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Workflow and Process Module 0.5 Credit CME

Creating Strong Team CultureEvaluate and improve team culture in your practice.

Team-Based Learning
Learning Objectives:
At the end of this activity, you will be able to:
1. Explain the importance of team culture
2. Describe strategies to improve team culture
3. List resources and tools that can be used to assess the current state of culture in your practice
4. Identify ways to engage your patients to help you build a stronger culture for your practice

STEPS Forward™ is a practice improvement initiative from the AMA designed to empower teams like yours to identify and attain appropriate goals and tactics well matched to your practice’s specific needs and environment. Wherever you find your team on the practice improvement continuum, the American Medical Association can help you take the next steps – the right steps – to improve your practice. Learn more

How will this module help me build a strong culture in my practice?

  1. Ten steps for building a stronger, healthier team culture

  2. Answers to common questions

  3. Case vignettes describing how practices have successfully enhanced team culture

Introduction

As anyone who has ever tried to change anything in a medical practice has noticed, sometimes the change sticks, and sometimes it doesn’t. Even more confusing, sometimes it’s a stunning success in one hallway, but the next hallway down nothing happens. Why is that? Did we use the wrong strategy? Employ the wrong people? Maybe the team needed more training? An important place to look for answers is culture.

What is culture in a practice?

Quiz Ref IDThink of your culture as the set of underlying rules and beliefs, usually unrecognized, that determine how everyone in your practice interacts with each other and with patients. Culture is the way an organization “does business.” New team members gradually absorb the practice’s culture without being taught, usually without even noticing.

Ten steps for cultivating strong relationships in the practice

  1. Diagnose the current state of your team culture

  2. Discuss the results and brainstorm possible improvements

  3. Create a staff compact as a group

  4. Create opportunities for team communication throughout the day

  5. Meet regularly

  6. Strengthen the team by focusing on individual development

  7. Get to know your team members

  8. Teach leaders to be mentors, not managers

  9. Create an environment that supports continual learning

  10. Engage patients

Step 1 Diagnose the current state of your team culture

Quiz Ref IDJust like we diagnose a patient before we treat, it is a good idea to diagnose your culture before you start intervening. Use surveys to gauge the health of your team culture. Examples of surveys to consider using in your practice include PeaceHealth’s TEAM Development Measure Survey and the Agency for Healthcare Research and Quality’s (AHRQ’s) Medical Office Survey on Patient Safety.

Make it clear that the survey is anonymous and that it will be used to improve the practice. These surveys should never be used to blame or punish any individual or group. Once the surveys are complete, share the results with the whole practice. Some practices may post the findings in a common area so team members can review and start to think about opportunities for improvement.

“Culture is what we say, what we do and what we value.”

Gurpreet Dhaliwal, MD, Internal Medicine, University of California, San Francisco

Gurpreet Dhaliwal, MD, Internal Medicine, University of California, San Francisco

Box Section Ref ID

Q&A

  • Why focus on practice culture?

    Your practice’s culture may be more important than individual strategies and policies you adopt. In fact, it has been said that “culture eats strategy for lunch.” Just as you can transform your processes, you can transform your culture. Furthermore, there is a feedback loop – your culture helps determine the success or failure of process transformation and how you transform your processes affects how your culture transforms. We believe you can engineer your culture to be one that will flourish in the current rapidly changing health care environment.

  • What drives successful team culture in health care?

    Successful team cultures have several attributes in common:

    • They have integrated teams

    • They are continuously learning

    • They engage patients in a meaningful way

    • They communicate well and listen to each other

Step 2 Discuss the results and brainstorm possible improvements

This can be as simple as asking people what results they think the group should work on and/or what they can do to improve in those areas.

  1. General rules about brainstorming:

    • Every idea matters. Don’t criticize the ideas of others. Don’t discuss the viability of the ideas while brainstorming

    • Combine and build on the ideas of others

    • Quantity matters more than quality. You can pare down the list of ideas later

  2. Ways to facilitate a brainstorming session:

    • Using a freewheeling approach, group members call out their ideas spontaneously and a scribe records ideas as they are suggested

    • In a round robin, the leader or scribe asks each member in turn for an idea. Participants may pass on any round, and the session continues until all members have contributed at least once and passed during the final round

    • In an individual or silent approach, each participant writes down his/her ideas on sticky notes and passes them to the facilitator

