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Journal of Interprofessional Care

ISSN: 1356-1820 (Print) 1469-9567 (Online) Journal homepage: https://www.tandfonline.com/loi/ijic20

What makes team communication effective: a qualitative analysis of interprofessional primary care team members’ perspectives

Linda Y. Kim, Karleen F. Giannitrapani, Alexis K. Huynh, David A. Ganz, Alison B. Hamilton, Elizabeth M. Yano, Lisa V. Rubenstein & Susan E. Stockdale

To cite this article: Linda Y. Kim, Karleen F. Giannitrapani, Alexis K. Huynh, David A. Ganz, Alison B. Hamilton, Elizabeth M. Yano, Lisa V. Rubenstein & Susan E. Stockdale (2019) What makes team communication effective: a qualitative analysis of interprofessional primary care team members’ perspectives, Journal of Interprofessional Care, 33:6, 836-838, DOI: 10.1080/13561820.2019.1577809

To link to this article: https://doi.org/10.1080/13561820.2019.1577809

Published online: 06 Feb 2019. Submit your article to this journal

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SHORT REPORT

What makes team communication effective: a qualitative analysis of interprofessional primary care team members’ perspectives Linda Y. Kima, Karleen F. Giannitrapanib, Alexis K. Huynha, David A. Ganza, Alison B. Hamiltona, Elizabeth M. Yanoa, Lisa V. Rubensteina, and Susan E. Stockdalea

aCenter for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; bCenter for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, Menlo Park, CA, USA

ABSTRACT Although numerous scholars have emphasized the need for effective communication between members of interprofessional teams, few studies provide a clear understanding of what constitutes effective team communication in primary care settings, specifically where patient-centered medical home (PCMH) teams have been implemented. This paper describes the elements of effective communication as perceived by members of interprofessional PCMH primary care teams, and identifies elements of effective communication that have persisted over time. Using transcribed text from 75 semi-structured interviews, we applied the grounded theory method of constant comparison to categorize emergent themes relating to elements of team communication. Interprofessional PCMH team members described the elements of effective communication as: 1) shared knowledge, 2) situation/goal awareness, 3) problem-solving, 4) mutual respect; and commu- nication that is 5) transparent, 6) timely, 7) frequent, 8) consistent, and 9) parsimonious. Parsimony is an emergent theme that may be especially relevant for interprofessional PCMH teams challenged with structured clinic schedules. Future work could focus on understanding how to teach and sustain effective parsimonious communication. Comprehensive quality improvement efforts incor- porating a variety of strategies, including team communication training, information and commu- nication technologies, and standardized communication tools may facilitate communication of pertinent patient information in a brief and concise manner.

ARTICLE HISTORY Received 19 February 2018 Revised 14 January 2019 Accepted 18 January 2019

KEYWORDS Qualitative method; team-based practice; interprofessional team communication; patient-centred practice

Introduction

With the implementation of the patient-centered medical home (PCMH), traditional physician-centric primary care practices are changing to environments where physicians work collaboratively with other members of an interprofes- sional team, sharing responsibilities for common face-to-face tasks such as health promotion and coaching, medication reconciliation, and reviewing test results and other findings with the patient and family, as well as non-face-to-face tasks such as telephone and email communication, processing clin- ical reminders, and handling of forms (Department of Veterans Affairs, Veterans Health Administration, 2014; Edwards et al., 2015; Kim et al., 2017). This increased com- plexity of PCMH team structure opens up new possibilities for shared care of patients, but also raises new issues about the most effective means of communication in an environment where more team members are interacting. Few studies pro- vide a clear understanding of what is perceived to be effective primary care team communication since the transition to PCMH. The objectives of this paper are to identify the ele- ments of effective communication as perceived by interprofes- sional PCMH team members in the primary care setting, and to identify whether these perceptions have persisted over time.

Methods

In 2010, the Veterans Health Administration (VHA) implemented the patient aligned care team (PACT), a PCMH model of patient care delivery, in primary care settings. PACTs consist of a primary care provider (PCP) – a physician, nurse practitioner (NP), or physician assistant (PA) – and three supporting team members including a registered nurse (RN) care manager, a licensed voca- tional nurse (LVN) or a health technologist, and a medical support assistant (MSA) or clerk (Department of Veterans Affairs, Veterans Health Administration, 2014). Teams are supported by ancillary staff, such as clinical pharmacists, nutritionists/dietitians, and social workers. Participants for this study were recruited from three VHA primary care practices implementing PACTs.

This study was conducted as part of a larger qualitative study (Rubenstein et al., 2014), which employed a semi-structured inter- view protocol to evaluate the early implementation experiences of PACT members. The interview guides covered multiple domains, including perceptions of team formation, team functioning, team member roles and responsibilities, and team communication. Team member interviews were conducted in two waves (wave 1: January-June 2012; wave 2: September 2013-January 2014).

