Development and validation of the primary care team dynamics survey

Joint problem-solving orientation, mutual value recognition, and performance in fluid teamwork environments

Introduction

Joint problem-solving orientation (JPS) has been identified as a factor that promotes performance in fluid teamwork, but research on this factor remains nascent. This study pushes the frontier of understanding about JPS in fluid teamwork environments by applying the concept to within-organization work and exploring its relationships with performance, mutual value recognition (MVR), and expertise variety (EV).

Methods

This is a longitudinal, survey-based field study within a large United States healthcare organization n = 26,319 (2019 response rate = 87%, 2021 response rate = 80%). The analytic sample represents 1,608 departmental units in both years (e.g., intensive care units and emergency departments). We focus on departmental units in distinct locations as the units within which fluid teamwork occurs in the hospital system setting. Within these units, we measure JPS in 2019 and MVR in 2021, and we capture EV by unit using a count of the number of disciplines present. For a performance measure, we draw on the industry-used measurement of perceived care quality and safety. We conduct moderated mediation analysis testing (1) the main effect of JPS on performance, (2) mediation through MVR, and (3) EV as a moderator.

Results

Our results affirm a moderated mediation model wherein JPS enhances performance, both directly and through MVR; EV serves as a moderator in the JPS-MVR relationship. JPS positively influences MVR, irrespective of whether EV is high or low. When JPS is lower, greater EV is associated with lower MVR, whereas amid high JPS, greater EV is associated with higher MVR, as compared to lower EV.

Discussion

Our findings lend further evidence to the value of JPS in fluid teamwork environments for enabling performance, and we document for the first time its relevance for within-organization work. Our results suggest that one vital pathway for JPS to improve performance is through enhancing recognition of the value that others offer, especially in environments where expertise variety is high.

The formation mechanism of primary health care team effectiveness : a qualitative comparative analysis research

BACKGROUND

Team-based care is an essential part of primary health care (PHC), and its team service delivery process is a systematic one involving multiple and complex influences. Research on the formation mechanism can help improve the effectiveness of primary health care teams (PHCTs).

METHODS

First, based on the Donabedian model, we explored the theoretical framework of a PHC team's effectiveness formation mechanism. Semi-structured interviews were conducted with 23primary health care team members in Hangzhou, Zhejiang Province, China. A total of seven factors were then included as conditional variables using the crisp set qualitative comparative analysis (csQCA) to explore the complex influences between them and the outcome variable through univariate necessity analysis and path configuration analysis.

RESULTS

Univariate necessity analysis showed that only "Clear Goals" in the structural dimension were necessary for team effectiveness perception. Six pathways to good primary health care team perception of effectiveness were identified. Two of these paths were more typical.

CONCLUSION

"Clear Goals" was the core variable that should be emphasized when exploring the mechanism of PHCT formation. The results suggest that human resources in the management team should be rationally allocated, goal-oriented, and given good attention. Future studies should explore complex combinations of PHCT factors to improve the effectiveness of PHCTs.

The influence of meaningful work on the mental health of SME employees in the COVID-19 era: can coping strategies mediate the relationship?

BACKGROUND

Stress, depression, and anxiety are prevalent issues among SME employees during the COVID-19 pandemic. Even while having meaningful work that expressively contributes to individual growth has been related to improving mental health, employees' work may also need to adopt coping strategies to increase outcomes. The purpose of this study was to examine the relationship between meaningful work (positive meaning, meaning-making, and greater good motivations) and mental health, as well as coping strategies (problem-focused and emotion-focused) as a mediator of this relationship.

METHODS

Meaningful work, coping strategies, and mental health were evaluated in empirical research based on a sample of 462 SME employees working in Malaysia. Structured questionnaires were used to collect the data and analyze it through Structural Equation Modelling (SEM) using AMOS 21.0.

RESULTS

The findings of the study show the importance of meaningful work in influencing the mental health of SME employees, particularly during a crisis like the COVID-19 pandemic. This suggests that the more they value and see their work as meaningful, the more capable they are of dealing with limitations and mental health problems associated with crises. The study also discovered a partial mediating role for coping strategies between employees' mental health and meaningful work.

CONCLUSION

This study encourages employees to constantly feel connected and discover continued possibilities to work and learn even during crisis situations. In order to improve human resource efficiency in emerging markets, managers and owners of SMEs must implement the model developed by the researchers.

Design and Validation of a Questionnaire to Measure Interprofessional Collaborative Practice for Auditing Integrated Hospital Care: Empirical Research

INTRODUCTION

Interprofessional teamwork is the key issue of delivering integrated hospital care; however, measuring interprofessional collaboration for auditing is fragmented. In this study, a questionnaire to measure InterProfessional collaborative Practice for Integrated Hospital care (IPPIH) has been developed and validated.

METHODS

A four-step iterative process was conducted: (1) literature search to find suitable questionnaires; (2) semistructured stakeholder interviews (individual and in focus groups) to discuss the topics and questions (face validity), (3) pretesting the prototype of the questionnaire in two different integrated care pathways for feasibility, usability, and internal consistency, and (4) testing (content and construct validity and responsiveness) of the revised questionnaire in eight integrated care pathways; the validation and responsiveness was tested by means of exploratory factor analysis, calculation of Cronbach alpha, item analysis, and linear mixed model analysis.

RESULTS

Based on six questionnaires and the opinion of direct stakeholders, the questionnaire IPPIH comprised 27 items. Five different domains could be distinguished: own skills, culture, coordination and collaboration, practical support, and appreciation with the Cronbach alpha varied from 0.91 to 0.48. The self-reported intensity of the collaboration within a specific care pathway significantly influenced the outcome (P = .000).

CONCLUSION

The product is a questionnaire, IPPIH, which can measure the degree of interprofessional collaborative practice in integrated hospital care pathways. The IPPIH was initially developed for quality assurance. However, the IPPIH also seems to be suitable as a self-assessment tool for directors to monitor and improve the interprofessional collaboration and the quality of their integrated care pathway.

Development and validation of the Perceived Benefits of Team-Interaction Training Questionnaire (PBTITQ) among undergraduates

BACKGROUND

The effectiveness of team-interaction training has been proven. However, there is a lack of objective and accurate evaluation tools for the impact and benefits of team-interaction training on participants. This study aims to develop and validate a tool for exploring undergraduates' perception of benefits in team-interaction. It can further insight into the perceived benefits of team-interaction training for undergraduates and evaluates the effectiveness of the course, and provides a reference point for the development of university team-interaction training courses.

METHODS

This study was conducted in three stages. Phase 1 consisted of item generation: A theoretical framework was crafted based on social cognitive theory, self-efficacy theory, and sports performance models. Fifty-two items were generated based on the theoretical framework, participant interviews, and literature review. After Delphi consultation and pilot tests, 39 items moved on to Phase 2. Phase 2 consisted of forming a preliminary questionnaire: the contents to be included were selected through item analysis and exploratory factor analysis (EFA). A total of 40 classes were selected for EFA. After EFA, a three-factor structure with 25 items was formed. The third stage tested psychometric properties through confirmatory factor analysis (CFA), test-retest reliability, criterion-related validity, and internal consistency.

