Team Up! Team-based primary and community care in action

This episode focuses on Stage 5 of the Learning Pathway: Team Evaluation, and the importance of evaluation in the context of team based primary care. The hosts explore how evaluation acts as both the end and beginning of the cyclical process of enhancing primary care teams. Sarah and Morgan delve into the distinctions and overlaps between Quality Improvement and evaluation, methods of performing meaningful evaluations, and the introduction of evaluation tools aimed at measuring team effectiveness. The episode emphasizes that evaluation is not a linear process but a continuous circle that can commence at any stage of team development. Morgan highlights how it is often best to begin evaluating sooner than later because it is easy to spend far too long planning what to evaluate. You can always complete another evaluation cycle. The hosts then share the plan for a TBC evaluation project in BC that is going to engage 30 clinics in evaluation over the next few months.

The episode ends with a call to action focused on starting your evaluation journey by looking at available resources, reminding listeners to check back in the show notes of previous episodes periodically as more the learning pathway will continue to evolve. The season wraps up with a bit of a teaser for the next season of TeamUP!

Special thanks to Amie Hough, a Leader in Health System Improvement for Primary and Community Care with Health Quality BC, and one of the creators of the learning pathway, who we will be hearing from throughout the season.

Links and Resources

For more information on the Team Based Care Learning Pathway check out https://teambasedcarebc.ca/team-based-care-pathway/

Measurement Plan Worksheet

Small worksheet to help identify what to collect, when and how to measure.

https://teambasedcarebc.ca/resources/measurement-plan-worksheet/#details

Team Effectiveness Tool

Taking us back to where we started with S06- check out the Team Effectiveness tool, a short multiple choice assessment to help huide your learning on team based care.

https://teambasedcarebc.ca/team-effectiveness-tool/

Through the TeamUp network we are working to advance supports for team based primary care. Please reach out to [email protected] if you would like to learn more!

This episode focuses on Stage Four of the learning pathway, emphasizing team performance and quality improvement within primary care settings. The hosts discuss the continuous learning approach as a key element of a healthcare system — which aims to improve patient-centred and team-centred care by applying evidence to practice. Morgan and Sarah explore the concept of quality improvement as an iterative process, emphasizing the importance of starting with a good question and evolving from there. The episode highlights how accepting a trial-and-error style approach may be a culture shift within a clinic. However, in doing so, the practice will improve with each iteration, the roles within the practice will become solidified, and colleagues will become more comfortable utilizing team-based care methods. Practical strategies such as leveraging available resources, engaging with coaching supports, and time-boxing QI cycles are discussed to encourage teams to initiate and sustain quality improvement methods.

Special thanks to Amie Hough, a Leader in Health System Improvement for Primary and Community Care with Health Quality BC, and one of the creators of the learning pathway, who we will be hearing from throughout the season.

Links and Resources

For more information on the Team Based Care Learning Pathway check out https://teambasedcarebc.ca/team-based-care-pathway/

Practice Support Program

The Family Practice Services Committee has a robust breadth of resources to help optimize your BC-based practice and delve further into team based care and if you have access to PSP or TBC Coaches, they are wonderful resources if you are thinking about QI in your team. Contact your local PSP team for support.

https://fpscbc.ca/psp

PSP also offer compensation and MainPRO+ credits for eligible primary care teams participating in PSP services.

Learning Pathway Resources

Check out the QI Team Member Matrix Worksheet

Through the TeamUp network we are working to advance supports for team based primary care.
Please reach out to [email protected] if you would like to learn more!

In this episode, Morgan and Sarah move into Stage 3 of the Learning Pathway for Primary Care Teams. The focus here is on — after we have built a team, how do we develop it further and showcase the continuity of care to patients? The hosts discuss how patients may perceive team-based care as a disruption to their healthcare continuity, and they provide ways to think about communicating this positive change to patients. Morgan then breaks down continuity into four types: information, management, relational, and inter-provider. Sarah highlights key resources and shares an anecdote where she realized that her MOA was integral for her continuity of care. Morgan and Sarah emphasize the importance of communication within the clinic, and including patients in conversations that demonstrate HOW you are communicating and connecting as a team in practice.

Special thanks to Amie Hough, a Leader in Health System Improvement for Primary and Community Care with Health Quality BC, and one of the creators of the learning pathway, who we will be hearing from throughout the season.

