A.1. Identification of Key Stakeholders and Impacts on Acquisition
The Executive Sponsor
The key contributor to successful change initiatives is a visible and active executive sponsorship (Moussa, Garcia-Cardenas & Benrimoj, 2019) . The primary role of the sponsor in the project is to determine the opportunities and possibilities for success, set the proper expectations about outcomes, provide funding, and to provide guidance and support to all project activities. The change will impact clinicians and physicians, and it is vital to hear from the executive leadership why the change is essential. Therefore, the executive sponsor will legitimize the need for change within the organization and sets the precedence for change through direct engagement with the impacted stakeholders.
Physicians and Nurses
In change management, obtaining physician and nurse adoption is the most challenging task irrespective of the results, such as improved patient outcomes and enhanced patient and staff satisfaction. The primary challenge is that the priorities and incentives of physicians and nurses are not always aligned (Moussa, Garcia-Cardenas & Benrimoj, 2019) . Physicians and nurses are vital stakeholders in driving change initiatives in healthcare institutions, and their buy-in is critical to the success of the project. Nurses and physicians must be involved in introducing the project to their peers and understand how it will impact patients and other employees at the hospital. Many change management projects fail because physicians and nurses are not empowered emotionally to deal with the change. For successful implementation and adoption, nurses and physicians must own the change in the practice (Moussa, Garcia-Cardenas & Benrimoj, 2019) . This can be achieved through open communication and effective collaboration so that everyone is empowered to embrace and embed the transition into practice.
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The Executive Management Team
Support and engagement from the executive management, as well as middle management, is the leading contributor to change management success. Th executive management is critical to the success of the initiative because of the relationship that they have nurses, physicians, clinicians, and other staff as they are positioned to teach and influence them through the change process (Moussa, Garcia-Cardenas & Benrimoj, 2019) . Often than not, healthcare employees want to find out about the change and how it will impact their work and future direction from managers. Therefore, the executive management is the primary source of information and how the change will occur at the topmost level of the healthcare institution. Thus, the executive managers will give the authority and credibility to the successful implementation of change, and they must at all times indicate that they are committed to the change, transmit information about the change, and support the implementation of change management.
Patients
In the healthcare delivery system, patients are the final customers, and their experiences are vital to how products and services are shaped. The primary objective of the change initiative is to meet the population health needs adequately, and it would be valuable for the change management team to take into consideration the patient’s perspective as a stakeholder (Moussa, Garcia-Cardenas & Benrimoj, 2019) . Reaching out to the patients will help identify challenges that hinder them from accessing healthcare products and services, thus tailor the change management initiatives to cater to their needs and use them as agents of change in the process.
A.2. Barriers for Change
The unavailability of internal and external resources to lead the change initiative.
The lack of a shared vision and strong leadership for the change initiative, including the executive management.
Individual-level barriers such as resistance form nurses, physicians, and other hospital employees.
Prioritization of the Barriers
The lack of a shared vision and strong leadership for the change initiative, including the executive management.
Individual-level barriers such as resistance form nurses, physicians, and other hospital employees.
The unavailability of internal and external resources to lead the change initiative.
The above barriers were prioritized based on the strategic alignment of the change initiative objectives to the strategic business goals of the organization. The executive management communicated the goals of the initiative which were 1) to effectively meet the health needs of the population and 2) to improve preadmission and post-discharge primary care for patients. Thus, the executive leadership should be at the focal of implementing the strategy, if not the change initiative will fail.
Leverage Points for Initiating Change
Executive Support and the Availability of Resources
The executive leadership at the healthcare institution has an unparalleled commitment towards the improvement of patient outcomes and positioning the facility to better the health needs of the population (Braithwaite, 2018) . Using effective communication and interpersonal skills, the executive leader can explain the importance and implications of the change initiative. The executive leadership are also good motivators, and they will encourage healthcare staff to embrace the change, thus making a positive contribution to the successful implementation of the project. The executive leadership is also determined to provide the required resources in order to ensure that the strategies reach their full potential.
