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Coleman Associates has trained and coached Patient Visit Redesign™ (PVR) teams since 1993. As well as we know teams, we find it difficult to de- scribe a high-performance team in terms that others would find insightful or illuminating. But the truth of the matter is that there are teams and there are TEAMS. And the differences between the two are profound and identifiable.

Meet the DT² Redesign Team. DT² ("Do The Damn Thing") was undistinguished as it lumbered through its initial work, but then it morphed into a high-performance TEAM.

Our PVR reporter, Molly Weisse-Bernstein, reveals the anatomy of a high-performance redesign team in this interview with DT² of Harbor-UCLA Medical Center's Wilmington Family Health Center in Wilmington, California.

What Makes a Great Team?

How does a team go from being a group of people working together to a shatterproof force that exceeds expectations? First, team members must strongly share a common purpose. The purpose of DT² was
"to transform the patient experience", and all team members believed passionately in this call to arms.

Second, the team must have a quantifiable goal by which it can judge its own performance objectively. The DT² goal was: "90% of all patient visits would be completed within 45 minutes or less." (Prior to redesign, the average cycle time was 107 minutes.)

Third, the team must be comprised of people who—collectively—have the skills, personal traits, and determination to resolve the problems that hinder progress and success.

Fourth, team members must be able to discuss openly even the touchiest topics and issues, including team dynamics; current processes and policies; resistance among staff and managers; budget constraints; as well as responsibility and accountability within the team.

Fifth, a team must work together frequently and face-to-face. Teams are not formed around conference calls, emails, and monthly meetings. Redesign teams complete their work in test clinics and work sessions where the work is done in real time by all team members.

"The thing that made us work well as a team," said Angela Nossett, MD, team leader and assistant medical director, "was that we were willing to work hard and address any topic together. We were committed to achieving results."

The Situation

At Wilmington Health Center the doors open at 7:30 a.m. and about sixty patients are waiting to enter the clinic. After that, walk-ins stream in throughout the day. Before redesign, the average patient visit took 1¾ hours and productivity averaged 2½ patients per clinician per hour. There were continuity-of-care issues as patients found themselves seeing different clinicians from visit to visit. The medical charts were a mess, with forms and lab results missing or incomplete. Sound familiar?

Most of the staff at Wilmington Family Health Center believed serious changes were necessary, and there was much discussion about creating a staff-driven task force to address some of the most pressing issues. But it never happened.

When the clinic was invited to form a redesign team for the Patient Visit Redesign™ Collaborative sponsored by CAPH/SNI (California Association of Public Hospitals/Safety-Net Institute), the staff thought this must be the oft-discussed county-commissioned task force that would make minor improvements.

Instead, guided by a PVR coach, site managers chose a team whose membership included two physicians, a nurse, the office manager, and a clerical associate. It was a typical PVR team in composition. Team members were not chosen for their positions or length of tenure, however, but for their personal attributes. "We looked for individuals who were frustrated with the current processes but were also problem solvers, team players, and good communicators," said Pamela Weisse, the team's coach.

"We had a mix of new blood and old blood on the team, and that was good." said Gina Wing, RN and team member, "You get new ideas as well as the things that have worked well in the past."

An Epiphany

To prepare for their first Learning Session (there are four in a Patient Visit Redesign™ Collaborative), team members tracked and documented a series of patient visits, minute by minute. Since the average visit consumed 107 minutes at Wilmington, tracking two patient visits took each team member over 3.5 hours to complete. Ouch!

DT² resented this extra work. "In the beginning, we didn't realize how big this project was and we just wanted to get it over with," said team member Mauricio Flores, MD. But during the tracking exercise, the team realized how poorly their system worked for patients. "It was depressing to find out how horribly we were doing," said Flores.

As they gathered in San Francisco for Learning Session One with eight other Patient Visit Redesign Teams from public hospitals across California, DT² began to realize this may be a unique opportunity. "It wasn't until Learning Session One that I understood what we were really trying to do," said Nossett. "I actually got very excited and energized about it. We had never had a forum like this to make sweeping changes."

