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Professional Issues
Guadalupe R. Palos, RN, LMSW, DrPH—Associate Editor
Enhancing Patient Outcomes in Healthcare Systems Through Multidisciplinary Teamwork Sara McComb, PhD, PE, and Megan Hebdon, RN, FNP-C
The increasingly complex needs of patients with cancer and their families call for a multidisciplinary team to achieve optimal patient outcomes. The purpose of the current article is to describe a teamwork model that can be used to address the needs of patients and the challenges associated with a healthcare system. The teamwork model was developed to address the mechanism needed to establish a paradigm shift in achieving high-quality patient care through effective teamwork. Sara McComb, PhD, PE, is an associate professor in the School of Nursing and the School of Industrial Engineering, and Megan Hebdon, RN, FNP-C, is a research assistant in the School of Nursing, both at Purdue University in West Lafayette, IN. The authors take full responsibility for the content of the article. The authors did not receive honoraria for this work. No financial relationships relevant to the content of this article have been disclosed by the authors or editorial staff. McComb can be reached at sara@purdue .edu, with copy to editor at [email protected]. Digital Object Identifier: 10.1188/13.CJON.669-670
P
ositive relationships between patients and healthcare providers, as well as those among providers, promote patient-centered care and enhance patient outcomes (Dwamena et al., 2012; Laine & Davidoff, 1996). The Institute of Medicine ([IOM], 2001) recommended establishing high-performing, patientcentered teams as a way to reinvent the healthcare system. The idea of patientcentered teams has been echoed in healthcare regulations with the advent of the Patient Protection and Affordable Care Act. The current article describes a multidisciplinary teamwork model based on the “Big Five” theory of teamwork that can be used to address the needs of patients and the challenges within a healthcare system (Salas, Sims, & Burke, 2005).
Teamwork Model A teamwork model for general medical units was introduced by McComb et al. (2012). The concept of teamwork was
evaluated using the Big Five dimensions of teamwork (i.e., team leadership, mutual performance monitoring, backup behavior, adaptability, and team orientation) and their coordinating mechanisms (Salas et al., 2005). McComb et al. (2012) proposed a teamwork model with a three-person central care team comprised of a physician, nurse, and patient. The physician and nurse also were members of the physician and floor team, respectively, where they functioned as intermediaries between other care providers (e.g., specialists, therapists) and the central care team. In addition, the central care team maintained stability when the patient care needs and corresponding care provider needs changed. The central care team was unique because the patient was included. The patient was integral to the central care team because his or her personal preferences, support network, and internal motivations affected overall well-being (Patient-Centered Outcomes Research Institute, 2012).
Clinical Journal of Oncology Nursing • Volume 17, Number 6 • Professional Issues
Teamwork in Oncology Given the complexity of oncology care, that teamwork model would be appropriate to apply in a cancer care setting with some expansion (see Figure 1). The authors propose including the patient’s support network as members of the patient care team. The core team structure (i.e., physician, nurse, and patient) would not be affected by the inclusion of the support network. The change would emphasize the importance of the patient’s family and friends in the care and wellbeing of the patient. When faced with a diagnosis of cancer and its treatment, patients may be overwhelmed by the amount of information they receive and choices they have to make. The patient often relies on the opinions and needs of family and friends to make healthcare decisions. Another important aim of the teamwork model is to include the healthcare system because of its impact on the central care team (i.e., nurse, physician, patient, and patient’s support network). Factors within the healthcare system that affect the central care team include organization culture, reimbursement by insurance providers, healthcare regulations, cost of and access to care, and disease and treatment complexity (IOM, 2012; Starr, 2013).