    • If your practice finds that multiple approaches could work, use a combination. Give everyone one to two minutes to silently brainstorm followed by round robin brainstorming. This is the best way to maximize participation by the quieter members of the group

  3. Categorize ideas for improving team culture:

    • If you have sufficient time available during the brainstorming session, begin to organize the ideas into categories as a group. If you don’t have time, the facilitator can organize the ideas later. Eliminate ideas that are not realistic for your practice, such as an idea that requires hiring a new employee or one that requires the EHR to function in a way that it does not. Let people know why certain ideas were eliminated so it does not appear you are criticizing an individual’s ideas

  4. Pick one or two ideas:

    • Consider “multi-voting” on an idea. For example, give everyone five pennies. Label cups, one for each idea you’re voting on. People can place all five pennies in the cup for one idea they support, one penny for each of five ideas, or any combination in-between. The cup with the most pennies wins. The advantage to this process is that it can be anonymous

    • Alternatively, create an impact-effort matrix. The matrix will help the practice determine where ideas fall on a scale of high to low effort of implementing and impact once adopted. Rate each idea on the impact you think it will have and the effort it will take to implement it. You can also do this as a group with sticky notes and whiteboard with “impact” on the x-axis and “effort” on the y-axis. Have the group place their sticky note on the graph based on the impact and effort they think each idea will have

Step 3 Create a staff compact as a group

Quiz Ref IDA staff compact is a written document that details how staff should treat each other. Everyone in the practice contributes to the staff compact. The process of creating the compact can be more important than the final product. The staff will be more invested in and live by the compact if they are involved in its creation. The process of drafting a staff compact strengthens the team by focusing them on values at the core of the practice’s culture. Annually updating the compact gives the opportunity to make appropriate changes and to involve new team members in making the compact their own.

Sample staff compact
Box Section Ref ID

Q&A

  • What should we include in a staff compact?

    It is essential that the staff compact be a list of behaviors that can be observed by everyone in the practice, so everyone can be held accountable. Items such as “I will treat my colleagues with respect” or “I will arrive on time and evenly share my work with my teammates” are useful. This is also an opportunity to focus on reinforcing positive behaviors to create an upbeat environment.

  • How do we get everyone to participate in creating the staff compact?

    Consider this process to encourage broad participation:

    1. Set the stage by using a “getting to know each other” activity, such as one of these icebreakers. You can also ask people to talk about positive team experiences they’ve had in the past, when a team they were on was in its “zone” and worked together to accomplish something important, such as winning a high school basketball championship.

    2. Do small group brainstorming around these two questions: “What do you expect from the people you work with?” and “What are you willing to promise them?”

    3. Have someone compile those ideas into a single document.

    4. Consider letting the group review other compacts and add additional items to the list.

    5. Combine similar ideas into single bullet points and then organize those points into categories, including communication, helping others, etc.

    6. Discuss what in the document resonates with the group. Using positive discussion or voting, try to limit the length of the document to one page.

    7. Share the draft compact with the team. To encourage those who are shy and do not speak up in groups, let people send in comments. Revise again.

    8. Vote for the final version of the staff compact. The goal is to reach a consensus where everyone is on board with the final document.

    9. Post laminated, colorful copies of the new compact in all the offices and team rooms.

    10. Use the staff compact. Refer to the staff compact to remind team members of their commitment to each other if a conflict arises between staff members. Also, when doing other culture-building activities as a team reference your compact to center the team before starting.

Step 4 Create opportunities for team communication throughout the day

Co-location (seating team members near each other), morning huddles, warm handoffs, end-of-day debriefs and weekly team meetings can all strengthen working relationships and build team culture.

Box Section Ref ID

Q&A

  • Why is communicating with each other so important?

    Teams that have the most face to face exchanges perform much better than those that don’t. One study found that practices with more face to face communication reduced the number of ER visits and urgent care visits among their patients and reduced the global costs of care by nearly $600 per patient per year.1

  • Our doctors prefer to have their own private offices. How can we show them co-location could be good for our teams?

    One of the key attributes of great teams is that they are able to have multiple brief conversations throughout the day. They are in constant communication with each other. Because people naturally talk with the person sitting next to them, co-location can foster these interactions. No matter the topic of conversation, these interactions can help build camaraderie, trust and reliance among team members.

