Healthcare team characteristics
Examples
Multidisciplinary
Multidisciplinary rounds in pediatric intensive care unit (Fig. 10.3)
Dynamic team formation, composition, and role assignment, blurry role differentiation
Ad hoc medical teams formed in ED to stabilize trauma patients
Distributed or collocated teams, or a combination
Multidisciplinary Medical Team (MMT) meetings with remote consultation with specialists; telemedicine
Coordination needed for continuous coverage
Shift handovers in inpatient care; patient transfer to ICU for close monitoring
May be defined by profession, discipline, physical location, temporal shift, patient needs, etc.
Pharmacists vs. radiologists; outpatient unit vs. ICU; day nurses vs. night nurses
Communication mediated through cognitive artifacts
EHR for physicians and nurses to communicate; whiteboard for residents’ patient assignment; intercom for broadcasting within a medical unit
It is important to recognize that a great variety of teams exist in healthcare, with varying degrees of shared objectives, clarity of role specifications, and interdependencies. For example, ED care is characterized by unpredictable and changing combinations of patient care needs, sometimes shifting abruptly from low-demand to highly complex and urgent. In response, ED teams tend to be highly adaptive and ephemeral, changing in composition, roles, and assignments based on shifting requirements of a fluctuating group of patients and care issues. Intensive care units (ICUs) also exhibit such ad hoc, self-assembling teams, which then dissolve once conditions have stabilized. For ICU teamwork, strategy and goal formulation was the most common team tasks, and the level of teamwork was significantly associated with ICU patient outcomes, as found in a recent systematic review (Dietz et al. 2014). By contrast, other healthcare contexts are characterized by stable, well defined teams, for example, a cardiac surgery suite where a small and select group of surgeons, nurses, surgical technicians, perfusionists, and anesthesiologists work together frequently, developing well defined roles and responsibilities, and familiar communication patterns.
A recent review of teamwork in healthcare (Xiao et al. 2013) used the concept of “organizational shell” to understand various types of teams in healthcare in terms of how an organization provides a structural context for the functioning of a team. A team may find a strong infrastructure (“organizational shell”) with explicit requirements on personnel with respect to training, skills, knowledge, certification, and privileges; well thought-out structures for team tasks such as protocols, standardized operating procedures; and well-designed technology support. Such a strong organizational shell reduces coordination needs (Ginnett 1993). In many healthcare settings, work demands may be less predictable or work systems less well designed. In these cases, team membership and task assignments may be less clear, work practices become adaptive, and workarounds become common. Such fluid behavioral norms and authority arrangements render it difficult to make general statements about healthcare teams independent of the care context and the degree to which an “organizational shell” exists.
In addition to the role that an “organizational shell” may provide, multiple factors contribute to effective team functioning in healthcare, including prior education, training, and experience, professional group influences, regulatory policies, and cultural norms (Ginnett 1993). As a result, team roles, expectations, and lines of authority are sustained across contexts and organizations, exhibiting what amounts to interoperability of health professionals as they move across organizational contexts.
10.1.2 Characteristics of Healthcare Teams
Xiao et al. (2013) highlight several features commonly found in healthcare teams, two of which are very relevant to the design of HIT. First, team composition changes, depending on settings and needs, or simply over time. A family physician may work with different supporting staff in her clinic to address varying issues and patient care needs. A nurse often must contact different physicians at different times of the day when making referral appointments for a patient so that her routine practices are not impacted. Hospital staff such as interns and residents in training, hospitalist physicians, or surgical specialists may rotate on and off duty over a short cycle time, resulting in fluctuating configurations of staff and a high degree of adaptability by team members. Moreover, team composition can change as a function of a patient’s illness and treatment trajectory, when the needs of a patient change. HIT can thus play important roles in enabling team members to see which clinicians have participated in the care of a patient and in providing up-to-date information on the roles of each team member in relation to a patient.
Second, the delineation of responsibility and the communication structure in healthcare teams may become unclear across temporal or functional boundaries. Individual patients, particularly in hospital settings, require participation by changing groups of health professionals, with cross-coverage responsibilities over nights or weekends and other changes to work and personnel arrangements. In military settings, a designated and clear structure for communication and role differentiation can reduce the overhead of communication and negotiation (MacMillan et al. 2002), a principle that may be applied in healthcare settings as well.