RESULTS

The final PBTITQ consisted of 23 items, each rated from "1" (fully disagree) to "5" (fully agree). EFA and CFA supported the three-factor structure of PBTITQ, which included Cohesion, Communication, and Efficiency. The Cronbach's alpha of the PBTITQ was 0.90, the test-retest reliability was 0.88, and the split-half reliability was 0.81. PBTITQ significantly correlated with the GEQ (r = 0.808, p < 0.05) and the TDM (r = 0.796, p < 0.05).

CONCLUSION

The PBTITQ is an effective tool for assessing the perceived benefits of team-interaction training among undergraduates.

Towards diagnostic excellence on academic ward teams: building a conceptual model of team dynamics in the diagnostic process

OBJECTIVES

Achieving diagnostic excellence on medical wards requires teamwork and effective team dynamics. However, the study of ward team dynamics in teaching hospitals is relatively underdeveloped. We aim to enhance understanding of how ward team members interact in the diagnostic process and of the underlying behavioral, psychological, and cognitive mechanisms driving team interactions.

METHODS

We used mixed-methods to develop and refine a conceptual model of how ward team dynamics in an academic medical center influence the diagnostic process. First, we systematically searched existing literature for conceptual models and empirical studies of team dynamics. Then, we conducted field observations with thematic analysis to refine our model.

RESULTS

We present a conceptual model of how medical ward team dynamics influence the diagnostic process, which serves as a roadmap for future research and interventions in this area. We identified three underexplored areas of team dynamics that are relevant to diagnostic excellence and that merit future investigation (1): ward team structures (e.g., team roles, responsibilities) (2); contextual factors (e.g., time constraints, location of team members, culture, diversity); and (3) emergent states (shared mental models, psychological safety, team trust, and team emotions).

CONCLUSIONS

Optimizing the diagnostic process to achieve diagnostic excellence is likely to depend on addressing all of the potential barriers and facilitators to ward team dynamics presented in our model.

Enabling System Functionalities of Primary Care Practices for Team Dynamics in Transformation to Team-Based Care: A Qualitative Comparative Analysis (QCA)

Team-based primary care has been shown to be an important initiative for transforming primary care to achieve whole-person care, enhance health equity, and reduce provider burnout. Organizational approaches have been explored to better implement team-based care but a thorough understanding of the role of system functions is lacking. We aimed to identify the combinations of system functionalities in primary care practices that most enable effective teamwork. We used a novel method, qualitative comparative analysis (QCA), to identify cross-case patterns in 19 primary care practices in the Harvard Academic Innovations Collaborative (AIC), an initiative for transforming primary care practices by establishing teams and implementing team-based care. QCA findings identified that primary care practices with strong team dynamics exhibited strengths in three operational care process functionalities, including management of abnormal test results, cancer screening and medication management for high-priority patients, care transitions, and in health information technology (HIT) functionality. HIT functionality alone was not sufficient to achieve the desired outcomes. System functionalities in a primary care practice that support physicians and their teams in identifying patients with urgent and complex acute illnesses requiring immediate response and care and overcoming barriers to collaboration within and across institutional settings, may be essential for sustaining strong team-based primary care.

Care delivery team composition effect on hospitalization risk in African Americans with congestive heart failure

The care delivery team (CDT) is critical to providing care access and equity to patients who are disproportionately impacted by congestive heart failure (CHF). However, the specific clinical roles that are associated with care outcomes are unknown. The objective of this study was to examine the extent to which specific clinical roles within CDTs were associated with care outcomes in African Americans (AA) with CHF. Deidentified electronic medical record data were collected on 5,962 patients, representing 80,921 care encounters with 3,284 clinicians between January 1, 2014 and December 31, 2021. Binomial logistic regression assessed associations of specific clinical roles and the Mann Whitney-U assessed racial differences in outcomes. AAs accounted for only 26% of the study population but generated 48% of total care encounters, the same percentage of care encounters generated by the largest racial group (i.e., Caucasian Americans; 69% of the study population). AAs had a significantly higher number of hospitalizations and readmissions than Caucasian Americans. However, AAs had a significantly higher number of days at home and significantly lower care charges than Caucasian Americans. Among all CHF patients, patients with a Registered Nurse on their CDT were less likely to have a hospitalization (i.e. 30%) and a high number of readmissions (i.e., 31%) during the 7-year study period. When stratified by heart failure phenotype, the most severe patients who had a Registered Nurse on their CDT were 88% less likely to have a hospitalization and 50% less likely to have a high number of readmissions. Similar decreases in the likelihood of hospitalization and readmission were also found in less severe cases of heart failure. Specific clinical roles are associated with CHF care outcomes. Consideration must be given to developing and testing the efficacy of more specialized, empirical models of CDT composition to reduce the disproportionate impact of CHF.

Facilitation of team-based care to improve HTN management and outcomes: a protocol for a randomized stepped wedge trial

BACKGROUND

There are well-established guidelines for treating hypertension (HTN), yet only half of patients with HTN meet the defined target of < 140/90. Team-based care (TBC) is an evidence-based strategy for improving blood pressure (BP) management and control. TBC is defined as the provision of health services by at least two health professionals "who work collaboratively with patients and their caregivers to accomplish shared goals to achieve coordinated, high-quality care". However, primary care practices experience challenges to implementing TBC principles and care processes; these are more pronounced in small independent practice settings (SIPs). Practice facilitation (PF) is an implementation strategy that may overcome barriers to adopting evidence-based TBC to improve HTN management in SIPs.

METHODS

Using a stepped wedge randomized controlled trial design, we will test the effect of PF on the adoption of TBC to improve HTN management in small practices (< 5 FTE clinicians) in New York City, and the impact on BP control compared with usual care. We will enroll 90 SIPs and randomize them into one of three 12-month intervention waves. Practice facilitators will support SIPs to adopt TBC principles to improve implementation of five HTN management strategies (i.e., panel management, population health, measuring BP, supporting medication adherence, self-management). The primary outcome is the adoption of TBC for HTN management measured at baseline and 12 months. Secondary outcomes include the rate of BP control and sustainability of TBC and BP outcomes at 18 months. Aggregated data on BP measures are collected every 6 months in all clusters so that each cluster provides data points in both the control and intervention conditions. Using a mixed methods approach, we will also explore factors that influence the effectiveness of PF at the organization and team level.

DISCUSSION

This study will provide much-needed guidance on how to optimize adoption and sustainability of TBC in independent primary care settings to reduce the burden of disease related to suboptimal BP control and advance understanding of how facilitation works to improve implementation of evidence-based interventions.

TRIAL REGISTRATION

ClinicalTrials.gov; NCT05413252 .

