Defining team membership in primary care: Qualitative analysis

Abstract

Primary healthcare is recognized as a team-based activity. Traditionally, a primary care team is considered to be a group of individuals that work together to satisfy patients’ needs for primary care services. Past studies show wide variation in the scope and structure of teams across primary care organizations, indicating ambiguity in the definition of primary care teams. In addition, it remains unclear why certain healthcare professionals are included/excluded from another professional’s “team”. This study explored the question: “How do healthcare professionals in primary care clinics define who is on their team?” Qualitative content analysis was performed on interview data from clinicians and staff in eight primary care clinics regarding team definitions. All participants acknowledged the importance of working in a team, yet they had very different perspectives on how their teams were defined. Multiple themes emerged including borrowing the expertise of another professional, sharing of patient panel, and policy requirements. This study can inform healthcare professionals and administrators, as well as health IT designers, consultants, architects and researchers interested in primary care teams and how they function in a clinic environment.

1. Introduction

Primary care is the foundation of US healthcare. Given the increasing patient population size and patient needs as well as the limited capacity of primary care physicians, primary care is relying more heavily on team-based practices. The composition of primary care teams is complicated and could vary largely due to differences in personnel between clinics as well as patients’ needs, and there is continuing ambiguity in how teams should be defined in primary care. Especially lacking in the analyses have been the perceptions of those inside the system. Understanding how teams are defined by primary care professionals themselves is important, since it provides crucial insights to primary care professionals and managers, as well as researchers, consultants and designers who work with primary care teams.

1.1. Background

Primary care plays a vital role in the US healthcare system ensuring patients’ healthcare needs get addressed. (Baicker & Chandra, 2004; Donaldson et al., 1996). As the first point of contact and source of continuing and comprehensive care for patients, primary care clinicians play a critical role in reducing unnecessary inpatient services and costs (Gauld et al., 2012). The importance of primary care in addressing patients’ preventive healthcare needs and chronic health problems cannot be overestimated (e.g. Epstein et al., 2008; Rubin et al., 2015).

As a result of increasing patient population size, patient needs as well as the limited capacity of primary care clinicians (including physicians and advanced practice professionals or APPs) themselves, the reliance on team-based practices has become the norm in primary care. Practices have moved from single, physician-based practices into teams of clinicians and staff in the past few decades. There are more advocates than ever for integrated and patient-centered teamwork models in primary care (e.g. Brown-Johnson et al., 2018) with one example being the Patient-Centered Medical Home (PCMH) model (AAFP, 2008; Fernald et al., 2019; Keckley, 2010).

Primary care team members should “collectively take responsibility for the ongoing care of patients” (AAFP, 2008, pp.1). Yet, there have been difficulties in defining “primary care teams”, with considerable debate regarding “who to include”. Especially, there is limited understanding of team composition from the perspective of primary care professionals, including clinicians and staff.

In working to understand primary care teams, the insiders’ viewpoints are crucial to consider. Although prior studies have discussed on primary care team membership, it remains unclear whether such membership is consistent with all primary care teams in the domain. Furthermore, as pointed out in a prior study (manuscript under review), the composition of primary care teams is complicated and could vary largely due to differences in clinic size, administrative policies, physical layout, clinic culture and personal preferences between clinics as well as patients’ needs.

1.2. Teams in the literature

A review of the literature on team definition provided insights to exploring this issue. In the literature, there have been discussions on the definition of the membership of a working team (highlighted in italicized text in this paragraph). For example, Hall & Rizzo argued that for an individual to be considered as part of a team, s/he needs to interact with other team members, and that teams can also be characterized with a certain structure agreed on by all the members. At the same time, if an individual has a formally assigned role on the team, then the individual is a member of the team (Hall & Rizzo, 1975) – for instance, in the primary care domain, Bodenheimer and colleagues proposed the “Teamlet” model as assignment for physicians and their assistants, or “health coaches” (Bodenheimer & Laing, 2007). Meister pointed out that those and only those who contribute towards the system goal/mission should be considered as members of the “team” (Meister, 1976). Meanwhile, individuals sharing the same task/responsibilities in operating the same equipment with each other can be seen as the same team (Glanzer, 1962). From the perspective of social identity theory, the social characteristics of team members, that is, the inter-personal relationship with other team members, also contributes to true team membership (Amason et al., 1995). Architectural and other physical characteristics of the workspace may play a role as well. For example, in primary care, one way of defining team membership is by using a “pod”, referring to the professionals sharing a “central area surrounded by exam rooms” (e.g. Bodenheimer, 2011, pp.6).

