1. Improving Cancer Care Coordination through Team Science Nancy J. Cooke PhD 1, Ayan Sen MD, M.Sc 2, Nathan J. McNeese PhD 1, Nandita Khera MD, MPH 3, Sara E. Wordingham MD 5, Noel Arring DNP 4, Sharon Nyquist MS, RN 2, Amy Gentry MS, RN 5, and Brian Tomlinson MPA, BSW 6, 1.Human Systems Engineering, Arizona State University, Mesa, AZ, 2.Mayo Clinic AZ Critical Care 3.Mayo Clinic AZ Hematology-Oncology 4.Mayo Clinic AZ Nursing 5.Mayo Clinic AZ Palliative Medicine 6.CancerCare, New York, NY SCITS 2016 Phoenix, AZ May 18 We acknowledge the support of NCI ASCO

2. Overview An illustrative case The challenges The NAS Report Science teams vs. Medical teams Interventions ◦ Composition, team & leader development ◦ Communication, coordination, interaction Next Steps

3. An Illustrative Case 57/F, JM, with a history of acute myelogenous leukemia who received a mismatched unrelated donor hematopoietic cell transplantation (HCT.) Developed pneumonia seven days after HCT and was started on broad-spectrum antibiotics The oncology team and Infectious Disease physicians expressed hope to the patient and family that her condition would improve after she engrafted JM progressively deteriorated and required endotracheal intubation and mechanical ventilation Critical care physician informed the family that she would likely die on the ventilator, and therefore, palliative care consultation should be considered for concurrent supportive care

4. An Illustrative Case (continued) Family wished to pursue all aggressive measures as the oncologists remained positive about her Renal failure required renal replacement therapy Critical care team asked nurse to hold renal replacement therapy due to hypotension Next AM the nephrologist told nurse in front of family that it should not have been held Question of ‘who is in charge’ Conflict among family members Nursing concern about suffering ‘Chemical code’ but did not wish to ‘pull the plug’ Progressive decline and palliative care involved Passed away after one month of aggressive therapy

5. The Challenges Complex team of specialists (nurse, nephrologist, critical care, oncologist, palliative care) ◦ Each specialty can involve multiple clinicians Specialists communicate to family through lens of their specialty ◦ Mixed, conflicting messages to the family Results: unwarranted aggressive care, increased medical expenses, poor quality of life

6. The Goal

7. The NAS Report: Enhancing the Effectiveness of Team Science The National Academies of Sciences, Engineering, and Medicine (2015)

8. Key Features that Create Challenges for Team Science Large membership diversity Deep knowledge integration Sometimes large size Goal misalignment with other teams Permeable boundaries Geographic dispersion High task interdependence

9. Key Features that Create Challenges for Medical Teams Large membership diversity Deep knowledge integration Sometimes large size Goal misalignment with other teams Permeable boundaries Geographic dispersion High task interdependence

10. Science Teams vs. Medical Teams… Science teams work on single problem over years Medical teams work on multiple “problems” (patients) in limited time Like NASA mission control, emergency response Cross between science teams and action teams Medical teams may not see themselves as a team Long-term, scientific discovery Short-term, practice/action

11. Interventions Report: Composition, team & leader development ◦ Medical specialist teams are already composed ◦ Little time for multidisciplinary team conferences Interventions for action teams (Cooke, Gorman, Myers, & Duran, 2013). ◦ Communication ◦ Coordination ◦ Interaction Cooke, N. J., Gorman, J. C., Myers, C. W., & Duran, J.L. (2013). Interactive Team Cognition, Cognitive Science, 37, 255-285, DOI: 10.1111/cogs.12009.

12. Cross training (aligned with shared cognition) vs. procedural/rigid training vs. Perturbation training (focused interactions) Team Training Cross training (aligned with shared cognition) vs. procedural/rigid training vs. Perturbation training (focused interactions)

13. Next Steps Develop Interventions: ◦ Coordinator Role (e.g., nurse, palliative care) ◦ Work flow that includes team communication and setting collaborative and clear goals ◦ Technological aids to collaboration  Interactive team white board to support real-time decision making  Electronic health records (next generation) Test interventions in context of critically ill cancer patients May extend team science to medical teams

14. Thank You Thanks to our science team Thanks to NCI ASCO Thanks to the NAS report team