Interprofessional collaboration within general practice teams following the inclusion of non-dispensing pharmacists

BACKGROUND

Pharmacists have been included in general practice teams to provide non-dispensing services in the Australian Capital Territory (ACT) since 2016. Interprofessional collaboration and team effectiveness are key considerations in providing high-quality patient care. These concepts have not been well studied following the inclusion of a pharmacist in general practice teams.

METHODS

A mixed methods study was conducted to explore collaboration between pharmacists and health professionals in eight general practices in the ACT, where pharmacists were included in their teams. A validated survey instrument was adapted and utilised to assess the changes in interprofessional collaboration over time following the addition of a pharmacist. Another validated survey was utilised to explore team effectiveness at the end of the study. Semi-structured interviews, with a thematic analysis, were conducted with a purposeful sample of general practice staff members to understand the factors influencing the development of interprofessional collaboration.

RESULTS

In total, 56 and 41 participants completed the baseline and follow-up survey, including 26 who completed both surveys to assess the change in collaboration over time. Interprofessional collaboration scores were high initially and did not change over time. Team effectiveness was also high at the end of the study. Twenty-one individuals participated in interviews, which generated four main interrelated themes related to interprofessional collaboration: professional working relationships, trust, commitment to collaboration, and barriers to collaboration. Trust was integral to professional working relationships and commitment to collaboration. The barriers to collaboration included not having a role description for pharmacists, inadequate interest to initiate working relationships, lack of dedicated time for interaction, lack of utilisation, and poor awareness of pharmacist-led activities in general practice.

CONCLUSION

Interprofessional collaboration was initially high and not influenced by the addition of a pharmacist, perhaps reflecting the inherent nature of the general practices willing to include a pharmacist within their team. Introducing a clear job description for pharmacists, and dedicating time to interact with pharmacists, could be beneficial in improving trust and professional working relationships and enhancing collaboration between the pharmacists and other general practice team members.

Scoping Review to Inform the Future Development of a Measure for Team-Based Care in Oncology

PURPOSE

Team-based care is the delivery of health services to an individual by at least two health care providers working collaboratively to achieve optimal care. Participants on the National Cancer Institute and the ASCO Teams in the Cancer Care Delivery Project have defined 13 key principles to serve as the foundation for a successful team; however, it is unclear whether there exist measures of these key principles.

METHODS

A scoping literature search was conducted for each key principle on PubMed and Embase to identify existing measures for key principles. Articles of interest were exported to a citation manager, Sciwheel, cataloged by the key principle. Existing measures were extracted via a two-stage screening process, with an abstract review followed by a full-text review.

RESULTS

Fifteen unique measures were identified, with items extrapolated for 12 of the 13 key principles. Measures were not exclusive and could represent more than one key principle. The number of measures varied per principle from zero to five, with Team Composition and Diversity yielding no existing measure.

CONCLUSION

The long-term goal is to compile and edit these measures, to create a comprehensive measure to be used in various team-based oncology care settings, and to address areas for improvement, ultimately optimizing patient care.

Interprofessional Collaboration and Team Effectiveness of Pharmacists in General Practice: A Cross-National Survey

As team-based care continues to evolve, pharmacists have been included in general practice teams in many countries, to varying extents, to improve medication use and patient safety. However, evidence on interprofessional collaboration and team effectiveness of pharmacists in general practice is sparse. This study aimed to compare the extent of interprofessional collaboration and team effectiveness of general practice pharmacists in Australia with international sites (Canada and the UK), and identify the factors associated with interprofessional collaboration and team effectiveness. General practice pharmacists from Australia, Canada, and the UK were identified through professional organisations and networks, and invited to participate in an online survey, adapted from existing validated tools. The survey explored interprofessional collaboration through four sub-domains (professional interactions, relationship initiation, trust and role clarity, and commitment to collaboration) and team effectiveness of general practice pharmacists. Of the 101 respondents (26 from Australia, 44 from Canada and 31 from the UK), 79% were female and 78% were aged below 50 years. Interprofessional collaboration and team effectiveness appeared to be high and similar between countries. Total scores for collaboration of pharmacists were 86.1 ± 7.4 in Australia, 88.5 ± 7.5 in the UK, and 89.1 ± 7.3 in Canada (mean ± SD, where higher scores represent more advanced collaboration), while the team effectiveness scores of the pharmacists were 88.6 ± 14.6 in Canada, 91.8 ± 14.6 in Australia and 97.5 ± 14.0 in the UK. Pharmacists who had worked in general practice for a longer time showed advanced interprofessional collaboration while those who worked exclusively in general practice had higher scores for team effectiveness. Overall, general practice pharmacists in the three countries were highly collaborative with general practitioners. Long-term employment and longer work hours could enhance interprofessional collaboration and team effectiveness in general practice pharmacists by improving trust and working relationships over time.

Moving from tangibility toward digitalization: investigating team dynamics and facilitator support among medical students in conventional and digital small-group tutorials

BACKGROUND

Small group tutorials (SGT) promotes self-directed learning and is widely used in medical education. The coronavirus pandemic (COVID-19) has accelerated the trend toward SGT digitalization, with unclear effect. We hypothesize that team dynamics and facilitator support influence SGT satisfaction in digital versus conventional SGT.

METHODS

During the spring semester of year 2021, medical students (the second, third, and fourth year; n = 433) participating in conventional face-to-face and digital SGT curricula were enrolled. Participating students completed the collaborative learning attitude scale (including team dynamics, team acquaintance, and facilitator support dimensions) and teamwork satisfaction scale, previously validated for small-group collaborative learning, and chose preference between conventional or digital SGT in future curricula. Exploratory factor analysis (EFA) was performed to extract the essential structural factors of these scales. Paired t-tests were conducted to compare differences in different dimensions and satisfaction between the conventional and digital SGT settings. Two sets of multiple regression analyses were done; one with team satisfaction scale results and the other with preference for digital SGT as the dependent variable were used to evaluate determinants of these two variables.

RESULTS

The EFA results revealed that the original collaborative learning attitude scale was concentrated on two dimensions: team dynamics and facilitator support. No significant differences were noted between the SGT settings for the two dimensions and teamwork satisfaction. Regression analyses showed that teamwork dynamics was independently correlated with teamwork satisfaction in both conventional and digital SGT. Facilitator support was positively correlated with teamwork satisfaction in conventional, but not digital SGT. Higher teamwork satisfaction was an important determinant of preference for digital SGT among medical students.

CONCLUSIONS

Team dynamics were closely linked to teamwork satisfaction among medical students in both conventional and digital SGT, while the role of facilitator support became less obvious during digital SGT.