Staff Buy-in and Improvement Strategies
The motivation and enthusiasm held by healthcare professionals is critical to the implementation of the change initiative. With support from the executive leadership, all employees at the institution had the willingness to change and thus play an effective role as the facilitators of change as they were ready to take up their new roles that promote patient-centred care (Braithwaite, 2018) . Staff buy-in will reduce the amount of resistance that may occur from a top-down approach.
Communication and cooperation
There is sufficient engagement between healthcare professionals, patients, and the executive leadership with regards to the initiatives of the change management and the expectations required from each group. Every stakeholder understands their roles and effectively collaborate with other individuals on the visions and objectives of the change initiative (Braithwaite, 2018) . There is trust in the process and, therefore, less resistance and conflicts from the management and clinicians with respect to the strategic objectives of the change initiative.
B.1. Approaches for Implementing the New Team-Based Model of Care Delivery
Physician-Led Team-Based Care
The United States is facing a healthcare workforce challenge as there is a shortage in both nurses and physicians, and at the same time, there is an increasing demand for the delivery of primary care. To maximize and complement the knowledge and skills of healthcare professionals is to implement a physical-led team-based care model. The central objective of a physician-led, team-based care delivery model is that everyone in the healthcare delivery team plays a vital in guaranteeing that patients have access to efficient, preventive, and comprehensive care. Rather than a single physical trying to achieve a 30 minutes check on a patient, a clinical team comprising of registered nurses, licensed practitioners, physicians, and medical assistants manage the patient, thus improving employee health and the same time patient outcomes (Moussa, Garcia-Cardenas & Benrimoj, 2019) . For example, the medical assistant conducts periodic checks on the patient; the physician develops and supervises the treatment plan. At the same time, the registered nurse educates the patients on self-care and oversees the implementation of the plan. Each patient is unique, and the health care delivery model should be tailored according to the needs of the patient, relevant laws, or the population served.
Advantages of Physician-Led Team-Based Care
Each of the individuals in physician-led team-based care brings to the table a unique perspective and valuable insights about the patient (Laurant et al., 2018) . Each practitioner notices different symptoms on the patient and considers various options. Working together, they provide a more holistic and comprehensive view of the patient. The availability of a physician-led team at the disposal of the patient results in interprofessional collaboration and improved patient care as well as outcomes (Moussa, Garcia-Cardenas & Benrimoj, 2019) . The physician-led team approach to care fosters the achievement of quadruple aims delivering better patient experience, reduce overall costs, better population health outcomes, and improved professional satisfaction (Laurant et al., 2018) . This approach also increases the confidence of patients in their health providers. Research shows that patients approve a physician-led team-based approach to care as they have observed an improvement in the quality of their doctor-patient interactions, access to care, the degree of shared decision-making, and in the coordination of care (Moussa, Garcia-Cardenas & Benrimoj, 2019) .
Disadvantages of Physician-Led Team-Based Care
The main disadvantage of this approach is that physicians fail to acknowledge other health professionals, such as nurses, based on both their professional skills and their ability to lead a team. In modern healthcare, there is an imbalance of power between physicians and nurses both inside and outside the realms of healthcare (Moussa, Garcia-Cardenas & Benrimoj, 2019) . The role of nurses is perceived as subservient to that of the physician both inside and outside the context of healthcare. The power imbalance is a result of the education and socio-economic difference between nurses and physicians, which develops the perception among nurses that their opinions are not valued, and many, at times, their views are overruled by physicians (Laurant et al., 2018) . This creates an environment full of tension and frustration on the part of nurses, which could result in reduced patient satisfaction and healthcare outcomes.
When working in multidisciplinary teams, the roles and expectations between team members may not be clearly defined, and this may result in stressed relationships between nurses and physicians (Braithwaite, 2018) . Also, with the different roles shared among the team members, some members may possess insufficient skills that are required for effective teamwork, thereby reducing the productivity of the team (Moussa, Garcia-Cardenas & Benrimoj, 2019) . Team members will not always work well together and focusing individual efforts on a common goal presents unforeseen challenges to completing tasks effectively. Sometimes these conflicts may be driven by the size of the team as communication and collaboration becomes more involved in larger teams than small ones and may fall prey to groupthink (Laurant et al., 2018) .