    Co-location creates more efficiencies in flow—the day’s work will finish earlier. The nurse or medical assistant (MA) and physician can discuss messages verbally rather than having time-consuming conversations over email or batching communications for the end of the day. The physician will have the opportunity to explain how and why decisions are made to increase the MA’s knowledge and skills.

  • What is a huddle?

    Huddles are informal five to ten minute meetings, which often occur before the clinic day or session starts. In these brief meetings, the team might discuss staffing (e.g., who is out today and who is filling in), the needs of particular patients on the schedule and any schedule changes.

    Huddles get the team on the same page about the clinic workflow each day. Letting the non-physician members run the huddle helps break down some of the hierarchy that can be damaging to team culture. This also helps shift the practice’s culture from physician-centric to one that fosters teamwork and team-based patient care. Huddles can not only change culture but make the day run more efficiently and improve patient care.

  • What is a warm handoff?

    A warm handoff happens when patient care transitions directly from one staff member to another. For example, after rooming a patient, the nurse brings the physician into the room and explains to the physician in front of the patient what she has learned about the patient during rooming. Another example is a physician introducing the patient to the behavioral health specialist in person and giving a brief synopsis of the patient’s case. Warm handoffs make it clear to the patient that their doctor and the other professional in the room are working together on the patient’s behalf.

  • At the end of the day, we all just pack up and head home. Is there a positive way to conclude the day?

    Some clinics have found that a quick debrief at the end of the day allows teams to reflect on the good work they have done together or to call attention to a process that should be added to their weekly team meeting schedule.

Step 5 Meet regularly

Regular team meetings that take place weekly or every other week will make a huge difference in the culture of your practice. It will improve relationships and productivity, and it will make the importance of building and improving the team more apparent.

Meetings should be scheduled and an agenda should be distributed in advance. Assign one team member to lead the meeting, one to act as a timekeeper to keep the meeting focused and one to act as a recorder to take notes on the discussion. Meeting time is for building relationships as well as discussing and solving problems. Be prepared to protect your meeting time from other interests and maintain this dedicated time to communicate with your team.

The team at the Brigham and Women’s Hospital Primary Care Associates Clinic in Boston had great success starting every meeting with a simple icebreaker, a patient story, shout-outs and a piece of data about practice performance. For more information, see the STEPS Forward™ team meetings module.

Box Section Ref ID

Q&A

  • Are there brief activities to start meetings that help build culture?

    Here are four ideas:

    • Icebreakers can provide a chance for team members to learn something new about each other. Try an activity that involves movement to wake people up and bring energy to the meeting

    • “Shout-outs” provide team members with the opportunity to publicly praise their teammates who have done something great. Shout-outs encourage team members to emulate positive behaviors, make the team feel good about their work and enhance team spirit. It is also an opportunity to let anyone in the practice publically thank others in the practice for helping them or a patient in the last week

    • Tell stories. Stories are how you figure out who you are as a group—an important aspect of culture. Encourage sharing stories of great patient care provided by the team to remind everyone why they work there

    • Find a piece of data and review with the team. Some people respond to stories, some respond to data, and some team members will respond to both. Stories and data are complementary. Stories tell you who you are; data tells you how you are doing

  • We are worried about losing revenue because we are spending time in a meeting that could be spent with patients. What should we do?

    Improving how your practice functions is worth every penny. You will make up the time devoted to the meeting by making your workflow more efficient, thus freeing up staff time to see patients. If this is a serious concern, you may need to meet before the clinic opens, at lunch or at the end of the day—though that risks sending the message that learning to be a team and improving how you work together is not real work.

  • The doctors meet regularly. Does that count?

    Unfortunately, no. To build a strong and effective team culture you must involve staff from all levels in your practice.

Step 6 Strengthen the team by focusing on individual development

People thrive in work environments where they can continue to learn and grow. Be mindful of creating opportunities for staff to take on new responsibilities. Likewise, being flexible in helping staff take courses, get a degree and take on new roles in the practice sends a powerful message about the values of a practice. In one clinic, the manager and medical director meet annually with every staff person. During this review, they discuss goals for advancement for the upcoming year and the next three years. Knowing these goals helps them map out a plan to reach them. Individuals who know their team is invested in them will be more engaged in their team and their work, leading to better performance.

