As today's health care delivery system evolves, all levels of professionals are learning that a "team" approach is both efficient and effective for providing quality patient care. However, while new graduates may learn to work as a team after entering the job market, little is currently done to provide students with the skills necessary for interdisciplinary team work during the educational process. The Academic Health Center's Team Development Task Force was created to respond to the need for a well-articulated approach to interdisciplinary health sciences education.

The Task Force, made up of leaders from selected health care disciplines already experimenting with team approaches to health care, undertook this challenge at the request of the Provost for the Academic Health Center of the University of Minnesota. At the beginning of the project, the Task Force was asked to accomplish the following goals:

1. Define the concept of the "health care team."
2. Develop a vision for team-based health care.
3. Describe the educational resources and processes necessary to support health team development.

Through our efforts to reach these goals, we have developed a list of competencies necessary to a successful health care team. In addition to this model, we offer four recommendations necessary for the training of professionals able to work effectively in health care teams:

1. Competency in skills needed for work in health care teams must be built into curricula of the Schools of Medicine, Nursing, Pharmacy and Public Health.

2. Some portion of the clinical training for student nurses, pharmacists and physicians must be in a setting where patient care is delivered through a team and where competencies in team delivery are taught.

3. "Continuing education" programs for nurses, pharmacists and physicians must include specific training in health care team competencies.

4. Commitment to the concept of health care delivery teams must be demonstrated at the highest possible level within the University and the Academic Health Center. The Vice Provost for Education would have responsibility for assuring that the three previous recommendations are implemented and directing the enactment of mechanisms for faculty development on this issue.

The remainder of this report provides the background and rationale for these recommendations. We begin with a discussion of how we view the future of health care delivery. The subsequent sections contain a description of the competencies of a good "health care delivery team," barriers and forces supportive to the development of such teams and some current examples of working teams around the Academic Health Center. The section "Implications for Academic Curricula" contains a discussion of the elements necessary for successfully training teams of health care professionals. Finally, we conclude with a brief discussion of the relevant stakeholders for implementation of the proposals.

The University of Minnesota Health Sciences has had a long standing interest in developing interdisciplinary programs. In 1970, the University was one of a few institutions of higher education to attempt the development of an integrated Health Sciences Center. During the years that followed, attempts were made to find effective ways to bring students together for interdisciplinary education. One example was the Windows of Opportunity program, where scheduled classroom time was reserved for interdisciplinary courses. Another example is a research program that places pharmacy students with medical students in a rural practice environment. One of the most successful efforts has been the Council for Health Interdisciplinary Participation, a student-led organization that offers seminars, programs, and retreats for all health sciences students including a winter series on bioethics, retreats on drug and alcohol abuse, and seminars on cross-disciplinary team work.

However, it has become apparent that these programs, albeit excellent ones, are not enough to prepare graduates for work in an increasingly complex health care environment. In tomorrow's world of health care, interdisciplinary collaboration will be seen as a requirement rather than an extra-curricular activity. In the summer of 1995, the Academic Health Center at the University of Minnesota initiated a process of change designed to more closely match the student's learning experience with the current environment of health care delivery. As part of this process, University faculty began to examine the relationships that the Academic Health Center has with new and existing students, alumni, the patient population, and the community. The findings from this initial data gathering process led to a series of committees charged with developing strategies and plans for innovation within the Academic Health Center. At about this time, Dr. Lawrence C. Weaver, Dean Emeritus of the College of Pharmacy, with the support of the Deans of Medicine, Nursing, Public Health, and the School of Medicine in Duluth, requested that the Provost form a committee for health care team development.

In response to this request, the Provost invited a group of individuals to form a Task Force focusing on interdisciplinary training. He gave the following charge:

1. Define the concept of the "health care team."

• Identify the essential elements of a health care team.
• Identify potential members of the health care team.
• Describe differences between teams

2. Develop a vision for team-based health care.

• Enunciate the forces supporting health team function in practice and in education.
• Enunciate the forces hindering health team function in practice and in education.

• Examine implications for curriculum development.
• Identify key groups to be enlisted in support of the concept and its successful implementation.

The Honorable Sandra Gardebring agreed to chair the Task Force, which met on a bi-weekly basis Wednesday, February 14, 1996 through June 12, 1996. Judge Gardebring, a member of the Minnesota State Supreme Court, brought to the Task Force an unbiased perspective as one who was not a member of either the University of Minnesota or a specific health discipline.

