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Team Culture Case Report: UCSF Liver Disease and Liver Transplant Clinic

The hepatology clinic at University of California, San Francisco, is a busy academic practice that books approximately 6,500 visits a year for patients with complex hepatic conditions. When a sense of disconnect and distrust developed between providers and the rest of the care team, patient satisfaction suffered. Clinic leaders knew they needed to act, and believed that building trust was the first step toward creating a care team that could better address the issues that had led to dissatisfaction among the clinic's patients and care team members.

The clinic began holding monthly team meetings, where all care team members could begin sharing their thoughts. One issue that surfaced from these meetings was practitioners' lack of acknowledgement of the other care team members when the practitioners arrived at the clinic for the day. The unacknowledged care team felt disrespected, and the lack of communication often led to delays for patients—for example, a patient would be placed in an exam room before the provider had arrived at the clinic. To solve these problems, the whole team worked together to create a check-in process. Now, attending physicians and fellows stop at the front desk and let the rest of the team know they have arrived. The change reduced misunderstandings and increased verbal communication among all care team members, fostering greater teamwork and a greater sense of appreciation among the team.

To continue the positive feedback loop of communication, clinic leaders also instituted 360° evaluations for the entire team. These evaluations included feedback from an employee's supervisors, peers, subordinates, and other co-workers. Clinic leaders solicited input from the entire department about potential questions to include in the evaluations, covering the topics of professionalism, empathy and work issues, and then selected a short list of questions. The list was entered into online survey tools—one for providers and one for other care team members.

The surveys were confidential, with the data available only to the leaders of the clinic. The leaders met with team members individually to review the results of their evaluations and to ask for feedback about the experience. The honest appraisals led to greater trust among clinic personnel, according to Bilal Hameed, MD, associate chief of the clinic. “The goal of doing the evaluations was to increase everyone's awareness about his or her own problem areas in teamwork and communication. The result was a greater sense of all working together to improve.” Clinic leaders believe that taking steps to develop trust and a friendlier work environment were essential to the success of subsequent quality-improvement projects.

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