Background: The University of Alabama, Birmingham (UAB) implemented the Patient Care Connect Program (PCCP) to improve the health and healthcare of patients while reducing costs. This qualitative case study examines the attributes of the PCCP team that contributed to its success.
Methods: In-depth, semistructured interviews were conducted with key members of the PCCP team (N = 6). Detailed notes were typed and imported into NVivo 10 for deductive coding based on characteristics of the Healthy Teams Model and the Critical Considerations of Teamwork framework. Both functional and temporal perspectives were explored.
Results: Interviews with a diverse group of UAB team members revealed most attributes of a Healthy Team and all of the influencing conditions and core processes of an effective team. The PCCP team described a strong interplay of context, composition, and culture as well as strong interdependence of cooperation, coordination, coaching, and communication, which supported shared cognition and strong conflict-resolution capacity. Given the importance of funder objectives, changes to funding for the program will very likely alter the navigation model and types of services provided.
Conclusion: The PCCP team provides an example of teamwork within a complex navigation program. PCCP attributes identified in this study support constructs identified in team science theory. Attributes of a strong team can be cultivated by other navigation programs to improve team cohesion and programmatic impact.
The University of Alabama, Birmingham (UAB) Navigation Network team implemented a 3-year Centers for Medicare & Medicaid Services (CMS)-funded healthcare innovation project called the Patient Care Connect Program (PCCP). The goal was to evaluate patient navigation in the context of the Triple Aim. Key strategies included empowering patients, addressing barriers to care, and improving care coordination of geriatric cancer patients with the highest needs in 12 cancer centers across 5 southeastern states. Measures of success were reductions in hospitalizations, emergency department visits, intensive care unit (ICU) admissions, and overall annual costs.
This study examined characteristics of the PCCP team as an exemplar given their demonstrated success in improving patient health and care experience while lowering costs of care through patient navigation.
Semistructured, in-depth interviews were conducted with key team members, including the principal investigator, the medical director, the administrative director, the nursing director, and 2 patient navigators (N = 6). Interviews lasted 40 to 60 minutes each. Detailed notes were typed and imported into NVivo 10. Themes were coded using a deductive approach based on characteristics of the Healthy Teams Model1 and Critical Considerations of Teamwork.2 Member-checking with the principal investigator and medical director ensured accuracy of reported findings.
According to Salas and colleagues, there are 3 “primary components of teams—multiple individuals, interdependencies, and a shared goal.”2 They theorize that 3 major influencing conditions (context, composition, and culture) and 6 core processes and emergent states (cooperation, coordination, cognition, conflict, coaching, and communication) are “critical considerations” for teams.2 These are not hierarchal but interdependent attributes. Furthermore, Mickan and Rodger posit that “Healthy Teams” have 6 characteristics: mutual respect, goals, leadership, communication, cohesion, and purpose (Table).1 In this analysis, the attributes described by Salas and colleagues are interpreted in the context of “Healthy Team” characteristics.2
In addition, functional and temporal perspectives were explored given that the team was brought together for a research purpose with concrete goals and a limited period of time.3 The functional perspective is goal oriented and most interested in productivity, efficiency, quality, leadership effectiveness, and group satisfaction with outcomes. The temporal perspective is most interested in how groups change over time with core constructs of group development, communication, group processes, and feedback.3
Interviews with a diverse group of UAB team members revealed attributes of a Healthy Team and all the influencing conditions and core processes of a functional team.2 For example, all interviews reflected shared cognition (one of Salas et al’s core processes) or common goals (1 of the 6 characteristics of Healthy Teams).1,2 Although some interviewees emphasized research goals over patient support goals, and others emphasized the opposite, all interviewees recognized the team goal was the Triple Aim. One interviewee said, “Besides lowering the cost of healthcare, it is decreasing or eliminating barriers to [patient] healthcare.” Four of 6 interviewees emphasized the importance of patient empowerment in achieving success. All interviews reflected strong respect of colleagues, cohesion, and pride in work accomplished. One respondent voiced pride in “[t]he way our patients feel—we have gotten thank you cards. They will let you know: ‘thank you for calling…. Just knowing that you are there is good enough for me.’” This pride reflects strong ownership over work achieved. In addition, 2 respondents explicitly mentioned the “interdisciplinary” or “multidisciplinary” nature of their work, signaling appreciation for diverse contributions for project success.
