Data Series: The Value of Small Teams in Healthcare
Early in my career, after a long day in the operating room, I typically went back to my office, which was usually empty and locked well after the last patient had been seen by my partner. Because I didn’t have the chance to go to the office in between cases, I always had a stack of sticky notes skewered onto a gold spike placed on my desk at the end of the day by either the nurse or the receptionist. They were messages that I had received while I was in surgery (that was in the mid-90s before cell phones).
I did my best to return calls to patients, patients’ family members, primary care offices, and other physicians who were usually calling to inquire about a patient I was taking care of or were trying to refer a patient. Physician offices were closed and tracking down doctors through their answering services was often frustrating and time-consuming; I was usually connected with the doctor on-call for their practice who knew nothing about the reason I had been called. Patients and family members were often having dinner or otherwise occupied. Attempting to return these messages could add about 1-2 hours to my day, and too often, I wasn’t able to contact the person who had called me.
Our modern healthcare system is a physician-centric system. The physician makes the decisions and often no one else has authority to have meaningful communications with other physicians or patients and their family members. Nurses are often limited by hospital rules or physicians’ preferences limiting their authority to do these activities. Sometimes, nurses and other team members aren’t even granted all permissions in the electronic medical record (EMR) system, which doesn’t allow them full access to a patient’s chart.
But as we learn more and more about the complexity of patient care processes and the best application of the principles of systems and data science, we’re learning that having one single medical doctor attempt to control the decision making and communication responsibilities is just not realistic. Yes, the physician-patient relationship is important, but it’s not sufficient for managing and improving the outcomes of a complex patient process.
Over the past few decades, the science of teams has demonstrated how important it is to work in small, diverse teams to optimally manage and improve any complex process. In data science, it’s well known that a small team made up of diverse perspectives around any complex problem or process is critical to achieve the best insight and outcomes.
In early 2005, a few months into my new position as Chief of General Surgery at the University of Missouri, we began to re-structure our division into patient-centered teams: a hernia disease team, a gastrointestinal disease team, etc. Each team was designed based on the needs of the patient. For example, our hernia disease team had a biologic engineer who was a materials expert, because in almost every adult patient who has a hernia repair, a plastic material (hernia mesh) is implanted. We also hired a new role for each team, a patient care manager.
Prior to this, when we all functioned as individual surgeons, the patient and family members were given the number for the hospital operator when they left the clinic or hospital. That often didn’t go well for the patient or for the operators.
It didn’t take long to see the value of working in small teams around each patient group. The patient care managers quickly learned about the specific disease processes for the team they were assigned to manage. They embraced their role, even going to the operating room to observe and learn about each disease process. As the patient care managers became comfortable with each disease process they managed, the surgeons gradually learned to share the work of caring for patients with them and the rest of the team. This freed up the surgeons to be more productive in the operating room and in many other scholarly and educational activities.
A true team does not exist when nurses, technicians, surgeons, and anesthesiologists are assigned to an operating room or when different types of physicians attend a tumor board meeting once a week to discuss cancer cases. A true team in healthcare would include a variety of roles all working together, dedicated to a whole patient care process, learning to trust each other, and demonstrating respectful communication at all times in a psychologically safe environment.
In an appropriate environment, a small team can make the outcomes of any process better and support each other to make the work experience better for everyone on the team. In fact, the science of teams has shown that small teams are better than larger teams at innovating and disrupting the status quo.
After our hernia team in Missouri had been working together for a couple of years, our patient care manager received a fax from the wife of one of the patients I had operated on a week earlier. I was in the operating room in the middle of another case that was scheduled to last several more hours. The wife had faxed a “Dear John” letter and asked our patient care manager to inform her husband that his possessions would be out of the house and he was not welcome to come home. Unfortunately, this patient had suffered from significant complications and was looking at a long recovery, including extensive rehabilitation.
Our patient care manager immediately contacted other hernia team members so they could come up with a plan. They contacted pastoral care and went together to break the news to our patient in the hospital. He was understandably upset, but they spent time with him and, along with the counselor, gave him the comfort and support he needed to deal with the devastating news. They worked with him to identify a relative in another city, revised the discharged transportation and rehab plan, and had all of the new arrangements confirmed.
As I checked in after my long OR case, I had no knowledge of what had happened. I barely caught the patient before he left the hospital with the new transport team. He was recovering from the news and thanked me for the amazing support our patient care manager and the team provided for him. There is no way that outcome could have happened if that “Dear John” letter was waiting for me on my desk to take care of after I was finished in the operating room.
One of the most beautiful elements in the principles of systems and data science is the absolute requirement to collaborate in order to reliably improve outcomes. This is true within small, diverse, local teams who can apply the principles of continuous improvement to any patient care process to improve outcomes. It’s also true in the networking of many small teams to share knowledge, ideas, and algorithms that result in collaborative networks, called the Ensemble Model for Learning. It’s not new payment models or complicated laws that will make healthcare sustainable (we’ve been demonstrating that for years). It is through the effectiveness of small teams and the appropriate application of systems and data science, that healthcare will be transformed.