Development and validation of the primary care team dynamics survey.

There is increasing recognition that team-based approaches to delivering care in ambulatory settings may be critical for improving health care services and outcomes for patients. When patients require services of nurses, social workers, pharmacists, case managers, receptionists, or schedulers in addition to their primary care providers (e.g., physicians, nurse practitioners, and physician assistants), quality and value depend on the ability of these professionals to work together in a coordinated fashion. Prior research has associated team-based primary care with improved care for patients with specific diagnoses (e.g., diabetes and depression) (Lemieux-Charles and McGuire 2006). However, findings have been mixed, given differences in the way teams were designed and implemented. Nevertheless, team-based care has become a key tenet of efforts to transform primary care practices into patient-centered medical homes (PCMHs) (The Patient-Centered Primary Care Collaborative 2007; National Committee for Quality Assurance 2014), and stakeholders are considering how to structure payments to primary care teams as opposed to individual physicians (Blumenthal et al. 2013). Despite heightened interest in improving teams and teamwork, little is known about how to assess team dynamics in ambulatory settings. While several survey instruments measure selected aspects of teamwork (e.g., conditions for team effectiveness), few tools comprehensively capture the team dynamics that evidence suggests may be valuable in ambulatory settings (Valentine, Nembhard, and Edmondson in press). Existing measures of teamwork are also either too specific (e.g., focused on geriatric care, targeted to nurses and physicians only) or not specific enough (i.e., thought applicable to any health care setting). Other surveys are designed for non-U.S. settings. Few surveys have measured, and even fewer have satisfied, standard psychometric criteria for validating surveys. A survey instrument that measures ambulatory-based team dynamics is needed because teams in these settings face challenges that are less prominent in inpatient care: high rates of patient and provider turnover, wide variation in patient needs, a need for provider coordination within and beyond facility boundaries, and increasing expectations of primary care providers to engage patients in their care. Assessing team dynamics in ambulatory settings would enable identification of team dynamics most critical for desired health care outcomes, and this would make more targeted interventions possible. To address this opportunity, we developed a novel survey that is grounded in an evidence-based conceptual model and draws on previous, psychometrically tested instruments. We administered the survey to all physician and nonphysician health care professionals caring for patients within 18 primary care practices in Massachusetts who are working to improve team-based care as part of a primary care learning collaborative. In this paper, we begin by presenting our conceptual model for how to measure team dynamics in ambulatory settings. We then describe the development of the survey instrument, explore its psychometric properties, and discuss implications for the survey, future research, and its application in ambulatory care.