The team's epiphany was that this would be a serious—maybe even profound—journey. Flores reports: "We said to ourselves: This is what we've been waiting for but just haven't gotten around to doing. This is the real thing. This is a one in a million shot. Why not give it all we've got?"

A Commitment Made Is a Commitment Kept

Redesign teams focus on cycle times and productivity, but the ultimate goal is patient-centered care. "Throughout the eight-month collaborative, the team never lost its focus on patients," said Pamela Weisse, PVR Coach. "They couldn't stand the old patient visit process, so they realized they were free to re-create it, as if the health center had just been invented today."

The team members shared the drive and determination to succeed—in a nutshell: a refusal to fail. Nossett puts it this way: "Even though we didn't hold hands and sing Kumbaya, the people on the team were committed to making redesign happen no matter what."

Debbie Cornelius, assistant nurse manager, describes the team as "...a lot of highly motivated people." Added Dr. Flores: "Nobody on the team ever said 'I don't want to do this. I can't do this.' None of us ever said 'No' to anything that was asked of us." Helen Soto, office manager and team member, adds: "Everything isn't always smooth and easy. There are going to be things that block your way and you've got to keep going." Pamela Weisse, their coach, characterizes the team as: "...quietly determined and unstoppable."

Communication and Conflict

A crucial juncture in the team's development was reached when a team member quit the team. This is always, among redesign teams, a cause for great self-reflection and truth-seeking. The team member was unquestionably dedicated to serving patients well, but repeated clashes in team sessions led to her withdrawal.

The resignation of a team member is not necessarily a bad thing, but it should always lead to the team examining its own modus operandi and making all necessary adjustments, as DT² did. PVR coach Weisse began pressing the team hard around issues of team dynamics. "It was really important to push them on team dynamics to accelerate their teamness—the quality of all team members being fully and emotionally committed to the team's work. Otherwise, I thought problems with their internal dynamics could undo them."

They learned from their setback, which is all you can ask of a team. "We became better listeners" said Wing. "We made sure we would hear each other out and were willing to give most ideas a try. We didn't want someone to feel squashed for speaking out," said Nossett. "I felt confident enough to bring up anything and know I would be respected."

DT² became a strong team precisely because of their struggles. "The character of a redesign team is determined by the way it responds to setbacks," adds Roger Coleman, a trainer and coach with Coleman Associates. "A team without struggles and setbacks is not destined to be a great team any more than a person without the experience of overcoming adversity will become a great person."

DT² team members have worked at Wilmington Health Center between two to twenty years. They've partnered on various projects in the past. But familiarity is no guarantee of openness to change, dialogue, or new ideas. It was the team's new emphasis on good communication and open dialogue that was crucial to its evolving into a high-performance team.

Results, Results, and More Results

DT² has accomplished a great deal. Staff members are happier. Clinicians are more productive (by 12%). And patients don't have to wait a long time in the waiting room because patient visit cycle time stays within the 33-45 minute range, on average, which is a decrease of over 60%. The team—and the staff with which they've worked so intimately—have achieved results beyond their wildest expectations. And the team made these changes quickly—in a matter of months—without having to jump through innumerable hoops. "We felt free to change just about anything we needed to," said Nossett.

Surely the Patient Visit Redesign™ methodology was crucial to the team's success since team members glowingly describe how empowering it was and how little it looked or felt like a typical project. And, the team's Patient Visit Redesign™ model was also a big factor in its success—a little engineering goes a long way in primary care.

But the most critical underpinning of DT²'s success was the collective talent, skills, and efforts of this redesign team. They were dedicated problem solvers who set aside their personal agendas to improve the clinic to benefit the patients.

"DT² is the epitome of a self-directed team," said Dawn Flores de Ramirez, administrator for ambulatory services at UCLA-Harbor Medical Center. "The team members are very motivated individuals who want to do what's right and what's best for their health center. I think that was their driving force."

DT² proved the point: Real teams blast through problems, obstacles, and barriers that otherwise wither individuals, groups, and committees. There are teams and there are TEAMS. DT² is a TEAM.