1.3. Objective

The definition of primary care team membership remains to be fully explored. Although the review of literature on team definition revealed multiple factors that might apply to primary care teams, it is not fair to assume that primary care teams can completely be defined using the definition of work teams in the literature, as: 1) the definition has been transforming in many ways in the past few decades; 2) primary care professionals frequently need to interact with specialists and healthcare practitioners in other settings, which adds to the challenge of setting the “boundary” of a primary care team; and 3) the actual tasks being performed, which closely relates to the needs of each patient, constantly changes across patients.

At the same time, understanding how teams are defined by primary care professionals themselves is important, as it can provide crucial insights to researchers, consultants and designers who work with primary care teams, as well as primary care professionals themselves and clinic management personnel. Knowledge of the team membership is needed to facilitate training, guide administrative policies, design and use health information technology, design physical layouts and articulating the attributes of the team to patients. The lack of clearly defined primary care teams poses challenges to researchers and healthcare organizations in studying and supporting primary care teamwork, as well as to health-IT designers on creating team-supporting technologies (Shalley, 2008).

Given the importance of an in-depth understanding of the membership of primary care teams, we conducted this study to address the question of “how do primary care clinic professionals define their teams?” In a prior study, we looked at what clinic roles are included in primary care teams and how often they are included. We found much variation in who were included on the team and the frequency of each role being included.

In our current study, we investigated the reasons behind why the professionals defined their teams in certain ways. We performed a directed content analysis on data from interviews with primary care professionals, following the framework identified with the literature review on working team membership definition.

2. Methods

This study is part of a larger project funded by the Agency for Healthcare Research and Quality (AHRQ) that examines primary care physicians’ and their team members’ cognitive work requirements with the goal of designing an electronic health record (EHR) prototype to better meet their cognitive needs. We performed a secondary data analysis on a subset of the data from this larger project to address this current study’s specific research question.

The project was approved by the Institutional Review Board of the authors’ organization. Informed consent was obtained from all participants.

2.1. Data Collection

2.1.1. Sampling Strategy

Eight Midwestern clinics with variant locations, patient populations, team structures, and ownership models participated. Table 1 provides a summary of the characteristics of these clinics. Primary care clinics with team-based care, i.e., the physicians or advanced practice professionals (APPs, i.e., Advanced Practice Nurse Practitioner or Physician Assistant) worked with an assigned medical assistant (MA) or nurse to see and care for patients were prioritized for recruitment.

Table 1.

Characteristics of Participating Primary Care Clinics

	# of clinics	% of clinics
Total	8	100
Location
Urban	2	25
Suburban	2	25
Rural	4	50
Ownership model
Integrated	4	50
Independent	3	37.5
Federally qualified health center	1	12.5
Physician Residency Teaching Site
Yes	1	12.5
No	7	87.5
Number of physicians/APPs in clinic
1–5	1	12.5
6–10	2	25
11–20	3	37.5
21–30	2	25
Specialty
Family Medicine	2	25
Internal Medicine	1	12.5
Both	5	62.5
Primary Care Clinic type
Freestanding	3	37.5
Located in building with other clinics	5	62.5

At each clinic, the researchers identified two core teams, each consisted of a Physician and the Nurse or MA s/he worked with performing supportive tasks for patient visits with the Physician, e.g. rooming patients. If the participating Physicians worked with APPs, then these APPs and the Nurse/MA working with the APP were also included. Other clinicians and staff at the clinic who worked with the core teams in supporting patient-care activities, were asked to participate if they present within the clinic itself. These include include social workers, pharmacists, health educators, receptionists, schedulers, registrars, behavioral health specialists, chronic care coordinators, imaging and lab technicians, etc. Thus, the breadth of data collected across various clinic settings and job titles was well suited for answering the question of “how do professionals working in primary-care clinics define their teams”. A summary of participants’ job titles, as well as how many clinics had participants of each role, is provided in Table 2.

Table 2.

Summary of Participants' Job Titles

Job title	# of participants	# of clinics with this role participating
Physician	14	8 (100%)
Family Medicine	10	6 (75%)
Internal Medicine	4	2 (25%)
Advanced Practice Professional	5	5 (62.5%)
Nurse	18	8 (100%)
Medical Assistant	17	6 (75%)
Pharmacist	3	3 (37.5%)
Health Educator	6	4 (50%)
Scheduler/Receptionist	17	8 (100%)
Other clinical staff	14	8 (100%)
Total	94	-

2.1.2. Participant Interviews

We conducted semi-structured interviews with each participant to inquire about their goals and cognitive work requirements in providing patient care both as an individual and as part of a team. The interview guides were developed based on the cognitive inquiry technique Goal-Directed Task Analysis (GDTA) (Endsley, 2016). At the beginning of the first interview with each participant, we asked the question: “Can you tell me who is on the care team that provides care to patients in your clinic?” We then also probed for more answers by asking, “Who else is on your team?” This part of the interview took about 5–10 minutes for each participant. All the interviews were audio-recorded and transcribed for data analysis. All identifying information was removed from the transcripts and replaced by participant and clinic participant numbers before data were analyzed. All interview data were collected between July 2015 and February 2018, and the data analysis was performed between February 2018 and July 2019.

