Team Science and Transformational Leadership in the Healthcare Field

Introduction
Complex healthcare environments, such as large, geographically dispersed hospital networks, specialized treatment centers, and research facilities, require strong leadership with multidisciplinary teams of healthcare professionals and scientists to work towards solutions (Stokols et al, 2008; Gadlin et al., 2010; Vogel et al., 2013; NRC, 2015). Modern healthcare problems cannot be solved in the traditional, linear manner because as new solutions to the problem are considered, the definition of the problem evolves (Stokols et al., 2008). A complex healthcare question, such as how to improve patient outcomes while reducing burden on a hospital, requires healthcare experts from many disciplines working together under the appropriate leadership. Having input from these healthcare professionals is vital in reaching a long-term, meaningful solution; each brings their own unique perspective based on their area of expertise (Stokols et al., 2005). Having the appropriate leadership in place is critical to a team’s success and productivity. Without the correct leadership at the helm, even teams of the brightest professionals can run aground or flounder. As treatment centers and patient care become more complex, the need for collaborative research, team science, and team leadership will continue to grow.

This chapter describes the current state of team science and collaborative patient care in the field of healthcare. Using classic papers on collaboration, team science, and transformational leadership, we will review and critique several large-scale team science initiatives in the healthcare field from the Cleveland Clinic to Aligning Forces for Quality Program. We will also discuss the transformational leadership aspects of each initiative and how those leadership tactics contributed to the programs’ overall success. Based on the current literature and the state of the science, recommendations will be made on the direction of future research in the healthcare field. The reader should finish the chapter with a thorough understanding of prior team science healthcare interventions and how transformational leadership can be employed to effect change at both the individual and team levels.

Background
One approach to solving complex modern organizational problems, including those in the field of healthcare, is called team science: a collaborative, multidisciplinary research process that brings independent researchers or healthcare professionals together into a collaborative group (Gadlin et al., 2010, Vogel et al., 2013; NRC, 2015). This has been a natural fit for healthcare organizations, such as hospitals or public health departments, as they shift their focus from disease treatment to preventative, whole patient care, and populations health (Zocchi et al., 2015). One example of this shift took place during the 2007 reorganization of the Cleveland Clinic, which will be discussed in further later in the chapter.

Team Science Overview
The past 20 years have seen a surge of investments into team science programs in innovation, research, and advancements in patient care. This kind of approach was often not possible within a single healthcare system working in isolation, but is now being explored through teams of healthcare professionals working together (Stokols, 2008). Healthcare research into organizations is further complicated by the fast-paced nature of technological advancement in modern medicine and public health. New technology is emerging every day that can improve patient outcomes and streamline hospital procedures. For example, how can healthcare facilities decide which changes to pursue and which technologies to implement? This question can often seem overwhelming and is often unaddressed by healthcare facilities large or small, who have their hands full managing patient care and trying to stay financially solvent. This combination of circumstances often results in the same practices continuing for decades because that’s “how things have always been done” even if more efficient or innovative methods emerge. Implementing team science is one way to bring large healthcare organizations into the future and explore benefits for patients, healthcare professionals, and the infrastructure of the healthcare system itself.

Challenges for Team Science
While team science has many advantages, there are also many challenges. Highly diverse team membership can create issues for research; there are cultural, linguistic, and institutional barriers to everyday interactions and long-term collaborations (Vogel et al., 2013; NRC, 2015). Deep knowledge integration presents difficulties as well; it challenges team members to share and build on each other’s knowledge across boundaries and disciplines (Olson & Olson, 2008).

Boundaries in the healthcare field are also permeable and goals or priorities themselves can change over time, resulting in an ever-changing landscape that is difficult for healthcare teams to navigate. Additionally, team membership often fluctuates as healthcare professionals join or leave the team. Finally, geographic dispersion can be a significant barrier to disseminating innovations evenly, particularly with communication and coordination (teams in different locations have little face-to-face interactions and different time zones necessitate additional planning to determine convenient meeting times for all parties) (Borgman et al., 2008; Olson & Olson, 2008). Overcoming these obstacles can be difficult, but not impossible, with the appropriate tools in place to facilitate communication.

