Care for a Patient With Cancer As a Project: Management of Complex Task Interdependence in Cancer Care Delivery

Abstract

Cancer care is highly complex and suffers from fragmentation and lack of coordination across provider specialties and clinical domains. As a result, patients often find that they must coordinate care on their own. Coordinated delivery teams may address these challenges and improve quality of cancer care. Task interdependence is a core principle of rigorous teamwork and is essential to addressing the complexity of cancer care, which is highly interdependent across specialties and modalities. We examined challenges faced by a patient with early-stage breast cancer that resulted from difficulties in understanding and managing task interdependence across clinical domains involved in this patient’s care. We used team science supported by the project management discipline to discuss how various task interdependence aspects can be recognized, deliberately designed, and systematically managed to prevent care breakdowns. This case highlights how effective task interdependence management facilitated by project management methods could markedly improve the course of a patient’s care. This work informs efforts of cancer centers and practices to redesign cancer care delivery through innovative, practical, and patient-centered approaches to management of task interdependence in cancer care. Future patient-reported outcomes research will help to determine optimal ways to engage patients, including those who are medically underserved, in managing task interdependence in their own care.

INTRODUCTION

Contemporary oncology offers unprecedented scientific achievements that promise treatments or cures for many cancers by a multitude of diagnostic and treatment modalities.¹ Yet, equally unprecedented are the complexity, fragmentation, and poor coordination in the delivery of these modalities to patients with cancer across clinical specialties.² Patients often must coordinate their own care, which increases their burden and potentially leads to life-saving treatments being delayed or forgone while avoidable care and costs are incurred.^3-7 These issues contribute to the situation the Institute of Medicine (IOM) describes as a system in crisis.²

The delivery of cancer care as a team—defined as two or more people interacting dynamically, interdependently, and adaptively to achieve a common goal^8,9—is hoped to provide a solution to care fragmentation.^10,11 Success of rigorous teamwork in non–health care industries^12,13 and in treating chronic diseases^14,15 creates a unique opportunity to apply teamwork principles to oncology. In this article, we focus on one of the central teamwork principles: task interdependence. We define task interdependence, describe it in the context of cancer care, and demonstrate how its active management can mitigate and/or prevent care delivery breakdowns as a result of poor coordination. In the effort to follow IOM recommendations,¹⁶ we propose an adaptation of concepts from the project management discipline to facilitate task interdependence management in oncology. We use the example of early breast cancer diagnosis and treatment, which could be considered the epitome of multidomain complexity and fragmentation.^4,10,17-19

This article builds upon work by Taplin et al,²⁰ which explored team interdependence during breast cancer diagnosis. We advance this topic by focusing on the next challenging phase of breast cancer care (ie, postdiagnosis treatment), which further examines the principle of task interdependence as a component of team interdependence and describes the systematic application of this principle in cancer care by using project management.

CASE SUMMARY

The patient is a 32-year-old female who is newly married, wishes to have children, and lives in a low-income suburb of an urban area. She is unemployed and has Medicaid insurance. The patient has stage II, 3-cm, triple-positive, clinically node-negative breast cancer. Parties involved in the patients’s case are the patient, the surgical office at a large hospital, the local oncology office, genetic counseling at the large hospital, an out-of-state genetic laboratory, a stand-alone fertility clinic, a local dental office, a local primary care provider, the psychosocial office at the large hospital, and the patient’s Medicaid insurance.

During her care, the patient experiences four situations in which parties fail to recognize that their tasks are interdependent with those of the other parties and/or do not effectively manage this interdependence. Consequently, the patient’s care is delayed or missed, which leads to suboptimal outcomes.

Neoadjuvant Therapy

Neither the patient nor the provider offices (surgical, oncology, PCP) manage the interdependence among the oncologist consult, completion of neoadjuvant therapy, and surgery. After referral mishaps and difficulty in finding an oncologist who accepts Medicaid insurance, the patient receives a much-delayed oncology consult when she is already scheduled for a preoperative surgical appointment, which left no time for neoadjuvant therapy. Having not received psychosocial assessment and care until adjuvant therapy, the patient experiences anxiety about delays and proceeds with a mastectomy and thus forgoes a chance for preoperative tumor reduction and breast-conserving surgery.

