Human Factors Quarterly / Fall 2017 / Issue 20

Problem Analysis of Team Care in the VA Health Care System

Abigail Noonan, Jennifer Herout, Jolie Dobre, Brian Moon, & Donna Baggetta, Human Factors Engineering, Office of Health Informatics

As one piece of ongoing work in analyzing clinical domains in support of Electronic Health Record Modernization (ERHM), Human Factors Engineering (HFE) conducted an in-depth study on team care. The objectives were to (1) understand how teams are defined and constructed and (2) understand how teams function today. Final analysis included:

  • How clinicians communicate, manage tasks, and coordinate with each other;
  • Issues with performing follow-up on ordered consults, orders, appointments, and labs;
  • How clinicians compensate when they can’t accomplish required work within the Veterans Health Administration (VHA); and
  • Findings that affect team cohesion, workflows, and patient coordination.

HFE practitioners conducted a review of policies affecting team care at the VA and a brief literature consultation (see the end of the article for works consulted) on team care in clinical settings. In addition, four focus groups, with fifteen clinician participants, and four subject matter expert (SME) interviews were conducted. The resulting data informed the site visit interview topics as well as providing data to be analyzed as part of the body of data on team care.

Lastly, five HFE team members performed a three-day site visit to a Level 1A VA medical center and affiliated Community Based Outpatient Clinics (CBOCs) in the Southeast United States. The site visits focused on provision of outpatient primary care by clinicians and staff. HFE conducted 21 interviews with these staff, attended three morning huddles, and observed three clinics for several multi-hour sessions.

For data analysis, the team divided the notes and transcripts into 1423 relevant raw data points . The data was coded by one of four HFE practitioners and audited by a second HFE practitioner, resulting in 8 primary codes with multiple sub-codes. The data was further analyzed by the study lead and assigned to a more actionable and illustrative finding, more easily used by developers and stakeholders, resulting in 163 individual (though frequently related) findings. Frequently noted findings are summarized below with the number of related data points in parentheses.

HIT Communication (118)

Teams use health information technology (HIT) to communicate across departments. Team members mentioned frequent use of co-signing to ensure their team members see CPRS information, but also noted that it contributed to the known problem of alert overload. Other examples of HIT communication cited include:

  • Team members used notes and orders, though they clutter the record;
  • Pharmacists indicated contra-indications via flagged orders;
  • Problem discussions and recommendations occurred through email-like exchanges called e-consults;
  • Clerks used HIT check-ins to note when a patient has checked-in;
  • Specialists provided direct patient care, spreading scarce resources.

Paper-Based Workflow (33)

Providers use personalized, paper-based methods of accomplishing their day-to-day task management, patient-care, health record management, and team coordination. The time delay, hand-written notes, and lack of inter-operability with HIT introduce possibilities for incorrect information being placed in the record. As one clinical pharmacy specialist said, “Every morning I print my list of patients for my clinic. If the patient cancels after the list is printed, I do not know that the patient cancelled…” In another example, a nurse shared the notes she took on a printed schedule as she facilitated their daily morning huddle (see Figure 1). Other paper-based methods of work arounds included:

  • Printed routing slips at check-ins;
  • Jotted notes for vitals and positive screens;
  • Printed schedules used by providers throughout the day for writing their notes about patients;
  • Post-it notes used for communication;
  • Faxed records from non-VA providers scanned into CPRS as difficult-to-search images; and,
  • Paper progress notes used during connectivity outages.
Example of handwritten note made during a huddle.
Figure 1. (Click for full sized image.) Notes handwritten during a huddle.

Messaging Task Management (31)

The main provider of a primary care team often uses Lync or a My HealtheVet (MHV) secure messaging (SM) inbox as a method of task management. Additionally, teams use group chat to maintain awareness of team member status. One team member described it, “We are always sending messages between each other [sic]. Or if someone was out and you covered their clinic and you want to catch them up. Or if you’re collaborating, and getting a second opinion.” However, these uses of messaging can allow information to fall through the cracks:

  • Lync doesn’t confirm messages are read.
  • MHV SM inboxes are shared by team members, who may assume someone else has addressed a patient concern.
  • MHV SM cannot be between primary teams.