Task Shifting Collaborative Care
Human resources are a vital component of the global healthcare delivery system, and their impact is defined by the availability of, access to, and the provision of quality healthcare delivery by healthcare professionals (Moussa, Garcia-Cardenas & Benrimoj, 2019) . In the United States and most third-world countries, sufficient healthcare workers are a challenge. As such, the shortage of healthcare workers hinders access to quality healthcare, and this is further impacted if the disproportionate distribution of human labor accompanies the deficiencies. The role and responsibilities of healthcare professionals over the past decade have been transformed across many countries (Dlamini-Simelane & Moyer, 2017) . An aging population with increased rates of acute conditions, have increased the demand for healthcare services and exerted pressure on healthcare systems to ensure the provision of high-quality and coordinated care.
To improve the reach and effectiveness of care, task shifting is the systematic involvement of changing roles between physicians, medical and nursing professions, as well as community health workers (Moussa, Garcia-Cardenas & Benrimoj, 2019) . Task shifting makes use of the well-established integrated models of care to follow the principles of team-based care using the healthcare needs of the population, treatment to target, and trained primary care providers to contribute to the delivery of effective patient care and improved patient outcomes (Braithwaite, 2018) . In a healthcare setting, the tasks that are usually achieved by a physician are assigned to a health practitioner with a different and lower education level and training or to another individual who has been taught to achieve the same task without having any formal education in health.
Advantages of Task Shifting
Task shifting in health care systems helps contribute to the sustainability of human capital. In countries that are facing severe shortages of health workers, task shifting can be used to address these shortages and, in some cases, increase the training capacity of health practitioners with low-level skills (Okyere, Mwanri & Ward, 2017) . Task shifting may also be used in addressing the issue of burnout among qualified health workers due to long hours of work or working in stressful conditions.
Task shifting also encourages the use of patient self-service, where family members and patients are involved in the tasks previously performed by healthcare professionals (Okyere, Mwanri & Ward, 2017) . This training results in reduced staffing costs while allowing for the delivery of more-personalized care for patients while ensuring uniformity and continuity when the patient is discharged thereby reducing the number of readmissions and postsurgical complications (Dlamini-Simelane & Moyer, 2017) .
Disadvantages of Task Shifting
Trade unions and professional associations have disputed the changes in responsibilities between qualified physicians and low-level of less educating individuals in taking care of the complex needs of patients as they threaten the quality of care dispensed to patients (Dlamini-Simelane & Moyer, 2017) . The implementation of task shifting in healthcare institutions would undermine the trust between the patient and the doctor, reduce the patients' right to a free choice of doctors and diminish the position of the healthcare profession when negotiating with social insurance funds. There is a need for evidence and the cost-effectiveness of task shifting (Dlamini-Simelane & Moyer, 2017) . In primary care, the ability of nurses to produce high-quality care and achieve positive patient outcomes has been defined. However, the research available on the cost-effectiveness of task shifting is limited.
Recommended Approach
The preferred approach in delivering in implementing a team-based model of care delivery is the physician-led team-based care delivery model. Physician-led, team-based care is the most appropriate method for healthcare institutions and federal government efforts in alleviating the challenges experienced in healthcare access (Gordon & Pollack, 2018) . Patients reserve the need to get the proper type of care from the right professionals and at the right time. Everyone in the physician-led team-based model of care delivery plays a critical role in guaranteeing that patients have access to care that is preventive, efficient, comprehensive, and, most importantly, effective (Gordon & Pollack, 2018) .
C.1. Sequence of Steps in Implementing the Strategy
The Identification of What will be Improved
The organization must identify the need to capitalize on the complementary skill sets of healthcare professionals in working as part of a diverse physician-led team (Braithwaite, 2018) . The strength of a physician-led team is that it allows everyone on the group irrespective of their profession to perform to the fullest capacity of their training. Physician-led, team-based care achieves common goals such as the provision of high-quality, coordinated, and patient-centered care (Braithwaite, 2018) . It improves the outcomes of the general population through collaboration among patients, families, and team members.