Commentary on "Integrating network theory into the study of integrated healthcare"

As medicine continues to advance, fragmentation problems in care delivery - and the promise of care integration to solve them - will remain central. But focused research over the past thirty years has yet to uncover the key factors that enable integrated care. In their paper, Burns and colleagues offer a path to new discovery in this well-trodden area: drawing on network theory to better understand the social processes through which integrated care is produced. Social processes are a vital and understudied aspect of integration, and applying network theory may help to refocus integration in a more comprehensive way. However, to transform our understanding of integrated care - and to enable impact in practice - will require expansion beyond the usual network approaches to also capture the communication and work processes that occur among entities. This is no small endeavor. It will take considerable humility, open-mindedness, and focus.

The relationship between team dynamics with healthcare coordination and clinical work satisfaction among Commune Health Workers: A Bayesian model averaging study

OBJECTIVE

To determine the relationship between team dynamics with healthcare coordination and clinical job satisfaction of the community health workers (CHWs).

METHODS

A cross-sectional study was conducted among 133 health workers (including doctors, nurses, or midwives) at 21 Commune Health Cent in Quoc Oai District, Vietnam, from July 2015 to May 2017. A self-administered questionnaire consisting of 5-Likert items regarding team dynamics and healthcare coordination clinical work satisfaction was utilised. Descriptive statistics and correlation matrix were applied for seven factors of team dynamic, clinical work satisfaction, and patient care coordination queried by primary care providers. Bayesian model averaging (BMA) was used to identify the predictors of the level of team dynamics and healthcare coordination.

RESULTS

The mean score of overall team dynamics among the study participants was 4.08. Clinical work satisfaction and patient care coordination scores among resident physicians were higher than those of attending clinicians; however, the differences were not statistically significant. The results of BMA analysis indicated that team dynamics significantly associated with clinical work satisfaction, and it explains 9% of the total variance in clinical work satisfaction. Team dynamics level was also positively associated with patient care coordination. Patient care coordination was not a significant mediator between team dynamics and clinical work satisfaction.

CONCLUSION

Team dynamics is a potential contributor to improving patient care coordination and clinical job satisfaction of CHWs. As no significant correlation between patient care coordination and clinical job satisfaction was observed, to improve team performance, providing conditions that facilitate team building and teamwork should be conducted for CHWs in CHCs.

Care team and practice-level implementation strategies to optimize pediatric collaborative care: study protocol for a cluster-randomized hybrid type III trial

BACKGROUND

Implementation facilitation is an effective strategy to support the implementation of evidence-based practices (EBPs), but our understanding of multilevel strategies and the mechanisms of change within the "black box" of implementation facilitation is limited. This implementation trial seeks to disentangle and evaluate the effects of facilitation strategies that separately target the care team and leadership levels on implementation of a collaborative care model in pediatric primary care. Strategies targeting the provider care team (TEAM) should engage team-level mechanisms, and strategies targeting leaders (LEAD) should engage organizational mechanisms.

METHODS

We will conduct a hybrid type 3 effectiveness-implementation trial in a 2 × 2 factorial design to evaluate the main and interactive effects of TEAM and LEAD and test for mediation and moderation of effects. Twenty-four pediatric primary care practices will receive standard REP training to implement Doctor-Office Collaborative Care (DOCC) and then be randomized to (1) Standard REP only, (2) TEAM, (3) LEAD, or (4) TEAM + LEAD. Implementation outcomes are DOCC service delivery and change in practice-level care management competencies. Clinical outcomes are child symptom severity and quality of life.

DISCUSSION

This statewide trial is one of the first to test the unique and synergistic effects of implementation strategies targeting care teams and practice leadership. It will advance our knowledge of effective care team and practice-level implementation strategies and mechanisms of change. Findings will support efforts to improve common child behavioral health conditions by optimizing scale-up and sustainment of CCMs in a pediatric patient-centered medical home.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04946253 . Registered June 30, 2021.

Exploring system features of primary care practices that promote better providers' clinical work satisfaction: A qualitative comparative analysis

BACKGROUND

Health care delivery system features can have a profound effect on how frontline physicians and other clinical personnel in primary care practices (primary care providers [PCPs]) view the quality and safety of what they deliver and, ultimately, their clinical work satisfaction.

PURPOSE

The aim of this study was to investigate the combinations of system features (i.e., team dynamics, provider-perceived safety culture, and patient care coordination between PCPs) that are most conducive to positively enhancing PCPs' clinical work satisfaction.

APPROACH

Nineteen Harvard-affiliated primary care practice sites participated in the Academic Innovations Collaborative 2012-2016, which aimed to establish team-based care and improve patient safety. An All-Staff Survey was administered to 854 PCPs in 2015. The survey measured provider experience of team dynamics, provider-perceived safety culture, patient care coordination between PCPs, and providers' clinical work satisfaction. We performed a qualitative comparative analysis to identify "recipes," that is, combinations of conditions necessary and sufficient for enhancing PCPs' clinical work satisfaction.

RESULTS

Strong provider-perceived safety culture and effective team dynamics constitute sufficient conditions that, when present in practices, could best support PCPs to achieve greater clinical work satisfaction.

CONCLUSIONS

Our findings suggest the importance of creating and sustaining a strong safety culture and of establishing and implementing highly functioning teams in primary care practices for enhancing PCPs' clinical work satisfaction.

PRACTICE IMPLICATIONS

Conducting the qualitative comparative analysis provides a new perspective for informing primary care and encouraging primary care practices to pursue strategic priorities for enhancing PCPs' clinical work satisfaction and providing safe, high-quality care.

A roadmap to operationalize and evaluate impact in a learning health system

BACKGROUND

Many health systems invest in initiatives to accelerate translation of knowledge into practice. However, organizations lack guidance on how to develop and operationalize such Learning Health System (LHS) programs and evaluate their impact. Kaiser Permanente Washington (KPWA) launched our LHS program in June 2017 and developed a logic model as a foundation to evaluate the program's impact.

OBJECTIVE

To develop a roadmap for organizations that want to establish an LHS program, understand how LHS core components relate to one another when operationalized in practice, and evaluate and improve their progress.

METHODS

We conducted a narrative review on LHS models, key model components, and measurement approaches.

RESULTS

The KPWA LHS Logic Model provides a broad set of constructs relevant to LHS programs, depicts their relationship to LHS operations, harmonizes terms across models, and offers measurable operationalizations of each construct to guide other health systems. The model identifies essential LHS inputs, provides transparency into LHS activities, and defines key outcomes to evaluate LHS processes and impact. We provide reflections on the most helpful components of the model and identify areas that need further improvement using illustrative examples from deployment of the LHS model during the COVID-19 pandemic.

CONCLUSION

The KPWA LHS Logic Model is a starting point for future LHS implementation research and a practical guide for healthcare organizations that are building, operationalizing, and evaluating LHS initiatives.