2.2. Data Analysis

In this study we focused on analyzing the interview data, particularly the participants’ answers to the question of “Can you tell me who is on the care team that provides care to patients in your clinic?” and related probing questions. We performed directed content analysis to understand how the participants defined the membership of their care team as described by Hsieh & Shannon (2005). A list of categories of team membership definitions was generated through literature review and was used to guide the initial coding of excerpts, as shown in Table 3.

Table 3.

Team Membership Definitions in Literature

Team membership defining categories	References
Having assigned roles on the team	Hall & Rizzo, 1975
Sharing equipment/tasks with other team members	Glanzer, 1962
Sharing goal/mission with other team members	Meister, 1976
Having agreed-on structure	Hall & Rizzo, 1975
Interaction/communication with other team members	Hall & Rizzo, 1975
Co-location	Bodenheimer, 2011
Personal relationship/belongingness	Amason et al., 1995; Turner et al., 1987

Two authors served as coders for the initial analysis using the above categories. The first author (a Human Factors Engineer (HFE)) created a codebook for content analysis based on the category list mentioned above. Definition for each category in the codebook was created by going through the excerpts from 3 clinics. The second author (HFE) helped in reviewing the codebook. The third and fourth authors (a primary care physician and an HFE) reviewed and tested the codebook on 10 sample excerpts. The inter-rater reliability reached 0.72. The first, third and fourth authors then met to resolve discrepancies and made clarifications to the codebook. The two coders (the first and third author) then used the updated codebook to independently code excerpts for 2 clinics and met to discuss and resolve discrepancies. They also updated the codebook, including name and definition for each category as appropriate during the discussion, to better reflect the data and the context of primary healthcare. This process was repeated until all data from the 8 participating clinics were coded. Dedoose® (a cloud-based qualitative analysis software) was used for data management throughout the coding process.

After this initial analysis was completed, the two coders reviewed coded excerpts to identify themes within each category. For the first few categories, the two coders worked together and discussed as they were reviewing the excerpts and looking for themes. They then independently reviewed the remaining categories’ excerpts and met to discuss and agreed upon the themes that emerged.

3. Findings

Overall, 79 participants were interviewed for the larger research project. Included in the data analysis of this study were the 69 participants asked the question “who is on your team” during interviews, including 14 physicians, 5 APPs, 14 nurses, 11 MAs, and 25 participants of other roles (e.g., schedulers, receptionists, lab technicians, social workers, nurse care coordinators, pharmacists, health educators including diabetes educators, and behavioral health specialists).

The content analysis supported all categories of team definition identified from the literature. In addition, a new category – “Resource”, which described how some professionals were included as team members for supporting patient care in certain ways – was identified from the data (more details about this category can be found later in this section). Multiple themes emerged under each category, further elucidating how primary care professionals defined their teams.

In this section, thematic results will be reported for each category. The names of the categories were updated by the coders during the data analysis process, in order to better reflect the context of primary healthcare. For the readers’ reference, the initial category names (generated through literature review, mentioned in section 2.2) will be included in parentheses in this section.

A summary of all categories and themes, with exemplar quotes for each theme, can be found in Table 4.

Table 4.

