Developing a Framework and Inventory of Instruments to Measure Team-Based Primary Care

Background: Team-based care holds promise to improve patient outcomes, care processes, and patient and provider experiences of care. However, the understanding of how care teams should function and ways to improve care teams is hampered by a lack of a strong theoretical conceptual framework and validated measures, specific to the primary care setting, which can be used for research, evaluation, and quality improvement purposes. Successful primary care redesign efforts such as the Patient-Centered Medical Home require a “high-functioning” primary care team that delivers “team-based care.” Thus, having a robust measure or measures of team-based care appropriate for the primary care setting is of utmost importance in order to evaluate and improve team functioning and patient outcomes. The objectives of this Agency for Healthcare Research and Quality (AHRQ)-funded project were to collect, evaluate and catalogue instruments to measure team-based care in a manner that would serve the needs of individuals engaged in quality or practice improvement in primary care settings, as well as researchers and evaluators. 

Methodology:To develop a conceptual model and identify measures of team-based care we explored several sources, including: measure databases (e.g., NQF, Nat’l Quality Measures Clearinghouse, HHS Measure Inventory, NIH GEM database), Measures Application Partnership, and CAHPS. We also sought input from experts in team care, examined reviews of team care measures, and completed a review of the peer-reviewed and grey literature on both teamwork and team-based primary care. 

Findings:The conceptual framework presents 4 domains that are mediators of high-functioning teams: cognitive (sense-making, continuous learning, shared explicit goals and accountability, and evolving mental models of roles), affective/relational (trust, respectful interactions, heedful inter-relating, and commitment), behavioral (communication, adaptable to context and needs, and conflict resolution) and leadership.  After reviewing over one hundred different measures of teamwork, we identified 57 instruments of relevance to team-based primary care. Thirty-five instruments were from health care.  Some instruments will require adaptation (e.g., wording changes) in order to use in primary care settings.  Most instruments were surveys (n=48); a few were observational checklists and other types of instruments. Most instruments address multiple conceptual framework constructs, but with differing degrees of emphasis.  Among the most common domains or attributes of teamwork and team-based primary care identified in the instruments include: communication, coordination, collaboration, respect, use of all team member’s expertise, conflict management, group cohesion or shared identity, shared workload, and role responsibility and understanding.

Conclusions and Implications: There are many instruments available to measure team-based care; however, further work is needed in the guidance that accompanies these instruments to support use, analysis and interpretation of results by individuals involved in practice improvement. The forthcoming web-based Inventory of instruments will be a valuable resource to support measurement of the requisite attributes of effective teamwork to ultimately advance and improve team-based care delivery in primary care.