A Mixed Methods Study of Change Processes Enabling Effective Transition to Team-Based Care

Team-based care is considered central to achieving value in primary care, yet results of large-scale primary care transformation initiatives have been mixed. We explore how underlying change processes influence the effectiveness of transition to team-based care. We studied 12 academically affiliated primary care practices participating in a learning collaborative, using longitudinal staff survey data to measure progress toward team-based care and qualitative interviews with practice staff to understand practice transformation. Transformation efforts focused on team formation and capacity building for quality improvement. Using thematic analysis, we explored types of change processes undertaken and the relationship between change processes and effective team-based care. We identified three prototypical approaches to change: pursuing functional and cultural change processes, functional only, and cultural only. Practice sites prioritizing both change processes formed the most effective teams: simultaneous functional and cultural change spurred a mutually reinforcing virtuous cycle. We describe implications for research, practice, and policy.

Evaluating collaborative practice within community-based integrated health and social care teams: a systematic review of outcome measurement instruments

Collaborative practice is a workforce priority for integrated health and social care systems internationally, requiring robust outcome measurement instruments (OMIs) to enable team development and good quality research. In this systematic review, we appraised self-administered OMIs that could be used to measure team-based collaborative practice within integrated health and social care teams in community settings. The most important measurement properties when selecting between OMIs are content and structural validity and internal consistency. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) systematic review method was modified to evaluate each OMI. For each measurement property, the methodological quality of individual studies and quality of each parameter were rated, and the level of evidence graded. A search strategy applied to 19 bibliographic databases identified 7 instruments that met eligibility criteria. A total of 6 development studies, 6 content validity studies, 8 studies for structural validity, and 10 for internal consistency were included. Only the shortened version of the Assessment of Interprofessional Team Collaboration Scale (ATICS-II) was rated as Sufficient for each measurement property with Very Low or Moderate quality evidence. Further validation of each OMI for use by community integrated teams is needed; studies evaluating relevance, comprehensibility and comprehensiveness are a priority.

Evaluation of General Practice Pharmacists: Study Protocol to Assess Interprofessional Collaboration and Team Effectiveness

The inclusion of pharmacists into general practices has expanded in Australia. However, there is a paucity of research examining interprofessional collaboration and team effectiveness after including a pharmacist into the general practice team in primary or community care. This is a protocol for a cross-national comparative mixed-methods study to (i) investigate interprofessional collaboration and team effectiveness within the general practice team after employing pharmacists in general practices in the Australian Capital Territory (ACT) and (ii) to compare interprofessional collaboration and team effectiveness of pharmacists in general practice across Australia with international sites. The first objective will be addressed through a multiphase sequential explanatory mixed-method design, using surveys and semi-structured interviews. The study will recruit general practice pharmacists, general practitioners, and other health professionals from eight general practices in the ACT. Quantitative and qualitative results will be merged during interpretation to provide complementary perspectives of interprofessional collaboration. Secondly, a quantitative descriptive design will compare findings on interprofessional collaboration (professional interactions, relationship initiation, exchange characteristics, and commitment to collaboration) and team effectiveness of general practice pharmacists in Australia with international sites from Canada and the United Kingdom. The results of the study will be used to provide recommendations on how to best implement the role of general practice pharmacists across Australia.

Care integration within and outside health system boundaries

OBJECTIVE

Examine care integration-efforts to unify disparate parts of health care organizations to generate synergy across activities occurring within and between them-to understand whether and at which organizational level health systems impact care quality and staff experience.

DATA SOURCES

Surveys administered to one practice manager (56/59) and up to 26 staff (828/1360) in 59 practice sites within 24 physician organizations within 17 health systems in four states (2017-2019).

STUDY DESIGN

We developed manager and staff surveys to collect data on organizational, social, and clinical process integration, at four organizational levels: practice site, physician organization, health system, and outside health systems. We analyzed data using descriptive statistics and regression.

PRINCIPAL FINDINGS

Managers and staff perceived opportunity for improvement across most types of care integration and organizational levels. Managers/staff perceived little variation in care integration across health systems. They perceived better care integration within practice sites than within physician organizations, health systems, and outside health systems-up to 38 percentage points (pp) lower (P < .001) outside health systems compared to within practice sites. Of nine clinical process integration measures, one standard deviation (SD) (7.2-pp) increase in use of evidence-based care related to 6.4-pp and 8.9-pp increases in perceived quality of care by practice sites and health systems, respectively, and a 4.5-pp increase in staff job satisfaction; one SD (9.7-pp) increase in integration of social services and community resources related to a 7.0-pp increase in perceived quality of care by health systems; one SD (6.9-pp) increase in patient engagement related to a 6.4-pp increase in job satisfaction and a 4.6-pp decrease in burnout; and one SD (10.6-pp) increase in integration of diabetic eye examinations related to a 5.5-pp increase in job satisfaction (all P < .05).

CONCLUSIONS

Measures of clinical process integration related to higher staff ratings of quality and experience. Action is needed to improve care integration within and outside health systems.

Conflict Management Education in the Intensive Care Unit

BACKGROUND

Conflicts in medical settings affect both team function and patient care, yet a standardized curriculum for conflict management in clinical teams does not exist.

OBJECTIVES

To evaluate the effects of an educational intervention for conflict management on knowledge and perceptions and to identify trends in preferred conflict management style among intensive care unit workers.

METHODS

A conflict management education intervention was created for an intensive care team. The intervention was 1 hour long and incorporated the Thomas-Kilmann Conflict Mode Instrument as well as conflict management concepts, self-reflection, and active learning through discussion and reviewing clinical cases. Descriptive statistics were prepared on the participants' preferred conflict management modes. A pretest/posttest was analyzed to evaluate knowledge and perceptions of conflict before and after the intervention, and 3 open-ended questions on the posttest were reviewed for categories.

RESULTS

Forty-nine intensive care providers participated in the intervention. The largest portion of participants had an avoiding conflict management mode (32%), followed by compromising (30%), accommodating (25%), collaborating (9%), and competing (5%). Pretest/posttest data were collected for 31 participants and showed that knowledge (P < .001) and perception (P = .004) scores increased significantly after the conflict management intervention.

CONCLUSIONS

The conflict management educational intervention improved the participants' knowledge and affected perceptions. Categorization of open-ended questions suggested that intensive care providers are interested in concrete information that will help with conflict resolution, and some participants understood that mindfulness and awareness would improve professional interactions or reduce conflict.

Team-Based Primary Care Practice Transformation Initiative and Changes in Patient Experience and Recommended Cancer Screening Rates

Team-based care has emerged as a promising strategy for primary care practices to provide high-quality care. We examine changes in patient experience of care and recommended cancer screening rates associated with a primary care transformation initiative that established team-based care. Our observational study included 13 academically affiliated primary care practices in the Boston, Massachusetts area that participated in 2 learning collaboratives: the first (2012-2014) aimed to establish team-based primary care, while the second (2014-2016) focused on improving patient safety and cancer screening. We identified 37 comparison practices of similar size and network affiliation. Using a difference-in-differences approach, we compared pre (2013) and post (2015) patient experience and recommended cancer screening rates between intervention and comparison practices. We estimated linear regression models, using inverse probability weighting to balance on observable differences. Massachusetts Health Quality Partners data on patient experience comes from surveys (with communication, integration, knowledge of patient, access, office staff, and willingness to recommend domains), and its data on screening rates for breast, colorectal, and cervical cancers is derived from chart abstraction. Relative to comparison practices, the communication score in intervention practices increased by 1.47 percentage points on a 100-point scale (P = .02) between pre and post periods. We did not detect immediate improvements in other measures of patient experience of care and recommended cancer screening rates. Communication may be the first dimension of patient experience that improves following establishment of team-based primary care, and changing care processes may require more time or attention in the transition to team-based care. Our findings also suggest a need to better understand the variation in implementation factors that facilitate some practices’ successful transitions to team-based care, and to use teams effectively to improve cancer screening processes.

