Primary Care Teamlet Formation and E

Implications for Women’s Health 

Hector P. Rodriguez, PhD, MPH

Associate Professor of Health Policy & Managemen

UCLA Fielding School of Public Health 

Affiliate Investig , atorVA Center for the Study of Healthcare Prov

Email: hrod@ucla.edu 
Today’s Goals 

1. To describe teamlet formation across three different prim

contexts – VA Healthcare System- VISN 22 (Los Angeles, San Die

Linda primary care practices- 6 practice sites) 

– A l i t h i i i ti (5 i A large private physician organization (5 primary care pr

sites in the greater Los Angeles area) 

– Federally-qualified health centers (FQHCs) in northern C

(14 practice sites) (14 practice sites) 

1. To discuss important practice context differences in th

imp lementation of p y rimarcare teamlets for women vetera

hope to shape a primary care teamlet key informant intapproach within VA women’s health care. 
VISN 22 Longitudinal Teamlet Study (VHA PACT Demonstration Lab

Collaborators and Funders 

• Susan Stockdale, PhD • Karleen Giannitrapani, MPH, MA • Alison B. Hamilton, PhD, MPH • John McElroy BA John McElroy, BA • Elizabeth Yano, PhD • Lisa V. Rubenstein, MD, MSPH Private physician organization teamlet study in the greater LA area • Sherry Grace, MPH FQHC study: Innovative Care Approaches through Research and Edu1R18HS020120, PI: Rodriguez) • Philip van der Wees, PhD • Mark W. Friedberg, MD, MPP Mark W. Friedberg, MD, MPP • Arturo Vargas-Bustamante, PhD • Dylan H. Roby, PhD 
Poll: Which comes closest to describ

your role with the VHA? 

• Primary care clinician or staff • Non-primary care clinician or staff 

M t 

y 

• Management • Research/Evaluation • Organizational Development/Consulting 
6/27/2012 

Delivery System Primary Care Team Reorgan

VHA primary VHA primary care 

practice sites in VISN 22 (Southern 

CA) 

Goals: • Accountability for the primary care 

panel of patients 

• Prioritizing continuity of care (prim

Prioritizing continuity of care (prim

physician visit continuity) 

• More consistency in the working re

p y p rimary care personnel

• More consistency in the amount and 

support available to PCPs 

Private physician organization in Los Angeles 

Goal: Integration of new team membecoach and RN care manager to supporsupport improvements in chronic illne

FQHCs (low income largely income, largely uninsured Latino patients) 

Goal: Integration of new team membemedical assistant panel manager for dimedical assistant panel manager for di

Poll: Is the PACT teamlet model 

appro

priate for women Veterans? 

• Yes, definitely 

Y h t 

pp p 

• 

Yes, somew

h

at 

• No, not really • No, not at all • Other 
Organization Most common practice Role C

Membership, Supervision, and Role Ch

Most common practice 

members at baseline 

Role C

VHA primary care practice sites in VISN 22 (S th CA) 

1. PCP 2. LVN/Health tech 3 RN 

• RN population man

care management 

22 (Southern CA) 3. RN LVN/t h h lth 

4. Clerk / MSA Discipline-specific supervision 

• LVN/tech health co

management 

• Clerk primarily focu

module activities 

Private physician organization in Los Angeles 

1. PCP 2. Medical Assistant 

LVN ii 

• RN management (n• Health educator (he

position) 

LVN supervision • St t d Structured t l team e c

(includes new roles

FQHCs (low income, largely uninsured 

Latino) 

1. PCP 2. Medical Assistant 

• Community health Or 

Latino) • Medical assistant pa

Clinic manager (nursing) supervision 

Medical assistant pa

position) 
T l eam et K I f S l Key Informant Samples 

Study Total Sample Sampling Approach RespoVHA Teamlets 90 teamlet members total 

(across 6 practice sites; 2 waves) 