Definition of teams can have profound implications for how HIT should be designed to enhance team communication and collaboration. For example, teams may be defined by profession and discipline, by physical or temporal context, or by emerging patient needs. Examples of professional or disciplinary teams include (a) surgeons who share the care of patients who have had surgery, (b) nurses who share responsibility for care of patients on a nursing unit, or (c) physical therapists who share responsibility for therapy needs of patients distributed throughout the hospital. Examples of contextually defined teams include the multidisciplinary team responsible for patients in a specific location such as an operating room or emergency department, or those responsible for care over a specific period of time such as the night shift. Examples of teams defined by emerging care needs include the ad hoc, self-assembling teams that form and dissolve in response to emergent needs in an intensive care unit or delivery room.
These forms of team definition and composition have implications for the processes and artifacts or tools used for communication and collaboration. To illustrate, a surgical resident may consider the attending surgeons and surgical residents on his/her surgical service as his/her team, sharing responsibility for the preoperative and postoperative care of patients receiving surgery from a member of their group. Such a group will typically have routines for group discussion to share patient information and care plans (during “rounds”), as well as shared cognitive artifacts (either paper or electronic) for recording and transferring this information within the group. These routines and artifacts support transfer of information, division of responsibility, and shared situation awareness that enable them to achieve the shared goal of caring for all the patients on their service throughout the day, ideally with processes that are robust to disruptions in availability and responsibility, such as when members of the team are unexpectedly called to or are delayed in the operating room, requiring others on the team to shift roles and responsibilities.
In contrast, multidisciplinary teams that are defined by context often have distinct routines or work processes for working together such as multidisciplinary rounds, and informal rules for turn-taking in discourse, as well as separate artifacts, such as whiteboards or printed lists, that support the somewhat different work that is accomplished in a multidisciplinary context.
Team composition and function may not be perceived in the same way by all members. As an example, the clinicians and staff who provide care to a patient often have defined roles and common goals, even though the patient may never think of them as comprising a team. At the same time, the patient’s family and loved ones may play significant roles in the determination and delivery of care, even though the clinician may be unaware of this. In designing HIT, it may thus be constructive to consider the entire group of healthcare professionals and family members as a team.
When healthcare teams working together to care for an individual patient are not located together in the same place at the same time, the need for technologies to support their interaction is especially great. In these cases, communication among team members in healthcare must be mediated by appropriate technologies, such as fax machines and increasingly through the EHR, whether by use of a common EHR system or through development of mechanisms for interoperability. As such, the design of HIT has direct impact on how team members “interact dynamically, interdependently, and adaptively” (Salas et al. 1992, p. 4). Inadequate understanding of how teams coordinate has resulted in suboptimal patient care (e.g., Abraham and Reddy 2008; Ash et al. 2004). Two examples are communication of medication orders and use of bar code medication administration systems (BCMA). With communication of medication orders, a physician may assume an order, once entered, will be acted upon immediately by the pharmacist or nurse, when in fact, many EHR implementations require the nurse to log in and specifically look for new orders. With BCMA systems, a nurse may assume the system checks the identity of the medication and of the patient, when in fact some systems do not confirm the identity of the patient (Henneman et al. 2012). Similar “illusion of communication” leads to many incidences of communication breakdowns (Ash et al. 2004). Therefore, some hospitals have developed policies, for example, for physicians to talk directly with nurses when time-sensitive orders are placed on EHR, so that harmful delays can be avoided.
10.1.3 Teamwork in Healthcare Practices
Healthcare work can be highly dynamic, requiring intense, often multidisciplinary, collaboration. Patient care teams often consist of a large number of personnel ranging from clinicians, e.g., doctors, nurses, and pharmacists, to non-clinical members, e.g., unit coordinators, administrative staff, and those responsible for equipment supply and maintenance (Lee et al. 2012; Strauss et al. 1985). These team members may be collocated, such as those in emergency care or during a routine family doctor visit (Aronsky et al. 2007; Benham-Hutchins and Effken 2010), but more often, they are distributed over different spatial locations (Bardram and Bossen 2005; Abraham and Reddy 2008). This is particularly the case for patients with complex or multiple illnesses, who require coordinated care from different specialists, each contributing to the treatment plan. Although HIT such as the EHR can help facilitate communication between distributed collaborators, the need for clinicians to move between distributed locations while conducting medical work has been found to be indispensible (Bardram and Bossen 2003, 2005). In addition, hospital work is typically under “continuous coverage” (Zerubavel 1979) in order to offer around-the-clock patient care. Thus, temporal coordination of work among team members must be carefully maintained (Reddy et al. 2002, 2006). Taken together, these collaboration challenges increase the risk of communication breakdowns and can negatively impact the quality of patient care if they are not properly considered and addressed (Chen 2010; Ebright et al. 2004; Gandhi 2006; Horwitz et al. 2009; Patterson et al. 2004; Riesenberg et al. 2010).