Warm Handoffs (28)

Patients may see multiple clinicians or staff in different departments (sometimes unplanned) during the same visit. Performing in-person (warm) handoffs ensures that complicated information is conveyed correctly and patients arrive at the correct department. Handoffs are, in general, a weak point for coordination. Patients can be sent to inappropriate clinics – like a female being sent to a Women’s Health Clinic despite needing a different type of care. Warm handoffs can alleviate errors.

Mental Health Roles (43)

Mental health services are provided by a range of roles including: psychologists, psychiatrists, social workers, mental health social workers, patient-centered medical home assessment staff, nurse practitioners, primary care providers, military sexual trauma coordinators, and pharmacists, as well as multiple types of non-VA providers. Patient assignment is done by availability, historical preferences of the patient, and presumed capabilities; because the roles do vary, this convenience assignment can have ramifications on care provided.

Adjustment for Criticality (24)

Patients with urgent needs necessarily disrupt established routines. Necessary triaging is integral to patient-centered care, but hard to predict, coordinate, and support. Examples include:

  • Unscheduled handoffs to embedded mental health providers;
  • Handoffs to the ER based on test results;
  • Appointment priority due to a positive pregnancy test; and,
  • Emergency walk-ins seen regardless of delays caused.

Team Cohesion (48)

Coordination relies on personal relationships between team members. Multiple positive examples of coordination that improved team cohesion were seen in the analysis and should be fostered and encouraged. Examples include:

  • Relying on group cognition and memory of patient history during huddles;
  • Using historical knowledge of the providers to more accurately predict timing and walk-in response; and,
  • Using personal contacts in other clinics/departments/facilities to get accelerated care for patients with urgent needs.

Patient Characteristics (32)

Team care is stressed when patients are less functional. Patients struggling with mental health can have behavioral issues, making team members reluctant to engage with them. Patients with cognitive impairments may have issues following instructions and care plans, or relaying their symptoms to the team. Both cognitive and behavioral impediments can contribute to patients missing or being late to appointments, causing long wait time and hurried patient encounters.

These findings are being used in the ongoing HFE journey map work to support VHA HIT initiatives. Potential next steps include an additional site visit, further validation by clinicians, providers, and staff, consultation with non-VA clinicians as they are an important part of many Veterans’ healthcare teams. Next steps will also include interviews with information technology (IT) and non-VA providers and a patient interview study for their perspective on their roles, pain points and facilitators.

1Data points resulted from natural breaks in observations or answers to questions. They could be a phrase or 1-2 sentences.

Works Consulted:

Carroll, J. S., Williams, M., & Gallivan, T. M. (2012). The ins and outs of change of shift handoffs between nurses: a communication challenge. BMJ Quality & Safety, 21(7), 586–593. https://doi.org/10.1136/bmjqs-2011-000614

Clements, D., Dault, M., & Priest, A. (2007). Effective teamwork in healthcare: research and reality. HealthcarePapers, 7 Spec No, 26–34. https://doi.org/10.12927/hcpap.2013.18669

Dobre, J., Carter, T., Moon, B., & Kabel, M. (2016). DCVAMC/PG County CBOC Site Visit: Women’s Health Providers Interviews. Retrieved from https://vaww.portal2.va.gov/sites/humanfactors/HFE Projects/eHMP v2.x/Womens Health Domain Definition and Site Visit Report.docx

Doherty, R. B., Crowley, R. a, & Policy, P. (2013). Annals of Internal Medicine Position Paper Principles Supporting Dynamic Clinical Care Teams : An American AND, (July), 1–8.

Foster, S., & Manser, T. (2012). The Effects of Patient Handoff Characteristics on Subsequent Care. Academic Medicine, 87(8), 1105–1124. https://doi.org/10.1097/ACM.0b013e31825cfa69

Hatten-Masterson, S. J., & Griffiths, M. L. (2009). SHARED maternity care: enhancing clinical communication in a private maternity hospital setting. The Medical Journal of Australia, 190(11 Suppl), S150-1. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/19485866

Klein, G., Feltovich, P. J., Bradshaw, J. M., & Woods, D. D. (2004). Common Ground and Coordination in Joint Activity. Retrieved from http://jeffreymbradshaw.net/publications/Common_Ground_Single.pdf

VHA HANDBOOK 1101.10: Patient Aligned Care Team Handbook. (2014). Department of Veterans Affairs. Xyrichis, A., & Ream, E. (2008). Teamwork: a concept analysis. Journal of Advanced Nursing, 61(2), 232–241. https://doi.org/10.1111/j.1365-2648.2007.04496.x