The membership of the Task Force included representatives appointed by the Deans of Pharmacy, Nursing, Medicine, and Public Health. Two of the members, Dr. Lowell Anderson and Ms. Gayle Hallin, joined as representatives from the practice community. Dr. Dan Benzie, from the School of Medicine in Duluth, joined as a representative of medical practice in rural Minnesota.

Throughout the four month period during which the Task Force met, a number of speakers came to present information on existing interdisciplinary programs. They included speakers from the Center for American Indian and Minority Health, the Interdisciplinary Geriatric Team Training Project, the Buyers Health Care Action Group, Health Partners, the Council for Health Interdisciplinary Participation, and the Integrated Care Management Program (from the University of Minnesota Health System). These speakers each provided the Task Force with their perspective on health care delivery, as it currently exists and how it will look in the future. Speakers were asked to discuss how team building is carried out within their organization and to describe the skills they would like to see from newly graduated health professionals. In addition to the presentations, an extensive literature search was carried out to identify trends in the practice and education of interdisciplinary health teams. This period of discussion and research facilitated the creation of the following sections of this report.

Chair
Sandra S. Gardebring
Associate Justice
Supreme Court of Minnesota

Lowell Anderson, DSC.
President, Watauga Corporation

Mila Aroskar, Ed.D., R.N.
Associate Professor
Division of Health Management and Policy
School of Public Health

Dan Benzie, M.D.
Rural Family Physician, Moose Lake
Clerkship Director UMD School of Medicine

Donna Zimmaro Bliss, Ph.D., R.N., CCRN
Assistant Professor
School of Nursing

Robert Cipolle, Pharm.D.
Director, Peters Institute of Pharmaceutical Care
College of Pharmacy

G. Scott Giebink, M.D.
Professor of Pediatrics and Otolaryngology
Associate Chairman of Pediatrics
School of Medicine

Gayle Hallin, MPH, R.N.
Health Administrator
Division of Health
City of Bloomington

Joseph Keenan, M.D.
Professor of Family Practice
and Community Health
School of Medicine

Lawrence Weaver, Ph.D.
Dean Emeritus
College of Pharmacy

The Task Force received extensive assistance from David Garloff, Ed.D., Health Sciences Learning Resources, Andrea De Vries, School of Public Health, and Jeannie Schwartz, College of Pharmacy Dean's Office.

Traditionally, the patient viewed the primary care physician as the point of reference when seeking care. The primary care physician was responsible for recommending health care interventions and for making sure the appropriate health professional assisted in delivering that care.

However, this traditional model has become increasingly complex. Today, patients often encounter a "triage" system which may direct them to many types of health professionals. A "case manager" may be involved in managing a patient's care or a nurse practitioner may deliver primary care for some conditions and refer the patient for other services when needed.

This change in the way patients receive care creates new challenges and exacerbates old difficulties among health professionals. These difficulties include duplication of services and costs associated with such duplication; poor communication among the different health professionals, and a poor understanding of each person's role in the care delivery process.

As perceived by patients, the need for a better integrated health care team occurs because of:

1. Poor Communication.

Part of the training in each area of health care includes acquisition of a new set of terminology. While this allows precision when discussing an issue within a particular field, communication across professions or fields may still be difficult. Dissimilar vocabularies and a lack of integrated record keeping systems result in an uneven and incomplete exchange of information among the professionals who provide health care services.

2. Duplication of Services

Communication between professionals is also not ideal as a result of a limited understanding of the expertise of other professionals. If a provider does not have access to test results previously ordered, a request will be made for new tests. Diagnostic tests and other services may be repeated by several providers, resulting in excess cost and additional stress for the patient. Errors and inappropriate therapy from prescription drug medications may also occur when more than one health professional is prescribing drugs for a patient.

3. Lack of Patient Focus

Patients are seeking continuity and coordination of care, competence, accessibility and timeliness, reasonable cost and some sense that someone in the "system" cares about them. When health care professionals do not work well together, patients feel that commitment to them as individuals in need of care is lost.

These factors lead the Task Force to a conclusion that a focus on coordinated patient care is exceptionally important. This is one statement on which health professionals -- physician, nurse, pharmacist, public health worker -- are in general agreement. Accomplishing this coordination, however, is another matter altogether. Factors including "turf issues" and the structure of financial incentives are barriers to the development of effective teams. However, it is the view of the Task Force that the biggest barrier is created by a lack of familiarity with "team work" in a health care setting. In the next section we will attempt to identify key characteristics of a health care team.