Cluster sampling (by role within 6 

sites) 1. 3 part-time PCPs 2. 3 full-time PCPs 

3. 3 RNs 4. 3 LVNs/Health techs 5. 3 clerks 

64% 

FQHC Teamlets 50 teamlet members toral 

( p ; across 14 practice sites;2 waves) 

Cluster sampling (by role within 14 site) 

1. 1 PCP 2. 1 CHW or medical assistant 

panel manager 

3. 1 floor MA 4. 1 RN/LVN or other practice 1 RN/LVN or other practice 

member involved in diabetes care 

35% (Np p articipinclude

Private Physician 20 teamlet members total Cluster sampling (by role within 75% 

Teamlets (across 5 practice sites; 2 (across 5 practice sites; 2 

waves) 

site) 1. 1 PCP 2. 1 MA 3. 1 health coach 4. 1 RN care manager 
Primary Care Team Compositio

Change Capacity

PRIMARY CARE TEAM

C

O

M

P

OSTIO

N

PRIMARY CARE

T

E

A

M

F

U

N

CTIO

NIN

G

C

O

M

P

OSTIO

N

Size

Clear Boundaries

Av

aila

bilit

y

o

f

E

x

p

e

r

s

e

T

E

A

M

F

U

N

CTIO

NIN

G

Skills and Knowledge

E

ffort

Capaci

Cha

Av

aila

bilit

y

o

f

E

x

p

e

r

s

e

GroupNorms

TeamInterpersonal

Processes

Adap 

Individual Factors

Age

G

d Situa on Monitoring

Teamwork Safety

Gen

der

Race/Ethnicity

Occupa on

J

o

b

t

e

n

u

r

e

A tude toward teams
Care Team Boundaries (Dedication)

90 

y = 0.6193x + 19.104 

R2 = 0.1187 

80 

ation) 

60 70 

es (Dedica 

50

oundarie 

30 40 

e Team B 

10 

Car 20e 

40 45 50 55 60 65 70 75 

Change Culture 
Care Tea

m Boundaries (Dedication) 

Care Team Boundaries (Dedication) 

90 80 70 60 50 40 30 20 10 

y = 0.6718x + 17.814 

R2 = 0.1933 

40 45 50 55 60 65 70 75 

Adaptive Reserve 
Situation Monitoring

85 80 75 70 65 60 55 50 45 40 

y = 1.0299x - 5.3631 

R2 = 0.6489 

40 45 50 55 60 65 70 75 

Change Culture 

Situation Monitoring
 
65

y 0 8766x + 7 5815 y 

= 0.8766x + 7.5815 

R2 = 0.6506 

Situation Monitoring

Situation Monitoring
 

85 80 75 70 65 60 55 50 45 40 

40 45 50 55 60 65 70 75 

Adaptive Reserve 
Teamlet Structure 

Size 

“Real Team”- Dedication and 

Stability Cli i i B t 

Organizational Readiness to Clin

Role Coverage 

Teamlet Composition 

Teamlet age 

Clinician Burnout 

Clinician Resilience 

Change 

Quality of organizational context 

Leadership 

Capacity of internal facilitation of 

QI 

Ca

Patient ass

Electron

Decis

Enha

Teamlet Functioning 

Compelling Direction 

Psychological safety 

Strength and extent of evidence of O t N Id 

QI intervention 

Clinic h

Other prac

Openness to New Ideas 

Team Communication 

Implementation of new Improve

Centered 

and Care 

m

teamlet roles to support 

improvements in patient 

centered care and care 

quality 

Quality of Primary Care- Specialty 

Interface 

Bi-directional Communication 
Teamlet Interview Study Methods 

• 45-60 minute key informant interviews of teamlet mem• Record transcribe clean transcripts Record, transcribe, clean transcripts • Develop code book based on review of 6 cleaned tran

and our team effectiveness logic model and our team effectiveness logic model 

• Use ATLAS.ti to code interviews • Employ “member checks” to ensure consistency of co

between researchers 
Emerging Teamlet Formation and 

Evolution Issues 

(across contexts)

