Leading innovation in transdisciplinary care
Martin Chadwick A * , Jennifer R. Hemler B and Benjamin F. Crabtree BA
B
Abstract
Benefits of effective team-based working in healthcare settings are well established, with the ultimate form being transdisciplinary teams. Achieving transdisciplinary teams at the large organisation or system level has not been extensively studied.
To examine and describe exemplar organisations where transdisciplinary working was enabled and that can be reproduced in other organisations.
An expert panel reached consensus on three healthcare organisations in the USA that exemplified transdisciplinary working. Available public information about each organisation was reviewed and site visits with direct observation and interviews were conducted with two of the three exemplar sites (the third completed remotely due to the onset of COVID-19). The process of immersion-crystallisation was used to review the collated material and to identify key themes that were then repeatedly checked with the expert panel.
Consistent themes were identified across all three organisations, although they each arrived at these commonalities via distinctly different routes. All had a clear and shared creation story as to how they came about as an entity, which was supported by consistent longitudinal leadership. This enabled an environment whereby each organisation created its own language that reflected their culture as an organisation, thus continually reinforcing the uniqueness of their organisation.
Large healthcare organisations can achieve the concepts of transdisciplinary practice. While no single achievement pathway was identified, common themes noted were a clear creation story, consistent leadership, and building a language that reflected the organisation.
Keywords: healthcare systems, healthcare workforce, organisational design, organisational culture, qualitative research, team culture, teamwork, transdisciplinary practice.
Introduction
Benefits of providing healthcare in a team environment has been well documented.1–4 Transdisciplinary practice emerging out of this tradition has potential to provide improved outcomes and services.5–8 Research in hospital units, especially in operating rooms and emergency departments, has shown the flexibility, efficiency, and care quality of a transdisciplinary approach.1,5,6,9,10 Using transdisciplinary teams increases the availability of suitably qualified practitioners and has reduced overcrowding, hospital admissions, and unscheduled re-presentations.9,10 Furthermore, staff job satisfaction is reported to improve when working in transdisciplinary teams.9,10 Primary care practices with good team culture and collaboration have been shown to perform better in terms of patient access and continuity of care.11
A major impediment to adoption has been that the language describing transdisciplinary teams has not yet solidified. The terms ‘intradisciplinary’, ‘interdisciplinary’, ‘multidisciplinary’, and ‘transdisciplinary’ are often used interchangeably.12 This confusion of language was highlighted by the Institute of Medicine 2014 workshop summary document Establishing Transdisciplinary Professionalism for Improving Health Outcomes.12 The workshop proposed more specific attention to the language we use, which was reinforced by Stevenson et al.13 Building on these works, we propose the definitions shown in Table 1 that describe both team elements that explain ‘how’ they work and that help team members overcome barriers caused by territorial professional boundaries.14
| Term | Meaning | Definition | |
|---|---|---|---|
| Intradisciplinary | Within | Where care is broadly provided within a singular person or professional group. | |
| Interdisciplinary | Between | Where care is provided by engaging more than one profession. It requires communication to facilitate the delivery of care, which is via a formal referral process. | |
| Multidisciplinary | Many | Where a formal team consisting of several professional groups is engaged in providing care delivery. The team has clearly defined roles and responsibilities and associated hierarchy. | |
| Transdisciplinary | Across | Where a team is engaged in care delivery, with the person receiving the care being a part of the team. Roles and responsibilities within the team are understood with actual care delivery being fluid and dependent on who is best placed to be delivering services. |
The concept of transdisciplinary working integrates professions, transcending traditional professional boundaries.12 A transdisciplinary team develops a common goal with the person receiving care. The team shares roles and responsibilities, with professionals identifying and sharing common skills but also acquiring new skills in areas different from each other.12 This results in a ‘blended’ team which can utilise the specific skillsets of different professionals while benefitting from the generic skills the team members hold; as an example, physiotherapists, occupational therapists, social workers, and nursing staff may work on a team and operate in this transdisciplinary manner. Simplistically, transdisciplinary practice is about creating environments whereby tasks that do not necessarily require specific skills of a specific discipline/profession are purposefully shared across professions/disciplines. It recognises that healthcare is complex and traditional intra/inter disciplinary approaches are often no longer adequate to meet the needs of communities.12 The National Academy of Sciences report goes on to define transdisciplinary professionalism as: ‘an approach to creating and carrying out a shared social contract that ensures multiple health disciplines, working in concert, are worthy of the trust of patients and the public in order to improve the health of patients and their communities’.12
While there are numerous reports of transdisciplinary teams in small units, how transdisciplinary teams function within larger organisations is not well understood. This study aims to help fill these knowledge gaps and advance the emergent field of transdisciplinary practice by describing exemplary models of health system transdisciplinary care. As a Harkness Fellow, the lead author was empowered to translate the experience of leading organisations in the USA to an Australasian context. From this perspective, we outline common elements that enabled three exemplars’ sustained success and discuss possibilities for adaptations and scale up to different healthcare contexts.