Big Five Dimensions of Teamwork The Big Five dimensions of teamwork include team leadership, mutual performance monitoring, backup behavior, adaptability, and team orientation 669
Team Leadership Physician team
Floor team
Team leadership is vital to effective teamwork because leaders are responsible for guiding and Nurse Physician structuring team progress. Strong leaders facilitate problem solving, Central care monitor the internal and external team environment, and establish perPatient formance expectations (Salas et al., 2005). Leaders also communicate with team members about Patient how organizational and national Healthcare team health policies affect patient decisystem sion making, and ensure that the goals of the team align with paFIGURE 1. Patient-Centered Teamwork tient preferences. For example, if Model in an Oncology Healthcare System a patient, caregiver, or healthcare provider have conflicting views on end-of-life care, an effective team leader would facilitate the necessary counseling to resolve the conflict as (Salas et al., 2005). Successful implewell as provide psychosocial support. mentation of the Big Five dimensions of teamwork is facilitated by the coordinating mechanisms. The coordinating Mutual Performance Monitoring mechanisms are closed-loop communiMutual performance monitoring is a cation, mutual trust, and shared mental team behavior in which members monimodels. According to Salas et al. (2005), tor each other’s work to avoid or detect closed-loop communication involves mistakes. This allows team members three steps: the initiation of a message to be aware of how the team is funcby the sender, the receipt of the message tioning, particularly during stressful by the receiver who acknowledges and tasks (Salas et al., 2005). Healthcare interprets the message, and follow-up by providers may encounter stressful tasks the sender to ensure the intended mesfrequently (e.g., terminal diagnosis, lifesage was received. That type of commuthreatening reaction to medication, prenication is central to teamwork because senting illness that requires heroic meait aids in continually updating the team’s sures to control). Healthcare providers shared mental models. Several diverse should monitor and provide feedback situations exist where the healthcare team to each other regarding mistakes and can use closed-loop communication, such oversights to prevent never events and as when ordering medication or planning promote patient well-being (Agency for a patient’s advanced directives. A culture Healthcare Research and Quality, 2012). of mutual trust contributes to multidisciplinary collaboration. Mutual perforBackup Behavior mance monitoring and backup behavior Backup behavior occurs when team are seen as team-building behaviors that members provide resources and help protect the team and its members rather each other when the workload is not than behaviors that convey mistrust (Salas evenly distributed within the team. et al., 2005). If the patient and support Team members can exhibit backup besystem trust the healthcare providers, havior by providing feedback, coaching, more time is spent supporting patient assistance, or task completion. Mutual recovery. Shared mental models help team performance monitoring supports backmembers establish a common understandup behavior because, once task overload ing about goals, capabilities, needs, and is detected, backup behavior is initiated performance expectations. With shared (Salas et al., 2005). Backup behavior can understanding, teams can improve comhelp achieve the mutual goal of patient munication and perform better, particusafety by sharing patient care tasks belarly when stress occurs in the oncology tween the patient, support network, and care setting (Salas et al., 2005). 670
healthcare providers. The cumulative emotional, physical, and time resources of those individuals would allow the team members to accomplish the goal of patient safety.
Adaptability Adaptability involves the team’s ability to recognize deviations from the expected course and adjust accordingly. It requires team members to have a global understanding of a task, to notice how changes in the internal or external environment may change team member roles in a task, and to recognize when changes occur (Salas et al., 2005). Adaptability is crucial in a complex healthcare environment that has constantly changing federal regulations, standards of practice, reimbursement requirements, and patient and family preferences (Starr, 2013). Healthcare team members should adhere to the goals, understand the needs and abilities of each team member, and know how to compensate when an unexpected event occurs. Those characteristics often are observed during treatment for cancer because changes in the patient disease trajectory can affect patient decisions regarding their care. Team members in that situation should re-evaluate patients’ desires and needs and maintain quality of life.
Team Orientation Team orientation, an attitudinal component, involves member preferences for working in teams and accomplishing tasks through coordination, evaluation, and input from team members (Salas et al., 2005). Members of the patient care team often believe they are independent from each other, but coordinated group behavior is required from the physician, nurse, patient, and support network to accomplish the goal of patient well-being (McComb et al., 2012).
Multidisciplinary Teamwork McComb et al. (2012) found that nurses and physicians understood the importance of multidisciplinary teamwork, but reported not having the skills and knowledge to effectively employ teamwork in a complex healthcare setting. (Professional Issues continues on page 672.)
