Presentation
Assessment of Teamwork Dynamics in Colorectal Cancer Screening: Identifying Pathways to Enhance Patient Care
DescriptionBackground:
Colorectal cancer (CRC) is the third most common cancer and the third leading cause of cancer deaths in the United States (US) (Siegel et al., 2023). Early detection of CRC through screening can significantly reduce mortality rates (US Preventive Services Task Force, 2021). Given these benefits, screening is critical to increasing survival. However, disparities in CRC screening (CRCS) uptake persist (Carethers, 2021; May et al., 2020), which can benefit from interventions at the provider-, clinic-, and community level (Hendren et al., 2011; Hudson et al., 2007).
Federally Qualified Health Centers (FQHCs) play a crucial role in providing accessible healthcare to underserved populations, including CRCS. Despite their efforts, FQHCs have lower screening coverage rates compared to the general population, with only 40.2% of patients receiving CRCS, compared to 72.3% in the general U.S. population (Amboree, 2024).
CRCS includes stool-based testing (Fecal immunochemical test – FIT) and colonoscopies, both of which depend upon effective coordination between members of the care team and between provider and patient. This study aims to understand current practices in CRCS, workflow, and teamwork dynamics of clinical care teams to ultimately identify areas for intervention to improve CRCS uptake for underserved communities. It is part of a larger study that seeks to enhance health services for underserved patients who receive care at FQHCs.
Methods:
We used a mixed method approach using surveys and interview(s) to identify underlying teamwork needs. Recruitment took place at 7 academically affiliated FQHCs within a regional network in the Midwestern US.
Participants: To be eligible to participate in the survey or interview, clinicians were required to be 18 years or older, be employed at one of the eligible clinics, and be directly involved in providing CRCS. Clinicians were recruited via e-mail sent through a listserv and through clinic presentations, with the option to participate in an interview, the survey, or both. Upon completion of the survey, participants could elect to be entered in a raffle to win 1 of 5 $100 Amazon gift cards. Interview participants were offered reimbursement with a Visa gift card. All materials were reviewed and approved by the Internal Review Board at the University of Illinois at Chicago and the UI Cancer Center (Protocol #2023-0821).
The survey includes the following questionnaires: Multi-Team System (MTS) Coordination Perceptions (5 items), Team cognition/ Shared Mental Models (4 items), MTS Communication Perceptions (4 items), Patient Related Barriers to Colorectal Screening (17 items), Team Related Barriers to Colorectal Screening (4 items), and System Related Barriers to Colorectal Screening (5 items). Responses were collected using a 5-point Likert Scale. MTS Coordination and all Barriers to Colorectal Screening were graded from (Not at all to To a Very Great Extent); while Team Cognition and MTS Communication Perceptions were graded from (Strongly Disagree to Strongly Agree).
Interviews were conducted using a semi-structured interview guide developed by investigative team members based on a macro-ergonomic framework to gather clinicians' views on CRCS practices. This method allowed us to analyze the work environment and its impact on screening. All interviews were done via Zoom and recorded with permission from the participants.
Analysis:
Survey. Descriptive statistics were conducted to characterize respondent demographics and responses. Data from each dimension was aggregated and analyzed at the dimension level. Given the limited sample size of the data set (n=21), non-parametric analysis was completed using SAS.
Interviews. Interviews were transcribed verbatim and uploaded into Atlas.ti for qualitative analysis. All transcripts were coded by at least two research team members, with all discrepancies resolved via discussion for 100% consensus. Coding was inductive and deductive, using the Heuristic for Teamwork (also known as the C’s of teamwork framework; Salas et al., 2009) for deductive coding structure. The team iteratively reviewed all codes for thematic analysis.
Results:
A total of 21 survey responses from 6/7 clinics were received, of which 14 (6 males and 8 females) were completed for analysis. Participants had various backgrounds: eight physicians, two clinical pharmacists, two nurse practitioners, a phlebotomist, and a certified medical assistant. A total of 9 people (all are primary care providers) also participated in an interview.
Comparisons of each individual item between the main clinic site (6 responses) and all other satellite sites (8 responses) of dichotomized Likert Scale responses (1-3) and (4-5) using Fisher’s test predominantly showed no significant differences except for 1 item (Too high demand for colonoscopy services p = 0.031). Data analysis was completed for the entire data set at the aggregate dimension level. The mean and std. dev for each dimension are reported here. MTS Coordination Perceptions (3.19 +/- 0.94); Team cognition/ Shared Mental Models (3.54 +/- 0.49); MTS Communication Perceptions (3.30 +/- 0.79); Patient Related Barriers to CRCS (3.53 +/- 0.63); Team Related Barriers to CRCS (2.82 +/- 0.65); System Related Barriers to CRCS (3.37 +/- 0.89).