Methods
Study design
The research team employed a comparative case study design to explore transdisciplinary practice at a systems level.15 We assembled an expert panel of healthcare researchers with experience in US and New Zealand healthcare systems to identify exemplar health systems in the USA. Inclusion criteria included having reputations as innovators; having extensive, researchable histories; and providing transdisciplinary services. The panel recommended Iora Health, Intermountain Healthcare, and Southcentral Foundation as exemplars, with a track record of top performers in their respective environments. This selection was supported by external critiques by the Havard Business Review for Iora Health and the Kings Fund who completed similar reviews on Intermountain Healthcare and Southcentral Foundation.16–18
Data collection
The lead author conducted site visits at two of the three health systems, Iora Health and Intermountain Healthcare, between January 2020 and March 2020. Site visits were 2-day events that included observation of practice activities, team meetings, and chance employee interactions, as well as audio-recorded semi-structured interviews with system and operational leaders and clinicians, and non-recorded interviews with key informants of different organisational levels.19 Observations and key informant interviews were captured in fieldnotes and expanded into detailed site visit reports. Audio-recorded interviews were professionally transcribed. This study received ethical approval from the Rutgers University Institutional Review Board.
Planning was underway for a site visit at the third exemplar, Southcentral Foundation, when the COVID-19 pandemic necessitated the lead author’s return to his home country. In lieu of a site visit, the study team compiled an extensive database of publicly available data about Southcentral Foundation and its leadership. The authors determined that these data were rich and extensive, and appropriate for secondary data analysis and case comparison. This database included peer-reviewed journal and grey literature, transcribed and video-recorded online interviews, and videos of keynote speeches and presentations, spanning from the 1990s to 2022.
Data analysis
The team analysed interviews and fieldnotes from the two site visits and the artifacts from the third exemplar to identify and characterise system attributes. The authors read transcripts and fieldnotes several times after each site visit, discussing important details and emergent themes. One of the authors pre-screened materials from the team’s database on Southcentral Foundation, and the team conducted a similar process in viewing materials and reading articles and transcripts together. Using this immersion-crystallisation process, which ‘consists of the analyst’s prolonged immersion into and experience of the text and then emerging, after concerned reflection, with an intuitive crystallisation of the data… [t]his cycle of immersion and crystallisation is repeated until the reported interpretation is reached’,15 the team first identified key themes for each case, repeatedly reviewing data until reaching consensus on the most critical themes, and then comparing cases to identify overarching themes.
Results
Transdisciplinary working can be achieved in multiple ways at a systems level. We found transdisciplinary working to be emergent and unique to each context, yet each form shared key elements that led to successful transdisciplinary team implementation and integration. These themes included:
Consistent leadership over extended time instills a consistent guiding hand and vision.
A clearly articulated creation story is shared throughout the organisation.
A new shared language is created that is well understood and pervasive throughout all roles and levels of the organisation.
Each organisation had created a clearly identifiable culture with a unique language that leadership continually reinforced with their creation story.
Case 1: Iora Health
The creation of Iora Health begins with its founder, Rushika Fernandopulle, MD, MPP, who viewed the healthcare system in the USA as progressively focused on billing functionalities instead of aligning services to care needs. To guide Iora through the process of creation to implementation and establishment, he instilled a mantra: ‘restore humanity to healthcare’.19 Building Iora evolved over several iterations before it arrived at its exemplar form. Rushika Fernandopulle described it as ‘building the airplane while flying it’.20 These iterations allowed repeated testing of systems, functions, and information technology systems to support this central mantra.
