A 6-item teamwork measure with good construct validity correlated with favorable provider outcomes including work experience, burnout, and intent to stay with the organization.
Objectives: To develop a brief teamwork measure and determine how teamwork relates to provider experience, burnout, and work intentions.
Study Design: Survey of clinicians.
Methods: We analyzed data from Optum’s 2019 biannual clinician survey, including a validated burnout measure and measures of provider experience and intent to stay. A 6-item measure of team effectiveness (TEAM) focused on efficiency, communication, continuous improvement, and leadership. Construct validity was assessed with content, reliability, and correlation with burnout. Generalized estimating equations with robust SEs determined relationships among TEAM score, provider experience, and intent to stay, controlling for demographics, clustering, and practice factors.
Results: Of 1500 physicians and advanced practice clinicians (1387 with complete data; response rate 56%), there were 58% in primary care; 57% were women, and 38% identified as Asian, Black/Hispanic, or another race/ethnicity other than White non-Hispanic. Burnout was present in 30%. The Cronbach α was excellent (0.86), and TEAM correlated with the validated burnout measure (adjusted odds ratio [OR] of lower burnout with high TEAM score, 0.28; 95% CI, 0.19-0.40; P < .0001). Clinicians with TEAM scores of at least 4 were more likely to have positive provider experiences (79% favorable vs 24% with low TEAM score; P < .001), had lower burnout rates (17% vs 44%%; P < .001), and more often intended to stay (93% vs 65%; P < .001). TEAM index score was strongly associated with provider experience (adjusted OR, 11.72; 95% CI, 8.11-16.95; P < .001) and intent to stay (adjusted OR, 7.24; 95% CI, 5.34-9.83; P < .001).
Conclusions: The TEAM index is related to provider experience, burnout, and intent to stay, and it may help organizations optimize clinical work environments.
Am J Manag Care. 2023;29(7):In Press
In the largest national ambulatory medical group, we used an annual work-life survey with a validated burnout measure to determine a valid metric of teamwork that correlated with favorable provider experiences and intent to stay with an organization. The 6-item TEAM measure incorporates aspects of efficiency, communication, continuous improvement, and leadership. It augments the literature by demonstrating construct validity in a brief measure and providing a metric correlating with provider-focused outcomes (work experience, burnout, and intent to stay). This study advances the much-needed work to better understand correlates of positive provider experiences and likelihood of remaining with one’s organization.
In recent years, burnout has reached high levels1 in a tired medical community facing challenges in their daily work lives, with employees leaving jobs in a phenomenon known as the Great Resignation.2 Although there has been ample research around how health care work environments affect burnout and related outcomes,3,4 less is known about the role of the health care team and what determines its effectiveness. Care teams are defined as 2 or more professionals who work collaboratively with patients and caregivers for shared goals.5,6 A team-based care model strives to meet patient needs by engaging patients while supporting clinicians who provide that care.7 Although team-based care contributes to value in our health care system, its relationship to favorable provider experiences and how it relates to retention remain less certain. This takes on added importance due to an aging physician workforce, projected physician shortages, and costs of burnout-related turnover.