Sample Quotes for Each Theme

Themes emerged in each category	Sample quote
Category 1. Assignment (having assigned roles on the team)
1.1 Physician/APP and Nurse/MA assigned to work together	“… I took the PC [primary care] program and kind of just got thrown in with [Physician] one day …” (Clinic A, Nurse/MA)
1.2 Assigned supervisor and supervisee working together	“So [physician], I think, brought me here, and from my conversation with him being hired, with the idea of setting up more of a team. And so I might have been here a year, maybe a little more, a little less. I'm not quite sure. We'll call it a year. And then there was a definite pairing of me working with him to assist him primarily with his patient panel. And we called it the [physician/APP] Care Team. ... In this situation, I no longer was a primary provider. I was here to assist in managing [physician]’s practice with the effort on his part of promoting me as a, as his partner. ...” (Clinic A, Physician/APP)
1.3 Organization embedded in clinics	“… we have our Center [name], which is a program working with … Anyway, so then thaťs sort of [an] offshoot of my other core team, because I'm very involved with that, and that would be [physician], [physician], me, and [another clinic team member], who is our Center [name]Coordinator.” (Clinic G, Nurse/MA)
Category 2. Shared tasks (Sharing equipment/tasks with other team members)
2.1 Shared patient panel	“And like, for instance, this morning even, a patient that [physician/APP name] primarily sees was seen by [physician/APP name].  Again, you know, it doesn’t really matter who you see here.  [physician/APP name]’s gone today.  The patient calls, has questions, then you go back to [physician/APP name].  Even though [physician/APP] hadn’t seen the patient, [physician/APP] knows him well enough.    So that kind of a team concept, anybody can answer anybody else’s patients’ questions.” (Clinic H, Nurse/MA)
2.2 Shared function	“So, there's definitely like a business team, you know, a reception, billing, management kind of team, and thaťs sort of [Clinic manager]’s purview. And then there's a clinical team, which is the nursing staff and the providers. And I guess I'm the boss of the clinical team. But, collaboratively, [Clinic manager] and [Nurse], who's the nurse manager, and I are the management team.” (Clinic H, Physician/APP)
Category 3. Shared goals
3.1 Collaborating to meet patient needs	“Oh, my care team, in the ideal, and I think we're getting pretty close to ideal; we look out for each other. You know, by that, I mean, being clear that our patients are looked after, that things donť slip, unattended. So thaťs the ethic. We have often talked about how we want this practice to be the sort of place where you would want to bring your family, and so if you wouldnť be proud of some circumstance if your family were to encounter it, then thaťs a problem we need to correct.” (Clinic F, Physician/APP)
3.2 Contributing to comprehensive care	“When we look at, if I go to a doctor's office, and the doctors usually have the doctors and the nurses, and thaťs all. And this clinic, it goes beyond that. We're able to have everything in one single place. I have to other places where, okay, you got the doctor, but then, oh, you need these. You know, you have to go to this other place and get that.” (Clinic D, Other clinic member)
Category 4: Structure
4.1 Leaders and those led by the leaders	“I'm kind of the leader in the area with the five or six people that are there.” (Clinic C, Nurse/MA)
4.2 Support clinicians’ work	“Oh, there's also a congestive heart failure clinic. So when there's a new congestive heart failure patient, day in and day out, the cardiology department has a nurse that will educate them and follow them for a while. So those are sort of, you know, might consider part of the team in terms of we are able to use their time, as we donť have to do that education piece where we are. So that saves us a lot of time.” (Clinic C, Physician/APP)
4.3 Close and distant team	“… yet, when you back up and look at the bigger picture, if I need something, I can go to any one of these nurses in this department. So thaťs the bigger picture, the bigger part of that team. So you have your immediate family, and then you have the rest of them.” (Clinic C, Nurse/MA)
Category 5. Communication
5.1 Frequent communication	“We sort of consider part of our team like the [front desk person], you know, the person in the front desk in a sense that, you know, we kind of keep in contact with her and we communicate with her and tell her like when we can see a new patient or if there's somebody walking in, are there anybody, any walk-ins or if we know somebody is going to be late. You know, so she keeps in communication with us, yeah. But with my day-to-day work and everything that I have to do and communicate with patients, iťs mostly me and [Nurse/MA] and the other MAs if they sent me tasks.” (Clinic D, Physician/APP)
5.2 Synchronous communication	“INTERVIEWER 1: Okay. So she's just part of the internal medicine practice, but she's not officially part of the [physician] team, is or isnť? RESPONDENT: I mean, yeah. I mean, like we do like team meetings still where iťs all of us together …” (Clinic D, Nurse/MA)
Category 6. Co-location
6.1 Shared workstation/office	“Probably the people who work in the nurses’ station would be the closest team, I guess, the nurses and the other MAs.” (Clinic H, Nurse/MA)
6.2 Located in the same pod	“Well, our team is this pod. So this clinic has three different pods. We're the “x” pod.” (Clinic F, Physician/APP)
6.3 Co-location in the same clinic	“INTERVIEWER 1: Okay. So everyone in the clinic. RESPONDENT: Yeah. INTERVIEWER 1: Is there anyone outside of the clinic that you feel like is kind of on the same team with you, like who doesnť work in this building that you work with regularly? No? RESPONDENT: Uh-uh.” (Clinic H, Nurse/MA)
Category 7. Relationship
7.1 Having similar/matching personalities	“We're always at the front there. [Another clinic scheduler], the girl that sits next to me now, she's hilarious, and we just work together well. She's just the same way.” (Clinic C, Other clinic member)
7.2 Familiarity & Trust	“Then I switched, I wanted to come to primary care. And specifically, I had known [non-team physician] for some time, and I came to internal medicine specifically to work with him. So it was 11 years in January.” (Clinic A, Physician/APP)
7.3 Fitting well with the team culture	“My core team? We literally just named ourselves the Fabulous Four yesterday. That would be myself, [lists 3 names].” (Clinic G, Other clinic member)
Category 8. Resource
8.1 Expertise/skills of team members	“The RNs that we do, I think we do try to have an RN in each pod. They are more of like triage and usually end up being a supervisor.” (Clinic F, Other clinic member)
8.2 Looking for consultancy	“When I have questions, concerns, I donť hesitate going to one of them. When there's some concern on an OB patient or needing help with something, these are the, usually, the two that I call.” (Clinic B, Physician/APP)
8.3 Licensure and policy requirements	“If iťs just a lab only, we do usually probably go straight to the physician, because we need an order, because, you know, we canť do anything without an order. And they seem to forget that.” (Clinic E, Other clinic member)