In this process, Iora created a language of practice that was uniquely theirs, as well as physical space that enabled their way of working. The clinics were purposefully designed, deconstructing the typical office hierarchy and encouraging integration of individuals in teams. No one had their own office but interacted with others in a central ‘bullpen’ area, which is an office area purposefully designed to facilitate staff interaction throughout the day. Practice staff reported this resulting in roles focused on better serving the wellness of their clients. They relabelled primary care physicians to providers, deconstructing the implied power behind the title as the ‘primary’ provider of care. Medical assistants were renamed operations assistants. A ‘healthcare coach’ is a role designed to link all roles. Iora Health hired talented people who reflected this way of working and were committed to its mantra. Their induction process was elongated but targeted to ensure that the components and principles that defined Iora Healthcare were reinforced.
Case 2: Intermountain Healthcare
The creation of Intermountain Healthcare had a defined date: 1 April 1975.21 This was the date the Latter-day Saints Church donated 15 hospitals to the non-profit organisation with a specific mandate to be a model healthcare system and continue operating the hospitals for the betterment of the community. Intermountain has had a low turnover of chief executives over its history. This consistency has allowed a gradual and purposeful shift in focus over three phases. The first was the acquisition and integration of facilities and service components, which lasted from 1975 to the mid-1980s. The next phase saw a shift towards service design and a focus on reducing unwarranted variation in the provision of services. This lasted from the mid-1980s to the late 2000s. The most recent phase has seen a more radical shift in focus from operating in geographic regions to integrating operations across their geographic spread.
During the time spent with the Intermountain team, it became apparent that this journey had dual drivers: (1) incorporating the voice of the consumer in care design and delivery; and (2) creating space to address clinical concerns of ways of working. The Intermountain Operating Model is a process of managing change that allowed clinicians to improve the quality and effectiveness of services. This model incorporates a unique language that has morphed over time to match the needs of clinicians and staff. Essentially a language of improvement, this operating model underpins daily operations but is especially present in their sequential ‘huddles’, which enable knowledge from activities throughout the organisation performed in the previous 24 h to escalate up to executive leadership when they cannot be resolved at a lower level. This process is described in detail by the Havard Business Review in 2018.22
Using the institutional philosophy of change is perhaps the best way to capture and understand this process further. At each stage, there has in essence been a point of disconnect whereby the organisation became out of sync with its environment, be it providers out of sync with the hospital system or the hospital system needing to be more aligned to the local needs of the community. Each phase has been a conscious effort to pull the organisation back to a place where it is pushing the bounds of what it is to be a model healthcare organisation. This has been guided by consistent leadership and a clarity of focus. Intermountain has demonstrated its ability to be an organisation that is willing to continue to change and evolve to meet its mandate challenge.
Case 3: Southcentral Foundation
With ample material available online, it is relatively easy to describe what Southcentral Foundation is.23,24 It is an Alaskan-based, native-owned, non-profit healthcare organisation servicing nearly 65,000 Alaska Native and American Indian people. Southcentral Foundation manages multiple Community Health Centres and Federally Qualified Health Centres across Alaska. Southcentral Foundation’s creation is part of the story of Alaskan peoples’ path towards self-governance and self-determination. The Alaska Native Claims Settlement Act of 1971 created 12 land-based Alaska Native regional corporations. Cook Inlet Regional, Incorporated (CIRI) was one of them. Southcentral Foundation became incorporated in 1982 as a Foundation under CIRI, which provided the framework for Southcentral Foundation to gradually begin to provide services independently. Katherine Gottlieb was appointed to President/CEO of Southcentral Foundation in 1991, a role that she continues to this day. Similar longevity can be found in Doug Eby who has been in post as the Vice President of Medical Services at Southcentral Foundation since 1995. While not the totality of the leadership team that has driven Southcentral Foundation, they have maintained organisational focus over an extended timeframe.