We know that primary care work conditions are associated with physician burnout and care quality and that improvements in workflow and communication enhance provider satisfaction.8 We also know that burnout is related to turnover9 and that burnout10 and turnover11 have serious business consequences for medical groups.12 There is some limited evidence that the quality of team relationships and perceptions of team function can affect burnout. A study from the United Kingdom in 202013 surveyed 50 primary care providers (PCPs) in 12 practices. Burnout was lower with better teamwork scores. Themes necessary for good team function included need for equity and fairness, high workload as a barrier, daily huddles as an effective team mechanism, and dedicated time for maintaining the team. Mijakoski and colleagues14,15 used the Agency for Healthcare Research and Quality’s Patient Safety Survey brief teamwork measure to show that teamwork relates to burnout and that teamwork had particularly strong relationships with job engagement and job satisfaction. Team relationships predict burnout among nurses, as do leadership and work conditions such as temporal pressure, work scheduling, psychological demands, and task autonomy.16 The nursing literature supports interprofessional teamwork as a predictor of job satisfaction17 (teamwork measured within a 33-item scale) and as a variable relating to intent to stay (with satisfaction and burnout as mediators of the teamwork–intent to stay relationship, using a 15-item teamwork scale).18 Körner et al studied organizational culture, teamwork, and job satisfaction with a 6-item teamwork measure19; their model encompassed numerous constructs, with culture, composition, communication, and conflict as inputs and performance, satisfaction, wellness, cost, and care quality as outputs. Processes that mediated these relationships included coordination, respect, and leadership. Providers’ assessment of their team’s efficiency, included in the validated 10-item Mini-Z measure,20 is a predictor of burnout.21 Several other job-related conditions predicting burnout had implications for team effectiveness (ie, time spent on the electronic health record, control over workload, work atmosphere, alignment with leader values).
Research has shown that a characteristic of chaotic clinics is less effective teamwork. In one study, provider perceptions of clinic chaos related to perceptions of work control, stress, satisfaction, and likelihood of leaving.22 These perceptions seemed clinically meaningful, as chaotic clinics had more missed opportunities for providers to work cohesively and to offer patients preventive services.22
We sought to (1) derive and validate a parsimonious metric for assessing provider perceptions of well-led, high-functioning teams, and (2) determine whether provider perceptions of their care team’s effectiveness were related to provider work experience and intent to stay with the organization.
Optum Care is the largest ambulatory medical group in the country, serving more than 20 million patients, with at least 73,000 aligned physicians and advanced practice clinicians (APCs) and 1600 clinics nationwide. The organization, which is composed of 29 care delivery organizations (CDOs) with varying compositions, geographies, and operations, administers a biannual experience survey to all employees. At the time the data were collected, the survey was distributed to physicians and APCs (physician assistants and nurse practitioners) in 17 CDOs. CDOs are mainly multispecialty with a predominance of PCPs and several subspecialties (cardiology, dermatology, gastroenterology, neurology, and orthopedic surgery). The majority of CDOs are ambulatory models, with the exception of 1 urgent care model. CDOs are situated in cities within the Mountain West, Midwest, Mid-Atlantic, Northeast, and Southeast regions of the United States.
We used data from Optum’s fall 2019 survey, which included 48 items measuring 12 constructs. The current study included providers with complete data from 6 CDOs with both provider experience and Net Promoter Scores (NPS) from patient experience surveys, hoping to use this sample for future analyses assessing patient experience. Clinics have leaders trained in communication and relationship-based approaches with patients, families, and care teams.
Dependent variables were burnout, intent to stay with the organization, and provider experience. Burnout was captured using a single-item measure validated against the emotional exhaustion subscale of the Maslach Burnout Inventory20,23,24: “Using your own definition of burnout, select the most accurate statement:” with the following options:
We dichotomized this variable, classifying scores of 1, 2, or 3 as “burned out” and scores of 4 and 5 as “not burned out.”
Intent to stay was also measured with a single item: “I see myself working at this medical group a year from now,” on a 5-point scale from “strongly disagree” to “strongly agree.” We also dichotomized intent to stay with scores of 1, 2, or 3 classified as “low” intent to stay and responses of 4 and 5 classified as “high.”
The Provider Experience Index is Optum’s parent organization’s (UnitedHealth Group’s) measure of provider sentiment in the care delivery environment. The measure, adapted from a model of employee engagement25 emphasizing purpose, accomplishment, belonging, and organizational commitment, has 6 questions using 5-point scales from strongly disagree to strongly agree:
This measure shows high internal consistency (Cronbach α = .91), moderate (.40-.60) correlations with other “sentiment” survey constructs, and factor analysis unidimensionality, with all 6 questions loading heavily on 1 principal component. A favorable provider experience was assessed when the mean score was at least 4 of 6.
