Practice transformation, in the context of medical home, starts with for​​ming a medical home improvement team.​​

​Teamwork involves a set of skilled cross-disciplinary interactions that are learned, practiced, and refined to provide better health care services, promote safety, and enhance outcomes.

Highly functioning teams are made up of those on the “front lines of care,” they engage family partners, have the capacity to test changes quickly, and possess the resilience to deal with the complexities of primary care. Additionally, successful teams require support from leaders in multiple areas of practice management such as administration, finance, and information technology. Parent/family advocates are essential members of any medical home improvement team.

Supported teams are able to gain practice wide buy-in for their improvement innovations and other procedural changes, which ensures success.

Teamwork is the foundation for effective medical home improvement.


Families are essential members of the medical home improvement team.

Finding the right family member/advocate to serve on a medical home improvement team requires clear communication from the team champion. A scope of work or job description can be useful to describe these expectations.​​​

 Team Members

1. A clearly identified improvement champion who is willing to lead the work

2. Parent/family advocate(s)

3. A variety of additional members involved in all practice processes and procedures such as:

  • ​Physicians
  • Non-physician clinicians
  • Practice managers
  • Practice administrators
  • Nurses
  • Nurse practitioners
  • Patient representatives (front desk staff, answering service representative)
  • Billing and referral specialists
  • Information technology practice staff
  • Dietitians
  • Social workers
  • Care coordinators
  • Community health workers
  • Community members​

 Attributes of Successful Teams

  • ​Gain and demonstrate leadership
  • Use effective communication between all team members
  • Delineate responsibilities of all team members
  • Set an agenda as a team
  • Organize meeting notes and assignments
  • Follow up on action items from meetings or other activities/projects
  • Meet regularly to continuously evaluate and improve the management and facilitation of processes and policies
  • Engage and share ideas with all team members (including all practice staff and families)
  • Proactively solicit input from all team members
  • Continuously report progress to the entire practice, not just the improvement team
  • Share successes, no matter how large or small​

 Tools and Resources

Key Elements of Highly Effective Teams
Peer reviewed article which features a framework for effective team-based care which can be applied in pediatric practices.

Creating Quality Improvement Teams
Step-by-step instructions for forming a quality improvement team.

The Science of Improvement: Forming a Team
Detailed information regarding effective teams for improvement in health care. Includes examples which can be replicated in practice.

Team Based Care Literature and Resources
Tools and resources for effective communication, interdisciplinary team care, leadership, and much more.

Toolkits, training conferences, and more to assist medical practices with team based care.​