High performance teamwork training and systems redesign in outpatient oncology.
BACKGROUND
Oncology care is delivered largely in ambulatory settings by interdisciplinary teams. Treatments are often complex, extended in time, dispersed geographically and vulnerable to teamwork failures. To address this risk, we developed and piloted a team training initiative in the breast cancer programme at a comprehensive cancer centre.


METHODS
Based on clinic observations, interviews with key staff and analyses of incident reports, we developed interventions to address four high-risk areas: (1) miscommunication of chemotherapy order changes on the day of treatment; (2) missing orders on treatment days without concurrent physician appointments; (3) poor follow-up with team members about active patient issues; and (4) conflict between providers and staff. The project team developed protocols and agreements to address team members' roles, responsibilities and behaviours.


RESULTS
Using a train-the-trainer model, 92% of breast cancer staff completed training. The incidence of missing orders for unlinked visits decreased from 30% to 2% (p<0.001). Patient satisfaction scores regarding coordination of care improved from 93 to 97 (p=0.026). Providers, infusion nurses and support staff reported improvement in efficiency (75%, 86%, 90%), quality (82%, 93%, 93%) and safety (92%, 92%, 90%) of care, and more respectful behaviour (92%, 79%, 83%) and improved relationships among team members (91%, 85%, 92%). Although most clinicians reported a decrease in non-communicated changes, there was insufficient statistical power to detect a difference.


CONCLUSIONS
Team training improved communication, task coordination and perceptions of efficiency, quality, safety and interactions among team members as well as patient perception of care coordination.
Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA. craig_bunnell@dfci.harvard.edu
Craig A
CA
Bunnell
Anne H
AH
Gross
Saul N
SN
Weingart
Michael Jason
MJ
Kalfin
Ann
A
Partridge
Sharon
S
Lane
Harold J
HJ
Burstein
Barbara
B
Fine
Nancy A
NA
Hilton
Clare
C
Sullivan
Erin E
EE
Hagemeister
Anne E
AE
Kelly
Lynn
L
Colicchio
Audrea H
AH
Szabatura
Eric P
EP
Winer
Mary
M
Salisbury
Susan
S
Mann
D000554:Ambulatory Care Facilities / Q000592:standards; D001943:Breast Neoplasms / Q000517:prevention & control*; D003191:Comprehensive Health Care; D004779:Environment Design; D005260:Female; D006801:Humans; D007318:Inservice Training / Q000379:methods*; D033183:Interdisciplinary Communication; D008495:Medical Oncology / Q000592:standards*; D010348:Patient Care Team / Q000458:organization & administration / Q000592:standards*; D061214:Patient Safety; D010865:Pilot Projects; D036301:Qualitative Research; D018570:Risk Assessment