When Questions about Health Care Teams Require a Team Science Approach
In May, 2012, Steve Clauser, PhD and Stephen Taplin MD, MPH of the National Cancer Institute (NCI) led a supplement in the Journal of the National Cancer Institute Monographs series that focuses on multilevel intervention research in health care (1). The supplement highlights the theoretical, methodological, and practical aspects of multilevel influences upon patients’ health, including the Affordable Care Act. While definitions of multilevel vary, we chose to define levels as units of human aggregation (individuals, teams, organizations, communities) and present them as an ecological model of care (Figure 1 ). Each of these levels can be a target for interventions and each affects the others in a variety of ways including through policy, communication, and behavior. The motivation for the supplement is the challenge that health interventions and improvements in health care are adopted slowly, in part because the context of health care delivery is often ignored. Therefore, to begin addressing the challenge of implementation, the Process of Care Research Branch and others at NCI are encouraging efforts to consider the context of care from the outset of intervention development. Such an approach would mean testing interventions that affect three or more levels of an ecological model of factors influencing care.
One of the first offshoots of our agenda to encourage tests of multilevel interventions is a focus on research into one of the most important – and complex – levels in the ecological model: health care teams. Specifically, the Process of Care Research Branch is interested in how organizations affect teams and how teams affect patient care. Unless organizations allocate training and meeting time and create a culture that makes teams successful, they will not achieve the improvements in care that are incented by the Affordable Care Act (2). While a great deal is known about teams, most of this knowledge has been generated through work outside of medical care settings. However, there is a need to understand how this knowledge translates to medicine, how the challenges in medicine can stimulate a deeper understanding of team functioning, and what research is needed to establish the foundation for team improvements in cancer care delivery.
Many health care providers believe they know how to work in teams. In medicine, health care teams have been written about in medical literature for decades. Now the Affordable Care Act incents the formation of medical homes where teams coordinate care and Accountable Care Organizations where teams span the boundaries between specialties and organizations delivering care. However, the creation of health care teams and a successful medical home has proved challenging (3). Team creation involves some radical and persistent changes in how providers and patients in the health care environment interact (3). In particular, physicians and other providers need to depart from the comfort of the hierarchical structure of medicine to share information and responsibility in new and explicit ways. However, medicine’s hierarchical culture and acute care orientation may prevent health care providers from explicitly addressing tasks such as establishing a decision process, learning to scan the environment of the office, reviewing the patient schedule, anticipating problems for the patients to be seen, and delegating responsibility and authority. As a result, the medical community has a long history of invoking teams as the solution to the challenges of health care delivery but a much more limited record of success creating functional teams (4). New and critical areas for advancing research on health care teams include understanding how teams function in the health care setting, what characteristics make a good team, how teams can be trained, and how team performance in health care is related to patient outcomes.
To address this emerging area of research, the Process of Care Research Branch is adopting some of what we have learned, and building on our experience with teams. For instance, our branch has brought an interdisciplinary team-based approach to our examination of the role of teams in health care delivery, including attempting to understand how to enhance teamwork in health care. Very early in this work, we realized the need for our group to itself adopt an interdisciplinary team-based approach to learning about health care teams. The pertinent literatures originated in sociology, psychology, organizational behavior, medical practice, nursing, and many other disciplines. Therefore, in order to understand the state of the art in teamwork, we brought representatives from these fields to the table.
Our first step to advance the study of teams in cancer care was to convene a meeting of 22 experts in team research, with backgrounds in diverse disciplines. The aim of the meeting was to apply these experts’ knowledge to the challenge of understanding health care teams. Held in May 2012 in Rockville, Maryland, the Role of Health Care Teams in Cancer Care meeting covered a range of topics, such as health care teams’ impact on quality of care and health outcomes; team performance and decision-making; team development; team cognition and motivation; and team conflict and innovation. In addition to convening scientists from multiple disciplines, the meeting was developed by a multidisciplinary team at NCI with expertise in social science, communication science, nursing, management, health services research, psychology, and medical practice. Our experience reinforced the idea that a team science approach is needed not only to understand health care teams but also to build the research base that will improve health care team functioning.
The timing is right to create the research teams and begin the research. The Affordable Care Act is incenting teamwork and it will change the way we currently deliver care. However, what we know about how to maximize cancer care team functioning is insufficient, so there will be an increased demand to expand our knowledge base in this area. Furthermore, The Affordable Care Act is occurring as a large generational cohort ages. Not only will more people have access to health care, a larger subpopulation will enter the age group where cancer is more common. At the same time, there is a looming shortage of primary and oncology care providers. This means that the challenge of delivering the safe, efficient, effective, timely, patient-centered care that the Institute of Medicine identified as a goal at the turn of the millennium is going to get more difficult because we do not have the workforce to do it. Therefore, we now face a challenge of achieving better outcomes for more patients, with fewer resources. While the improvement of health care team functioning is not proposed as a wholesale panacea for problems in health care delivery, it may play an important role in enhancing the quality of patient care. To reach the goal of improved health care teams, we need multidisciplinary teams to explore the issues and test and implement solutions. To ensure that the latter team is most effective, we need to learn from the science of team science and apply proven principles to the development of this effort.
Order a free copy of the supplement, "Understanding and Influencing Multilevel Factors Across the Cancer Care Continuum," from https://pubs.cancer.gov. Enter T433 in the search field and follow the site’s instructions for placing the order.
About the Authors
Stephen Taplin MD, MPH, National Cancer Institute, Division of Cancer Control and Population Sciences, Behavioral Research Program, Process of Care Research Branch
Heather Edwards PhD, SAIC-Frederick, Inc.
(1) Taplin SH, Anhang Price R, Edwards HM, et al. Introduction to the journal supplement: understanding and influencing multilevel factors across the cancer care continuum. J Natl Cancer Inst Monogr 2012;44.
(2) Public Law 111-148: Patient Protection and Affordable Care Act. 2010.
(3) Crabtree BF, Nutting PA, Miller WL, et al. Summary of the National Demonstration Project and recommendations for the patient-centered medical home. Ann Fam Med 2010;8 Suppl 1:S80-S90.
(4) Grumbach K. Can health care teams improve primary care practice? JAMA 2004;291(10):1246-51.
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