Authentic teamwork means smooth flow in primary care

“In primary care it is all about the team. Everybody plays an important role and everybody is assigned to what they do best.”

– Ingrid Gerbino, MD 

Virginia Mason makes five promises to patients in their primary care practices:

  • We will prevent you from getting sick whenever possible.
  • We will provide enhanced access to your care when you do get sick.
  • We will partner with you to manage your chronic/complex conditions.
  • We will ensure your care is coordinated between providers.
  • We will keep you informed about and engaged in your care. 

How does Virginia Mason fulfill such an ambitious series of pledges to patients? 

The answer is teamwork by skilled clinical professionals aligned around the needs of the patient. This approach is a marked departure from the way primary care has traditionally been delivered. 

Perhaps the key to its success is that this approach does not pile every detail of a patient’s care onto a doctor’s shoulders. Instead, other talented team members – nurses, pharmacists, medical assistants and others – play critical roles in delivering care along with the physician. 


Ingrid Gerbino, MD

“In primary care it is all about the team, says Ingrid Gerbino, MD, an internal medicine physician and deputy chief for the Department of Primary Care. “Everybody plays an important role and everybody is assigned to what they do best.” 

One of the positions that is relatively new in recent years – and was essentially invented at Virginia Mason – is the role of “flow manager.” Flow managers are medical assistants who keep care moving for the maximum benefit of patients and to enable physicians to focus on “doctor work” rather than bureaucracy. 

“I partner with my flow manager throughout the day,” says Dr. Gerbino. “Every piece of information that comes to me – electronically, by fax, paper, phone – is scrubbed first by the flow manager.” 

What this means in practice is that flow managers are trained in standard work to take care of many requests that come to the doctor. Some questions and requests the flow manager handles herself. Others she steers to nurses, administrators, pharmacists or behavioral specialists. In other words, the flow manager reduces the burden of work on the doctor, meaning the doctor’s time is used much more efficiently diagnosing and treating patients. 

External Setup
Perhaps the most valuable contribution of the flow manager is what is known as external setup – an essential element within lean management. External setup involves the flow manager getting everything ready for the visit before the visit so that the physician can concentrate on what doctors do best – diagnose and treat patients. 

When the flow manager rooms a patient she is guided by standard work. “They review health maintenance items, such as mammograms, colonoscopies, immunizations, etc., and they are very good at making sure patients are up to date on these critical tests and screenings,” says Dr. Gerbino. 

One of the major challenges in health care in the United States today is burnout and dissatisfaction among large number of primary care physicians. Many primary care doctors throughout the country feel overwhelmed with so much bureaucratic work that they are unable to do what they are trained to do. 

The solution at Virginia Mason, says Dr. Gerbino, is “leveraging the talents of the whole care team, and I think that’s what we’ve done well. It’s better for the patient and it’s better for all team members.” 

While medical assistants focus on patient setup and flow, nurses spend much of their time treating and counseling patients with a variety of chronic conditions, and nurses have proven highly skilled and effective at this work. 

Also, there is now a clinical pharmacist in every Virginia Mason clinic to fill the essential team role of managing medications for all patients, but particularly for patients with chronic conditions whose medications require continuous monitoring and regular adjustment. This is the area where the pharmacist’s skill is so valuable. 

Roger Woolf

Roger Woolf

The team approach, says Roger Woolf, administrative director, Pharmaceutical Services, improves overall productivity in clinics “and helps keep the physicians in flow. It allows our physicians to focus on the most important things they need to focus on which is diagnosing and treating the most complex patients.” 


Catherine Potts, MD

Catherine Potts, Chief of the Department of Primary Care, says the team approach is fundamental in establishing a patient centered medical home model. With the primary care physician as the leader of the team, and utilizing skill task alignment with the other team members, care is comprehensive, coordinated and provided by the right person on the team. The entire team is focused on the patient’s health needs, including wellness and prevention and acute and chronic care.


Leave a comment


  1. Would like to experiment with a partner in South Africa with such a model?

  2. I love the flow manager concept (and, of course, I love teamwork).

    Sami Bahri DDS, “the world’s first Lean dentist” also created a flow manager position, which he describes in this podcast:

  3. Mike Sprouse, Virginia Mason

     /  January 15, 2014

    Thanks Mark!

  4. Mike Sprouse, Virginia Mason

     /  January 15, 2014

    Thanks Visegan. I would encourage you to contact the Virginia Mason Institute. The phone number is (206) 341-1600. The email address is:

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