The change initiative will focus on improving the above processes, and it is vital to identify the focus and strategic objectives of the approach. Realizing what needs to be done creates a firm foundation for clarity, ease, and successful implementation of the initiative.
Buy-in from the Management and Business Stakeholders
Organizational change cuts across distinct business units, functions, and boundaries, and this is where the engagement of stakeholders will lead to successful outcomes. For effective and successful implementation, stakeholder engagement and buy-in are vital (Braithwaite, 2018) . They include internal teams or departments within the organization or external partners such as vendors, insurance providers, and consultants (Braithwaite, 2018) . Both internal and external parties need to know what resources are required and what is expected from them.
Plan for Change
The change plan is regarded as the "agenda for action" that describes the inception of the plan, the path to be taken, and the strategic objectives that will be achieved. The required resources and stakeholders, the scope of the project, the intended outcomes, mitigation of risk, and costs are leveraged and integrated into the plan (Satiani & Vaccaro, 2010) . The change plan will provide a multi-tiered approach to how the change initiative will occur rather than a sudden and unplanned change.
The Acquisition of Resources
The identification of resources and funding are vital elements of the planning process. In implementing a physician-led, team-based model of care, it is essential to identify the financial implications of working with diverse groups and with different levels of expertise (Satiani & Vaccaro, 2010) . It is also important to note the use of technological resources such as electronic health records to facilitate collaboration and communication among the team (Satiani & Vaccaro, 2010) . Consideration should also be placed on the re-education and training of healthcare professions at the facility in order to meet the expected outcomes.
Communicating the Change
The golden rule in change projects is communicating the change among the involved stakeholders and change agents in a structured and systematic way (Satiani & Vaccaro, 2010) . Proactive communication is critical in minimizing resistance and ensuring that everyone feels like they are part of the process.
Implementation
Once the plan has matured, roll-out, and implementation of the plan in distinct stages begins based on the timelines stipulated in the change management plan.
Follow-up and Managing Resistance
Once the change has been affected, it is critical to follow-up and assesses the progress of the change and if the change is delivering the intended results. Resistance is part of the change management process, but the fear of if the unknown by healthcare professionals could threaten the success of the project (Mitchell et al., 2019) . Thus, it is the responsibility of the management to deal with staff who cannot embrace change and point them in the right direction.
Celebrate Success
It is vital to celebrate significant milestones of the change as this creates and builds the anticipation and momentum for significant changes (Mitchell et al., 2019) . Once the physicians and nurses have understood the importance of the change, they become an essential part of the process for planning and implementing the change, thus increases the chances for a successful implementation.
Approaches for Measuring the Intended Change
Measuring Individual Performance
Measuring individual performance is a critical metric in determining whether the change impacted physicians and nurses and if they are progressing through their change journeys (Moussa, Garcia-Cardenas & Benrimoj, 2019) . One of the metrics for measuring individual performance is employee understanding and awareness of the change. This metric ensures that physicians understand the objectives of the change initiative, and they are working towards achieving better patient outcomes as the end goal (Mitchell et al., 2019) . Measuring employee awareness and understanding of change also includes behavior changes among the staff in working towards a shared vision of the change initiative plan (Moussa, Garcia-Cardenas & Benrimoj, 2019) .
Measuring Change Management Performance
Measuring the implementation of the change management initiative is directly linked to the activities stipulated in the change plan and carried out by the change management team (Mitchell et al., 2019) . One key metric in measuring change management is performance improvements. The strategic business objective of the change initiative plan was to measure the effectiveness of team-based care in improving patient satisfaction and meeting the healthcare needs of the population (Moussa, Garcia-Cardenas & Benrimoj, 2019) . Improved communication among diverse teams promotes quality and safety as well as patient satisfaction, which is a vital quality outcome indicator of healthcare in the institution.