Links and Resources

For more information on the Team Based Care Learning Pathway check out https://teambasedcarebc.ca/team-based-care-pathway/

What Matters to You

These resources helps us use conversations to understand more about our patients

https://teambasedcarebc.ca/resources/what-matters-to-you/

What matters to Patients with Virtual Care appointments

RN Virtual Virtual Primary Care Practice Guide

https://isu.ubc.ca/registered-nurse-virtual-primary-care-practice-areas/

Relational Continuity Change Package

https://actt.albertadoctors.org/pmh/panel-and-continuity/continuity-posters/

Through the TeamUp network we are working to advance supports for team based primary care. Please reach out to [email protected] if you would like to learn more!

Morgan and Sarah continue their discussion on Stage 2 of the Learning Pathway for Primary Care Teams. This episode is focused on Team Building, and specifically, seeing Patients as Team Members. The hosts make a point that patients are essential team members, and understanding the patient perspective when transitioning to team based care is important. If a practice is moving to team based care, patients likely won’t know what to expect, and may even be worried that their standard of care is lowering. Morgan and Sarah highlight the importance of exploring methods of communication to help explain this new care model. Furthermore, the discussion emphasizes how small communication changes in everyday practice can have a significant influence and help patients feel more supported. Finally, practical suggestions are made to help healthcare establishments in manifesting their teams via checklists, orientation activities for new patients, posters, and website representation.

Special thanks to Amie Hough, a Leader in Health System Improvement for Primary and Community Care with Health Quality BC, and one of the creators of the learning pathway, who we will be hearing from throughout the season.

Links and Resources

For more information on the Team Based Care Learning Pathway check out https://teambasedcarebc.ca/team-based-care-pathway/

To get started check out the culture change toolbox and the “Questions to consider before getting started” on P 12 of the toolbox.

Read over the AHRQ White Paper discussed in this episode “Creating patient Centred Team Based Care” (2016). This includes a great list of strategies for providing patient centred team based care (p. 7-19)

Check out the activities laid out in the Patient Centred Teams “Setting the Stage” handout

Past Podcast Episodes that may be of interest:

• TeamUp podcast: S05 E02 Patients as team members
• Explore more of the resources in Stage 2 of the Team Based Care Learning Pathway.

Through the TeamUp network we are working to advance supports for team based primary care. Please reach out to [email protected] if you would like to learn more!

Stage 2 of the Learning Pathway for Primary Care Teams is focused on Team Building. In this episode of Team Up, Sarah and Morgan focus on a key element within this stage: the importance of building relationships within a team. We explore the value of returning to shared purpose and shared goals as a tool to support effective team building and collaboration. We also provide practical tips and discuss some of the great resources that are highlighted in the Team Building Stage of the Team Based Care Learning Pathway.

Special thanks to Amie Hough, a Leader in Health System Improvement for Primary and Community Care with Health Quality BC, and one of the creators of the learning pathway, who we will be hearing from throughout the season.

Links and Resources

• For more information on the Team Based Care Learning Pathway check out https://teambasedcarebc.ca/team-based-care-pathway/
• For more information about shared purpose and some the resources we highlight in this episode check out the Shared Purpose Facilitation Guide
• Take a look at this template for Team Agreements and this collection of resources focused on Team Huddles, all resources that are connected to the Learning Pathway.

Past Podcast Episodes that may be of interest:

• TeamUp Webinar Feb 17 2022: Skill Building for Teams- Huddles
• TeamUp Podcast: S03 E03: Distributed Teams and Team Huddles
• TeamUp Podcast: S01 E07: Practical Tools for Virtual Team Based Care

Explore more of the resources in Stage 2 of the Team Based Care Learning Pathway.

Through the TeamUp network we are working to advance supports for team based primary care. Please reach out to [email protected] if you would like to learn more!

In this episode, Morgan and Sarah continue their discussion of the first stage of the learning pathway: Where to start with team based care. Our hosts focus on the importance of thinking about both service design and team readiness when transitioning to team-based care in primary care clinics. They emphasize the need to consider the existing services in the community when designing or redesigning a team. Sarah and Morgan also highlight a number of resources available for primary care teams in the first stage of the learning pathway, highlighting the Team Readiness Checklist as something for listeners to try out in practice.