1. Structured teamlet communication (huddles and me2. I l t ncomple

te t l team

et memb hi ers p 

3. Visit continuity and access to care tradeoffs 4. Coordinating coverage across teamlets 

5. Role clarity and role overload 6. Leadership change facilitation 7. 

Using small tests of change for practice improvemen

small tests of change for practice improvemen

6/27/2012 
Pi Cr mary Care T l team e F ti Formation 

Across Practice Contexts 

1. Some informants expressed that they were able to influence wh

individuals they would be working with as a teamlets, but most in

indicated that schedules and other criteria were the determin

teamlet memb hi ers p. Hi h i bili f f i High variability of formation process acro

within organizations. 

2. Communication and guidance on how to develop primary care 

member roles is needed across all organizational contexts is needed across all organizational contexts 

3. Primary care teamlet development is considered a difficult and 

organizational change. 

4. Respondents highlighted the benefits and drawbacks of using 

approach operationally. A clear challenge for teamlet implemenpart-time status of many primary care clinicians and balancneeds of resident training demands. Less of an issue in priva

more of an issue for the VHA more of an issue for the VHA. 
Teamlet Formation in the 

VHA 

• The development of teamlets was “a huge change actually...beca

work a lot closer with other people in the clinic rather than it’s ju

clerks, it’s just the nurses, it’s just the doctors, it’s just the practition

• “I think more of the planning came from leadership and then it kind 

down to us because...it was kind of a really quick transition... ma

month or two. It was just quick, like we found out we’re going to be 

this PACT thing, they gave us our groups, we started meeting, tfigure out what's what. We started going to the training that was about PACT and then we just boom, put it in.” 

• Staff received “a memo stating...you're now on Teamlet A, B, C, D, 

knew. I think they drew names out of a hat and put you on a teHere you, this is your teamlet, this is your doctor, your nurse practit

you re 'the LVN you the LVN, you re 'the whatever and that was your the whatever, and that was your teamlet teamlet ”. 
Incomplete Teamlets in the VHA 

• “A lot of the providers and a lot of the LVN, MSA, even th

are complainin

gthat the PACT model was implemente

we don’t have the proper staffing. On any given day, tlot of teams missing their RNs.” 

• “I thi kn

k resources would b [ d d t ] k h ld 

be [nee

d

ed 

t

o] ma

ke sure each 

properly staffed. I think the PACT model, because eachas such a specific role, if one person is missing, the just really falls apart.” 
• T ’ h lth li i h diff i True, women’s health clinics have different t pracice re

• False, similar teamlet formation issues will be operatin• Hard to tell/Other 

Poll: True or False: Teamlet formation unfold differently for women’s health cland designated providers. 
Major Challenges to the Developm

New Teamlet Roles in the VHA 

1. High variation in individual teamlet member responsibilit

teamlet (call backs, scrubbing) 

2. Sometimes PCPs face challenges with tasking their te

members because of discipline-specific reporting relation

3. RN roles are generally underdeveloped per PACT mo

due to walk-in patient demand and coverage problems. Creminders are sometimes on the backburner for nursing brole overload. 
• “My MSA would like for me to have full nursing every day ju

id B t th t’ i ibl b h ld b i ki 

Nursing and Role Overload in VHA Prim

providers. But that’s impossible because who would be pickin

slack when I'm doing those nursing appointments? That box wfull [because] I would be with that patient and those providers wbecause of me. So I don’t want that.” 

• “I think working with the RNs to evolve that role and the care 

role, that would be the biggest [improvement], and taking the eaway from managing and triaging walk-ins to really managof patients. It’s a different skillset. It’s more case managemen

very diff t th b i t i different than being a triage nurse. 