For the purposes of this study, we used output from all text segments referring to team communication. A grounded theory

CONTACT Linda Kim [email protected] This article has been republished with minor changes. These changes do not impact the academic content of the article.

JOURNAL OF INTERPROFESSIONAL CARE 2019, VOL. 33, NO. 6, 836–838 https://doi.org/10.1080/13561820.2019.1577809

© 2019 Taylor & Francis Group, LLC

method of constant comparison was used to categorize emergent themes relating to elements of team communication. All analyses were conducted using ATLAS.ti software, Version 7 (Scientific Software Development, 2013). All procedures were approved by the Institutional Review Board of the VHA Greater Los Angeles Healthcare System (2011-070725).

Results

The themes presented emerged via analysis of 75 interprofessional PACT team member interviews: PCPs (wave 1: n = 14; wave 2: n = 13), RNs (wave 1: n = 8, wave 2: n = 8), LVNs (wave 1: n = 9, wave 2: n = 11), and MSAs (wave 1: n = 7, wave 2: n = 5). Interprofessional PCMH team members described the elements of effective communication as: 1) shared knowledge, 2) situation/

goal awareness, 3) problem-solving, 4) mutual respect; and com- munication that is 5) transparent (open), 6) timely (prompt), 7) frequent (often), 8) consistent (regular), and 9) parsimonious (concise). These nine elements along with the description of the elements and team members’ quotes are listed in Table 1.

Shared knowledge was described as sharing information and knowledge about patient care issues, as well as strategies to achieve positive patient and clinic outcomes. Situational awareness involved giving a “heads up” to team members about what is currently happening and what needs to happen to accomplish team goals. Problem-solving was described as the process of joint decision-making, resolution of patient care issues, and conflict resolution/management, which was often facilitated through shared knowledge within and between teams. Mutual respect was a sense of being respected and valued, regardless of one’s relative position on the team.

Table 1. Summary of elements of interprofessional team communication.

Elements of Interprofessional Team Description of Element Sample Quotes

Shared Knowledge Giving and receiving: “We talk about different roles and any problems that came up, any news that people have from other meetings they’ve gone to that they bring in to share information.” [PCP]• Information

• Knowledge • Ideas/strategies for

improvement “We sometimes share, you know, like this is how we do it. Like when we develop like a group, so we get some ideas from other groups also and sometimes those who haven’t had, we give them like tips how we do it, so we kind of share that way…” [RN]

Situation/Goal Awareness

Preparing (giving “heads-up”) about:

“We try to, talk to each other as far as what we require from each other and what we need from each other and if there’s any questions about what’s going on and if we need any extra help whether – what our schedule looks like and so forth.” [LVN]• What is currently going on

• What is to come “These people are coming in. You know, I’m anticipating, you know, this guy is going to need this and, you know, this. Let’s make sure that that happens.” [PCP]

Problem-Solving Joint (with members of the team): “We talk in the interdisciplinary group about, you know, whether it was a compliance problem or frequencies and why he keeps going to the ER for psychiatric reasons or pain medicine or whatever, and we’ll come up with some sort of plan or solution…” [RN]

• Decision-making • Resolution to patient care

issues • Conflictresolution/

management “It’s a team meeting since we’re a smaller group… So often things get hammered out in that meeting or if they need to get tossed to someone up above for input, then that decision is made there.” [PCP]

Mutual Respect Giving and receiving/feeling: “And, again, just try to be very respectful to each other.” [RN] • Respect • Valued “I value the input of both my LVN and RN. If they feel like… we really need to sit down and really

carve out a time, we’ll do that…” [PCP] Transparent (Open) Honest and open ““We talk about, you know, our own concerns. We give ideas. We share our ideas with the team and

basically, you know, we’re pretty open with a lot of suggestions.” [MSA]Without hidden agendas or motives Having a voice and being heard Giving and accepting: • Input/feedback/suggestions “I think that all concerns are taken seriously and we do discuss them veryopenly at our meetings so

nothing’s really hidden. I mean we always put everything out on the table.” [RN] Timely (Prompt) Information is shared promptly

Resolving issues quickly “I think it’s also, yeah, really [the LVN] being able to communicate with the provider either by messaging me, getting back to me in a timely fashion about stuff, handling stuff quickly…” [PCP] (Ex: Untimely Communication) And the communication… Well, I know with one clerk [MSA], she will, she’ll get a call from the patient who has a problem. She’ll try to pass it to the RN, but the RN isn’t very, doesn’t do it in a timely manner so then the patient ends up coming in because you know, there’s no really communication with what needs to be done in however amount of time [MSA]

Frequent (Often) Communicating often “My RN, I meet with her on a multiple daily basis, usually before clinic, mid-morning, lunchtime, afternoon, end of the day. I mean it’s constant.” [PCP] “We huddle a lot… I don’t know, maybe more than ten times a day… That’s why we know what’s going on with the patients, even our clerk [MSA] … one of the patients need this, or there’s a problem with this, then we communicate.” [RN]