Communication is the common theme that unites complex modern research problems and collaborative solutions. One of the main determinants of the collaborative capacity (and thus potential success) of a healthcare team are the technological resources and organizational support that allow team members to network data over the course of a project (McGrath & Hollingshead, 1994; Majchrzak et al., 2000; Olson & Olson, 2008; Stokols, 2008). Working collaboratively, even within a single department or hospital, can be a challenging and when departmental or institutional boundaries are crossed, these challenges increase (Borgman, 2008; DeSanctis & Jackson, 1994, Galdin et al., 2010).

The National Institute of Health (NIH) 2010 Team Science Field Guide states that one of the biggest challenges facing new cross-organizational teams is that there are no procedures or infrastructure in place to facilitate these interactions (Galdin et al., 2010). This lack of infrastructure can be crippling to a healthcare network, particularly one that is new to team science and seeking to implement changes for the first time (Borgman, 2008; DeSanctis & Jackson, 1994, Galdin et al., 2010). These challenges will be addressed in this chapter and several cases of healthcare organizations who have attempted to implement these changes will be analyzed.

Context
In this chapter, we will address the context in which team science can be integrated into the healthcare field to improve outcomes such as hospital efficiency, patient satisfaction, and hospital costs. The NIH Field Guide describes team science as “a collaborative and often cross-disciplinary approach to scientific inquiry that draws researchers who otherwise work independently or as coinvestigators on smaller-scale projects into collaborative centers and groups.” Team science requires strong and effective leadership to ensure a high-functioning, effective team. Most research on this topic focuses on transformational leadership, a leadership style that “induce[s] followers to transcend their interests for a greater good” (Kozloqski & Ilgen, 2006). There are myriad benefits to working with teams with strong leadership, particularly in healthcare or public health settings which by their very nature are interdisciplinary.

Puga et al. state that using transdisciplinary teams in healthcare “brings together a diverse group of individuals who fully integrate theories, methodologies, and frameworks from their respective fields to work as a cohesive unit on complex issues.” By working in teams, individuals are able to pool both physical and intellectual resources to “draw on multiple disciplines, fields, and professions” (Vogel et al, 2013). In research science, this results in more advanced and comprehensive interdisciplinary studies; in the field of healthcare, this results in a more comprehensive approach to patient wellness. Team science is a natural fit for healthcare systems such as the Cleveland Clinic where major restructuring organized healthcare professionals by organ system to improve patient care (Porter & Teisberg, 2016). Coordinating large scale healthcare systems and disseminating information through or planning improvements for those systems is also a task well suited to the team science structure (Zocchi et al., 2015; Porter & Teisberg, 2016). While team science is a valuable tool in healthcare settings, significant improvements need to be made in both the resources and support available for healthcare systems in order to further incorporate team science.

Healthcare Team Science and Transformational Leadership
Trans- or interdisciplinary teams are extremely valuable in the field of healthcare, as they “bring together a diverse group of individuals who fully integrate theories, methodologies, and frameworks from their respective fields to work as a cohesive unit on complex issues” (Puga et al., 2013). In a thorough literature review conducted by Buscemi et al., researchers recommend that a stronger emphasis be put on collaboration and teamwork between health professionals (2012). The results of those studies indicate that interdisciplinary teams can yield more positive patient outcomes and that inter-professional collaboration is most effective when all professionals treat each other’s opinions with respect and communicate well (Buscemi et al., 2012). Because respect and communication are not always a given, the authors encourage evaluation and preparation for collaboration before the team is launched.

Team science is supported by several studies on transformational leadership. In their meta-analytic review, Wang et al. found that transformational leadership was “positively related to individual-level follower performance” and that strong leadership contributed positively to productivity outcomes at several levels (2011). The National Academy of Sciences corroborates these findings with their handbook “Enhancing the Effectiveness of Team Science” and states that transformational leadership approach facilitates “subordinate motivation and effort” and that effective transformational leadership often results in better outcomes at the team and individual levels than other leadership strategies (2015). There is a general consensus that future research is needed to analyze the efficacy of interdisciplinary teams and leadership (specifically transformational leadership) in the healthcare field and that additional tools should be developed to facilitate these goals.

Case Studies in Healthcare Team Science and Transformational Leadership
Aligning Forces for Quality Case Study
In their 2015 study, Zocchi at al. further examine the need for improved leadership and teamwork in a field of healthcare (emergency medicine, specifically) and implements and analyzes such extensive changes. For this study, 172 interventions were implemented across 42 hospitals as part of the Aligning Forces for Quality program. Two-thirds (28) of the hospitals from the study saw improvement on one or more metrics. Many of the truly impressive changes achieved through this study (reduction in patient wait time, rates of patients who left without being seen, unnecessarily long stays, etc.) were improved through changes in leadership and the introduction of teams, even if only for educational and not collaborative purposes.