1. Patient Centered Focus

A good team must have as its first priority meeting the patient's needs. A team with a patient centered focus will consider and respect the patients' values and preferences when making care decisions.

2. Establishment of a Common Goal

If the patient's needs are to be the focus, it is critical that all team members know what a successful outcome for each patient's care will be. In many cases, defining a successful outcome can be straightforward (i.e. clearing up an infection). However, in some instances a successful outcome may not be self-evident. For example, health care professionals treating a critically ill patient may work at cross purposes if some feel the patient should be treated aggressively while others feel that the patient should only receive palliative care. Such confusion may be avoided only through an explicit process for goal definition. If choices are to be made between competing outcomes, the patient (or the patient's family) must, of course, be involved.

3. Understanding of Other Members' Roles

The team members must be familiar with the professional capabilities of other persons on the team and must be willing to acknowledge greater expertise and, in some instances, to defer to other team members.

4. Confidence in Other Team Members

Confidence in other team members develops with time, and most certainly requires an understanding of other members' roles. Each member must be able to trust the work of others. If professionals do not have trust in another's work, duplication of services may occur. For example, a specialist physician who is not confident in the care provided by the primary care physician may order extra or unnecessary tests for the patient.

5. Flexibility in Roles

While understanding and respect for each person's specific role is important, flexibility in assignments is also important. Using basketball as an example, the guard is not expected to make many baskets. However, if the opportunity presents itself (i.e. a foul has been called) then the player should be able to score points for the team. Similarly, it is undesirable for each team member to duplicate efforts made by others; but, if meeting the agreed upon objective calls for changes or flexibility in roles, team members must be prepared to act accordingly and with respect to professional standards of practice.

6. Joint Understanding of Group Norms

Members of successful teams will be aware of the expectations of others in the group. These expectations are often behavioral -- punctuality or willingness to stay current in one's field.

7. Mechanism for Conflict Resolution

Every health care team will experience instances of conflict. However, a successful health care team will identify a specific mechanism, clearly understood by all, for resolving conflict, through a team leader, outside leader, or other process.

8. Development of Effective Communications

Good health care team communication involves at least two components -- a shared, efficient and effective record keeping mechanism, electronic or other, and a common vocabulary. While wholesale reform of medical record keeping is beyond the reach of even the Academic Health Center, development of common language among professionals is not, nor is instilling in students the need for shared, clear patient records.

9. Shared Responsibility for Team Actions

Effective team functioning can occur only if each team member shares fully the responsibility for actions of the team as a group -- and is willing to be held accountable for those actions. Undertaking of such responsibility requires, of course, confidence in the abilities of the other team members, good communication and agreement upon a common goal. Thus, these team "competencies" must reinforce each other.

10. Evaluation and "Feedback"

Team design must be dynamic: open for evaluation and revision on a continuing basis. A model that worked previously may no longer be optimal as there is change in the patients' needs, the health care delivery system or the expertise of team members. A specific mechanism must be developed for ongoing evaluation of a team's effectiveness and redesign where needed.

Other team characteristics may be considered, but the Task Force believes these are central to successful delivery of health care by fully integrated teams of professionals. If competencies in each of these areas are developed, nurses, pharmacists and physicians will be prepared to function effectively in a team-based setting.

1. Teamwork in Academic Curricula: Interdisciplinary Geriatric Team Training

One example of teamwork in academic curricula is the Interdisciplinary Geriatric Team Training Project currently being developed by Dr. Robert Kane and Dr. Joseph Keenan at the University of Minnesota. This program integrates discipline specific training (in participating schools and departments) and interdisciplinary teaching and training exercises (in a common core) with clinical observation and patient care primarily in a geriatric managed care environment. Currently, the members of this project are in the process of developing:

• Established learning objectives for interdisciplinary training.
• A common didactic and clinical core of interdisciplinary training.
• Mechanisms for integration of the training program with existing disciplinary programs.
• Opportunities to observe and participate in geriatric team care across a clinical continuum of community based care.

This project has been funded by the Hartford Foundation and will be implemented over the next several years. The University of Minnesota Department of Family Practice, the Geriatric Evaluation and Management Clinic, the Wilder Foundation, HealthEast Transitional Care Units, and Fairview Health System will serve as partners in this effort.