^*“Other clinic member” = professionals other than Physician/APP or Nurse/MA

Category 1. Assignment (having assigned roles on the team)

At some clinics, professionals were assigned to work together as a “team”. Each professional has a certain assigned role on this team. As a result, the assignment was acknowledged by those who were involved as their own definition of team. Three themes emerged in this category, including physician/APP and nurse/MA assigned to work together, assigned supervisor/supervisee, and embedded organization.

Theme 1.1 Physician/APP and Nurse/MA assigned to work together

Physician/APPs and nurse/MAs assigned to work together commonly mentioned each other as their team members. In this assignment, the nurse/MA would facilitate the work of the physician/APP, and they interacted frequently to share information with each other. Some nurse/MAs also reported that they were the “point of contact” for the physician/APP they were assigned to work with. In other words, they took all the phone calls, messages and other forms of incoming communications, and would involve the physician/APP when they need the physician/APP’s help to address the incoming communications.

Theme 1.2 Assigned supervisor and supervisee working together

APPs reported that the physicians assigned to supervise their work are members on their team. Meanwhile, physicians who were assigned to supervise an APP or resident also mentioned their APP supervisees as part of the team by assignment. At different clinics, there were different policies on when a physician had to be involved for APPs to carry out certain patient-care tasks, and the APPs believed that the physicians were important to allow these tasks to be carried out. The physicians, on the other hand, felt they were responsible to make sure that the APPs were doing the right thing in caring for patients. Some participants also noted the lack of assignment to a team during parts of their career.

Theme 1.3 Organizations embedded in clinics

Some clinics assigned embedded organizations or entities which included a subset of clinic members. Such organizations/entities usually targeted on a specific aspect of patient needs, or a certain part of the clinic’s patient population. For example, some participants described themselves working in a “XX department” within the clinic and defined their team members as the colleagues within that same department. Some participants also mentioned working for a “center” embedded in the clinic targeting at a special population, and that those working in that “center” were all part of the team.

Category 2. Shared tasks (Sharing equipment/tasks with other team members)

Some participants stated that those who shared the same tasks with themselves were their team members. When two (or more) people were sharing a task, whoever had time to address that task would do so. Many different types of tasks were involved in primary healthcare, and the tasks varied in how much medical knowledge or skills they required. As a result, one professional might end up sharing different tasks with different colleagues, and all of them would become this professional’s team members. Two themes that emerged under this category included shared patient panel and shared function.

Theme 2.1 Shared patient panel

In primary care, most Physician/APPs have a “patient panel”, or a group of patients who have this Physician/APP listed as their Primary Care Physician (PCP). The PCP and their team take care of all the healthcare needs of the patient panel. However, due to limited time availability of each single primary care professional as well as various patient needs, some PCPs closely work together and see each other’s patients on a regular basis. Some Physician/APPs and nurse/MAs included the other clinicians (and the nurse/MAs assigned to work with them, if any) who helped to take care of their patients as part of their team, because those clinicians (and their nurse/MAs) helped in addressing the patient’s needs.

Theme 2.2 Shared function

Some participants defined their team members as those who performed the same or similar functions as themselves. For example, a participant who performed care coordination for chronic patients specified that the other persons working on the same coordination function in that clinic is on their team, as they share this “care coordination” function in the clinic – although they both had their own patients to take care of and did not routinely share any patients. Similarly, some participants who provide social services believed that the local community social service providers are their team, as they all took care of patients’ social needs.

Category 3: Shared goals

Some participants believed that their team worked together to achieve certain goals, and they defined their team members as those sharing the same valued goals with themselves. In other words, those who worked to have the goals achieved were considered part of the team. Two themes emerged in this category, including collaborating to meet patient needs, and contributing to comprehensive care.