Interprofessional rounding design features and associations with collaboration and team effectiveness

Multiple models of interprofessional rounding (IPR) exist. However, researchers find mixed effects for the impact of IPR, pointing to the possibility that variations in design may influence the effectiveness of the practice. We explored whether IPR design variations (location, use of script, and role of the leader) are associated with team collaboration (partnership and cooperation) and team effectiveness as perceived by practitioners and patients (i.e., patient inclusion). A cross-sectional, survey-based method design was used targeting practitioners on 15 different hospital units at two academic health centers. Routinely collected Hospital Consumer Assessment of Healthcare Practitioners and Systems scores were used to capture patients' perceptions. Statistical methods included multilevel modeling with moderation analysis. There were several significant relationships among design, team collaboration, and team effectiveness. For the design, role of the leader and use of a script had a significant positive association with cooperation. Practitioners' perceptions of team effectiveness were associated with use of script, and cooperation moderated the relationships between practitioners' perceptions of team effectiveness and location, as well as the role of the leader. There was a significant inverse relationship between cooperation and patient inclusion. Results can inform organizations that are exploring, implementing, or improving IPR as well as considering alternative ways to evaluate their practices.

Embedding collective leadership to foster collaborative inter-professional working in the care of older people (ECLECTIC): Study protocol

Background: The National Integrated Care Programme for Older People (NICPOP), formerly NCPOP aims to support older people to live well in their homes by developing primary and secondary care services for older people, especially those with complex needs. The programme develops integrated intermediate care which traverses both hospital and community settings through multidisciplinary and interagency teams. This team-based approach to the integration of health services is a novel innovation in Irish health service delivery and will require, over time, a shift in cultures of care to allow for the development of competencies for inter-professional collaboration across the care continuum.

The ECLECTIC project will develop an implementation framework for achieving, maintaining and monitoring competencies for interprofessional collaboration among multi-disciplinary teams charged with delivering care for older people across the continuum from acute to community settings.

Design: The ECLECTIC research design has been developed in collaboration with the NICPOP. In phase one of the project, a co-design team will collaborate to define and shape competencies for interprofessional collaboration. Phase two will involve the delivery of a collective leadership intervention over a 10-month period with multidisciplinary professionals working with older people across two geographical regions (Mullingar/Midlands and Beaumont/Dublin North). Each group will comprise of members of two multidisciplinary teams charged with coordinating and delivering care to older people across the continuum of acute to community care. Observations of collaborative inter-professional working will take place before, during, and after intervention. In phase three of the study, analysis of the interview and observation data will be presented to the co-design team in order to develop an implementation framework for future teams.

Discussion: The co-design process will develop core competencies and performance indicators for collaborative interprofessional working. The resulting implementation framework will be implemented nationally as part of the NICPOP.

Intentional or Not: Teamwork Learning at Primary Care Clinics

BACKGROUND AND OBJECTIVES

Primary care teamwork has been shown to increase satisfaction and decrease stress for physicians but the impact of outpatient teamwork for primary care residents' learning has not been described. This study aimed to understand the role of teamwork in residents' learning during and after the establishment of teams.

METHODS

Interviews with 37 primary care residents addressed their experiences at outpatient clinic, including their perceptions about whether team-based care affected their educational experience. Using qualitative thematic analysis, transcripts were coded to identify themes about teamwork and learning, both positive and negative.

RESULTS

Residents described learning both about and through teamwork at continuity clinic, despite variation in the speed and extent of initial integration into teams. As residents learned how to work on a team, they realized the importance of face-to-face time together and trusting one another. Team members also taught residents about the clinical system and social aspects of patient care, as well as some procedural skills, which led them to understand how teamwork can improve patient care and efficiency. Finally, residents learned, through both optimal and suboptimal first-hand team experiences, to see team-based care as a model for future primary care practice.

CONCLUSIONS

While integrating residents into primary care teams, educators should consider the potential value of teamwork as an intentional learning method. Team members, beyond the preceptor, can offer valuable instruction, and team-based workplace learning prepares residents to use teamwork to optimize care for patients.

Team Functioning And Beliefs About Team Effectiveness In Inter-Professional Teams: Questionnaire Development And Validation

Purpose

Few validated instruments are available to measure team functioning in acute and primary care teams. To address this, we developed a questionnaire measuring healthcare provider perceptions of team effectiveness (Provider-PTE) and assessed its psychometric properties.

Patients and methods

Empirical evidence and a conceptual model were used for item generation. The 41-item self-completed questionnaire was developed. A cross-sectional survey of healthcare providers (n=283) across a range of settings was performed. Psychometric properties were assessed for French and English language questionnaires using Cronbach alpha (α) for reliability, the feedback form for face validity, expert opinion for content validity, and the known-group technique for construct validity. Responsiveness was examined by comparing scores in high and low functioning teams.

Results

The mean time needed to complete the questionnaire was less than 9 mins. Respondents were typically female (84%), and employed full time (80%) in urban settings (82%). Cronbach α values were as follows: Team Processes = 0.88; PTE-Overall = 0.91; Outcomes = 0.72. Significant differences were found by professional group (p = 0.017), length of time in the team (p = 0.025), and presence of nurse practitioners. Responses to Outcomes varied by employment status (p = 0.017). Differences were identified in high and low functioning teams (p<0.001). Feedback indicated that two questions related to team meetings needed to be added.

Conclusion

The study produced evidence of validity for English and French language Provider-PTE questionnaires. The revised 43-item instrument represents an important contribution by providing a validated questionnaire to measure team functioning across a range of settings that is consistent with a conceptual framework.

Measuring attributes of team functioning in primary care settings: development of the TEAMS tool

This study examines attributes of a high-functioning primary care team by creating a survey measuring staff perceptions of team culture in primary care practices with innovative team-based workforce models. Survey data from a national study of 30 exemplar primary care practices with innovative team-based workforce models was used. Staff and clinicians (n = 943) at the 30 primary care sites completed a 31-item survey online. Survey items came from previous surveys of adaptive reserve and team culture. Factor analysis, reliability and validity were examined for the survey. Case summaries from site visits and survey comments were compared for high and low scoring sites to establish validity. Three core attributes of a high-functioning team were identified: joy in practice (4 items), personal growth (3 items), and leadership and learning (20 items). Four items did not measure any attribute. Using item correlations, the 20 items for leadership and learning were reduced to 7 items. All three attribute subscales had good reliability and validity. The final 14-item survey measuring joy in practice, personal growth and leadership and learning may be useful in clinical practice as a practical tool to gauge progress in developing a high-functioning team. Further research is needed to determine the sensitivity of this instrument to change over time with interventions designed to improve team functioning in primary care.

