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Teams, Practice Models and Patients

Despite the controversy and negativity about our healthcare system of late, we seem to have come to the realization that healthcare is indeed about the patient and that delivery systems should be designed or redesigned to suit that purpose. In the past, systems in hospitals and offices tended to be more provider-centric than patient-centric, features that contributed to frustrations such as long wait times, care fragmentation and low patient satisfaction.

In an era when cost control is of paramount concern, value in medical care has taken on a new emphasis and definition. Improving the value of healthcare delivery is driven by the need to contain costs in a marketplace where patients are demanding better access quality. Work toward the attainment of improved value has also led to the development of new and innovative models of healthcare delivery, such as integrated networks. Such systems are often put forth as models for other practices to emulate. However, even these can be difficult to replicate in other systems.1 Another example of novel care models is the patient-centered healthcare home, a concept that has gained attention in part due to its inclusion in healthcare reform.

Four Habits

Providing increased value in healthcare delivery is a challenge. Barriers include wide differences in structure, resources and culture among medical practices and delivery models.1 No single model has emerged as superior.

It has also proven to be difficult to transfer successful models that work in one system to another; regional differences seem to play a role.

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Nonetheless, one expert has identified four habits that characterize high-value providers and organizations (see box).1

These habits stand out as prominent attributes of successful models. Key to the effective functioning of new models of care delivery is the emphasis on teams.2

Team at the Center

In healthcare delivery, it is now nearly universal that teams are organized and established for meeting specific needs within delivery systems (habit 1). Such approaches represent a departure from the traditional provider-focused structures of care in which the physician is the dominant decision-making provider. In newer models, the team - particularly in primary care and ambulatory settings - comprises physicians, PAs and NPs.

In such care models, NPs and PAs are full participants in the design of system and decisions related to patient flow, the establishment of essential diagnostic and management criteria, and the development of clinical support systems. Moreover, care delivery is specific and planned. In such systems, operational decisions are defined.

Decision Making

Another important element that is part of habit 1 is shared decision making. The inclusion of patients in the determination of therapeutic decisions or the design of systems that take into consideration patient preferences and choices represents another progressive step in care delivery.

Habits 3 and 4 are hallmark characteristics of successful health systems and practices and are interrelated.

The desire to improve system performance and effectiveness, along with the institution of groups to measure and monitor such parameters, is a practice drawn from the business and management worlds. Organizations that embrace these concepts go beyond mere reporting of measurements.

They form self-evaluation units to apply quality, efficiency and value measures to clinical processes. They refine their systems constantly.1

Setting the Standard

NPs and PAs are a significant part of the transition to new models of healthcare delivery. Their presence in the workforce in staffing novel and emerging healthcare models of care is now standard or soon will be.


1. Bohmer RM. The four habits of high-value health care organizations. N Engl J Med. 2011;365(22):2045-2047.

2. Lee TH. Care redesign - A path forward for providers. N Engl J Med. 2012;367(5):466-472.

James F. Cawley is a physician assistant who is a professor in the Department of Prevention and Community Health in the School of Public Health and Health Services at George Washington University in Washington, D.C. He is the 2011 recipient of the Eugene A. Stead Jr. Award of Achievement from the American Academy of Physician Assistants.

Role & Growth Archives

As a full time clinician my team and I have been doing outcomes research on an interdisciplinary model of stroke rounds in an acute care setting. The four habits mentioned in this article we have used in our model. In fact I recently took a trip to London England where I visited an NP at St. Thomas's Hospital in London who showed me their team efforts to taking care of stroke patients. They seemed ahead in working as a team as I toured the stroke unit. The NP and physicians shared the same workroom/office on the unit and all the therapists needed for care of stroke patients were centralized right there on the unit. The NP relayed that she found it inconceivable that it could be any other way because, " we're a team".

Lana Pasek,  NP,  Sisters of Charity Hospital November 27, 2012
Buffalo, NY


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