The 1999 opening of the Alaska Native Medical Center, an award-winning medical center with a 173-bed hospital, is a direct outcome of the creation of Southcentral Foundation. With this facility, Alaska became the first state in the nation to have all health facilities for Native Americans designed by the community and managed by Native organisations. To mark this shift, Southcentral Foundation calls local peoples accessing services and using facilities customer-owners, not patients. Customer-owners who work at Southcentral Foundation are expected to attend a week-long onboarding process and ongoing training events to embed themselves in the philosophy of the Southcentral Foundation way of working and the focus on the customer owner. This approach has been codified as the Nuka system of care.
Southcentral Foundation has designed its physical spaces and its team networks to support the Nuka system of care. At the Foundation, most of the office space is open plan, to facilitate teamwork and to reflect cultural principles. Team members work to top capacity, such that customer-owners receive care from the most appropriate and available team member, not the highest certified. Outside of the Southcentral Foundation building in Anchorage, Southcentral Foundation has applied its team-based principles to solve care delivery related to Alaska’s geography and population spread. Southcentral Foundation incorporates community members into the care delivery team, so that service delivery depends on who is best positioned to deliver care, not who is the most certified provider.
Discussion
A panel of experts identified three health systems that achieved system-level transdisciplinary working. Clear themes emerged across the three entities, but each journey has been uniquely different. Each has a definitive creation story and mission, a designed unique language and culture, and strong, consistent leadership. Each creation story is woven into the DNA of the culture of each workplace. Consistent and committed leadership helps maintain these cultures, employing language unique to each organisation to reinforce its mission and values and guide its operational processes.13,25,26
While organisations with long histories cannot control their creation stories, they can control how these stories are articulated and integrated into the culture and fabric of the organisation to facilitate transdisciplinary practice. New organisations should be conscious of how their creation stories manifest. Incorporating transdisciplinary practice is context specific and not always a linear process, as the exemplar sites demonstrated. The use of specific terminology and concepts enable ways of working. This relationship is captured in Fig. 1. One of the key arguments being depicted in Fig. 1 is that achieving transdisciplinary working is not necessarily a linear process. Rather, it is a process that builds and reinforces itself. The language used facilitates specific actions. The actions are reinforced by the physical spaces which allow a way of working to occur. What is observed in one part of the organisation can be translated into others and physical spaces can be constructed to further reinforce a way of working that is reflected in the language used. As all three exemplar sites demonstrated, it is not always a linear process, but circular, and often progressing in both directions. We have attempted to capture this diagrammatically here.
Organisations cannot necessarily promise long tenures from individual leaders, but can maintain consistent leadership.27 These exemplars emerged in part from their consistent leadership, even if, as in the case of Intermountain, individual leaders change. Looking at health systems leaders across the world, we often see short tenures, with 2–3 years appearing to be the norm. With changing of leaders, it is all too common to see a rebranding of the system and disruption of important supporting leadership. While this rebranding is a direct attempt to ensure that the system remains aligned to its environment, often it comes at the expense of maintaining its historical thread. The challenge is to not lose leadership with institutional memory when transitioning to new leadership and from one brand to the next.
This study has several limitations. First, we did not specifically set out to examine policy or funding settings that enable transdisciplinary working; rather, we believe this came through the process we undertook. Second, although we studied exemplar health systems selected by experts in the field, our findings are limited due to this highly selected sample. While the overarching themes we discussed have broad appeal beyond the US setting, we recognise the US location of the exemplars as a potential limitation. Last, a further limitation was our inability to undertake a physical visit to Southcentral Foundation. However, the large amount of publicly accessible information on Southcentral Foundation, including extensive interviews that covered the exact topics we examined in the other two systems, enabled robust analysis and data triangulation.
Conclusion
Large healthcare organisation can achieve transdisciplinary working relationships. True transdisciplinary working maximises contributions of individual healthcare professions and achieves the greatest effects by utilising professionals’ unique skillsets and not unnecessarily duplicating tasks. Team-based healthcare can take multiple forms and be achieved through multiple pathways; but, regardless of the pathway, organisations can create a successful transdisciplinary environment by articulating a clear narrative about the mission and aims of the organisation (including the ‘creation story’) and incorporating language and space that reinforce the uniqueness of the healthcare entity.
Declaration of funding
This work was undertaken while the lead author undertook a Harkness Fellowship supported by The Commonwealth Fund.
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