Milestone 6 Summary

Description: Practice sets clear expectations for each team member’s functions and responsibilities to optimize efficiency, outcomes, and accountability.


What does success look like?


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The practice has not established clear roles for each member of the care team or set clear expectations for each team member’s functions and responsibilities to optimize efficiency, outcomes, and accountability. The practice has identified the work required before, during, and after patient visits and identifies the skills and credentials needed to perform that work. The practice has matched the work that must be done with the team member who will do the work. The practice has documented each team member’s role and accountability lanes and each team member works to the maximum of his skill set and credentials in order to optimize efficiency and outcomes.

 Note: numbers are PAT scores


Why is this important?

Patient experience has been increasingly recognized as one of the three pillars of quality healthcare, along with clinical effectiveness and patient safety.1 Patient experience has been positively linked to health outcomes such as adherence to medical treatment, better use of preventative services, and improved mandatory reported safety indicators.2 Patients and their families are essential partners in the effort to improve the quality and safety of health care.

A number of approaches to improving the patient care experience have demonstrated notable impact, measured by patient satisfaction surveys, including perceived quality of communication between the clinical staff and patient, perceived and expected waiting times, and improved patient understanding of the care they receive.3


Potential Tactics

  • Understand the demands for services and supply of clinical resources
  • Start small- Trial a team-based approach with clear roles around a specific process
  • Create standard protocols and standing orders to streamline processes
  • Assign responsibilities based on level of skill- all team members should be using their highest levels of expertise
  • Communicate as a team – use daily huddles to clarify roles and needs


Tools and Resources


What might this look like in practice?




  1. Hupke, Cindy. “Team-Based Care: Optimizing Primary Care for Patients and Providers.” IHI Communities Blog. 2014 May 16. Available HERE 
  2. Hupke, Cindy. “Team-Based Care: Moving from Ideas to Action” IHI Communities Blog. 2016 Jan 29. Available HERE
  3. Institute for Healthcare Improvement. Optimizing the Care Team. Resources. Available HERE
  4. Institute for Healthcare Improvement. Measure and Understand Supply and Demand. Available HERE