2. Teamwork in Clinical Practice: Integrated Care Management

Within the University of Minnesota Health System, Joanne Disch, Director of Patient Care Services, and William Payne, Professor of Surgery, have co-chaired a program for Integrated Care Management. They have defined "integrated care management' as a collaborative process of care delivery in which clinical pathways and principles of case management are used to achieve specific outcomes. Over the past year, they have created:

• Jointly developed clinical pathways.
• Interdisciplinary care planning processes and tools.
• Integrated patient assessment tools.
• Integrated transition/discharge tools.
• Interdisciplinary quality improvement systems.
• Shared management systems.
• Opportunities for decision-making and dispute resolution.

The integrated care management program has been implemented within the Surgical Intensive Care Unit at the University of Minnesota Health System. Following implementation of this program, the unit achieved positive results such as decreased length of stay, decreased medication errors, and cost savings of $10 million.

3. Teamwork in Continuing Education: Comprehensive Advanced Life Support

The Minnesota Academy of Family Physicians has supported the development of an interdisciplinary continuing education course for rural health professionals in the area of Comprehensive Advanced Life Support (CALS). This course has been developed over a three year period with the cooperation of a range of health professionals from throughout the state of Minnesota and faculty within the University of Minnesota Health System. The Comprehensive Advanced Life Support Course is unique for a number of reasons. First, the course is comprehensive, containing essential information from many areas of emergency care such as cardiac care, trauma, pediatrics, and obstetrics. This means that the health professional is only required to take one course rather than five or six. Second, CALS is taught through a team approach rather than through discipline specific instruction. The CALS philosophy is that since emergency care is provided as a team, continuing education for emergency care should also be a team effort. Third, the course is provided in a local setting, where the team actually provides medical care. This course is in the final stages of development. The first pilot testing for this course will begin in the fall of 1996.

As noted earlier, there are a number of barriers that prevent the development of successful training in team based health care delivery. These barriers include a lack of leadership, crowded curricula, lack of a reward structure, lack of understanding of other professions, and issues of accreditation.

1. Lack of Leadership

Most educators and health professionals would agree that development of competencies in team based health care delivery is a "good idea." However, the establishment of curricula in support of this "good idea" has not been a priority within the professions, faculties, or at a central University level. In the absence of a powerful "champion" or highly-placed leadership, the value of such training has not been recognized.

2. Crowded Curricula

Courses that include training in the competencies described above will be in competition with a large and increasing number of other courses for students in the health professions. Finding time to fit new courses in already overcrowded curricula is a non-trivial problem for faculty and their students.

3. Lack of Reward Structure

Faculty receive credit for courses taught within their own department and discipline. Working with other disciplines requires additional effort and time for all involved. At this point, there is not a significant tangible reward for providing training in the competencies necessary for good team delivery of health care other than that of a professional contribution.

4. Lack of Understanding

Faculty who themselves were trained according to a specific discipline may wish to remain within their own area of expertise. Many educators would feel that they do not have the background necessary to work as part of an interdisciplinary effort.

5. Accreditation

Each profession is required by its accrediting agency to equip its students with a particular set of skills and knowledge base. Comprehensive curriculum changes that focus on skills outside this narrow range may not meet accrediting standards.

6. "Turfism" and financial structures.

Current health care payment mechanisms and Academic Health Center reward structures do not encourage cooperative delivery systems. While external forces are at work changing the payment mechanisms, there will be a need for internal Academic Health Center change as well.

Supporting Forces

In spite of the barriers, there has also been an increase in the forces that support the development of health care delivery teams. These can be leveraged further by the careful elimination of some of the barriers addressed above.

1. Perceived Need Among Practitioners

Among health care professionals there is a sense that "we can do things better than what we are doing now." This is especially apparent when one considers the current emphasis on population based health care and the effort to target high risk groups with prevention programs. These approaches both lend themselves well to team based delivery approaches and may provide models for use of teams in other contexts.

2. Pressure from Managed Care Organizations

The concept of team based health care delivery is also endorsed by many managed care organizations. A managed care organization often provides care through a capitation arrangement rather than a traditional fee for service arrangement. In the fee-for-service model, the provider receives payment according to each service that is provided. This means that financial incentives are primarily focused on an individual effort. However, in a capitated system, providers do not submit a bill for each service provided. Instead, the group practice receives a predetermined payment for each enrollee in exchange for assuming responsibility for patient care. The incentives have changed so that the rewards are now accumulated through a group effort rather than an individual effort. This change in emphasis means that the managed care organization will look to see who can provide services most efficiently within the organization. Thus, training providers to work as a team is viewed as both cost effective and quality enhancing for the organization.