Theme 3.1 Collaborating to meet patient needs

Some participants considered meeting the patients’ needs as the most important goal to achieve. To achieve this goal, there sometimes required team collaboration between the participants and their teammates, in order to react to patients’ needs in a timely manner. Thus, participants believed that those who were part of their team should be ready to demonstrate this kind of collaboration. For instance, when a patient of physician A needed to be seen urgently while physician A did not have any openings on the schedule, then physician B willingly seeing this patient was considered as part of the team because they then were able to adapt to the patient’s need (of coming in to be seen) as a team.

Theme 3.2 Contributing to comprehensive care

Patients with multiple health issues, especially multiple chronic conditions, often had more complex needs in healthcare. Some participants mentioned that their goal in caring for these patients was to provide comprehensive care, or to ensure the patient’s healthcare needs were taken care of as much as possible during a visit to the clinic. Thus, those who contributed to comprehensive care are considered part of the team. For instance, if a patient had a co-visit with a physician and a behavioral health specialist (BHS), then the physician considered the BHS as part of the team because the BHS helped in addressing part of the patient’s healthcare needs in the clinic.

Category 4: Structure

Some participants defined their team with a certain structure – whoever fit in this structure was part of the team. In this case, the participants did not only define who is on his/her team, but also revealed the structure of his/her team, which led to insight to how team members worked together. Three themes in this category included leadership, support clinicians’ work, and close/distant team.

Theme 4.1 Leaders and those led by the leaders

Some participants claimed leadership on their teams that was not assigned supervision by the clinic. Thus, whoever was led by that participant became part of his/her team. The leadership took place for different reasons. For example, among a group of nurses, the most experienced one became the leader. A nurse could also be a team leader for MAs, as the nurse had more medical training than the MAs and was able to perform patient care activities that the MAs could not.

Theme 4.2 Support clinicians’ work

In primary care clinics, the physicians and APPs were considered as the “head” of a team in providing patient care, and the other professionals worked together to support them. As a result, those who supported physicians and APPs became part of their team – and per some participants, these even included healthcare providers out of their own clinic. And for professionals other than the physician/APP, those who worked together with them in supporting the same clinicians’ work as well as the clinicians themselves were their team members.

Theme 4.3 Close and distant team

Some professionals mentioned that their teams have different levels of closeness, and most of them defined their team as a “close team” and a “distant team” – or, as described by the participants, “immediate family” and “the rest of them”. While both close team and distant team belonged to a professional’s definition of “team”, the members in these two teams are different. For instance, some participants believe that those who they work with daily were part of the “close team”, and the ones who they interacted with from time to time were the “distant team” members. Some other participants believed that those who sat closest to themselves were the “close team”, and those whose offices are further away were part of the “distant team”.

Category 5: Communication

Some participants defined their teams with the (work-related) communication they had with those professionals. They felt that for someone to be on their team, the communications between that person and themselves had to meet certain criteria. Two main themes emerged as the criteria, which are frequent communication, and synchronous communication.

Theme 5.1 Frequent communication

Some participants felt that those who they frequently communicated with belonged to their teams. On the other hand, if they did not interact with a professional frequently, then that professional was less like a part of the care team. The communication here included face-to-face communications as well as those happened through phone calls, emails or instant messaging.

Theme 5.2 Synchronous communication

Some participants felt that if they communicated with another professional with synchronous communication, then that professional was more likely part of their team. In other words, the use of synchronous communication made the other person part of the team. Synchronous communication included to those channels that allow instant feedback from the receiver. Examples of synchronous communications mentioned by participants included meetings, face-to-face talking and phone calls. On the contrary, asynchronous communications – not supporting instant feedback – included emails, routing of messages/reports in EHR.

Category 6: Co-location

Many participants mentioned that they viewed those who were physically co-located with themselves as part of the team. Some of them used the shared space itself as the definition of their teams. There are three themes under this category: shared workbench/office, pod, and in clinic.

Theme 6.1 Shared workstation/office

Some participants shared a workbench or office with some other professionals, and they felt those other professionals became part of the team; a few participants also mentioned that they believed some professionals were not part of the “team” because they did not share a workbench/office. This theme emerged for professionals who have the same/similar job titles, i.e. MAs sharing workbench with MAs or nurses, and several health educators sharing the same office.

Theme 6.2 Located in the same pod

At some clinics, participants defined teams with the term “Pod”, or a few offices/workbenches and exam rooms connected with hallways and open spaces. Those who worked in a specific “Pod” would spend most of his/her time in that same Pod and rarely going to elsewhere, and everyone working in this “Pod” became part of the team. Different from the theme “shared workbench/office”, a Pod usually had a mixture of different roles – including physicians, APPs, nurses, MAs, health educators, etc.