Given the goal-oriented structure of research, the functional perspective emerged as most prominent among interviewees. The team had clear protocols and reporting structures. Success was measured based on quantitative reductions to emergency department visits, unplanned hospital readmissions, and ICU visits as well as earlier palliative care at end of life. Project goals did not change over time. However, the temporal perspective emerged when discussing the role and value of the patient navigator as a new member of the team. In other words, acceptance and appreciation for the navigator increased over time. Also, the funding source changed from a Center for Medicare and Medicaid Innovation Award to the Oncology Care Model (OCM), restructuring project goals based on funder priorities.
Context, composition, and culture were the major factors that influenced teamwork. The context of the project spanned “[a]cross 5 states, different hospital sizes—mostly small community hospitals with the exception of two.” The geographic span provided a powerful platform to operationalize the team’s work, described as: “Awesome and challenging at the same time.” The composition of the team included evaluation and training teams, site-specific physician-nurse site manager-navigator teams at each of the 11 satellites, marketing support, and data analytic support.
The wide-spanning context and complex team composition could have created challenges for team culture. However, interviews showed remarkable cohesion that impacted both team culture and climate. One person said, “I’m most proud of our ability to apply a conceptual framework across multiple settings while being able to adapt and modify to the institution…[to] the organizational culture…while maintaining the integrity of the program as designed.” Another person voiced intrinsic rewards: “When a patient says thank you, it is the best feeling ever….You made a difference in someone’s life. They know that you care, because you called.” Mutual respect across team members was clear: “We had this cadre of incredibly experienced advisors/coinvestigators… that added a level of depth that was unique.” Another interviewee indicated, “This may be the best job I’ve ever had….We are like a small family—help each other professionally and personally….” Another person echoed that the team was “like a family.”
Interdependence of core processes cooperation, coordination, coaching, and communication emerged from the interviews. As Salas and colleagues note, nesting of teams within a team (eg, the evaluation and analytics teams and site-specific teams nested within the PCCP team) can be important for coordination in a large, dynamic system, which is often true in healthcare.2 Strong communication, clear role boundaries, and feedback loops helped support cooperation and coordination, although—as 1 leader noted—it took a lot of time and effort: “We had quarterly administrator meetings to share information…. [M]onthly phone calls to administrators….[Q]uarterly on-site meetings and quarterly webinars to share best practices and look at results together…[We also talked about] sustainability plans.” Coordination also meant processes for strong communication within and across sites. Proactive outreach and transparency of navigators were key. One navigator said, “We introduced ourselves to all the doctors and nurses….It was hard at first. Being the new face, the new service, new program….Once they got used to us coming around, it was okay.” Operationally, feedback to and across sites guided programmatic improvements: “Constant feedback was key….patient feedback so they could use the info to guide program. It was like a community needs assessment.”
Strong and engaged leadership was cited as a facilitator for success. Leadership or coaching is needed at various levels to create structure and set direction for clear goals.2 One person said, “Our physician is very independent and free thinking.” Established processes helped guide solutions: “We had care maps for how we qualify patients for the program….[what to do] after each chemo, give them 24 to 48 hours, then call….” In complex situations (eg, when a patient tried to commit suicide), navigators elevated the issue to the nurse manager. “After this situation, we put a protocol in place....” Care maps, open leadership, and creation of new protocols with learning helped team members successfully accomplish team goals. Another interviewee mentioned, “the medical director was key to making it work—we had medical directors at all sites. The medical director served as liaison to the medical team and navigation staff. They explained what the role of the navigator is, how they support the team.”
The positive team culture helped with conflict resolution. Conflict is a critical condition for a team, because any team doing important work with passionate people will encounter conflict as a part of human interaction. Salas and colleagues suggest that interpersonal conflict is generally counterproductive2; however, limited-duration task conflict can be positive in determining the best way of doing things to accomplish team goals. Interviews reflected strong team capacity for resolving conflict: “In the beginning there was some conflict,” one navigator said, “We aren’t trying to step on any toes.…We are trying to divide the workload, create an easy flow for patients so they get what they need, and they are not going back and forth to the ER.” This is a classic instance of “storming” in which conflict emerges as a new team develops2: “Once we built relationships, it was okay.” This conflict started as interpersonal, but once relationships were established, the conflict dissipated. The team also experienced conflict after creating a new protocol for advance directives: “The biggest challenge was implementing the Respecting Choices program….It really took an extensive amount of communication and information sharing.” This example of “process conflict”2 was mitigated by an adaptive leadership style that allowed site flexibility with implementation as long as core components of protocol fidelity were in place. By addressing problems head-on, clarifying roles, and sharing information, the team productively dealt with conflict to accomplish its shared goals.
