Core principles and values of effective team-based health care

Institute of Medicine of the National Academies, October 2012. Downloaded from:http://www.iom. edu/Global/Perspectives/2012/ TeamBasedCare.aspx Core Principles and Values of Effective Team-Based Health Care is a discussion paper produced by the Best Practices Innovation Collaborative of the Institute of Medicine Roundtable on Values and Science Driven Health Care. Comprised of an interprofessional authorship (nursing, medicine, physician assistants, pharmacy), and inclusive of a representative from the American health-data agency, PatientsLikeMe, the group aims to identify core principles of effective team-based health care. The stated objective is to illuminate the basic principles of effective teams that can be ‘‘measured, compared, learned, and replicated’’ (p. 1) with the hope that the identification of these core principles will help ‘‘health professionals, researchers, policy makers, administrators, and patients to achieve appropriate, high-value team-based health care’’(p. 1). The authors begin with proposing a high level definition, considering team-based care to be ‘‘the provision of health services to individuals, families, and/or their communities by at least two health providers who work collaboratively with patients and their caregivers – to the extent preferred by each patient – to accomplish shared goals within and across settings to achieve coordinated, high-quality care’’ (p. 5). The article then proceeds to propose five core principles developed through a search of health care literature, expert consultation, and interviews with members of team-based health care practices from a variety of settings across the USA. The bulk of the article explains the core principles of (1) shared goals, (2) clear roles, (3) mutual trust, (4) effective communication, and (5) measurable processes and outcomes. Each principle is described in more detail, complete with specific, context rich examples from the various teams involved in the interview process. A particularly salient theme throughout the principles is the continued return to the concept of patients as team members, and not objects of team-based care. An often unexplored implication of this framing is the nature of team composition. Where a number of different patients and families come in and out of teams many times per day, the authors acknowledge that to have patients as team members, health care providers must also recognize that the team is forming and reforming on a regular basis. The team itself is different with each new patient encounter. To consider the team as constantly forming and reforming becomes problematic in some of the existing analogies of healthcare teams, including the analogy of health-care as a team sport or as the performance of an orchestra. Both of these analogies are used in this article, as well as comparisons to other high-risk industries such as aviation and nuclear power. Careful consideration of the fluid nature of health care has already pointed to the limitations of these analogies in the health care context (Reeves, Kitto, & Masiello, 2013; Reeves, Lewin, Espin, & Zwarenstein, 2010). Considering other analogies of teams and team-based activity (such as knotworking (Engeström, 2008) or teams as sand-dunes (Hackman & O’Connor, 2004) would do much to increase the complexity of the conversation about teambased work in health care. For example, considering the fluid nature of teams in emergency departments raises interesting nuances about the nature of leadership, revealing a process that is dynamic and highly situational while remaining hierarchical; a discussion that challenges much of traditional leadership theory (Klein, Ziegert, Knight, & Xiao, 2006). Further, examining the fluid boundaries of teams and how participants perceive their position in teams reveals differing understandings of the nature and value of teamwork (Cott, 1998). Finally, considering the different organizational processes at play in stable membership teams, as compared to fluid groups or networks (Reeves et al., 2010), has implications for the nature of trust, demonstrating contrasts between personal and impersonal (or systems oriented) trust (Meyerson, Weick, & Kramer, 1996). All of these lines of inquiry have important implications for the five core principles proposed in this discussion paper. In summary, this discussion paper has furthered an argument for core principles of team based health care that is anchored in the lived experiences of teams across various practice settings. The article has also succeeded in elevating how we think about patients as team members. An ongoing way forward would be take these principles beyond a normative framework into a conceptualization that appreciates the relational, processural, organizational, and contextual (Reeves et al., 2010) factors that characterize the many forms of interprofessional work in health care.