To assess team effectiveness, we applied concepts from the field of psychology to derive a measure identifying items that characterized a highly functioning clinical team and for the most part omitting items that reflected conditions under which the clinical team operates (ie, team enablement). Although the survey did not explicitly include a teamwork dimension, the several items spread across several dimensions—specifically, provider engagement (1 item), collaboration (2 items), organizational enablement (2 items), and provider well-being (1 item)—were felt to reflect aspects of a highly functioning care team. Six survey items were identified as characteristics of team effectiveness in the following manner. Four investigators—2 physicians (M.L., M.S.), an epidemiologist (Z.S.), and an industrial/organizational psychology PhD (M.M.)—unanimously selected 5 items, with the review team divided on a sixth item: “My medical group is effectively managed and well run.” After a short debate, the investigators agreed that the item more accurately reflected characteristics of the team than the conditions under which it operated and included this item in the index. These 6 items (referred to as the TEAM index) were combined into an evenly weighted index, with items measured on 5-point scales from strongly disagree to strongly agree (unless otherwise noted in parentheses):
These items address domains of well-being, operating discipline, collaboration, and organizational enablement. In addition to having strong face validity, reflecting qualities that many providers are likely to agree are present in highly functioning teams, the TEAM measure had psychometric support, with a Cronbach α of 0.86 and factor analysis of survey items evidencing construct unidimensionality, with all 6 questions loading heavily on a single principal component. Construct validity was confirmed by readily answered questions selected by experts, strong Cronbach α, its basis in principles of psychology, and correlation with the validated burnout item (see Results).
Regression analyses determined associations between TEAM scores and provider experience, burnout, and intent to stay, adjusting for age, gender, ethnicity (White vs non-White), provider type (physician vs APC), primary care (general internal medicine, family medicine, pediatrics, medicine pediatrics) vs subspecialty care, CDO, and acquisition status (CDO acquired within 2 years of survey, more than 2 years before survey, or not acquired). Each outcome was modeled as a binary variable using generalized linear modeling, with binomial distribution with a logit link. Generalized estimating equations, with robust SEs, were used to account for clustering of clinicians within CDOs. Because of previous evidence that the relationship between time in practice and burnout changes over time (risk initially low, higher after 6 years, then declines after 10-15 years),26 the analysis used 5-year age groups to allow for nonlinearity.
Institutional review board exemption was obtained due to use of deidentified data.
We surveyed 6509 providers, with a 55.7% response rate (n = 3654). After limiting our cohort to CDOs that provided NPS (patient) data and including only respondents with nonmissing (complete) data, we retained an analytic sample of 1387 (see eAppendix Figure and eAppendix Table for information on CONSORT diagram [eAppendix available at ajmc.com]). Characteristics of these 1387 respondents are seen in Table 1. Three large groups made up 86% of respondents. Providers were roughly evenly split between physicians and APCs, with a slight preponderance of female providers and PCPs. After stratifying into exposure group based on TEAM index median (< 4 vs ≥ 4), groups were fairly balanced on age groups and organizational tenure. Almost 40% were providers of color (Asian, Black, Hispanic, or other). Most had been at Optum for less than 10 years, and most practices had not been acquired. The group with TEAM scores lower than the median had fewer physicians (48% vs 57% in high TEAM group), fewer PCPs (53% vs 62%), more female providers (61% vs 54%), and a larger proportion who identified as White (69% vs 55%).
The 6 included CDOs with NPS data were somewhat larger and had been integrated within the organization longer than the 11 nonincluded CDOs.
Responses to provider experience, burnout, and intent-to-stay questions are summarized in Table 2. Of the 1387 providers, 52% had favorable provider experiences, 30% reported burnout, and 79% indicated a high intent to stay within 1 year. These proportions were significantly different between the groups with high vs low TEAM scores (Figure 1).