Genetic Testing

The patient undergoes a genetic assessment preoperatively to incorporate the results in her surgical decision. However, the interdependence between obtaining genetic results and the surgical decision was not managed by the providers involved (surgical office, genetic counseling, genetic laboratory). Delay in Medicaid’s authorization contributes to task misalignment. Consequently, results arrive on the day of the patient’s mastectomy. The patient regrets not knowing her positive mutation status; with that information, she would have preferred a bilateral mastectomy and oophorectomy. Eventually, she receives contralateral mastectomy, additional reconstruction, and oophorectomy.

Fertility Preservation

The patient and her husband wish to undergo fertility preservation, but the interdependence between completion of fertility preservation and start of systemic therapy is not recognized by the fertility office or is managed by the oncology office. A delayed fertility appointment and projected start of the procedure conflict with the beginning of systemic therapy. Filled with anxiety, the patient proceeds with the latter without the former. Her fertility is impaired by systemic therapy.

Dental Care

Although repeatedly warned by her oncologist, the patient procrastinates in obtaining much-needed dental care before the start of systemic therapy. When she finally seeks dental care, she has difficulty finding a dentist who accepts Medicaid. She develops a severe dental infection and a subsequent drop in blood count, which causes hospitalization, interruption of systemic therapy, and the need for colony-stimulating factor support. Here, the patient first ignored the interdependence between completion of dental work and the start of systemic therapy and then had difficulty managing this interdependence due to out-of-pocket costs. The full case study appears in the Data Supplement along with two additional studies not analyzed in the article.

INTRODUCTION OF TASK INTERDEPENDENCE

Task interdependence is the degree to which the interaction and coordination of team members are required to complete tasks.^21,22 It is considered one of the most important team design features^23-25 and has been found to be a crucial contributor to team effectiveness.^26-28 In health care, task interdependence affects provider performance across conditions and settings^29-33 and improves the patient-centered focus of care teams.³⁴

Although the importance of task interdependence has been recognized for decades,^35-37 its significance in contemporary teamwork continues to increase. As teams become dynamic, fluid, and less formal, task interdependence defines a team and is the link that connects team members, even those not belonging to one formal organizational unit.³⁸ This is highly relevant in health care, where teams are inherently fluid.^33,34,39

Studies have shown that task interdependence management is challenging in cancer care because of the complexity of cancer care delivery, lack of tools to coordinate tasks across providers and organizations, care delays caused by insurance authorization, and other reasons.^17,40,41 However, the opportunities to address these challenges, optimize task interdependence, and assess its impact on cancer care remain unexplored.⁹

EXPLANATION OF TASK INTERDEPENDENCE

Task interdependence is not merely a boundary of teamwork but an object of deliberate design and management.^24,42,43 For it to contribute to team effectiveness in health care, task interdependence must be understood, designed within a specific care setting, and managed for individual patients. Following is an explanation of task interdependence in the context of these three steps (Table 1).

Table 1.

Understanding, Design, and Management of Task Interdependence

Understanding and Design of Task Interdependence in a Cancer Care Setting

An initial step in understanding task interdependence is the recognition of the types that exist in a specific setting. The literature describes four task interdependence types^20,24,35,36 (Table 1), which in the real world exist in a hybrid.^24,28,33,35 In cancer care, a complex hybrid of sequential and reciprocal task interdependence is common,^16,32,48 where participants are both sequentially and reciprocally interdependent (eg, in the patient’s case, the genetic assessment depends on a surgeon’s referral, whereas the surgical decision depends on the genetic results). This complexity creates challenges and potential care breakdowns.^4,16,17 Following are the features that further explain sequential and reciprocal task interdependence in general and in the context of cancer care.

Timing and sequencing.