Theme 6.3 Co-location in the same clinic

Some participants believed that everyone working in the same clinic (i.e. co-located in the clinic) should be part of his/her care team. Thus, their teams were defined with the physical boundary of the clinic itself. This was theme frequently brought up by those professionals working in small and/or stand-alone clinics, comparing to larger clinics or clinics that are associated with another healthcare organization nearby.

Category 7: Relationship

In some situations, especially where the professionals had been working together long enough and/or getting along well with each other, the personal relationship among them became a crucial part of the team definition. The three themes emerged in this category included personality, familiarity and trust with someone, and team culture.

Theme 7.1 Having similar/matching personalities

Some participants mentioned that they enjoyed working with those who have similar personalities or have the personality that matched their own. As a result, being able to work together with enjoyment made those other people part of their team. Participants also mentioned snippets of happily working together as how they viewed their team, including telling jokes and giving each other nicknames.

Theme 7.2 Familiarity & Trust

Some participants stressed the fact that they had been working with their team members for some time – mostly over 10 years. As a result of working together for a long time, the team members became more familiar with each other, and trust developed. As a result of such familiarity and trust, co-workers became team members.

Theme 7.3 Fitting well with the team culture

Some participants believed that for someone to be considered as part of the team, that person had to fit well with the team culture. For example, many participants acknowledged that team members should be supportive to each other – not only helping out with work, but also emotionally when needed. Also, some participants mentioned that team members should be respectful and considerate to each other, especially when handing off tasks to other team members.

Category 8: Resource

In addition to the categories mentioned above, we also identified this new category from the data. When another professional could be borrowed as a “resource” in providing care to patients, then that professional was considered as part of the team by some participants. This category differed from Shared Tasks in that the “resource” professional had some skill/knowledge that the borrower did not necessarily have. There are three themes emerged in this category: expertise/skills of other team members, limited self-confidence, and policy.

Theme 8.1 Expertise/skills of team members

Professionals got involved in caring for a patient as a “Resource” most commonly because of the expertise/skills that s/he owned. And as a result, that professional was included as part of the team because of the expertise/skills they had. For example, a behavioral health specialist (BHS) was often involved to deal with patients’ behavioral health problems, and the same with social workers (SW) being involved for patients’ social issues.

Theme 8.2 Looking for consultancy

Another common reason to involve another professional as “resource” was to look for consultancy. When professionals had problems or questions in patient care, then someone else would be involved – as that person had higher level of experience or medical knowledge, either in general or for certain patient needs. As a result, that person became part of this professional’s team. For example, APPs frequently mentioned relying on physicians for advice in medical decision making. On the other hand, some physicians rely on other physicians/APPs for advice when they are treating some illness, they are not familiar with.

Theme 8.3 Licensure and policy requirements

Sometimes another member was included in the team because of restrictions of their clinical licensure or per the “policy”, including those from insurance companies and other possible sources. For instance, when a lab technician noticed that a lab order was needed (or needed to be corrected), and since s/he did not have authority to make changes in that order, a physician would have to be involved. In this case, the physician became part of the team due to the ability of making changes in the order. Similarly, an MA might ask a nurse to perform some patient-care tasks that requires nurse licensure, which then led to the nurse being considered as part of the MA’s team.

4. Discussion

This study shows that for professionals working in primary care clinics, there are many ways of defining who is considered part of a healthcare professional’s team. Results of this study supported all categories in team definitions found in the literature and identified an additional category of “Resource”. We also identified themes under each category to help further elucidate how these categories applied to primary care team definitions. The elicitation of such knowledge leads to insight for designing work systems and supporting Health IT for primary care teams.

4.1. Highlights of findings

The literature review identified multiple categories in team definition, and analysis of the data of this study confirmed that all those categories are viewed as valid by the primary care professionals. On top of that, a new category – “Resource” – was identified from the data. This category describes how some professionals are viewed as a team member because of special expertise or skill or license they have, as valuable “resource” in providing patient care. It is especially important in primary care. In the current primary care environment, the workload to satisfy all patients’ needs is far beyond the capacity of primary care physicians or APPs (Linzer et al., 2009). Given the shortage in primary care physicians (Petterson et al., 2015) and the limitation in the skillsets of any one individual, it is useful to have team members who specialize in certain aspects of patient care involved in the process and be available as “resource to go to” when needed (Bodenheimer & Smith, 2013). Especially, having this resource available in the clinics (vs. having to send patients to specialists elsewhere) makes it easier for teamwork and care sharing (Ghorob & Bodenheimer, 2012).