Special thanks to Amie Hough, a Leader in Health System Improvement for Primary and Community Care with Health Quality BC, and one of the creators of the learning pathway, who we will be hearing from throughout the season.

Links and Resources

• For more information on the Team Based Care Learning Pathway check out https://teambasedcarebc.ca/team-based-care-pathway/
• For more information about Team Mapping, a tool to support teams working together on how they want to work together, in a patient centred way take a look at the following resources:
• Team Mapping MIROVERSE toolkit
• Price M, Bellwood P, Hill TT, Fletcher S. Team Mapping: A Novel Method to Help Community Primary Healthcare Practices Transition to Team-Based Care. Healthc Q. 2020 Jan;22(4):33-39. doi: 10.12927/hcq.2020.26086. PMID: 32073389.

Past Podcast Episodes that may be of interest:

• S03 E07: A Quick intro to Team Mapping
• S03 E09: Clearer Roles in Distributed Primary Care Teams

For links to the job descriptions and role material described in this episode explore stage 1 of the team based care learning pathway

• Role Descriptions
• Sample RN posting

Find the Team Readiness checklist here to try it out in practice

Through the TeamUp network we are working to advance supports for team based primary care. Please reach out to [email protected] if you would like to learn more!

https://teambasedcarebc.ca/team-based-care-pathway/where-to-start-with-team-based-care/

In this episode, Morgan and Sarah introduce the first stage of the Team Based Care Learning Pathway and focus on the importance of getting to know your patients. Morgan and Sarah explore two ideas related to getting to know patients,

1. Utilizing EMR data for demographic insights and chronic condition trends and
2. Conducting patient surveys to uncover needs.

Special thanks to Amie Hough, a Leader in Health System Improvement for Primary and Community Care with Health Quality BC, and one of the creators of the learning pathway, who we will be hearing from throughout the season.

Links and Resources

For more information on the Team Based Care Learning Pathway check out https://teambasedcarebc.ca/team-based-care-pathway/

Here are a few of the highlighted patient experience survey tools from a recent review by the ISU:

• Patient-Perceptions of Team Effectiveness (PTE) questionnaire (43 item survey- Canadian)
• Kilpatrick K, Tchouaket É, Paquette L, Guillemette C, Jabbour M, Desmeules F, Landry V, Fernandez N. Measuring patient and family perceptions of team processes and outcomes in healthcare teams: questionnaire development and psychometric evaluation. BMC Health Serv Res. 2019 Jan 6;19(1):9. doi: 10.1186/s12913-018-3808-0. PMID: 30612571; PMCID: PMC6322340.
• (Demonstrates strong reliability and validity in assessing healthcare team functioning, covers critical dimensions of integrated care such as role clarity, boundary work, perceptions of team effectiveness, and outcome of care. It is easy to administer and aligns well with the primary care context)
• **Patient Reported Indicators Survey (PaRIS) (121 item survey that can be broken up into sections- International)**
• Slawomirski, L., van den Berg, M., & Karmakar-Hore, S. (2018). Patient-Reported indicator survey (Paris): aligning practice and policy for better health outcomes. World Medical Journal, 64(3), 8-14.
• The Innovation Support Unit is currently working on a comprehensive review of patient surveys to recommend a survey for use as part of the TBC evaluation. Watch this space for updates!

Through the TeamUp network we are working to advance supports for team based primary care. Please reach out to [email protected] if you would like to learn more!

https://teambasedcarebc.ca/team-based-care-pathway/where-to-start-with-team-based-care/

In this episode, Morgan and Sarah introduce Season 6 of Team Up and discuss the new team-based care pathway. They highlight the motivation behind creating the pathway and how the pathway will structure the season. The episode also includes a tangible takeaway for listeners, as Morgan and Sarah suggest trying out the team effectiveness tool available on the teambasedcarebc.ca website as a place to start!

Special thanks to Amie Hough, a Leader in Health System Improvement for Primary and Community Care with Health Quality BC, and one of the creators of the learning pathway, who we will be hearing from throughout the season.

Links and Resources

For more information on the Team Based Care Learning Pathway check out https://teambasedcarebc.ca/team-based-care-pathway/

The Team Effectiveness Tool is a short, multiple-choice assessment that gathers information about your team’s values, communication, roles, and existing supports to help guide your learning on team-based care. https://teambasedcarebc.ca/team-effectiveness-tool/

Through the TeamUp network we are working to advance supports for team based primary care. Please reach out to [email protected] if you would like to learn more!