Healthcare is often considered information work as collaboration relies on a variety of information media, such as verbal exchange, paper, and display media (Bardram 2000; Cabitza et al. 2005; Kovalainen et al. 1998; Luff et al. 1992; Randell et al. 2010; Xiao et al. 2001). In particular, paper artifacts are often used to record and track a work plan, as a bedside information source, opportune notepad, and tool for information transfer within and across shifts (Tang and Carpendale 2007, 2008). In addition, patients’ medical records are instrumental in supporting collaborative practices, acting as a “collection and distributing device” (Berg 1996) that constitutes and mediates social relations and interrelated patient care tasks. The medical records also serve as a communication vehicle, linking heterogeneous health professionals and mediating much of the healthcare system (Berg and Bowker 1997).
10.2 Key Concepts and Theories for Team Performance
10.2.1 Sociotechnical Aspects of Teamwork
Previous studies on healthcare teamwork investigated a variety of sociotechnical issues, e.g., mobility (Bardram and Bossen 2003, 2005; Morán et al. 2007), temporality (Bardram 2000; Reddy and Dourish 2002; Reddy et al. 2006), coordinating artifacts (Bardram and Bossen 2005; Cabitza et al. 2005), communication channels (Coiera and Tombs 1998; Gurses et al. 2006; Patterson et al. 2004), and richness of information (Baldwin and McGinnis 1994; Bates et al. 2003; Currie 2002; Kerr 2002). From these studies, we have gained considerable insights into the processes and challenges for achieving effective collaboration in healthcare.
10.2.1.1 Dynamic Communication Behaviors
Effective communication is essential for successful teamwork. In medical settings, communication is ubiquitous and accounts for a substantial portion of daily routines, including interactions and information sharing in varying contexts, across temporal and spatial dimensions (Bardram and Bossen 2005; Bossen 2002; Schmidt and Bannon 1992). Communication failure among clinicians, however, has been frequently found to contribute to preventable adverse events (Gurses et al. 2006).
Face-to-face communication offers a richer communication experience, providing paralinguistic and nonverbal information in addition to the words themselves, and likely offers the best quality and spectrum of communication (Kraut et al. 1988; Orlikowski and Hofman 1997; Hatten-Masterson and Griffiths 2009; Xiao et al. 2001). Furthermore, colocation of healthcare work permits indirect and informal communication (Vuckovic et al. 2004), enhancing situational awareness among members of the group in a manner similar to more formalized coordination mechanisms such as “voice loops” (Patterson et al. 1999). The mobile and dynamic nature of medical work presents challenges to effective communication. Artifacts such as whiteboards and bulletin boards, used both synchronously and asynchronously, provide a flexible shared workspace that facilitates joint discussion and provide shared and persistent information display (Wilson et al. 2006; Xiao et al. 2001, 2007), promoting awareness and coordination of ongoing activities (Bardram 2000; Xiao et al. 2001).
In hospitals especially, healthcare work is peripatetic: it is necessary for patients, health professionals, and equipment to move among spatially distributed “work centers” (e.g. emergency department, imaging suite, operating room, intensive care unit), each with specialized personnel and equipment. Mobility is therefore crucial, for people, equipment, and the HIT that connects them. Thus, Bardram and Bossen (2005) regarded medical work as mobility work because mobility is often required to bring together “the right configuration of people, resources, knowledge and place in order to carry out tasks”. Although mobility itself does not usually accomplish any concrete tasks, without mobility, many tasks cannot be fulfilled. In particular, mobility enables distributed collaborators to conduct rich face-to-face communication, and to access information artifacts such as large whiteboards located in different units in order to achieve effective patient care.
Meanwhile, communication across temporal boundaries such as work shifts is essential to ensure continuity of monitoring, diagnosis, and treatment regimes. Staggers and Jennings (2009) investigated nursing shift report in seven medical and surgical units to identify the content and context of information exchange across nursing shifts. Their findings aligned with the results of a systematic review of studies on nursing and physician handovers (Collins et al. 2011), which revealed that there were many types and situational varieties of handovers and shift handovers and concluded that these could be better supported by an EHR system if a standardized set of key information was exchanged in a structured manner.