Consistent (Regular) Regular (schedule of) communication Consistency Routine

“Well, actually I meet with my doctor every day. I do my huddle with my doctor every day. Before I leave for work I make sure that I give him a copy of his appointment for the following day.” [LVN] (Ex: Inconsistent Communication) I think sometimes when, for example, if my LVN has been told by us to do certain things and she sees that the other teamlets are not doing it, she may work really well for a week or two, but then, she falls right back to her old ways. And the same thing with the clerk [MSA]… she will be really good maybe two weeks after the meeting, then it goes right back to the old ways. [PCP]

Parsimonious (Concise)

Concise communication: “It could be just, you know, a couple of minutes, but those couple of minutes are really productive.” [PCP]• To the point

• Not overly detailed I’m huddling and I have patients like waiting, I don’t like all the chit-chatty. I got people waiting on me. So in my case, this [short huddle] works out very well. It’s black and white, the nitty gritty, and then do what we need to do. [LVN]

JOURNAL OF INTERPROFESSIONAL CARE 837

Communication features included transparency, which was described as sharing concerns, suggestions, and team goals hon- estly and openly, without worrying about ridicule or scorn, which further promoted knowledge-sharing and situational awareness. Timely communication allowed for information to be shared promptly and questions to be answered quickly so that all mem- bers of the team have situational awareness. Frequent communi- cation promoted exchange of timely information throughout the day about immediate issues, while consistent information- sharing allowed team members to have team awareness of what is planned for the future. Finally, parsimonious communication was described as information that is accurate, yet concise.

Discussion

Our study findings highlight a new element of team commu- nication–parsimony, which has not been noted in previous literature. Parsimonious communication, in which team members accurately and succinctly convey all relevant infor- mation to other team members, may be especially critical in primary care settings where patients have scheduled appoint- ment times for their visits. Due to this time limitation, team members not only need to communicate patient information promptly, frequently, and consistently, they also need to com- municate parsimoniously.

To enhance team function in PCMH, future work should assess 1) what are the critical pieces of information that need to be shared/transmitted to allow for better PCMH team functioning and 2) what communication mechanisms and processes facilitate parsimonious interactions. For instance, a comprehensive quality improvement program incorporating the use of communication strategies such as SBAR (situation, background, assessment, recommendation), along with var- ious information and communication technology (e.g., secured text and/or instant messaging) may facilitate commu- nication of pertinent patient information in an accurate, yet concise manner. Further research should clarify what parsi- mony in the context of PCMH really means.

Our findings also provide support for elements of team communication seen across other non-primary care settings (e.g., acute, long-term, and palliative care) being present in primary care in the PCMH era. Our study findings show that the elements of communication are not mutually exclusive; rather, communication effectiveness and relationships between members of the interprofessional PCMH team are interrelated. Another notable finding was that all the commu- nication elements identified in Wave 1 were also present in Wave 2. These results provide tentative evidence of commu- nication elements that may persist over time. Evaluation of longitudinal data from subsequent studies and future studies applying a survey or an interview guide specifically designed to measure these team communication domains, may further strengthen conclusions about these and future findings.

One limitation of this study is that this analysis represents a secondary analysis of interviews collected for a broader imple- mentation evaluation; therefore, the interview guide was not designed specifically to address team members’ perceptions of elements of effective team communication (e.g., parsimony).

Nonetheless, various elements of team communication were discussed and emerged from the interviews and given the large sample, thematic saturation was reached. Another limitation was that the interviews in this study were conducted in three primary care practice sites in one VA administrative region.

Conclusion

In identifying what makes team communication effective in primary care settings, we identify one underexplored element – parsimony, which may be especially relevant in interprofessional PCMH teams. In addition, we found that elements of effective communication identified in other settings also may be found in primary care in the PCMH era. Future studies evaluating the effectiveness of targeted interventions aimed at improving these elements of team communication over time, are critical for sustainment of effective communication between interprofes- sional PCMH team members, which promotes better team function and delivery of coordinated, patient-centered care.

Acknowledgments

We would like to thank Dr. Danielle Rose for reviewing drafts of this manuscript.

Disclosure Statement

The authors report no conflicts of interest.

Funding

Funding for this project was supported through a grant from the VA Veterans Assessment and Improvement Laboratory for Patient- Centered Care (VAIL-PCC) Patient Aligned Care Team (PACT) Demonstration Lab (#XVA 65-018). LK’s effort was supported through a grant from the Agency for Healthcare Research and Quality (#T32HS00046) and salary support from the Quality Scholars Program funded by the VA Office of Academic Affiliations (#TQS 65-000). A part of KG’s effort was supported through the VA Locally Initiated Project (LIP #65162). The content does not represent the views of the U.S. Department of Veterans Affairs or the United States Government.

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