While important improvements for a number of hospitals were made, one-third of the hospitals enrolled in the study did not show improvements, and 40 of the initial 82 hospitals who signed up to participate in the Aligning Forces for Quality program dropped out of the study, convinced that they could not make the changes necessary. More work needs to be done to help hospitals prepare for large-scale changes and incorporating teams. One of the main challenges reported was a lack of buy-in from senior leadership and lackluster support for the “change champions” using transformational leadership strategies to implement the Aligning Forces for Quality program (Zocchi at al., 2015).

The authors suggest that one explanation is the lack of face-to-face meetings, resulting in reduced engagement and a lack of leadership opportunities, despite the transformational leadership style of team leaders (Zocchi at al., 2015). Zocchi et al. suggest that for future interventions team leaders of healthcare works should be more involved at the planning stage, so as to decrease staff resistance to change (2015). The authors also state that improved transformational leadership is necessary to early success of the program to even get the intervention started (2015).

Cleveland Clinic Case Study
In their review of the changes made at the Cleveland Clinic for the Harvard Business School Case, Porter and Treisberg emphasize the importance of working in teams with strong transformational leadership. After Delos M. Cosgrove, M.D. became the Clinic’s CEO in October 2004, he instituted many changes starting with a stronger emphasis on patient care and satisfaction and a drive for unified clinical leadership. He also reorganized departments from medical/surgical classifications to teams focused on specific organs or organ systems and developed 106 “Care Pathways.” While this initiative began as a way to improve the patient experience, it blossomed into the formation of multidisciplinary care teams lead by transformational leaders who were more cost and time efficient while also delivering a better patient experience. As a result, operating costs for the Clinic decreased, patient satisfaction increased, and several other major hospital systems began adopting this model.

Incorporating transformational leadership into the Cleveland Clinic re-organization was largely responsible for its success. Team were made up of “caregivers” (formerly referred to as non-professional staff) who work together in teams to discuss the mission, values, and patient experience. Data was collected from these teams on day-to-day hospital operations so that action items could be set at the team level for continued improvement (Porter & Treisberg, 2016). Known as “Leadership Rounding,” this process encouraged all caregivers to take ownership in the success of the Clinic and patient satisfaction. The re-organization of the Cleveland Clinic clearly demonstrates the value of using teams of dedicated professionals and non-professional staff lead by transformational leaders in the field of healthcare.

Personal relevance
Working for SNAP-Ed (the Supplemental Nutrition Assistance Program- Education) requires a significant amount of interdisciplinary collaboration. SNAP-Ed serves low income audiences across the country and Ohio (ranked 6th in food insecurity in the nation) has a great need for that guidance. SNAP-Ed is housed in the Family and Consumer Sciences (FCS) branch of Extension at the Ohio State University. Within Extension, SNAP-Ed works collaboratively with the other Extension branches: Community Development, Agriculture and Natural Resources, and 4-H (youth programming).

Internal Transdisciplinary Teamwork
Each branch of Extension comes with their own priorities and areas of expertise. While the overarching goal of all Extension branches is to serve Ohioans, it can be challenging to work together because SNAP-Ed is required to focus exclusively on low income populations with very strict programmatic guidelines. These difficulties are compounded by the fact that each county in Ohio has an Extension office, each with their own Extension specialists, Program Coordinators, and Program Assistants. Because Extension personnel are intentionally geographically dispersed to better serve Ohio’s diverse population, tools to enhance long-distance collaboration are desperately needed. In this vein, OSU Extension leadership have implemented several initiatives, including a major restructuring, an annual Extension conference, and the adoption of the Zoom collaborative software platform.

Within FCS, SNAP-Ed works collaboratively with other Community Nutrition programs, including EFNEP (the Expanded Food, Nutrition, and Education Program), Farm to School, and Healthy Living programs (including Healthy Relationships and Healthy Finances). While each of these teams fall under the umbrella of Community Nutrition programs and are overseen by a single Associate Dean, they serve different audiences in different contexts in different settings across the state. While the shared focus and the fact that all Community Nutrition programs are housed on OSU campus make collaboration somewhat easier, there are still the typical challenges experienced by any diverse, interdisciplinary team.