• “For example, some other teamlets, the LVNs does all the scru

me, my LVN said that it’s too much for her so I’m helping he

days a week she does two days a week days a week, she does two days a week. “
Teamlet Reorganization Can Uncover Indiv

Differences in Effort and Readiness for Cha

• “One of the biggest complaints that I see with the PAC

that a lot of the older employees are refusing chan

these are the employees that have been with the VA fthese are the employees that have been with the VA fyears or longer....And so those people were so used tpeople] picking up the slack because everything was done bunch, y y nobod

y really 

g y ot accounted for what the

y 

doing.” 
Leadership’s Role and Role Clarity 

• “I think they need to talk about more-more specifically 

people’s roles need to be in the teamlet process becathink there's, you know, people aren’t aware of what the 

abl t d h t th RN i d t b d i I thi k 

ble 

to 

do, w

h

at the RN is supposed 

to 

be 

d

oing. I thi

nk 

was some kind of training-well, not even necessarily trainjust something where we can specify what people in the should be doing rather than passing it off to whoever.” 
How Important is Structured Te

Communi i cat on (H ddl u es, M 

eet

• Communication structures

– Routine communication through paper an

electronic information flow

– Minute‐to‐minute communication through 

verbal interactions among team members

– Team meetings

• Communication processes

– Feedback

– Conflict resolution
“It is naïve to brin

g to

gether

a hi

g y hl

y diverse

group of people and expect that, by calling

them

a team, they will, in fact, behave as

a

team. It is ironic indeed to realize that

a

football team spends 40 hours

a week

practicing teamwork for the

2 hours on

Sunday afternoon when their work really

coun

ts.

Teams in organi ti za ons seldom

spend

2 hours per year practicing when

their ability to function as

a team counts 40

hours

a week

”.

Harold Wise, Making Health Teams

Work
Efficient communication is critica

work of “real” interdisciplinary 

• Structured communication is essential for imple

role changes changes, such that each member of the tea

functions at the top of his or her scope of practic

• When implementing interdisciplinary care team

approaches, it is important to develop a teachin

learning environment where team members’ sk

knowledge can be enhanced.
Objectives Objectives of Huddles Huddles

1. Plan for daily tasks and roles

2. Review any barriers or facilitators of the day’s w

3. Reflect on the previous day’s work (what worke

didn’t work so well)

4. Identify and develop solutions for addressing sy

problems

THESE MEETINGS CREATE CONSISTENT STRUCTURE

OPPORTUNITIES FOR IMPORTANT AND ONGOIN

COMMUNICATION AND COORDINATION.
Poll to practicing clinicians and staf

Do you h ddl u e d il a y wi ht your teamlet/t

• Yes, usually• Yes, sometimes

• Not sure

• Yes, but infrequently

• No, never
• Primary care huddles were instituted early in the 

organization organization s ’life 

• Remnants of the policy still appear in clinician sche

some sites (non-bookable time in scheduling template

reserved for huddles)

Private Physician Organization (Los Ang ) eles area) and the Huddles Inter

reserved for huddles). 

• Organization aims to resurrect huddles as part of rou

primary care. 

• O i ti d t d Organization conducted t eam communi cati on t rai ni n

provided supports for huddle implementation to 5 prac

• Key informant interview study is aimed at understan

f ilit t d b i t h ddl i l t ti d facilitators and barriers to huddle implementation and 

integration of new team member roles (RN care manahealth coach). 
Anatomy Anatomy of a Huddle Interven

Interven

 Brief “check‐ins” among teamlet members* relate

specific actions and goals as highlighted in the str

agenda

 Daily consistent meeting times for 5‐10 minutes

Generally prior to morning and afternoon patient

appointments

 Agenda Content

Review‐ workload and clinic operations status (staffin

equipment, etc)

Identification‐ scheduling changes and patient’s spec

and circumstances

Preparation‐ discussion of special care processes and

expectations for patients

Growth‐ deliberate deliberate communication communication about issues relat

relat

expansions (critical to interdisciplinary team care)

*Teamlet = small team, no more than 6 members
Who Sets the Agenda

Agenda

• Most organized team member should take on 

agenda development responsibility. This indivi

should ensure that all members contribute to tagenda.