Figure 2shows distribution of the TEAM index. The TEAM index has a theoretical range from 1.0 to 5.0. In this sample, the mean score was 3.83, with an SD of 0.75.
Table 3 shows provider outcomes based on TEAM index. In unadjusted models, odds of having a better provider experience index (experience score ≥ 4) were 12.1 times higher, odds of having a high intent to stay were 6.9 times higher, and odds of burnout were 73% lower for those with higher than or equal to median TEAM index scores compared with those with lower TEAM scores. After adjusting for clustering by CDO and covariates, odds of having a better provider experience (score ≥ 4) were 11.7 times higher, intent-to-stay odds were 7.2 times higher, and odds of burnout were 72% lower for those with higher than or equal to median TEAM index scores compared with those with lower TEAM scores.
In this study of 1387 providers in a large, multisite provider organization, we found that all 3 provider outcomes—provider experience, burnout, and intent to stay—were associated with a novel TEAM index related to efficiency, collaboration, communication, continuous improvement, care quality, and leadership. Intent to stay, a strong predictor in our organization of actual turnover, and provider experience had especially strong associations with teamwork (adjusted odds ratios, 7.2 and 11.7, respectively). These data suggest that a brief TEAM index may provide valuable information that could eventually be used to improve provider experience and, ultimately, recruitment and retention.
The TEAM index has several key elements: efficiency, communication, collaboration, continuous improvement, excellence, and leadership. The index performs well, with excellent reliability/internal consistency and necessary components of construct validity (straightforward construction, easy-to-answer questions, input by experts, good reliability, strong theoretical background, and high correlation with a validated burnout measure). The index also correlates with 2 additional clinically meaningful outcomes, the provider experience metric and intention to leave. It is brief (6 items) and as such differentiates itself from several prior measures, such as TeamSTEPPs27 (35 items) and adaptive reserve28 (23 items). It does overlap in part with several domains of TeamSTEPPs (especially team perceptions) and with constructs within adaptive reserve, and as such, it should add nicely to the available metrics. We propose that this measure can also be used to identify “bright spots” of effective teams; deeper dives into these teams’ work-life successes could inform interventions in less well-functioning teams. During the recovery from the COVID-19 era with work-life challenges, such as compassion fatigue29 and moral injury,30 a brief, clear, and effective metric of team function could be highly valuable.
This study reports and distills what others have reported: High-functioning health care teams come in a variety of compositions, yet most possess several key features that make them successful, including meaningful meetings, staffing, space, safety, communication, respect, conflict resolution, and team coordination.31 The strong Cronbach α, linking all 6 variables, and the unidimensionality support there being a single domain of teamwork in the TEAM metric that relates to lower burnout, better provider experiences, and greater intent to stay with the organization. As such, it represents a strong complement to the existing literature.
The literature shows that physician job satisfaction is a complex phenomenon.32 The single-item burnout measure correlates with emotional exhaustion in the Maslach Burnout Inventory,23 and dissatisfaction with work-life alignment is a predictor of intent to leave one’s current practice.33 Intent to leave and burnout are both strongly associated with actual turnover.34 Crucially, dissatisfaction among physicians is associated with patient dissatisfaction35—and dissatisfied patients are less likely to adhere to treatments36 and more likely to leave their physicians.37 Thus, there are many reasons to target provider reactions such as burnout, satisfaction, and intent to leave; this study provides new information about an aspect of clinician work life that is apparently related to many of these—better teamwork.
A team-centric view of experience may obscure the role of individual characteristics that differ among team members. Review of the literature on burnout does not reveal definitive ethnic or racial differences in burnout—although some research indicates that more experience-focused metrics and more nuanced interpretations are needed.38 Female providers have higher burnout rates than male providers, and gendered differences in patient panel composition and gendered expectations of female physicians (by patients) may contribute to this difference.39 During the COVID-19 pandemic, stress was higher among nursing assistants, medical assistants, social workers, inpatient workers, women, and persons of color, and was related to workload and mental health; importantly, stress was lower when individuals felt valued by their organization.40 Our findings raise new hypotheses about how an effective team can relate to lower stress in these groups as the pandemic lingers, burnout rises, and health care workers’ energies ebb.