These are inherently required for orchestrating sequentially interdependent tasks^13,22,28,50 (Table 1). Timing is particularly central to designing and managing task interdependence in two aspects: relative timing of interdependent tasks^13,50 and elapsed timing (the timeframe required to complete a task sequence⁵³). Timeliness is an IOM-recommended dimension of quality¹⁰ and an important metric of care delivery.^16,54 However, timing of cancer care remains challenging^2,3 because it causes breakdowns in interdependent care, delays, and patient loss to follow-up.^17,19,49,55 To ensure effective cancer care delivery, timing and sequencing of interdependent tasks should be formalized and documented in a written patient care plan^16,49,56 (Table 1). We propose that care planning be the responsibility of the lead physician supported by the lead care organizer, both of whom are described later in this article.

Criticality.

Another important task interdependence feature, criticality,^23,37 determines how important the interdependence between tasks is to the overall task work performance^22,25,43 (Table 1). Criticality is used to design the right level of task interdependence. The design of too much or too little task interdependence may be detrimental to teamwork,^28,43 with coordination costs outweighing benefits.^35,57 Thus, to achieve the right degree of task interdependence is important. The concept of criticality is instrumental in determining which tasks are included in interdependent task design and management.²⁴ In oncology, coordination is complex and costly, and certain tasks may be performed autonomously^29,30,34; thus, the attainment of the right degree of task interdependence on the basis of criticality is necessary.

Responsibilities for task interdependence.

Clear assignment of responsibilities is important for effective task interdependent teamwork.^21,38,42,58 In oncology, experts call for clearly identifying responsibilities for various portions of cancer diagnosis^10,20 and care.^2,3 We further propose to establish an explicit, formal responsibility for timing and sequencing of critically interdependent tasks among care team members (Table 1). Of note, care coordinators or patient navigators, although beneficial overall, are not able to fully orchestrate interdependent tasks in a time-sensitive fashion unless task participants themselves recognize and incorporate interdependence in their practices.^52,56 For example, in the patient’s case, the genetic office and genetic laboratory need to streamline their workflows to deliver timely genetic testing for patients like the patient who is awaiting test results for surgical decisions. Navigators or coordinators rarely have the authority to facilitate such workflow adjustment across provider offices or organizations.

Patient-centered approach to task interdependence.

An IOM report explored the merit, opportunities, and barriers of forging partnerships between patients and care teams, including patient engagement as a team member with explicit responsibilities.⁵² It may be particularly important to involve patients as team members because many patient tasks are interdependent with provider tasks, and task timing and sequencing may have crucial health implications. Patient tasks with critical interdependence should be identified, and their timing and sequencing should be formalized as his or her responsibility (Table 1). For patients unable or unwilling to assume task interdependent responsibilities, involvement of a family member, caregiver, or another representative (eg, navigator) who could facilitate the patient’s tasks may present a viable alternative. (In this article, reference to the patient includes the family/caregiver and/or representative.)

Management of Task Interdependence in Care for Individual Patients With Cancer as a Project: The 4R Approach

Scholars advise that task interdependence should be deliberately and explicitly managed during the course of teamwork.^35,50 Accordingly, task interdependence for individual patients with cancer should be defined at diagnosis and actively managed during a patient’s care. This is challenging^10,16 because of the complexity of care timing and sequencing, the multitude of providers involved in care for one patient, as well as other reasons as illustrated by the patient’s case.

To address these challenges, we propose the use of project management, the discipline of planning, executing, and managing the work of a team to achieve project objectives.^44,45 Project management uses a project plan to define the timing and sequencing of tasks, clearly specify team members’ responsibilities, and specify task dependencies.^44,46,47 It is broadly used to manage complex task interdependence in many industries.^46,47 In health care, the approach to every patient’s care as a project has been proposed^56,59,60 but unexplored. Project management is inherently fitting to manage task interdependence in cancer care because it addresses key dimensions and design considerations (Table 1) and allows adaptability during a patient’s episode of care. Many patients are familiar with project management from their workplaces as are many providers through quality improvement and other organizational projects.^31,33