The transition to a post-pandemic world has drawn increased attention to the tensions, pressures and capacity challenges that are experienced by health care providers and patients in primary care systems around the world. In the face of these challenges, in British Columbia, policy makers, funders, providers, and patients are working through another transition- the transition to team based primary care. The Innovation Support Unit, in the Department of Family Practice at the University of British Columbia, has been working to develop a series of implementation supports for communities, teams, providers and patients engaged in this transformation of Primary Care. Designed to accelerate planning and implementation, the mapping methods support inclusive, patient-centred and equity focused discussion and decsion-making.

This podcast episode tells the story of the evolution and iteration of the mapping tools and supports that have been co-developed by the ISU and communities across BC engaged in the implementation of team based care in primary care.

Drawing on the experiences of the ISU team as well as community interviews, the episode highlights the challenges, opportunities and potential new directions in the transition spaces of primary care transformation. Please see the resources below for more information about the primary care supports highlighted in this story.

Thanks to our guests!

Megan Sloan is the manager of the Qathet Primary Care Network, the regional district that surrounds the city of Powell River. Over the last 13 years, Megan has very engaged with the local community of physicians and nurse practitioners in Qathet and has taken on a variety of roles supporting primary care practices and planning.

Leslie Keenan: is the Executive Director of the South Island Division of Family Practice. Leslie has a long history of supporting primary care in communities, prior to her time with South Island she was the ED of the Nanaimo Division of family practice.

Amanda Frazer is the Strategic Lead of Primary Care Implementation Supports with the Innovation Support Unit. We are so grateful she was able to join us from her maternity leave! Amanda is passionate about the intersection between community engagement and system change. Prior to joining the ISU Amanda worked with the Campbell River Division of Family Practice.

Aleah Ross is the Primary and Community Care Mapping Lead with the Innovation Support Unit and is currently a PhD student at the University of Victoria in clinical psychology.

Morgan Price is the director of the ISU. He is an Associate Professor at UBC and affiliate faculty at UVic Division of Medical Sciences, Computer Science, and Health Information Science. Morgan is a family physician and practices in a Community Health Centre where he provides team-based care to underserved populations in the inner-city in Victoria. His research is in health systems change and clinical information system design and adoption.

Resources

For more information about Team Mapping:

• Read Team Mapping: A Novel Method to Help Primary Care Teams in Transition
• visit teammapping.ca
• check out our MIROVERSE template at https://miro.com/miroverse/team-mapping/

For more information about PACC mapping:

• Read Primary and Community Care Mapping: Helping Communities Collaboratively Plan Health Services in a Patient-Centred Manner
• please check out our MIROVERSE template at https://miro.com/miroverse/isu-pacc-mapping/

You may also be interested in checking out some of the material related to TEAL organizations through the Re-Inventing Organizations WIKI based on the work of Fredrick LaLoux.

If you would like to learn more about the ISU or if you have any ideas for future podcasts please email [email protected]

It’s the end of Season five! In this wrap-up episode Morgan and Sarah reflect on the variety of roles that were showcased this season, share some season highlights and key recommendations for action and give a with a sneak peak at what’s to come- first a break, then SEASON 6!

Exciting plans are already in the works for Season 6, which will be focused on PRIMARY CARE CLINIC STORIES and (spoiler alert!) may include more in-person conversations and in-the-field reflections! Reach out to [email protected] you know of a clinic whose team story should be shared!

Thanks to our Guests and to the ISU Team

No guests this episode but a huge thank you to all the wonderful people who connected with us this season. Thanks to the over 30 providers who helped us create season five - we are so grateful to everyone who agreed to talk with our team!

Special thanks goes out our amazing ISU team who were behind the scenes making this season a reality! Thanks to Josephine Lam and Erza Mjekiqi who both jumped in to interviews, reviewing transcripts and coordinating and connecting with guests and special thanks to Tlell Elviss who did all that AND joined our script writing and production team!

Resources

If you are interested in learning about resources and supports available to primary care teams, try out the new Team Effectiveness Tool , part of www.teambasedcarebc.ca

As we take a break over the next few months take a listen to some our favourite episodes of Season 5 or spend some time listening to our earlier seasons!