December 2013 • Volume 17, Number 6 • Clinical Journal of Oncology Nursing
Professional Issues (Continued from page 670) Barriers included inconsistent attitudes toward team leadership, lack of communication, absence of backup behavior, limited mutual performance monitoring, and insufficient interdisciplinary mutual trust (McComb et al., 2012). A culture change within healthcare organizations is necessary to promote teamwork and change how it is applied and who it includes. Teamwork should be valued, taught, and reinforced, and the central care team should include the patient. The central care team has the potential to make patient-focused teamwork easier. Future research should address the use of the Big Five in healthcare teams, clarify the patient’s role in the central care team, and articulate the influence of healthcare system issues (e.g., regulation, reimbursement, complexity of team functioning). Using teamwork to guide patient care and involving the patient in the central care team would be beneficial in providing patient-centered care and maintaining overall quality of life.
events. Retrieved from http://w w w .psnet.ahrq.gov/primer.aspx?primer ID=3 Dwamena, F., Holmes-Rovner, M., Gaulden, C.M., Jorgenson, S., Sadigh, G., Sikorskii, A., . . . Olomu, A. (2012). Interventions for providers to promote a patient-centered approach in clinical consultations. Cochrane Database of Systematic Reviews, 12, CD003267. doi:10.1002/14651858 .CD003267.pub2 Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press. Institute of Medicine. (2012). Best care at lower cost: The path to continuously learning health care in America. Washington, DC: National Academies Press. Laine, C., & Davidoff, F. (1996). Patientcentered medicine: A professional evolu-
tion. JAMA, 275, 152–156. doi:10.1001/ jama.1996.03530260066035 McComb, S.A., Henneman, E.A., Hinchey, K.T., Richardson, C.J., Peto, R.R., Kleppel, R., & Rose, D.N. (2012). Improving teamwork on general medical units: When teams do not work face-to-face. Joint Commission Journal on Quality and Patient Safety, 38, 471–478. Patient-Centered Outcomes Research Institute. (2012). Patient-centered outcomes research. Retrieved from http://www.pc ori.org/research-we-support/pcor Salas, E., Sims, D.E., & Burke, C.S. (2005). Is there a “Big Five” in teamwork? Small Group Research, 36, 599–605. Starr, P. (2013). Law and the fog of healthcare: Complexity and uncertainty in the struggle over health policy. Saint Louis University Journal of Health Law and Policy, 6, 213–228.
Do You Have an Interesting Topic to Share?
References Agency for Healthcare Research and Quality. (2012). Patient safety primers: Never
Do You Have an Interesting Topic to Share?
672
December 2013 • Volume 17, Number 6 • Clinical Journal of Oncology Nursing
Copyright of Clinical Journal of Oncology Nursing is the property of Oncology Nursing Society and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Professional Issues
Guadalupe R. Palos, RN, LMSW, DrPH—Associate Editor
Enhancing Patient Outcomes in Healthcare Systems Through Multidisciplinary Teamwork Sara McComb, PhD, PE, and Megan Hebdon, RN, FNP-C
The increasingly complex needs of patients with cancer and their families call for a multidisciplinary team to achieve optimal patient outcomes. The purpose of the current article is to describe a teamwork model that can be used to address the needs of patients and the challenges associated with a healthcare system. The teamwork model was developed to address the mechanism needed to establish a paradigm shift in achieving high-quality patient care through effective teamwork. Sara McComb, PhD, PE, is an associate professor in the School of Nursing and the School of Industrial Engineering, and Megan Hebdon, RN, FNP-C, is a research assistant in the School of Nursing, both at Purdue University in West Lafayette, IN. The authors take full responsibility for the content of the article. The authors did not receive honoraria for this work. No financial relationships relevant to the content of this article have been disclosed by the authors or editorial staff. McComb can be reached at sara@purdue .edu, with copy to editor at [email protected]. Digital Object Identifier: 10.1188/13.CJON.669-670
P
ositive relationships between patients and healthcare providers, as well as those among providers, promote patient-centered care and enhance patient outcomes (Dwamena et al., 2012; Laine & Davidoff, 1996). The Institute of Medicine ([IOM], 2001) recommended establishing high-performing, patientcentered teams as a way to reinvent the healthcare system. The idea of patientcentered teams has been echoed in healthcare regulations with the advent of the Patient Protection and Affordable Care Act. The current article describes a multidisciplinary teamwork model based on the “Big Five” theory of teamwork that can be used to address the needs of patients and the challenges within a healthcare system (Salas, Sims, & Burke, 2005).