Challenges to Sustaining Change
Leadership and Staff Commitment to Change
The sustainability of the change initiative largely depends on the ability to have an engaged leadership who value the principles of a physician-led, team-based approach in providing high-quality patient care (Mitchell et al., 2019) . Challenges arise in sustaining change when the management and the executive leadership do not have buy-in into the change initiative, which in turn reduces employee motivation in believing in the transition. The lack of maintaining proper communication channels leads to challenges in sustaining the change plan. If both leaders and employees fail to commit to the change plan, then it becomes difficult for them to embrace the plan, thus sustaining, it becomes problematic (Mitchell et al., 2019) . This is usually an indication that not everyone was on board at the beginning of the change. If they do not believe in the transition, they will begin to question why the changes are being made.
Approaches for Overcoming Challenges
Build, Communicate and Deploy the Healthcare Institutions Philosophy of Patient-Centered Team-based care
Effective communication is vital in implementing and sustaining change because it allows the change management process to develop trust and commitment towards the change, generate emotional connections, and share norms, values, and knowledge (Gordon & Pollack, 2018) . To overcome the challenge of sustaining the change, the practice will develop their own principles and philosophies of what constitutes patient-centered, team-based care that is consistent with the institution's mission to provide high-quality patient care with participation from the management, patients, team members, and other stakeholders (Mitchell et al., 2019) . Once the philosophy has been developed, the institution will use it to inform its approach to implementing, delivering, and assessing team-based care under the change plan (Gordon & Pollack, 2018) . The executive and middle management will effectively share these philosophies with physicians, nurses, clinicians, and other staff that will make them more committed to sustaining the change.
At the same time, the institution will elect internal champions who will engage all stakeholders in developing and reinforcing the guiding philosophies that will encourage the adoption of the change plan throughout the organization (Gordon & Pollack, 2018) . For example, champions can emphasize the philosophy and principles of patient-centered, team-based care when orienting new hires (Mitchell et al., 2019) . The philosophy and principles should be communicated widely at the practice, and this can be achieved through posters in offices and patient rooms to remind both staff and patients or the practice's guiding principles (Mitchell et al., 2019) . These philosophies and directions can also be incorporated into the organization's hiring, training, and performance review processes.
References
Braithwaite, J. (2018). Changing how we think about healthcare improvement. BMJ , k2014. doi: 10.1136/bmj.k2014.
Dlamini-Simelane, T., & Moyer, E. (2017). Task shifting or shifting care practices? The impact of task shifting on patients’ experiences and health care arrangements in Swaziland. BMC Health Services Research , 17 (1). doi: 10.1186/s12913-016-1960-y
Gordon, A., & Pollack, J. (2018). Managing Healthcare Integration. Project Management Journal , 49 (5), 5-21. doi: 10.1177/8756972818785321.
Laurant, M., van der Biezen, M., Wijers, N., Watananirun, K., Kontopantelis, E., & van Vught, A. (2018). Nurses as substitutes for doctors in primary care. Cochrane Database of Systematic Reviews . doi: 10.1002/14651858.cd001271.pub3.
Mitchell, J., Haag, J., Klavetter, E., Beldo, R., Shah, N., & Baumbach, L. et al. (2019). Development and Implementation of a Team-Based, Primary Care Delivery Model: Challenges and Opportunities. Mayo Clinic Proceedings , 94 (7), 1298-1303. doi: 10.1016/j.mayocp.2019.01.038.
Moussa, L., Garcia-Cardenas, V., & Benrimoj, S. (2019). Change Facilitation Strategies Used in the Implementation of Innovations in Healthcare Practice: A Systematic Review. Journal of Change Management , 19 (4), 283-301. doi: 10.1080/14697017.2019.1602552.
Okyere, E., Mwanri, L., & Ward, P. (2017). Is task-shifting a solution to the health workers’ shortage in Northern Ghana? PLOS ONE , 12 (3), e0174631. doi: 10.1371/journal.pone.0174631.
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