Strengths and Limitations
Strengths of this study include a diverse cross-section of providers across the country and a high response rate, contributing to both validity and generalizability. Limitations include this being a cross-sectional study, with outcomes measured at the same time as exposures. Second, outcomes and exposures were measured on the same questionnaire, and responses may be correlated. Third, although we discuss physician and APC perceptions of teamwork, we did not include other care team members. Fourth, the single-item burnout measure correlates well with emotional exhaustion yet not as well with depersonalization, and thus may miss identifying some burned-out individuals. Fifth, there may have been a bias toward including those thinking of staying and of those with burnout by using the top 3 scores of 5 for both; however, this is the literature-accepted standard for the burnout measure,3,23 and the work intentions literature for intent to leave uses the top 3 choices for that.41 Sixth, the 6 questions under the Provider Experience Index were all stated in the affirmative. This could have led to a stronger assessment than if some had been worded negatively to neutralize the tendency for respondents to simply run down the list with the same response.
The novel teamwork index was associated with favorable outcomes (lower burnout, higher intent to stay, and more favorable provider experience) that relate to organizational loyalty and longevity. This is important, given projected physician shortages from accelerated retirements42 and job shifting due to COVID-19. Because physician practices ensure the health of communities and support jobs, support for them is important. PCP turnover leads to almost $1 billion in annual US health care spending, with nearly a third of costs from burnout.32 Determining how best to retain a viable workforce is an operational imperative for health systems.12 The TEAM index may provide a means of assessing team function and structuring interventions for improved provider experience and retention.
Author Affiliations: Optum Health LLC (ANH, ZS, MM, KP, OA, CEC), Eden Prairie, MN; Hennepin Healthcare (ML, MS, SP), Minneapolis, MN; UnitedHealth Group (AF), Minnetonka, MN.
Source of Funding: Optum.
Author Disclosures: Dr Linzer and Ms Poplau are employed by Hennepin Healthcare, which has contracts with Essentia Health, Gillette Children’s Hospital, American Medical Association, and Institute for Healthcare Improvement for their time to perform burnout reduction projects and has a contract with Optum for their time to work on this work-life improvement project; Hennepin Healthcare receives funds from the Agency for Healthcare Research and Quality (AHRQ) as part of a subaward for a learning health system training grant and has a pending grant from AHRQ for a series of conferences to develop a research agenda for health care wellness. Dr Linzer is also a consultant on a team with Harvard University researchers on diagnostic accuracy and work conditions.Dr Stillman received support through his employer, Hennepin Health System, to conduct work on burnout reduction through contract work with Optum. Dr Ameli is a full-time employee of UnitedHealth Group and owns stock in UnitedHealth Group. Ms Chaisson is a full-time employee of Optum and owns stock in UnitedHealth Group, the parent company of Optum. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.
Authorship Information: Concept and design (ANH, ML, ZS, AF, MM, MS, SP); acquisition of data (ZS, AF, MM); analysis and interpretation of data (ANH, ML, ZS, AF, MM, MS, KP, OA, CEC); drafting of the manuscript (ANH, ML, ZS, MM, MS, KP, SP); critical revision of the manuscript for important intellectual content (ANH, ML, AF, MM, MS, OA, CEC); statistical analysis (AF, OA, CEC); obtaining funding (ANH); administrative, technical, or logistic support (ANH, ZS, KP, SP); and supervision (ANH, ML).
Address Correspondence to: Amy Nguyen Howell, MD, Optum Health LLC, 11000 Optum Circle, Eden Prairie, MN 55344. Email: email@example.com.
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