In addition, medical team members such as physicians, nurses, and pharmacists typically have different temporal work routines and shift cycles, increasing the challenges of coordinating team activities Reddy and Dourish (2002). Breakdowns in communication between teams have been found to contribute to many adverse events. For example, Horwitz et al. (2009), examining adverse events at the transition from ED to in-hospital care, found that “communication failure at some point of care was central to most” reported errors. As an example, an investigation into the amputation of a patient’s wrong leg revealed an inadvertent communication error during shift report (Strople and Ottani 2006). More recent research on patient handover between medical units in the same hospital revealed a variety of communication challenges that involved competing departmental goals, resources, and teams. This sometimes led to limited information sharing between departments. For example, a department may conceal bed availability information from other departments so that they can make their own decisions on bed assignments, which not only affected the inter-departmental coordination but also reduced the organizational efficiency (Abraham and Reddy 2008; Abraham 2013).
10.2.1.2 Medical Records for Supporting Collaborative Work
Amongst the diversity of coordination artifacts and mechanisms used in healthcare work, patient medical records are the fundamental information infrastructure enabling collaboration across time and space. Medical records are not merely a documentation tool for patient’s health conditions (Berg 1996), but also an information collection and distribution device that connects interrelated patient care tasks and social relations in a clinical environment. For instance, while a surgical team interacts face-to-face inside an operating room, team members also communicate through clinical notes in the patient’s medical record when working independently on different threads of patient care activities.
In recent years, EHR systems have been widely implemented to replace paper medical records in clinical settings. The benefits of EHR systems include improvements in accessibility, patient safety, accountability, and cost-savings (Bates et al. 2001, 2003). However, the design of these systems has largely focused on EHR systems as an information storage and retrieval tool for administrative, research, and legal usage (Paul et al. 2003), with little attention to how the EHR can support communication, coordination, and collaboration of healthcare teams (Ackerman et al. 2008; Berg et al. 2006). Many prior studies reported cases in which poorly designed HIT systems have led to unintended negative consequences after deployment, including dissatisfaction, adoption failures, inefficiencies, and even increased medical errors (Campbell et al. 2006; Edinger et al. 2012; Handel and Poltrock 2011; Hardstone et al. 2004). These studies suggest that HIT systems do not properly support communication and coordination activities in team-based healthcare.
In contrast, properly designed and implemented HIT solutions have the potential to support collaboration among a variety of stakeholders, from patients to clinicians, individuals to institutions, and policymakers at all levels. In recent years, through government programs and incentives, the EHR and other HIT have become virtually universal, making it critically important and timely to address these issues resulting from the complex interplay among human, organizational, and technological systems in healthcare.
Relational Coordination and Social Interaction in Teamwork
The dynamic and often urgent nature of healthcare work amplifies the need for effective coordination of interdependent work tasks. In this respect, interpersonal communication and relationships have been found to facilitate work coordination (Gittel 2002), as evidenced in the reduction of adverse events such as hospital-acquired infections and medication errors (Havens et al. 2010). Specifically, work coordination in healthcare settings requires frequent communication of accurate and timely information, and can be enhanced through relationships via shared goals, shared knowledge, and mutual respect. Such relational coordination is particularly instrumental in healthcare settings as patients’ illness trajectories are often associated with a high degree of uncertainty. For example, when a patient’s condition unexpectedly becomes unstable, effective communication and efficient work coordination among relevant healthcare team members would be critical for addressing the unexpected emergency. Coordination among team members can be more effective if positive interpersonal relationships exist (Grudin 1988; Orlikowski and Scott 2008; Whittaker et al. 1994; Kraut et al. 1988; Nardi et al. 2000; Gittel 2002).
Interpersonal relationships are often achieved through informal social interactions, which are generally characterized by being impromptu, brief and context-rich, and often involve small groups of people triggered by their proximity (Whittaker et al. 1994; Nardi et al. 2000). These informal social interactions are important for articulating work among team members and coordinating shared resources for collaboration (Bannon and Schmidt 1992; Berg 1999). Yet, as healthcare work becomes more fragmented and time-pressured, clinicians less frequently find time to interact socially with their colleagues during their shift (Tang and Carpendale 2008). This may be made worse by HIT because systems may hinder articulation work and social interactions (Shipman and Marshall 1999). For example, physical interaction through circulation of paper charts and paper prescriptions among team members allows impromptu interpersonal interactions (Luff and Heath 1998), while a shift to greater use of EHR is often coupled with time spent in isolation at the computer (Poissant et al. 2005), reducing mobility (Richardson and Ash 2008), and hindering interpersonal communication (Tang and Carpendale 2008).