A common way that people identify their work team members is through assignment from the organization/supervisor (Hall & Rizzo, 1975; Thamhain & Wilemon, 1988). However, in our study, not all participants used this assignment to identify their team – only 43 out of 79 (54%) participants mentioned assignment as their own definition for their teams. There are a few possible reasons. First, although some clinics have assigned “care teams”, some other clinics do not have such assignment – especially smaller clinics. Also, as shown in the themes under the “Assignment” category, the clinic assignment heavily focuses on the core team members (Sinsky et al., 2010) – i.e. the Physicians, APPs, and rooming Nurses/MAs. The other clinic members are less frequently considered in the assignment. However, they do have their own “teams” – for those who participated in this study, they were all able to provide their own definitions for the “team”.

Noticeably absent from participant’s definition of teams in roles are the patients (and their families). As more researchers start to acknowledge the importance of teamwork between primary care professionals and patients (e.g. Grover & Niecko-Najjum, 2013), there have been models in HFE looking at collaborations between the healthcare professionals and patients (including patients’ family and/or caregivers; e.g. Holden et al., 2013). However, this study illuminates a different view from the other side – the primary care professionals rarely consider patients as their team. In this study, no participant included patients when being asked about who they view as their care team.

4.2. Implications

We believe that understanding how teams are defined by primary care professionals can have implications on designing for primary-care teams and teamwork, including the design of Health IT as well as of the whole work system of primary care clinics.

First of all, as noted above, some professionals are considered as part of the team as a “Resource” to support patient care. They are usually involved based on patients’ needs, instead of always being part of the team. For instance, multiple participants mentioned they would likely involve extra team members to care for a patient’s chronic issues, which is also common in the literature (e.g. Katon et al., 2010). As a result, it is important to support the communication between the PCP and the other team members as well as other functions that the other team members need to perform with the Health IT, e.g. being able to identify patient-specific needs in receiving health care (Ngoh, 2009), and the ability to easily share care with the PCP and other team members (Bauer et al., 2014; Chen & Yee, 2011).

Health IT designers should keep in mind the importance of designing to support teamwork and how the teams are being defined in the primary care practice – which will vary considerably from any assignment of “teams” created by the clinics or organizations. Healthcare professionals have stated that health IT does not sufficiently support their needs for teamwork (Beasley et al., 2011). Our study highlighted the importance of acknowledging the other clinic members as essential part of the teamwork in primary care teams. As their cognitive requirements in teamworking are likely to differ from members on the “core team”, Cognitive Task Analysis (CTD; one example being GDTA) is recommended as a technique to understand the different user’s requirements as a basis for technology design and design to support teamwork (Endsley, 2016).

The fact that no participant mentioned the patients as part of their “team” reveals the lack of acknowledged collaboration between healthcare professionals and the patients. However, they are encouraged to do so, as to better engage patients in managing their own health status, which will lead to higher adherence to care plan as well as patient satisfaction (Loh et al., 2007). At the same time, we recommend that Health ITs, especially EHRs, should also be designed to support the involvement of patients in their own healthcare. For instance, patients and their family/caregiver could be given more authority in managing their own chart, to promote shared decision making on health problems as well as to reduce the workload from the primary-care professionals’ side.

Designing of work systems of primary care clinics should take into consideration how teams are defined by the primary care professionals themselves as well. For example, as co-location was acknowledged as important part of team definition, physical layout could be used as a type of “team assignment” by the clinic. Or at least the assignment of physical location (e.g. offices, workbench) should not become a barrier for team members to work together (Holden et al., 2013). Also, as we found that working together for long time makes team members feel more related with each other, it is suggested that clinics consider reducing personnel changes in team assignment. For professionals frequently involved as “resource” in patient care (e.g. the health educators), clinics should consider provide support in coordinating their work effectively with the clinicians for more efficient teamwork – e.g. by setting up schedules overlapping with clinicians who see patients that need to involve the “resource” professional, make sure appropriate communication modes are available.

4.3. Limitations & next steps

The limitations of this study are threefold. First, we performed secondary data analysis; the interview data were not originally collected for the purpose of this study. Some original team participants were not asked the interview question and were not included. More time in our interviews discussing team definition may have yielded additional findings. Second, as the larger project focused on using cognitive task analysis for health IT design, we included more “core team” members and less clinic members of other roles. Thus, the results are physician, APP, nurse, and MA centric. We did not include all of the clinicians and their teams at each site, so the variation of team definition at individual sites is unknown. If there were more participants with the other roles involved, they might provide additional insights as to how their teams are defined. Lastly, the clinics and participants may not be representative of US primary care clinics, clinicians and teams since clinics were from one region of the US and not sampled to reflect the characteristics of primary care clinics nationwide.