing in silos with separate schedules, but rather all team members participating in a fluid care process in which all help each other out) will all define how effectively a team works together.

Why an emphasis on teams? I believe that highly functioning teams are the only viable method of meeting the increasing demands and expectations of a large panel of patients while at the same time enhancing the professional well-being of all team members. The best approach to a high-stress work environment is to have a team deal with the stressors together rather than leaving each individual to fend for themselves.

During my 20 plus years with Kaiser Permanente, I have had opportunities to witness several high performing teams. Here are some of my learnings:

1. The effectiveness of the physician team leader is the most frequent direct predictor of the team's level of performance. It's the leading, not the managing, that makes the difference.
2. The team needs to know what is expected of them and needs crystal-clear, regular feedback on these expectations. The closer the performance measurements (eg, patient satisfaction, cost, quality measurements, People Pulse scores) are to the team, the more impact the feedback will have on their performance.
3. Since we know that one of the most important drivers of professional satisfaction is the level of influence that clinicians have over their work, involvement of team members in the functioning of the module is essential. Regular team meetings, team interviews and input on new team applicants, and team leader involvement in reward and corrective action of team members may sound strikingly different than present processes--but therein lies the value!

In the future I would like to see the Health Systems section of The Permanente Journal present the experiences you have had working on health care teams. I'm very interested in your personal testimonies. Are health care teams simply a fad, or are they in fact the future building block for our success? We want to hear from the Permanente community--what do you think? E-mail your thoughts and ideas to me at Lee.Jacobs@kp.org.

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