Team-based primary care: The medical assistant perspective

BACKGROUND

Team-based care has the potential to improve primary care quality and efficiency. In this model, medical assistants (MAs) take a more central role in patient care and population health management. MAs' traditionally low status may give them a unique view on changing organizational dynamics and teamwork. However, little empirical work exists on how team-based organizational designs affect the experiences of low-status health care workers like MAs.

PURPOSES

The aim of this study was to describe how team-based primary care affects the experiences of MAs. A secondary aim was to explore variation in these experiences.

METHODOLOGY/APPROACH

In late 2014, the authors interviewed 30 MAs from nine primary care practices transitioning to team-based care. Interviews addressed job responsibilities, teamwork, implementation, job satisfaction, and learning. Data were analyzed using a thematic networks approach. Interviews also included closed-ended questions about workload and job satisfaction.

RESULTS

Most MAs reported both a higher workload (73%) and a greater job satisfaction (86%) under team-based primary care. Interview data surfaced four mechanisms for these results, which suggested more fulfilling work and greater respect for the MA role: (a) relationships with colleagues, (b) involvement with patients, (c) sense of control, and (d) sense of efficacy. Facilitators and barriers to these positive changes also emerged.

CONCLUSION

Team-based care can provide low-status health care workers with more fulfilling work and strengthen relationships across status lines. The extent of this positive impact may depend on supporting factors at the organization, team, and individual worker levels.

PRACTICE IMPLICATIONS

To maximize the benefits of team-based care, primary care leaders should recognize the larger role that MAs play under this model and support them as increasingly valuable team members. Contingent on organizational conditions, practices may find MAs who are willing to manage the increased workload that often accompanies team-based care.

Measuring patient and family perceptions of team processes and outcomes in healthcare teams: questionnaire development and psychometric evaluation

BACKGROUND

There is a lack of validated instruments examining dimensions of team functioning from the perspective of patients and families consistent with a conceptual framework. The study aimed to develop and assess the psychometric properties of the Patient-Perceptions of Team Effectiveness (PTE) questionnaire.

METHODS

A cross-sectional survey was undertaken in three studies. Data were collected from May-October 2016 for Study 1, April 2018-ongoing for Study 2, and October 2016 to June 2017 for Study 3. Online and paper versions of the self-administered questionnaire were available in English and in French. The initial questionnaire included 41 items. Study 1 included 320 respondents. Reliability was assessed using Cronbach alpha. Face validity (n = 250) was assessed using a structured questionnaire. Content validity was examined using subject matter experts and Spearman's item-total correlations. Construct validity was examined using known group comparisons (i.e., clinical specialty, education, length of follow-up, reason of consultation). Content analysis was used for open-ended questions.

RESULTS

The questionnaire took 10 to 15 min to complete. Positive assessments were noted for instructions, formatting, font size and logical ordering of questions. In Study 1, reliability indices for the PTE-Overall, Team Processes and Outcomes subscales ranged from 0.72 to 0.84. Item-total correlations ranged from 0.551 to 0.794 (p <  0.001). Differences were noted between clinical specialties, education, length of follow-up, reason of consultation, low and high functioning teams. No differences were noted between English and French language respondents. Psychometric properties were re-assessed in Study 2 and 3 after unclear questions were reworked. Reliability indices for the subscales ranged from 0.76 to 0.94 and differences remained significant between low and high functioning teams.

CONCLUSION

The final 43-item instrument is easy to administer to patients and families. The studies provide evidence of validity to support the propositions in the conceptual framework. The patient-level measures can be aggregated to the team, organizational or system level. The information can be used to assess healthcare team functioning in acute and primary care and determine the role patients and families are playing in teams. Further testing is needed with patients and families who are hospitalized or receiving care from teams in rural areas.

Association of Team-Based Primary Care With Health Care Utilization and Costs Among Chronically Ill Patients

IMPORTANCE

Empirical study findings to date are mixed on the association between team-based primary care initiatives and health care use and costs for Medicaid and commercially insured patients, especially those with multiple chronic conditions.

OBJECTIVE

To evaluate the association of establishing team-based primary care with patient health care use and costs.

DESIGN, SETTING, AND PARTICIPANTS

We used difference-in-differences to compare preutilization and postutilization rates between intervention and comparison practices with inverse probability weighting to balance observable differences. We fit a linear model using generalized estimating equations to adjust for clustering at 18 academically affiliated primary care practices in the Boston, Massachusetts, area between 2011 and 2015. The study included 83 953 patients accounting for 138 113 patient-years across 18 intervention practices and 238 455 patients accounting for 401 573 patient-years across 76 comparison practices. Data were analyzed between April and August 2018.

EXPOSURES

Practices participated in a 4-year learning collaborative that created and supported team-based primary care.

MAIN OUTCOMES AND MEASURES

Outpatient visits, hospitalizations, emergency department visits, ambulatory care-sensitive hospitalizations, ambulatory care-sensitive emergency department visits, and total costs of care.

RESULTS

Of 322 408 participants, 176 259 (54.7%) were female; 64 030 (19.9%) were younger than 18 years and 258 378 (80.1%) were age 19 to 64 years. Intervention practices had fewer participants, with 2 or more chronic conditions (n = 51 155 [37.0%] vs n = 186 954 [46.6%]), more participants younger than 18 years (n = 337 931 [27.5%] vs n = 74 691 [18.6%]), higher Medicaid enrollment (n = 39 541 [28.6%] vs n = 81 417 [20.3%]), and similar sex distributions (75 023 women [54.4%] vs 220 097 women [54.8%]); however, after inverse probability weighting, observable patient characteristics were well balanced. Intervention practices had higher utilization in the preperiod. Patients in intervention practices experienced a 7.4% increase in annual outpatient visits relative to baseline (95% CI, 3.5%-11.3%; P < .001) after adjusting for patient age, sex, comorbidity, zip code level sociodemographic characteristics, clinician characteristics, and plan fixed effects. In a subsample of patients with 2 or more chronic conditions, there was a statistically significant 18.6% reduction in hospitalizations (95% CI, 1.5%-33.0%; P = .03), 25.2% reduction in emergency department visits (95% CI, 6.6%-44.0%; P = .007), and a 36.7% reduction in ambulatory care-sensitive emergency department visits (95% CI, 9.2%-64.0%; P = .009). Among patients with less than 2 comorbidities, there was an increase in outpatient visits (9.2%; 95% CI, 5.10%-13.10%; P < .001), hospitalizations (36.2%; 95% CI, 12.2-566.6; P = .003), and ambulatory care-sensitive hospitalizations (50.6%; 95% CI, 7.1%-329.2%; P = .02).