Step 7 Get to know your team members

It may seem obvious, but getting to know your team members is a simple way to strengthen team culture. Simple methods to learn more about your colleagues and improve team spirit include:

  • Celebrate birthdays, work anniversaries, a new team member joining and a team member’s promotion or retirement

  • Celebrate your local sports teams—including letting people break the dress code and wear shirts with logos of their favorite team

  • Celebrate holidays

  • Host potlucks or institute a monthly rotation where specific staff members, such as the nurses or doctors, cook for the rest of the practice

  • If you are in a building with multiple groups (e.g., primary care and specialty practices), have one group invite all the other groups over for lunch to forge new relationships

  • Eat lunch together. Studies show that something as simple as rearranging the lunchroom to have one large communal table improves how well a team functions. This arrangement encourages people to sit next to someone they may not know

“Walk a mile in my shoes” is another exercise used to get to know team members and their roles. At an initial staff meeting, break everyone into groups based on their role (i.e., front desk staff, medical assistants, nurses, doctors, etc.). If a team member has a specialized role (e.g., you only have one nurse care coordinator) they should do the initial activity alone, so the rest of the team can be oriented to their role and that of their colleagues. Use a structured brainstorming technique (see examples in step 2) to answer a few of the questions listed here:

  1. What is your role?

  2. What training did you receive to do your role?

  3. What is not part of your role?

  4. What do you do during a typical day?

  5. What do you like about your job?

  6. What don’t you like about your job?

  7. What can others on the team do to help you do your job better?

  8. Is there anything else you think other people would find useful or interesting about your role?

Have a team member in each group record the ideas generated during the brainstorming activity and eliminate duplicate responses. You may discover that some team members enjoy aspects of their role that others in the same role do not like. You may want to have practice or organization leadership review the lists to ensure that people are performing the duties required of them and that they are conforming to policy and regulations. When reviewing these lists, you may discover there are certain activities that no one in the practice is doing, which should be addressed to ensure there are no gaps in care.

Each group should then take five to ten minutes at a subsequent meeting and present their answers to the questions to the entire team. Encourage everyone on the team to participate, even if it means each team member presents the answer to only one question. Leave time for questions from other team members.

Box Section Ref ID

Q&A

  • How can we build culture from the first day of employment?

    One organization begins to build culture during the job interview process by having a patient interview the prospective employee. Another includes shadowing as part of the orientation process. For example, a medical assistant spends time in the call center observing work there that will impact his/her work in the clinic.

Step 8 Teach leaders to be mentors, not managers

Leadership plays a significant role in setting the tone for the culture of the practice. Successful team cultures promote leadership that emphasizes teaching and mentoring over traditional management structures. As physicians, we use leadership and coaching daily through communicating with and teaching patients, so we should strive to use those skills in our interactions with our teams as well.

Effective leaders should:

  • Facilitate, encourage and participate in improvement efforts alongside team members and patients

  • Communicate clearly and keep all team members on the same page and moving in the same direction

  • Demonstrate humility and show interest in their team members. Most members of the team have something to share or give, and there is always more to learn

  • Teach, guide and coach patiently and with clarity

  • Build day-to-day processes loosely to give the team flexibility to do their work most effectively, but protect and foster the processes that determine your culture

Leaders can teach staff how to give positive, actionable feedback. Like any skill, giving feedback needs to be taught and practiced before it becomes a habit. You may find it helpful to receive training on giving effective feedback from someone outside your organization. Once you are trained, practice giving feedback for a few months until it becomes comfortable and routine.

Suggestions for giving feedback:

  • In general, feedback that reinforces and encourages positive behavior is more effective than negative feedback

  • Give positive feedback in public so that other team members can learn by example. Shout-outs at team meetings are a good forum for giving positive feedback. Use caution with this approach, however, because team members who are infrequently mentioned could become less engaged

  • Give negative feedback constructively and in private. The goal of negative feedback is not to embarrass or shame the person receiving it, but to help them improve

  • All feedback should be timely

One of the challenges for physician-leaders is that they spend most of their time in rooms with patients or in front of computers by themselves. This limits the opportunities to coach the team they lead. Consider spending time with your team observing their work. This can be done when a patient no-shows, before or after a session or even eating lunch with your staff instead of with your electronic health record. Ask how things are going, how you can help, and use the feedback to find areas in need of improvement. Use a patient story to do a little clinical teaching.

Step 9 Create an environment that supports continual learning

A strong team culture will enable a practice to remain nimble in today’s ever-changing health care environment. Continuous learning and identification of opportunities for improvement within the practice will help the team grow and evolve together, thereby strengthening the team culture. For tools to guide you in creating an environment of learning and improvement, review the STEPS Forward™ Lean module.