Cognition refers to the shared vision and understanding of team members regarding the context and mission of the team. Interview themes reflected self-awareness of the components and characteristics needed to accomplish the team’s goals. One respondent indicated: “Being a navigator takes a lot of patience and a lot of heart….I see it as a calling….It is not one of those instant gratification type jobs.” This cognitive orientation aligns with the service orientation needed to address patient-level barriers and goals. Design thinking for healthcare improvement was reflected in leadership cognition: “The opportunity exists because the models provide new money up front with the expectation that the redesign will result in reduced unnecessary expenditures.” This leadership ability to take risk was critical to the team’s success. Finally, “collective efficacy” is cited by Salas and colleagues as important for coordination2; however, it is also critical for cognition. The role of collective efficacy was apparent in one person’s reflection: “I’m most proud that we did it.” The ability of team members to collectively envision and believe in success was an important component for this project’s success.
Another support for shared cognition was the focus on health rather than disease: “It’s difficult to translate for people who want to get into [navigation],” explained an interviewee. “It’s a paradigm shift. We want to emphasize health promotion….Take this and do this for the patient— that is just throwing another person at the problem.” The job of the navigators “was not to do things for the patients but to use their internal resources to bring them to self-management and self-efficacy….It was not only the patient but the family that surrounded the patient and the providers.” Project success hinged on culture change, not simply adding people to the workforce.
This case study of a navigation team revealed a strong interplay of context, composition, and culture with composition and culture constitutive of context. In addition, there was strong interdependence of cooperation, coordination, coaching, and communication, which supported shared cognition and strong conflict-resolution capacity. External communication from Medicare made the project possible and accelerated learning and quality improvement: “It was eye opening for me” said one of the leaders, for the “first time….I was getting claims data real-time on patients…looking at data and sharing it together with intent to improve care.” This insight supports the need for better data integration across payers and healthcare providers to improve care not just during research but in ongoing clinical practice.
Lessons learned from the PCCP included the importance of communication and coordination across a complex network as well as upfront planning, strong communication, and adaptation. Second, the funding mechanism directly affected sustainability of the program and the role and functions of the navigator. As UAB transitioned from the CMS innovation project to the Oncology Medical Home (OCM) pilot program, resources available for navigation were reduced, and navigator activities changed. A new disease-focused approach emerged for navigation, which was a positive trend, according to navigators: “Now it is a lot better” since doctors, nurses, and social workers are only “seeing ONE navigator.” This new approach also provided an opportunity for greater inclusion of the navigator in “interdisciplinary team” meetings to discuss patient needs.
Limitations and Strengths
This was a case study and therefore not generalizable to all navigation programs. Interviews are subject to social desirability and recall bias. A strength of the study is its novelty: it is the first known analysis of a navigation program examining team science using theory.
This study contributes to literature on team science by identifying attributes optimal to an effective navigation team as well as challenges that remain even in the context of a strong team. UAB’s high-functioning, team-oriented network facilitated this success. With the transition to the OCM, leadership had to adapt services to align with fewer resources, altered patient eligibility, and changing incentives. Additionally, the change in funding streams demonstrated that financing directly affects the focus and metrics for success for the navigation program. As the field of navigation continues to explore sustainability options, establishing a financing mechanism that incentivizes highest-yield and within-scope patient navigator activities will be paramount.
- Mickan S, Rodger S. Effective health care teams: a model of six characteristics developed from shared perceptions. J Interprof Care. 2005;19:358-370.
- Salas E, Shuffler ML, Thayer AL, et al. Understanding and improving teamwork in organizations: a scientifically based practical guide. Human Resource Management. 2015;54(4):599-622.
- Poole MS, Hollingshead AB, McGrath JE, et al. Interdisciplinary perspectives on small groups. Small Group Research. 2004;35(1):3-16.