We propose that the care plan for a patient with cancer be developed at diagnosis as an individualized project plan that defines the timing and sequencing of interdependent tasks and clearly indicates patient and provider responsibilities. The patient and all providers involved in his or her care use the care project plan to manage tasks at the right time and in the right sequence (Fig 1). Plan development and management are performed by a designated role of the lead physician (assumed by a surgeon, oncologist, or another physician) and lead care organizer (assumed by a nurse and/or navigator). The lead physician and lead care organizer facilitate care planning and task interdependence management across the care team, including various specialties, offices, and practices. This approach is termed 4R—right information and right care for the right patient at the right time.⁶¹ 4R facilitates patient-centered care by providing a patient with information and control over critical tasks while following the IOM mandate that the patient is the source of control in his or her care.¹⁰ For patients and/or caregivers unable or unwilling to play an active role, the team should designate a representative (eg, navigator) to facilitate the patient’s interdependent tasks on the patient’s behalf.

FIG 1.

Example of a care project plan: visual project schedule. Appt, appointment; DO, dental office; FO, fertility office; GC, genetic counseling; GL, genetic laboratory; LCO, lead care organizer; LP, lead physician; OO, oncology office; P, patient; PCP, primary care physician; PsO, psychosocial office; SO, surgical office; Wk, week.

APPLICATION TO THE CASE

In the patient’s case, task interdependence was not addressed at any of the three necessary levels. It was not understood; not explicitly designed in the patient’s care setting; and not managed by the patient, her providers, or Medicaid insurance (Table 2). Care tasks were not effectively sequenced or timed (eg, oncologist consult versus surgical decision, referral to fertility preservation versus systemic therapy); critical tasks were not treated as such (eg, receipt of the genetic results to inform the surgical decision); assumed sequential interdependencies were unnecessary and not at the right level (eg, insurance verification after genetic consult); and responsibilities for adhering to task interdependence were not clarified or fulfilled (eg, the patient did not obtain dental care before systemic therapy). Next is an optimized scenario that shows how key task interdependence aspects and the 4R approach could be applied to the patient’s case.

Table 2.

Task Interdependence in the Case of the Patient

Task Interdependencies in the Patient’s Care Setting

In an optimized scenario, long before the patient’s arrival, her providers recognize the importance of task interdependence and understand how it affects care for their mutual patients. They realize the detrimental implications of ignoring task interdependence in their patients’ care and do not consider the management of task interdependence an administrative burden. They are educated on task interdependence basics, including timing and sequencing, and agree with the importance of explicit provider and patient responsibilities. Typical problematic situations in which task interdependence is mismanaged for patients (eg, the four situations in the patient’s case) are identified. Providers understand that interdependent care for one patient spans multiple domains and organizations (eg, surgical office in a large hospital, local oncology office, out-of-state genetic laboratory, stand-alone dental office) and agree to work with relevant organizations to manage task interdependence for mutual patients. The creation of such awareness requires a concerted educational effort and leadership across and within institutions. Although this effort is far from trivial, its accomplishment is feasible as institutions grow more accustomed to collaboration and as task interdependence concepts become intuitive to many providers who implicitly manage numerous interdependent tasks.

4R Approach to Task Interdependence Design in the Patient’s Care Setting

An understanding of task interdependence is necessary but not sufficient to prepare providers and the patient to systemically manage task interdependence in the patient’s care. Before the patient’s arrival, providers should collaborate to deliberately design and document task interdependence for problematic situations identified in the first step. A task interdependence working group that represents institutions and practices that share care for patients like the one in this setting should be formed to accomplish these tasks. The working group would facilitate discussions and agreement about critical interdependent care tasks, their timing and sequencing, and typical responsibilities. The working group could use the 4R approach and project management to proactively document this design in the form of templates for care project plans. A visual of the project schedule may help to depict timing, sequencing, and responsibilities for care events across the entire care episode (Fig 1). Templates that are not only disease specific (eg, breast cancer) but also patient-subgroup specific would be beneficial. For example, providers would agree on a care project template for young patients with early-stage breast cancer who are indicated for neoadjuvant therapy and genetic assessment and who are interested in fertility preservation. In this way, providers are prepared to manage critical interdependent tasks for the patient. Thereafter, the working group would convene regularly to reassess and, if needed, adjust the care project templates.