Teamwork Model A teamwork model for general medical units was introduced by McComb et al. (2012). The concept of teamwork was
evaluated using the Big Five dimensions of teamwork (i.e., team leadership, mutual performance monitoring, backup behavior, adaptability, and team orientation) and their coordinating mechanisms (Salas et al., 2005). McComb et al. (2012) proposed a teamwork model with a three-person central care team comprised of a physician, nurse, and patient. The physician and nurse also were members of the physician and floor team, respectively, where they functioned as intermediaries between other care providers (e.g., specialists, therapists) and the central care team. In addition, the central care team maintained stability when the patient care needs and corresponding care provider needs changed. The central care team was unique because the patient was included. The patient was integral to the central care team because his or her personal preferences, support network, and internal motivations affected overall well-being (Patient-Centered Outcomes Research Institute, 2012).
Clinical Journal of Oncology Nursing • Volume 17, Number 6 • Professional Issues
Teamwork in Oncology Given the complexity of oncology care, that teamwork model would be appropriate to apply in a cancer care setting with some expansion (see Figure 1). The authors propose including the patient’s support network as members of the patient care team. The core team structure (i.e., physician, nurse, and patient) would not be affected by the inclusion of the support network. The change would emphasize the importance of the patient’s family and friends in the care and wellbeing of the patient. When faced with a diagnosis of cancer and its treatment, patients may be overwhelmed by the amount of information they receive and choices they have to make. The patient often relies on the opinions and needs of family and friends to make healthcare decisions. Another important aim of the teamwork model is to include the healthcare system because of its impact on the central care team (i.e., nurse, physician, patient, and patient’s support network). Factors within the healthcare system that affect the central care team include organization culture, reimbursement by insurance providers, healthcare regulations, cost of and access to care, and disease and treatment complexity (IOM, 2012; Starr, 2013).
Big Five Dimensions of Teamwork The Big Five dimensions of teamwork include team leadership, mutual performance monitoring, backup behavior, adaptability, and team orientation 669
Team Leadership Physician team
Floor team
Team leadership is vital to effective teamwork because leaders are responsible for guiding and Nurse Physician structuring team progress. Strong leaders facilitate problem solving, Central care monitor the internal and external team environment, and establish perPatient formance expectations (Salas et al., 2005). Leaders also communicate with team members about Patient how organizational and national Healthcare team health policies affect patient decisystem sion making, and ensure that the goals of the team align with paFIGURE 1. Patient-Centered Teamwork tient preferences. For example, if Model in an Oncology Healthcare System a patient, caregiver, or healthcare provider have conflicting views on end-of-life care, an effective team leader would facilitate the necessary counseling to resolve the conflict as (Salas et al., 2005). Successful implewell as provide psychosocial support. mentation of the Big Five dimensions of teamwork is facilitated by the coordinating mechanisms. The coordinating Mutual Performance Monitoring mechanisms are closed-loop communiMutual performance monitoring is a cation, mutual trust, and shared mental team behavior in which members monimodels. According to Salas et al. (2005), tor each other’s work to avoid or detect closed-loop communication involves mistakes. This allows team members three steps: the initiation of a message to be aware of how the team is funcby the sender, the receipt of the message tioning, particularly during stressful by the receiver who acknowledges and tasks (Salas et al., 2005). Healthcare interprets the message, and follow-up by providers may encounter stressful tasks the sender to ensure the intended mesfrequently (e.g., terminal diagnosis, lifesage was received. That type of commuthreatening reaction to medication, prenication is central to teamwork because senting illness that requires heroic meait aids in continually updating the team’s sures to control). Healthcare providers shared mental models. Several diverse should monitor and provide feedback situations exist where the healthcare team to each other regarding mistakes and can use closed-loop communication, such oversights to prevent never events and as when ordering medication or planning promote patient well-being (Agency for a patient’s advanced directives. A culture Healthcare Research and Quality, 2012). of mutual trust contributes to multidisciplinary collaboration. Mutual perforBackup Behavior mance monitoring and backup behavior Backup behavior occurs when team are seen as team-building behaviors that members provide resources and help protect the team and its members rather each other when the workload is not than behaviors that convey mistrust (Salas evenly distributed within the team. et al., 2005). If the patient and support Team members can exhibit backup besystem trust the healthcare providers, havior by providing feedback, coaching, more time is spent supporting patient assistance, or task completion. Mutual recovery. Shared mental models help team performance monitoring supports backmembers establish a common understandup behavior because, once task overload ing about goals, capabilities, needs, and is detected, backup behavior is initiated performance expectations. With shared (Salas et al., 2005). Backup behavior can understanding, teams can improve comhelp achieve the mutual goal of patient munication and perform better, particusafety by sharing patient care tasks belarly when stress occurs in the oncology tween the patient, support network, and care setting (Salas et al., 2005). 670
healthcare providers. The cumulative emotional, physical, and time resources of those individuals would allow the team members to accomplish the goal of patient safety.