Further context can be provided to the perceived system- and team barriers from semi-structured interviews. Clinicians shared the need for more clear coordination of CRCS, noting that sample return of FIT tests and completion of colonoscopy prep often prevented successful CRCS. For instance, one notable system barrier was the availability of colonoscopies at the local health system, where appointments for screening required months of waiting. As one clinician shared, “But still, you know, some months out from the time the patient calls to getting that [colonoscopy] appointment… the farther that you book out any appointment, you know, the data shows that it's higher, that someone's gonna No Show that, and so I think that that is another barrier is just, you know, booking something 3, 4, 5 months away. difficult for a patient to remember to follow through with it.”
Other barriers noted included transportation, scheduling appointments, and patient education.
Another clinician reported, “The other really big thing is the colonoscopy issue out when people that do need them or elect to them is the transportation issue, post colonoscopy is a huge issue. Had many, many patients that do not have someone in their life that can transport them back when they're done with colonoscopies, and so just don't get them done.”
Conclusion:
Results from the survey show that participants have a neutral to positive perception of their MTS coordination, shared mental models, and team communication practices. Notably, patient-related barriers to CRCS, such as finances, housing, transportation, health literacy, etc., were present (avg. = 3.53 +/- 0.63) and rated as a greater concern than Team Related Barriers (2.82 +/- 0.65).
Ultimately, barriers to CRCS were found to be present at the patient, team, and system levels, indicating a need to address teamwork dynamics and collaboration strategies to enhance overall performance in care delivery. At the same time, the insights gathered from the survey and semi-structured interviews reveal critical barriers to effective CRCS that extend beyond teamwork dynamics, relating to the “C” of Conditions for teamwork. The need for improved coordination in the screening process highlights systemic challenges that must be addressed. Additionally, issues such as transportation, appointment scheduling, and patient education emerged as obstacles hindering successful CRCS completion. By addressing these barriers, healthcare teams can develop more effective strategies to promote CRCS, ultimately improving patient outcomes.
Colorectal cancer (CRC) is the third most common cancer and the third leading cause of cancer deaths in the United States (US) (Siegel et al., 2023). Early detection of CRC through screening can significantly reduce mortality rates (US Preventive Services Task Force, 2021). Given these benefits, screening is critical to increasing survival. However, disparities in CRC screening (CRCS) uptake persist (Carethers, 2021; May et al., 2020), which can benefit from interventions at the provider-, clinic-, and community level (Hendren et al., 2011; Hudson et al., 2007).
Federally Qualified Health Centers (FQHCs) play a crucial role in providing accessible healthcare to underserved populations, including CRCS. Despite their efforts, FQHCs have lower screening coverage rates compared to the general population, with only 40.2% of patients receiving CRCS, compared to 72.3% in the general U.S. population (Amboree, 2024).
CRCS includes stool-based testing (Fecal immunochemical test – FIT) and colonoscopies, both of which depend upon effective coordination between members of the care team and between provider and patient. This study aims to understand current practices in CRCS, workflow, and teamwork dynamics of clinical care teams to ultimately identify areas for intervention to improve CRCS uptake for underserved communities. It is part of a larger study that seeks to enhance health services for underserved patients who receive care at FQHCs.
Methods:
We used a mixed method approach using surveys and interview(s) to identify underlying teamwork needs. Recruitment took place at 7 academically affiliated FQHCs within a regional network in the Midwestern US.
Participants: To be eligible to participate in the survey or interview, clinicians were required to be 18 years or older, be employed at one of the eligible clinics, and be directly involved in providing CRCS. Clinicians were recruited via e-mail sent through a listserv and through clinic presentations, with the option to participate in an interview, the survey, or both. Upon completion of the survey, participants could elect to be entered in a raffle to win 1 of 5 $100 Amazon gift cards. Interview participants were offered reimbursement with a Visa gift card. All materials were reviewed and approved by the Internal Review Board at the University of Illinois at Chicago and the UI Cancer Center (Protocol #2023-0821).