• Since the teamlet is organized around the PCP’

panel, it is important for PCPs to develop ment

skills and facilitate facilitate the learning learning process process. This is 

to implementing role expansions.

• The unit/department manager plays a critical 

ensuring ensuring that teamlets teamlets are functioning functioning well and

provide feedback and help resolve system issue

identified as impediments to patient‐centered 
Huddles are Likely Most Critical for Complex 

Tasks and Tasks that Require Patient Participat

Patient Self‐Management

Clinic Task Complexity Teamwork M

Gather preventativeservice history and

ensure gaps are

addressed

Medium Medium

ColorescreenFlu vac

Pap/ M

Screen patients fordiseases Medium Low Adult B

Assess patientlifestyle lifestyle factors factors andcounseling

High High

Weighnutriticounseassistasmoki

Track patientdiagnostic factors Low Medium

LCL‐C s

HbA1c BMI
Structured Teamlet Communicati

Communicati

VHA Primary Care 

1. Huddles are not routinely implemented and generally do 

consistently include the full teamlet because of opposing sch

Communication between Communication between teamlet members occurs as mostly 

members occurs as mostly 

between meetings between two teamlet members (the PCP for example). 

1. Instant messaging is perceived to be a “leaner” form of 

communication than in-person meetings, especially for tecommunication between clinical encounters. Are huddles (d

structured communication) essential? structured communication) essential? 
Innovative Teamlet Communicati

the VHA 

• “We use instant messaging which is, I think is the best, because be

whenever I need to talk to the provider or the nurses, I have to go them everywhere. I would be like going in a circle just to find tnow, since with the instant messaging it’s so convenient. This patie

labs this patient needs medical refills and labs, this patient needs medical refills, and I get an answer right a

I get an answer right a

they will do it right there and then. “ 
Teamlet Development for Women Ve

1. Individual VA women’s health clinics have diverse 

organization and scope of services because of di

in local patient volume, clinical expertise available in in local patient volume, clinical expertise available in 

care, and organizational capacity. 

2. We hope to expand our teamlet development stu

teamlets for women for women Veterans. 

3. We aim to understand how women’s health teaml

formed, how they function, how they affect individua

roles and responsibilities, how they interface with noroles and responsibilities, how they interface with noteamlet primary care staff, and how they affect the wVeterans’ experiences of care. 
How effective are How effective are teamlet teamlet “huddles huddles ” as an tea

as an tea

communication improvement strategy for VH

Women’s Health? 

• Very effective 

Women s Health? 

• Somewhat effective • Not effective or ineffective • Somewhat ineffective • Ineffective 
5 Key Issues for Teamlet Developm

Women Veterans 

1. Limited women’s health clinic operations at some sites 

achieving PCP continuity of care especially challenging 

2. Man

yVHA women’s clinics are small,so will or

g g anizin

g c

small organizational units (teamlets) be an efficient and way of providing interprofessional care to women veterans

3. At sites with a high proportion of walk-ins, how to handle t

workload o

f women’s health providers with limited app

capacity to effectively handle same-day referral/triage volu

4. Women veterans, on average, are more likely to need supp

services and specialty services services and specialty services. Information transfer and 

nformation transfer and 

coordination across organizational boundaries and outVHA is even more salient for improving the care of women 

5. Given the wide ran

g e of health services used by women ve

departmental/service agreements may be even more imto solidify as VHA women’s health implements the PACT temodel. 
Poll: What is the most important issue to cons

when implementing PACT for women Veteran

• How to balance PCP continuity and access to care • Social workers, mental health, etc. are part of the team• Th te par

t

-ti t t f WH PCP / ti l l

time s

t

a

tus o

f many WH PCPs 

/ operational l

• Care coordination across organizational boundaries • Other 
Poll: Will the PACT teamlet model 

for women Veterans? 

• Yes • With some modifications/tailoring • No