CONCLUSIONS AND RELEVANCE

While establishing team-based care was not associated with differences in the full patient sample, there were substantial reductions in utilization among a subset of chronically ill patients. Team-based care practice transformation in primary care settings may be a valuable tool in improving the care of sicker patients, thereby reducing avoidable use; however, it may lead to greater use among healthier patients.

Relationship among team dynamics, care coordination and perception of safety culture in primary care

BACKGROUND

There remains a need to improve patient safety in primary care settings. Studies have demonstrated that creating high-performing teams can improve patient safety and encourage a safety culture within hospital settings, but little is known about this relationship in primary care.

OBJECTIVE

To examine how team dynamics relate to perceptions of safety culture in primary care and whether care coordination plays an intermediating role.

RESEARCH DESIGN

This is a cross-sectional survey study with 63% response (n = 1082).

SUBJECTS

The study participants were attending clinicians, resident physicians and other staff who interacted with patients from 19 primary care practices affiliated with Harvard Medical School.

MAIN MEASURES

Three domains corresponding with our main measures: team dynamics, care coordination and safety culture. All items were measured on a 5-point Likert scale. We used linear regression clustered by practice site to assess the relationship between team dynamics and perceptions of safety culture. We also performed a mediation analysis to determine the extent to which care coordination explains the relationship between perceptions of team dynamics and of safety culture.

RESULTS

For every 1-point increase in overall team dynamics, there was a 0.76-point increase in perception of safety culture [95% confidence interval (CI) 0.70-0.82, P < 0.001]. Care coordination mediated the relationship between team dynamics and the perception of safety culture.

CONCLUSION

Our findings suggest there is a relationship between team dynamics, care coordination and perceptions of patient safety in a primary care setting. To make patients safer, we may need to pay more attention to how primary care providers work together to coordinate care.

Feeling inadequate: Residents' stress and learning at primary care clinics in the United States

BACKGROUND

Educators hope that residents' experiences in primary care continuity clinics will influence more trainees to enter primary care careers. Unfortunately, evidence shows that outpatient primary care training in the United States is stressful and fails to promote primary care careers. We conducted qualitative interviews with residents to understand the source of stress and to explain this failure.

METHODS

In-person individual interviews were conducted with 37 primary care residents training at outpatient clinics in the US. Analysis used the constant comparative method and included open and focused coding, allowing themes to emerge inductively from the data.

RESULTS

73% of residents interviewed reported negative emotions about clinic. Beyond stress, residents reported feeling inadequate as primary care physicians at clinic. Four factors contributed: mental distractions, unfamiliarity with primary care medicine, management of outpatients, and relationships with patients. Residents' comparisons of hospital-based and outpatient experiences favored the former in relation to the four factors.

CONCLUSIONS

Residents feel unprepared for primary care and inadequate as primary care physicians, and these feelings discourage them from practicing primary care. This phenomenon must be studied within the entire context of residency, as residents' attitudes about their outpatient experiences were shaped in relation to their inpatient experiences.

Measuring Team Effectiveness in the Health Care Setting: An Inventory of Survey Tools

Background:

Guidance for measuring team effectiveness in dynamic clinical settings is necessary; however, there are no consensus strategies to help health care organizations achieve optimal teamwork. This systematic review aims to identify validated survey instruments of team effectiveness by clinical settings.

Methods:

PubMed, MEDLINE, and ISI Web of Knowledge were searched for team effectiveness surveys deployed from 1990 to 2016. Validity and reliability were evaluated using 4 psychometric properties: interrater agreement, internal consistency, content validity, and structural integrity. Two conceptual frameworks, the Donabedian model and the Command Team Effectiveness model, assess conceptual dimensions most measured in each health care setting.

Results:

The 22 articles focused on surgical, primary care, and other health care settings. Few instruments report the required psychometric properties or feature non-self-reported outcomes. The major conceptual dimensions measured in the survey instruments differed across settings. Team cohesion and overall perceived team effectiveness can be found in all the team effectiveness measurement tools regardless of the health care setting. We found that surgical settings have distinctive conditions for measuring team effectiveness relative to primary or ambulatory care.

Discussion:

Further development of setting-specific team effectiveness measurement tools can help further enhance continuous quality improvements and clinical outcomes in the future.

A Comprehensive Theory of Integration

Efforts to transform health care delivery to improve care have increasingly focused on care integration. However, variation in how integration is defined has complicated efforts to design, synthesize, and compare studies of integration in health care. Evaluations of integration initiatives would be enhanced by describing them according to clear definitions of integration and specifying which empirical relationships they seek to test-whether among types of integration or between integration and outcomes of care. Drawing on previous work, we present a comprehensive theoretical model of relationships between types of integration and propose how to measure them.

Etiology and Treatment of Pain and Psychosocial Issues in Patients With Inflammatory Bowel Diseases

There is increasing evidence that brain-gut interactions are altered during development of inflammatory bowel diseases (IBDs). Understanding the relationship between the neurobiology, psychological symptoms, and social ramifications of IBD can guide comprehensive care for the whole patient. The most common psychological conditions in patients with IBD are chronic abdominal pain, anxiety, and depression. We review the evidence-based data and rates of these conditions and their respective relationship to IBD and the diagnostic approaches to identify patients with these conditions. Different treatment options for pain and psychosocial conditions are discussed, and new models of team-based IBD care are introduced. Providing the health care provider with tools to diagnose and manage psychological conditions in patients with Crohn's disease or ulcerative colitis is necessary for their total care and should be part of quality-improvement initiatives.

A human factors systems approach to understanding team-based primary care: a qualitative analysis

BACKGROUND

Research shows that high-functioning teams improve patient outcomes in primary care. However, there is no consensus on a conceptual model of team-based primary care that can be used to guide measurement and performance evaluation of teams.

OBJECTIVE

To qualitatively understand whether the Systems Engineering Initiative for Patient Safety (SEIPS) model could serve as a framework for creating and evaluating team-based primary care.

METHODS

We evaluated qualitative interview data from 19 clinicians and staff members from 6 primary care clinics associated with a large Midwestern university. All health care clinicians and staff in the study clinics completed a survey of their communication connections to team members. Social network analysis identified key informants for interviews by selecting the respondents with the highest frequency of communication ties as reported by their teammates. Semi-structured interviews focused on communication patterns, team climate and teamwork.

RESULTS

Themes derived from the interviews lent support to the SEIPS model components, such as the work system (Team, Tools and Technology, Physical Environment, Tasks and Organization), team processes and team outcomes.

CONCLUSIONS

Our qualitative data support the SEIPS model as a promising conceptual framework for creating and evaluating primary care teams. Future studies of team-based care may benefit from using the SEIPS model to shift clinical practice to high functioning team-based primary care.