3. Change in Patient Expectations

Patients expect to be treated by health professionals who care, who are competent, and who are consistent over time. However, patients are more vocal in their requests that there be clear communication between themselves and their providers, as well as continuity in the delivery of care. These expectations are often best met in the context of team delivery of health care.

4. Opportunity Created by the Ongoing Restructuring

The University of Minnesota Academic Health Center (and other Academic Health Centers across the country) are undergoing a period of change. This creates a window of opportunity for introducing new curricula design that focus on the development of competencies supportive to team based health care delivery.

5. Research on Health Care Teams

Traditionally, faculty from diverse schools and colleges both within and outside the Academic Health Center have collaborated in multi-disciplinary research projects. Health care outcomes research is one such interdisciplinary effort. Since successful health care outcomes are the goal of team health care delivery, Academic Health Center support of expanded outcome research is likely to facilitate curriculum change in team delivery.

But taking into account the likely resistance to such change, we propose no revolutionary overhaul of the curriculum. Rather, we believe that, given adequate institutional leadership, modest curriculum changes can have a significant long term effect. To that end we propose that the Education Committee involved with the current reorganization of the Academic Health Center incorporate the following concepts into the curriculum redesign for Medicine, Nursing, Pharmacy, and Public Health.

1. Workshop on Team Theory.

We propose a weekend, interdisciplinary workshop for students in all three professional schools, to introduce the concept of health care delivery teams. Content of the workshop would also include an introduction to the expertise of the other health care professions. Optimally, the workshop would be offered as part of the orientation now provided to students entering into programs.

2. Curriculum Reform.

We propose that each professional school require that all students graduate with some experience in courses that are interdisciplinary in content and targeted to assuring the competencies discussed in Section IV of this report. Such courses should include faculty from the other schools and ideally would be team taught, as a way of modeling professional respect and cooperation. They would also occur later, rather than earlier, in professional training because team skills are best taught when students have sound professional skills and a good understanding of their own role in the delivery of health care.

3. Clinical Practice.

We propose that the programs for Medicine, Nursing, and Pharmacy require all students graduate with clinical training in team settings, specifically designed to train in the team delivery competencies. The medical student Ambulatory Medicine curriculum (Clinical Medicine IV) is a good example of a model for this requirement. A technique such as the Objective Structured Clinical Evaluation (OSCE) could also be incorporated into the clinical team training.

In this issue, we also propose that some clinics or departments of the University Hospital be specifically reorganized to operate with a team based delivery model, in order to provide clinical training settings for medical, nursing, and pharmacy students and to "model" the behavior we seek in the community.

4. Continuing Education.

We propose that continuing education offered by the professional schools should include training in the health care team competencies described in the other section, that it be promoted to the graduates of all of the schools and that approval for multi-professional training be sought from the various continuing education authorities.

5. Faculty Development.

We propose that the Provost provide incentives to Academic Health Center faculty to participate in and develop courses and clinical practice directed to the team delivery competencies discussed in this report. In particular, incentives should be provided to encourage: teaching "across schools," interdisciplinary faculty sabbatical projects and other faculty efforts directed at increasing the use of teams in the academic setting.

6. Research

We propose that the Provost provided funding for interdisciplinary groups of faculty to develop novel health care team teaching and curriculum models and health care team delivery research.

7 Leadership.

We propose that the Provost, through an appropriate management structure, provide the strongest possible support for the curriculum reform recommended in this report. If team delivery of health care is not regarded as central to the Academic Health Center's mission and teaching approach, the current effort will fail, as have past efforts.

1. Faculty of Medicine, Nursing, Pharmacy, and Public Health.
2. State and local professional associations.
3. Managed care organizations and other employers of Academic Health Center graduates.
4. Accrediting bodies.
5. Professional licensing authorities.

In conclusion, we are convinced that forces already at work in the health care system will ensure that increased interaction between health professionals will occur. To maintain its role as a premier provider of health education, the Academic Health Center must ensure that the graduates of its professional schools are equipped with the necessary competencies for successful collaboration. We believe that this report provides some modest, but important, proposals for reform of nursing, medical, pharmacy, and public health education in order to meet this objective.