Step 10 Engage patients

Quiz Ref IDPhysicians and other health care workers are often too close to the work to experience health care as their patients do. Fortunately, when asked, most patients will share feedback with you to build a stronger practice. There are multiple ways to engage patients in redesigning your operations and culture:

  1. Focused surveys. If you have specific questions about a process, policy or pilot program your team is trying out, ask patients what they think. Create a one to three question survey and ask patients to complete it at checkout. Emailing a survey link is another cost-effective way to obtain patient feedback.

  2. Patient/Family Advisory Council. Do you find that you frequently solicit patient input? Select the right patients from your practice and form an advisory council. Invested patients are happy to volunteer their time to serve as a sounding board to help the practice develop its team culture. Advisory council meetings can occur at a frequency that works best for the practice, such as monthly or quarterly. Members are often treated to dinner during evening meetings or given a small gift card to show appreciation for their time. Patient volunteers should be able to:

    • See beyond their own personal experiences

    • Help the practice work toward attaining its goals

    • Listen well

    • Respect the perspectives of others

    • Speak comfortably in a group

Box Section Ref ID
AMA Pearls
Connecting with colleagues

Intentionally sharing meaningful stories and experiences with our co-workers makes for a richer work life and builds on itself. Giving these stories a title, such as “The reason I came to work today,” can help overcome our natural reluctance to speak positively about the value of our work.2

Observe your team IQ

Research shows that teams do have an IQ, and that one of the predictors of a team being smart is “equality in distribution of conversational turn-taking.” That is, making sure everyone talks to everyone else.3 To gain the full benefit of your practice’s team IQ, use the tactics in this module to synergistically combine every team member’s knowledge and problem-solving abilities to create better results than each individual could achieve on their own.

Create your practice “tribe”

According to Dave Logan’s book, Tribal Leadership, very few workplaces have the giant “uni-cultures” exhibited by companies such as Zappos and Nordstrom. In fact, his book argues that culture lives at the tribe level in groups of 25 to 100 people. Interestingly, this is the typical number of people found in our cell phone address books and the size of the average group of primates.4 Using this logic, this module can help change culture at the practice level. Even as practices merge with other groups to form larger health care systems, individual practices can retain aspects of their own culture as long as they are aligned with the mission and vision of the larger organization.

Use Lean to build your culture

Lean has become a very popular way to improve processes in the health care setting. But Lean doesn’t always produce a better process than one person could individually come up with. Lean is successful because it involves everyone on the team and helps to change the relationship between workers and leaders, building a stronger culture. When done right, Lean builds continuously learning, integrated teams and collective intelligence. See the STEPS Forward™ module on starting Lean in your practice.

Conclusion

Team culture is an indicator of the health of an organization. Use the strategies in this module to build and strengthen your team and improve your team culture.

“Culture is the sum total of shared habits and expectations. Culture has tremendous inertia. That’s why it’s culture. It works because it lasts.”

Bill Thomas, MD Excerpt from the book Being Mortal by Atul Gawande, MD

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Where CME credit is designated, the activity is part of the American Medical Association's accredited CME program. The AMA is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
Article Information

Target Audience: This activity is designed to meet the educational needs of practicing physicians.

Statement of Competency: This activity is designed to address the following ABMS/ACGME competencies: practice-based learning and improvement, interpersonal and communications skills, professionalism, systems-based practice, interdisciplinary teamwork and quality improvement.

Planning Committee:

  • Rita LePard, AMA CME Program Committee

  • Ellie Rajcevich, MPA, Practice Development Advisor, Professional Satisfaction and Practice Sustainability, AMA

  • Sam Reynolds, MBA, Director, Professional Satisfaction and Practice Sustainability, AMA

  • Christine Sinsky, MD, Vice President, Professional Satisfaction, American Medical Association and Internist, Medical Associates Clinic and Health Plans, Dubuque, IA

  • Krystal White, MBA, Program Administrator, Professional Satisfaction and Practice Sustainability, AMA

Author Affiliations:

  • Stuart Pollack, MD, Brigham and Women’s Physician Organization, South Huntington; Joseph Frolkis, MD, PhD, Brigham and Women’s Hospital, South Huntington

Faculty:

  • Joseph Frolkis, MD, PhD, Vice Chair for Primary Care, Department of Medicine, Brigham and Women’s Hospital; Stuart Pollack, MD, Medical Director, Brigham and Women’s Advanced Primary Care Associates, South Huntington; N.S. Damle, MD, MS, FACP, Founding and Managing Partner, South County Internal Medicine Inc.; David DeLong, MD, FACP, Assistant Clinical Professor, College of Physicians and Surgeons, Columbia University and Chief, Division of General Internal Medicine, Bassett Healthcare, Cooperstown, NY; Mark B. Hallett, MD, MBOE, Chief Clinical Officer, ThedaCare; Ellie Rajcevich, MPA, Practice Development Advisor, Professional Satisfaction and Practice Sustainability, AMA; Sam Reynolds, MBA, Director, Professional Satisfaction and Practice Sustainability, AMA; Christine Sinsky, MD, Vice President, Professional Satisfaction, American Medical Association and Internist, Medical Associates Clinic and Health Plans, Dubuque, IA

About the Professional Satisfaction, Practice Sustainability Group: The AMA Professional Satisfaction and Practice Sustainability group has been tasked with developing and promoting innovative strategies that create sustainable practices. Leveraging findings from the 2013 AMA/RAND Health study, “Factors affecting physician professional satisfaction and their implications for patient care, health systems and health policy,” and other research sources, the group developed a series of practice transformation strategies. Each has the potential to reduce or eliminate inefficiency in broader office-based physician practices and improve health outcomes, increase operational productivity and reduce health care costs.

Disclosure Statement: The content of this activity does not relate to any product of a commercial interest as defined by the ACGME; therefore, neither the planners nor the faculty have relevant financial relationships to disclose.

References
1.
Mundt  MP, Gilchrist  VJ, Fleming  MF, Zakletskaia  LI, Tuan  W-J. Effects of primary care team social networks on quality of care and costs for patients with cardiovascular disease.  Ann Fam Med. 2015;13(2):139-148.Google ScholarCrossref
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Newbell  B.Schafer  D, Pfenninger  JL,  et al.  10 big ideas that could make your practice better.  Fam Pract Manag. 2008;15(8):33-41. http://www.aafp.org/fpm/2008/0900/p33.html. Accessed April 17, 2015.Google Scholar
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Woolley  AW, Chabris  CF, Pentland  A, Hashmi  N, Malone  TW. Evidence for a collective intelligence factor in the performance of human groups.  Science. 2010;330(6004):686-688.Google ScholarCrossref
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Logan  D, King  J, Fischer-Wright  H. Tribal Leadership: Leveraging Natural Groups to Build a Thriving Organization.  New York, NY: HarperBusiness; 2011.
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Hochman  M. Improvement happens: team-based primary care, an interview with Stuart Pollack.  J Gen Int Med. 2015;30(4):521-528.Google ScholarCrossref
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Agency for Healthcare Research and Quality.  Medical Office Survey on Patient Safety Culture. http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/medical-office/index.html. Published February 2015. Accessed April 17, 2015.
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 Icebreakers: the best games & activities.  Icebreakers website. http://www.icebreakers.ws/. Accessed April 17, 2015.
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Institute for Patient- and Family-Centered Care.  Creating patient and family advisory councils. http://www.ipfcc.org/resources/Advisory_Councils.pdf. Published 1998. Updated 2002. Accessed April 17, 2015.
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Toussaint  J. A management leadership and board road map to transforming care for patients.  Front Health Serv Manage. 2013;29(3):3-15.Google ScholarCrossref
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 Truly human leadership: Bob Chapman at TEDxScottAFB [video].  Illinois: TedxScottAFB; May30 , 2012. https://www.youtube.com/watch?v=njn-lIEv1LU. Accessed April 17, 2015.
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Nutting  PA, Crabtree  BF, Miller  WL, Stange  KC, Stewart  E, Jaén  C. Transforming physician practices to patient-centered medical homes: lessons from the National Demonstration Project.  Health Aff (Millwood). 2011;30(3):439-445.Google ScholarCrossref
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Woolley  M, Malone  TW, Chabris  CF. Why some teams are smarter than others.  The New York Times. January16 , 2015. http://www.nytimes.com/2015/01/18/opinion/sunday/why-some-teams-are-smarter-than-others.html. Accessed April 17, 2015.
14.
Gawande  A. Being Mortal: Medicine and What Matters in the End.  New York, NY: Metropolitan Books; 2014.
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