The survey includes the following questionnaires: Multi-Team System (MTS) Coordination Perceptions (5 items), Team cognition/ Shared Mental Models (4 items), MTS Communication Perceptions (4 items), Patient Related Barriers to Colorectal Screening (17 items), Team Related Barriers to Colorectal Screening (4 items), and System Related Barriers to Colorectal Screening (5 items). Responses were collected using a 5-point Likert Scale. MTS Coordination and all Barriers to Colorectal Screening were graded from (Not at all to To a Very Great Extent); while Team Cognition and MTS Communication Perceptions were graded from (Strongly Disagree to Strongly Agree).
Interviews were conducted using a semi-structured interview guide developed by investigative team members based on a macro-ergonomic framework to gather clinicians' views on CRCS practices. This method allowed us to analyze the work environment and its impact on screening. All interviews were done via Zoom and recorded with permission from the participants.
Analysis:
Survey. Descriptive statistics were conducted to characterize respondent demographics and responses. Data from each dimension was aggregated and analyzed at the dimension level. Given the limited sample size of the data set (n=21), non-parametric analysis was completed using SAS.
Interviews. Interviews were transcribed verbatim and uploaded into Atlas.ti for qualitative analysis. All transcripts were coded by at least two research team members, with all discrepancies resolved via discussion for 100% consensus. Coding was inductive and deductive, using the Heuristic for Teamwork (also known as the C’s of teamwork framework; Salas et al., 2009) for deductive coding structure. The team iteratively reviewed all codes for thematic analysis.
Results:
A total of 21 survey responses from 6/7 clinics were received, of which 14 (6 males and 8 females) were completed for analysis. Participants had various backgrounds: eight physicians, two clinical pharmacists, two nurse practitioners, a phlebotomist, and a certified medical assistant. A total of 9 people (all are primary care providers) also participated in an interview.
Comparisons of each individual item between the main clinic site (6 responses) and all other satellite sites (8 responses) of dichotomized Likert Scale responses (1-3) and (4-5) using Fisher’s test predominantly showed no significant differences except for 1 item (Too high demand for colonoscopy services p = 0.031). Data analysis was completed for the entire data set at the aggregate dimension level. The mean and std. dev for each dimension are reported here. MTS Coordination Perceptions (3.19 +/- 0.94); Team cognition/ Shared Mental Models (3.54 +/- 0.49); MTS Communication Perceptions (3.30 +/- 0.79); Patient Related Barriers to CRCS (3.53 +/- 0.63); Team Related Barriers to CRCS (2.82 +/- 0.65); System Related Barriers to CRCS (3.37 +/- 0.89).
Further context can be provided to the perceived system- and team barriers from semi-structured interviews. Clinicians shared the need for more clear coordination of CRCS, noting that sample return of FIT tests and completion of colonoscopy prep often prevented successful CRCS. For instance, one notable system barrier was the availability of colonoscopies at the local health system, where appointments for screening required months of waiting. As one clinician shared, “But still, you know, some months out from the time the patient calls to getting that [colonoscopy] appointment… the farther that you book out any appointment, you know, the data shows that it's higher, that someone's gonna No Show that, and so I think that that is another barrier is just, you know, booking something 3, 4, 5 months away. difficult for a patient to remember to follow through with it.”
Other barriers noted included transportation, scheduling appointments, and patient education.
Another clinician reported, “The other really big thing is the colonoscopy issue out when people that do need them or elect to them is the transportation issue, post colonoscopy is a huge issue. Had many, many patients that do not have someone in their life that can transport them back when they're done with colonoscopies, and so just don't get them done.”
Conclusion:
Results from the survey show that participants have a neutral to positive perception of their MTS coordination, shared mental models, and team communication practices. Notably, patient-related barriers to CRCS, such as finances, housing, transportation, health literacy, etc., were present (avg. = 3.53 +/- 0.63) and rated as a greater concern than Team Related Barriers (2.82 +/- 0.65).
Ultimately, barriers to CRCS were found to be present at the patient, team, and system levels, indicating a need to address teamwork dynamics and collaboration strategies to enhance overall performance in care delivery. At the same time, the insights gathered from the survey and semi-structured interviews reveal critical barriers to effective CRCS that extend beyond teamwork dynamics, relating to the “C” of Conditions for teamwork. The need for improved coordination in the screening process highlights systemic challenges that must be addressed. Additionally, issues such as transportation, appointment scheduling, and patient education emerged as obstacles hindering successful CRCS completion. By addressing these barriers, healthcare teams can develop more effective strategies to promote CRCS, ultimately improving patient outcomes.
Authors
Event Type
Oral Presentations
TimeWednesday, April 211:37am - 12:00pm EDT
LocationQueens Quay
Patient Safety and Research Initiatives (PS)