Formal and Informal Work
The use of technology in healthcare settings has been criticized for a tendency toward “formalizing” work practices, such as increasing the structuralization of information representation, and making work processes standardized and rigid (Bowers et al. 1995; Dourish 2003; Shipman and Marshall 1999). Therefore, team members may have to rely on informal practices to leverage the flexible and spontaneous aspects of collaborative work (Isaacs et al. 1997; Kraut et al. 1990; Mejia et al. 2007; Nardi et al. 2000; Whittaker et al. 1994). Informal practices identified in the literature include impromptu human interactions and the use of tools outside of the central system (Kraut et al. 1990; Mejia et al. 2007; Nardi et al. 2000; Whittaker et al. 1994), such as face-to-face conversations, instant messaging, and text messaging which overcome the rigidity and formality of EHR systems (Brown et al. 2009; Ellingson 2003; Lee et al. 2012).
In practice, clinicians frequently adopt informal workarounds beyond the standard operations of health applications and HIT (Koppel et al. 2008) in order to circumvent problems that emerge when a newly deployed IT system disrupts workflows and interferes with task performance or goal attainment (Azad and King 2008; Zhou et al. 2011). These workarounds can be new or reconfigured tools, artifacts, or ways of interacting with an EHR system (Ash et al. 2004; Campbell et al. 2006; Handel and Poltrock 2011; Park and Chen 2012; Tang and Carpendale 2008). Well-documented examples of workarounds are the use of “scraps” or “paper notes” (Chen 2010; Fitzpatrick 2004; Hardey et al. 2000; Hardstone et al. 2004; Tang and Carpendale 2008) and clinicians’ avoidance of documenting social-psycho-emotional information in EHRs (Ames 1993; Zhou et al. 2009).
In healthcare settings, organizational culture and policy determine the kind of information an artifact should contain and who may view or alter this information. Some information artifacts are meant to be maintained permanently as the official legal record of care. Other information artifacts are created for temporary and informal use, to mediate work processes (Gorman et al. 2000) or transmit sensitive information (Ames 1993), only to be disposed of afterwards. Clinicians often use a variety of informal, sometimes individualized information tools to represent information in ways that support specific tasks, in addition to the official, archival EHR record. Temporary storage on paper or personal computing devices may be used to gather fragments of information found in different information systems or in fragmented locations within a single EHR. Portable and temporary forms of information may support tasks and work activities or support certain activities that EHRs fail to support. These informal artifacts have been pervasively used by clinicians and play a vital role in coordinating healthcare work (Fitzpatrick 2004; Hardey et al. 2000; Hardstone et al. 2004; Sexton et al. 2004; Tang and Carpendale 2007, 2008).
Previous studies also found that clinicians often chose to refrain from entering social-psycho-emotional information regarding a patient’s care in EHR systems, as this type of subjective information often conflicts with the objective and factual requirements of EHR-based formal documentation (Ames 1993; Mentis et al. 2010; Zhou et al. 2009). Thus, informal artifacts such as the “kardex” are frequently used for sharing work-related information including subjective patient care information during shift transitions (Fitzpatrick 2004; Gorman et al. 2000; Hardey et al. 2000; Hardstone et al. 2004; Tang and Carpendale 2008) and they carry flexible and work-in-progress notes that are not ready to be documented in archival format in the EHR (Chen 2010; Park and Chen 2012; Tang and Carpendale 2008).
Visible and Invisible Work
Current HIT is primarily designed for performing explicit, visible tasks and supporting visible roles, but healthcare work also involves important but less visible roles and tasks (Spence and Reddy 2007). The concept of visible and invisible shares some similarities to the front-stage-back-stage concept; an explication of the latter is presented in the second case study at the end of the chapter. Examples of invisible tasks include those performed by nurses to conduct comfort work (Strauss et al. 1985) and secretaries to coordinate patient transfer (Bossen et al. 2012; Holten Møller and Vikkelsø 2012). These tasks are not recorded, thus become invisible, in patient medical records, but these invisible tasks are important, and often indispensible, for work accomplishment. However, invisible work has been overlooked in the design of many IT systems (Star and Strauss 1999).
Thus, the design of complex collaborative systems should recognize and represent all invisible roles, tasks, and processes in the collaboration process (Nardi and Engestrom 2001; Suchman 1995). This goal of making work visible is difficult to achieve, however, with EHR designs that are focused primarily on explicit tasks and documentation. For example, non-clinical or unlicensed staff in hospitals and clinics such as clerical personnel, social workers and case managers, or medical assistants often remain invisible in systems, and the critical roles they play in providing and coordinating care may not be taken into account in the IT infrastructure (Bossen et al. 2012; Holten Møller and Vikkelsø 2012; Spence and Reddy 2007). Other important work processes are also neglected. In particular, EHRs often display aggregated tasks without showing and tracking the multiplicity of individual work tasks involved (Chen 2010). The lack of a systems-level representation of these invisible but critical steps can result in serious collaboration breakdowns.
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