Adaptability Adaptability involves the team’s ability to recognize deviations from the expected course and adjust accordingly. It requires team members to have a global understanding of a task, to notice how changes in the internal or external environment may change team member roles in a task, and to recognize when changes occur (Salas et al., 2005). Adaptability is crucial in a complex healthcare environment that has constantly changing federal regulations, standards of practice, reimbursement requirements, and patient and family preferences (Starr, 2013). Healthcare team members should adhere to the goals, understand the needs and abilities of each team member, and know how to compensate when an unexpected event occurs. Those characteristics often are observed during treatment for cancer because changes in the patient disease trajectory can affect patient decisions regarding their care. Team members in that situation should re-evaluate patients’ desires and needs and maintain quality of life.
Team Orientation Team orientation, an attitudinal component, involves member preferences for working in teams and accomplishing tasks through coordination, evaluation, and input from team members (Salas et al., 2005). Members of the patient care team often believe they are independent from each other, but coordinated group behavior is required from the physician, nurse, patient, and support network to accomplish the goal of patient well-being (McComb et al., 2012).
Multidisciplinary Teamwork McComb et al. (2012) found that nurses and physicians understood the importance of multidisciplinary teamwork, but reported not having the skills and knowledge to effectively employ teamwork in a complex healthcare setting. (Professional Issues continues on page 672.)
December 2013 • Volume 17, Number 6 • Clinical Journal of Oncology Nursing
Professional Issues (Continued from page 670) Barriers included inconsistent attitudes toward team leadership, lack of communication, absence of backup behavior, limited mutual performance monitoring, and insufficient interdisciplinary mutual trust (McComb et al., 2012). A culture change within healthcare organizations is necessary to promote teamwork and change how it is applied and who it includes. Teamwork should be valued, taught, and reinforced, and the central care team should include the patient. The central care team has the potential to make patient-focused teamwork easier. Future research should address the use of the Big Five in healthcare teams, clarify the patient’s role in the central care team, and articulate the influence of healthcare system issues (e.g., regulation, reimbursement, complexity of team functioning). Using teamwork to guide patient care and involving the patient in the central care team would be beneficial in providing patient-centered care and maintaining overall quality of life.
events. Retrieved from http://w w w .psnet.ahrq.gov/primer.aspx?primer ID=3 Dwamena, F., Holmes-Rovner, M., Gaulden, C.M., Jorgenson, S., Sadigh, G., Sikorskii, A., . . . Olomu, A. (2012). Interventions for providers to promote a patient-centered approach in clinical consultations. Cochrane Database of Systematic Reviews, 12, CD003267. doi:10.1002/14651858 .CD003267.pub2 Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press. Institute of Medicine. (2012). Best care at lower cost: The path to continuously learning health care in America. Washington, DC: National Academies Press. Laine, C., & Davidoff, F. (1996). Patientcentered medicine: A professional evolu-
tion. JAMA, 275, 152–156. doi:10.1001/ jama.1996.03530260066035 McComb, S.A., Henneman, E.A., Hinchey, K.T., Richardson, C.J., Peto, R.R., Kleppel, R., & Rose, D.N. (2012). Improving teamwork on general medical units: When teams do not work face-to-face. Joint Commission Journal on Quality and Patient Safety, 38, 471–478. Patient-Centered Outcomes Research Institute. (2012). Patient-centered outcomes research. Retrieved from http://www.pc ori.org/research-we-support/pcor Salas, E., Sims, D.E., & Burke, C.S. (2005). Is there a “Big Five” in teamwork? Small Group Research, 36, 599–605. Starr, P. (2013). Law and the fog of healthcare: Complexity and uncertainty in the struggle over health policy. Saint Louis University Journal of Health Law and Policy, 6, 213–228.
Do You Have an Interesting Topic to Share?
References Agency for Healthcare Research and Quality. (2012). Patient safety primers: Never
Do You Have an Interesting Topic to Share?
672
December 2013 • Volume 17, Number 6 • Clinical Journal of Oncology Nursing
Copyright of Clinical Journal of Oncology Nursing is the property of Oncology Nursing Society and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
