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High performance teamwork training and systems redesign in outpatient oncology
  1. Craig A Bunnell1,
  2. Anne H Gross2,
  3. Saul N Weingart3,
  4. Michael Jason Kalfin2,
  5. Ann Partridge1,
  6. Sharon Lane4,
  7. Harold J Burstein1,
  8. Barbara Fine2,
  9. Nancy A Hilton2,
  10. Clare Sullivan2,
  11. Erin E Hagemeister2,
  12. Anne E Kelly2,
  13. Lynn Colicchio2,
  14. Audrea H Szabatura5,
  15. Eric P Winer1,
  16. Mary Salisbury6,
  17. Susan Mann7
  1. 1Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
  2. 2Department of Nursing and Patient Care Services, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
  3. 3Division of General Medicine and Primary Care, Center for Patient Safety, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
  4. 4Center for Patient Safety, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
  5. 5Department of Pharmacy and Clinical Support, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
  6. 6The Cedar Institute, Inc., No. Kingstown, San Antonio, Texas, USA
  7. 7Department of Obstetrics and Gynecology, Beth Israel-Deaconess Medical Center, Boston, Massachusetts, USA
  1. Correspondence to Dr Craig A Bunnell, Department of Medical Oncology, Dana-Farber Cancer Institute 450 Brookline Ave, Room D 1614, Boston, MA 02215, USA; craig_bunnell{at}


Background Oncology care is delivered largely in ambulatory settings by interdisciplinary teams. Treatments are often complex, extended in time, dispersed geographically and vulnerable to teamwork failures. To address this risk, we developed and piloted a team training initiative in the breast cancer programme at a comprehensive cancer centre.

Methods Based on clinic observations, interviews with key staff and analyses of incident reports, we developed interventions to address four high-risk areas: (1) miscommunication of chemotherapy order changes on the day of treatment; (2) missing orders on treatment days without concurrent physician appointments; (3) poor follow-up with team members about active patient issues; and (4) conflict between providers and staff. The project team developed protocols and agreements to address team members’ roles, responsibilities and behaviours.

Results Using a train-the-trainer model, 92% of breast cancer staff completed training. The incidence of missing orders for unlinked visits decreased from 30% to 2% (p<0.001). Patient satisfaction scores regarding coordination of care improved from 93 to 97 (p=0.026). Providers, infusion nurses and support staff reported improvement in efficiency (75%, 86%, 90%), quality (82%, 93%, 93%) and safety (92%, 92%, 90%) of care, and more respectful behaviour (92%, 79%, 83%) and improved relationships among team members (91%, 85%, 92%). Although most clinicians reported a decrease in non-communicated changes, there was insufficient statistical power to detect a difference.

Conclusions Team training improved communication, task coordination and perceptions of efficiency, quality, safety and interactions among team members as well as patient perception of care coordination.

  • Team Training
  • Patient Safety
  • Teamwork
  • Quality Improvement
  • Ambulatory Care

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