4R Approach to Managing Task Interdependencies in the Patient’s Care Setting

In an optimized scenario, after the patient’s diagnosis and referral to a surgical office, she is assigned a lead physician (eg, her surgeon) and lead care organizer who supports the lead physician (eg, a patient navigator). Jointly with the patient, they develop the patient’s initial care project plan. A project template is used and adjusted collaboratively with the patient to reflect her preferences (eg, interest in neoadjuvant therapy, preoperative genetic assessment, fertility preservation). Critical care events timing and sequencing are documented in a visual project schedule (Fig 1).

The lead care organizer identifies potential providers in the patient’s care plan, discusses them with the patient, and proactively verifies their eligibility in the patient’s insurance network. Providers are explicitly assigned to time-sensitive tasks, and their offices are alerted. The lead care organizer discusses the patient’s responsibilities for time-sensitive tasks, such as to seek timely appointments, convey care delays, and report adverse symptoms in a timely fashion to the lead physician and lead care organizer. The patient explicitly agrees to these responsibilities. She and her providers proceed with her care according to the project plan. As described in Table 2, in each of the four situations, the patient’s care is now optimized. She receives neoadjuvant therapy and genetic test results before her surgical decision, which allows a more informed and expanded set of surgical options. The patient also is able to complete her fertility preservation procedure before neoadjuvant therapy and simultaneously obtains timely dental care to prevent infection, hospitalization, and treatment interruption (Fig 1).

During the patient’s care, her project plan may need adjustment to reflect her response to therapy and treatment strategy changes. The lead physician and lead care organizer work with the patient to adjust the project plan and alert participating providers of changes.

IMPLICATIONS FOR CLINICAL PRACTICE

At a time of health care reform, new payment and quality structures, such as accountable care organizations, embed increasing expectations for well-coordinated team-based care.^62,63 This article describes a systematic, yet practical approach to facilitate cancer care coordination by managing task interdependence through the 4R method. We outlined at a high level how 4R could be applied in practice. However, the 4R implementation requires strategies to direct real-life implementation and adaptation of the approach to specific care settings and patient subgroups. The Comprehensive Dynamic Trial (CDT) method by Rapkin et al⁶⁴ provides a structure for such implementation as a learning and continuous improvement system. This method recognizes over time new care settings, patient situations, and care tasks that need to be managed for interdependence and incorporates them into the care setting cyclically. Under CDT, a task interdependence champion and working group would be designated in a specific care setting to develop care project templates and establish key 4R components, including assignment of the lead physician responsibility among clinical specialties, communication mechanisms among team members, patient engagement methods that reflect patient population characteristics in a specific setting, and strategies for addressing insurance concerns. The working group would oversee the cyclical 4R implementation in its setting by using its accumulated experience to inform updates to care project templates and improve how the care teams and patients use them. (The Data Supplement describes the application of CDT to 4R implementation in more detail.)

Implementation of 4R may help cancer institutions to incorporate task interdependence–related metrics, such as timing and sequencing of guideline-recommended care, in institutional quality metrics and payer contracts. This will convey the value of their efforts and help reimbursement. Of note, payers are increasingly willing to incorporate payment for care coordination, including the role of lead physician and midlevel staff (who could assume the role of lead care organizer), in the new payment models.^65,66 Further efforts will be necessary to ensure that the new payment models adequately account for these roles and activities.

Work with payers provides an opportunity to address another issue highlighted in this case study: Payer policies and practices contribute to care delays and misalignment (eg, delayed authorizations, lack of payment for a key procedure). Care project templates may be used to secure authorizations proactively or obtain an authorization for the project plan that spans an episode of care.

IMPLICATIONS FOR RESEARCH

This article raises a spectrum of research questions about the effectiveness of the 4R approach to manage task interdependence in cancer care. However, patient-centered research topics should be considered a priority. The literature demonstrates that patients desire an active role in treatment decision making and planning,^67-70 but systemic, practice-level, attitudinal, and other barriers exist.^70-72 Future research topics include not only patient engagement in treatment planning but also patient/caregiver involvement in the delivery of interdependent tasks as a care team member and whether the 4R approach can facilitate this involvement. Among the mechanisms of patient engagement, the role patient portals play in electronic medical records and decision support systems should be evaluated. Patient-reported outcomes research offers an effective methodology for examining these topics^73,74 and informing patient-centered task interdependence management. In addition, as highlighted in this case, task interdependence may be especially challenging for medically vulnerable populations. The identification of effective mechanisms of empowering and supporting these populations to participate in teamwork will contribute to equitable cancer care delivery.