External Transdisciplinary Teamwork
External transdisciplinary teamwork is also a critical facet of SNAP-Ed’s outreach and success. SNAP-Ed was a founding member of the Ohio State Nutrition Action Committee (SNAC) and has spearheaded several innovation projects on behalf of SNAC. Most recently, SNAP-Ed launched a social marketing campaign, Celebrate Your Plate, with the support of SNAC members including the Ohio Department of Health (WIC and Creating Healthy Communities), Ohio Department of Education, Ohio Department of Aging, Ohio Department of Job and Family Services, EFNEP, and the Mid-Ohio Foodbank.

The success of this social marketing initiative is dependent on strong teamwork and communication between SNAC members to disseminate messages and materials across the state. External (and in this case inter-agency) collaboration at the state level can be complicated, even when team members are all highly motivated and working towards the same goal. There is often a disconnect between the implementing agency (in this case, SNAP-Ed) who needs to make the day-to-day decisions about the project and other team members. Additionally, SNAC is made up of one state-level representative of many government or non-profit agencies, so decisions that need to be approved by the various SNAC partners or regional level officials delay progress significantly. These challenges to transdisciplinary team science are being evaluated via a process evaluation so that changes can be made in the future to enhance collaboration.

Discussion
The field of healthcare, including public health, is becoming increasingly complex with the introduction of new technology and scientific developments. Complex problems, such as how to improve patient outcomes while reducing burden on a hospital, requires healthcare experts from many disciplines lead by an individual practicing transformational leadership. As we observed with the Cleveland Clinic case study, these challenges exist within a single hospital or healthcare system.

New leadership and teamwork strategies, such as team science, are essential to the continued success, development, and expansion of healthcare-related services. Having input, guidance, and pooled knowledge from a team of healthcare professionals allows team members to combine their expertise to achieve solutions far beyond what would have been capable with those individuals working in silos. When team science is combined with transformational leadership, the level of success increases exponentially. This transformational team science approach is a logical fit for healthcare and other public health organizations as healthcare problems have become more complex over time and require more advanced resources to resolve. In public health the utility of this approach is even more pronounced as the focus has shifted over the past century from disease treatment to disease prevention.

We used the Cleveland Clinic case study and the Aligning Forces for Quality Program to demonstrate that there is significant interest in using team science and transformational leadership to improve healthcare systems. In both cases, major changes were made to improve the patient experience as well as hospital functioning metrics. However, is it possible to apply these strategies to other healthcare systems? Would the Cleveland Clinic restructuring have been as successful without such strong support from management and administrative professionals within the hospital? Porter and Treisberg cite examples of how the strategies employed by the Cleveland Clinic have been implemented in other hospital networks. This indicates some potential for replicating these results in other systems, but without the administrative support and a significant amount of financial support this major restructuring would not have been possible.

Based on the literature and studies reviewed in this chapter, we can conclude that team science can be successfully applied to healthcare settings if certain conditions are met. First, there must be significant support from management and administrative branches of the institutions looking to make the changes. Second, the future team members must be prepared to work together and embrace the shifting dynamic for the team to succeed. Team members might require training to become successful leaders or team members and how to work with others in a more collaborative setting. Ideally, the team leader will have had substantial leadership training and be prepared to employee transformational leadership strategies. Third, there must be sufficient resources (financial, infrastructure, personnel, etc.) to support the changes that are needed. As seen in the Aligning Forces for Quality study, hospitals who do not have sufficient resources, staff buy-in, or support from senior staff in the healthcare organization will not be able to make the necessary changes. Finally, sufficient tools and technology must be in place to support the emerging team science; long distance collaboration or even localized communication within a single organization or location must be optimized for teams to succeed.

Conclusions
After reviewing the Cleveland Clinic case study and the Aligning Forces of Quality initiative, it is evident that team science and transformational leadership can be effective tools in healthcare settings. Well implemented interdisciplinary teams can result in improved communication and collaboration between many levels of the healthcare system (among providers, patients, administration, community partners, etc.), improved patient and hospital outcomes, and enhanced sharing of resources among large, geographically dispersed organizations. While team science and transformational leadership can generate remarkable results in the field of healthcare, they must also be accompanied by senior-level leadership support from within the organization, buy-in from other staff, and sufficient financial resources to support restructuring and training to ensure success.