In conclusion, this article examines how task interdependence across providers and care events affects care for a patient with breast cancer and how this care can be improved by task interdependence recognition, deliberate design, and explicit management. By using project management, we describe how a patient’s care project plan that explicitly outlines sequencing, timing, and responsibilities for interdependent tasks helps to orchestrate complex care and prevent breakdowns. A patient-centered approach to task interdependence management is key to empowering patients to fulfill their tasks in care in a time- and sequence-sensitive manner that is based on patient preferences and goals. Care organizations may benefit from implementing formal task interdependence management along the cancer care continuum. Further research will guide the evolution of these concepts in cancer care.

AUTHOR CONTRIBUTIONS

Conception and design: Julia R. Trosman, Melissa A. Simon, Debra L. Madden, Bruce D. Rapkin, Elisa S. Weiss, Ilana F. Gareen, Lynne I. Wagner, Art Small, Christine B. Weldon

Administrative support: Julia R. Trosman, Christine B. Weldon

Collection and assembly of data: Julia R. Trosman, Ruth C. Carlos, Bruce D. Rapkin, Mikele M. Bunce, Christine B. Weldon

Data analysis and interpretation: Julia R. Trosman, Ruth C. Carlos, William J. Gradishar, Al B. Benson III, Seema A. Khan, Mikele M. Bunce, Art Small, Christine B. Weldon

Manuscript writing: All authors

Final approval of manuscript: All authors

Accountable for all aspects of the work: All authors

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Care for a Patient With Cancer As a Project: Management of Complex Task Interdependence in Cancer Care Delivery

The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or jop.ascopubs.org/site/misc/ifc.xhtml.

Julia R. Trosman

Consulting or Advisory Role: Genentech (Inst), Foundation Medicine (Inst)

Ruth C. Carlos

No relationship to disclose

Melissa A. Simon

No relationship to disclose

Debra L. Madden

Employment: Associated Neurologists

William J. Gradishar

No relationship to disclose

Al B. Benson III

Consulting or Advisory Role: Genentech, Sanofi, Bristol-Myers Squibb, Merck Serono, Merck, Schering-Plough, Spectrum Pharmaceuticals, Eli Lilly, ImClone Systems, Celgene, Genomic Health, National Cancer Institute, Vicus Therapeutics, Pharmacyclics, Holemics, Taiho Pharmaceutical, Bayer AG, Alchemia, Infinity Pharmaceuticals, Boehringer Ingelheim, Astellas, EMD Serono, IntegraGen

Research Funding: Genentech (I), Gilead Sciences, Amgen, Astellas, Advanced Accelerator Applications, Bayer AG, Onyx Pharmaceuticals, Novartis, Alchemia, AVEO Pharmaceuticals, Infinity Pharmaceuticals, Merck Serono (Inst), EMD Serono (Inst)

Travel, Accommodations, Expenses: Genentech, Eli Lilly, ImClone Systems, Bayer AG, Sanofi, Spectrum Pharmaceuticals, AVEO Pharmaceuticals, Gilead Sciences, Astellas

Bruce D. Rapkin

No relationship to disclose

Elisa S. Weiss

No relationship to disclose

Ilana F. Gareen

No relationship to disclose

Lynne I. Wagner

Consulting or Advisory Role: EveryFit, Janssen Pharmaceuticals, Gilead Sciences

Seema A. Khan

No relationship to disclose

Mikele M. Bunce

Employment: Genentech

Stock or Other Ownership: Genentech

Travel, Accommodations, Expenses: Genentech

Art Small

Employment: Genentech

Stock or Other Ownership: Genentech

Christine B. Weldon

Consulting or Advisory Role: Genentech (Inst), Foundation Medicine (Inst)