key roles and issues of the multidisciplinary team

Key Roles and Issues of the Multidisciplinary Team

Marsha Jean Foun ta i n

I T HAS BEEN SAID that cancer will become the dominant specialty for American hospitals in

the twenty-first century.~ Because people are living longer and heart disease is being prevented, cancer will soon be the leading reason for hospital admissions (inpatient or outpatient) in the United States. Health care organizations must plan effective ways to deliver the care in a cost-effective manner that meets the needs of the consumers (patients and physicians). Although more people are being diagnosed with cancer, the survival rate is increasing. The immediate needs of the person with cancer must be met and the maximal level of rehabilitation must be facilitated.

To provide the best cancer care in the changing health care system of today, a multidisciplinary team approach is necessary. The Association of Community Cancer Centers (ACCC) and the American College of Surgeons (ACoS) have stressed the importance of a multidisciplinary patient care team. 2'3 The multidisciplinary or interdisciplinary team is defined by Ducanis and Golin 4 as "a functioning unit, composed of individuals with varied and specialized training, who coordinate their activities to provide services to a client or group of clients." The importance of teamwork in patient care was reported in the literature as early as 1922. 4 Rehabilitative medicine was one of the first specialties to stress the importance of a multidisciplinary approach to patient care. Cancer patients, like rehabilitative medicine patients, often move from inpatient care to outpatient care with a multitude of needs. Problems include physical deficits as well as psychosocial deficits. In addition, employment issues and insurance problems may be faced. Thus, the model of the rehabilitative medicine team approach is often used as a resource in developing the significant components of the oncology team.

To understand the role of the multidisciplinary team in cancer care, the continuum of care and services needed for cancer patients and their fam- ilies must first be understood. The services offered to cancer patients and "worried well" patients cover a wide spectrum. Figure 1 illustrates the range of services a cancer program should offer to cover the entire spectrum of care. The care must

appear seamless and meet all the needs of the patients. The health care organization is best suited to coordinate the care of the newly diagnosed patients' needs and assure access to necessary services. There are four important considerations in developing the role definitions for the multidisciplinary team: (1) define the purpose of the team and develop team goals; (2) develop standards for cancer care (excellence); (3) let the needs of the consumers (patients/physicians) guide the program; and (4) be 100% responsible and account- able for success. Lack of role definition can make it difficult for the team to function and to organize themselves in a collaborative manner, therefore, the contributions of each member must be recognized. There will be overlap in many of the roles, but efforts must be made to coordinate the plan of care for each individual patient. 5 For example, in some instances the social worker may be able to provide both psychosocial support and discharge planning. In others, a referral to a psychologist may be necessary. Because of the complexity of needs, each member of the team must understand and augment the care being given by other members of the team. An independent decision can have vast implications for the patient and other members planning care.

THE MULTIDISCIPLINARY TEAM

The members that comprise the team caring for the person with cancer are essentially unlimited because cancer is a multisystem disease that affects the body, mind, and spirit. Possible team members are identified in Fig 2. As cancer becomes a chronic disease, it must be treated from the rehabilitative aspect, including both physical and psychosocial needs. In the past, when few people with

From the Department of Oncology, Harris Methodist Fort Worth, Fort Worth, TX.

Marsha Jean Fountain, RN, MSN: Director, Oncology, Har- ris Methodist Fort Worth.

Address reprint requests to Marsha Fountain, Director, On- cology, Harris Methodist Fort Worth, 1301 Pennsylvania, Fort Worth, TX 76104.

Copyright �9 1993 by W.B. Saunders Company 0749-2081/93/0901-000555.00/0

Seminars in Onco/ogy Nursing, Vol 9, No 1 (February), 1993: pp 25-31 25

26

I Prevention Programs ]

I Eady Detection 1

ITreatmen| Planning I Treatments (Includino Research Protocols} 1

9ery, Chernotherapy/Biolo~ics, Radmti~

I Psychosocial Support Services I ~ c ~

I Re~itat= [

[ Hospice/Bereavement I

Fig 1. Cancer program components: the continuum of care.

cancer survived longer than 1 year, the goal was to assist the patient with primarily physical needs. However, now it is important for the health care team to help the patient achieve an optimal level of functioning (potentially equal to that before the diagnosis of cancer). Each member of the team brings an individual and new perspective to the needs and care of the patient. No one person on the team is more important than the other in the care being delivered. In fact, the primary team member may change according to the needs of the individual patient. However, it is imperative to have a case manager or care coordinator (or someone who functions in that role) to oversee potential and ac- tual needs and to assure that each need is being addressed and goals are being reached. Perhaps the person most able to do this is a Clinical Nurse Specialist (CNS). 6 However, it may be a different team member according to resources available. One should develop the multidisciplinary team so that the entire spectrum of care is addressed. As with traditional rehabilitative medicine, the spectrum of care includes preventive, restorative, sup- portive, and palliative needs. 7'8 As more cancer

Rese~ch Nurse Hoe Enterostomal ~ Therapist,,\.

P s y c ~ P e y ~ ~ Nurse specialis~

Financial Counselor /

Pain Management Teem 1 Consultant

Fig 2.

)ice Nurse

$exua

Radiation Therapy / Tech~Co~t

! . / , / ~ _ erge Planner

;~cology C,b~al ~ , ,nhsr Speciallst

macist

XN~e~sc'h~aring)

E x e r c i s e Physio~t

Members of the oncology multidiscipllnary team.

MAFISHA JEAN FOUNTAIN

patients are being cured, the needs of the cancer survivor must also be addressed.

At institutions with a small number of cancer patients, it is usually the responsibility of the CNS or nurse manager to assist the patient and family in meeting their needs. Very often, the specialists of a multidisciplinary team are not available. In that case, referral for specific problems to specialists outside the institution may be necessary. The patient care coordinator or team leader can arrange for consultations to these specialists.

If specialists are available on site, the team is developed. At the onset, the team requires education about cancer, and it's impact on the individual. Many health care professionals still think that cancer is a terminal disease, and they need to be educated on such basics as goals of treatment (cure, control, palliation). Others feel that their skills are better used on patients with longer life expectancies. It is important to identify persons who want to learn, want to be a part of the cancer care team, and wish to work in an area filled with changes. Frymark 9 notes that a strong knowledge base, leadership, coordination, role blending, support, and trust are necessary factors for team effectiveness. In addition, Ducanis and Golin 4 de- scribe four barriers to team effectiveness: (1) goal conflicts, (2) organizational structure, (3) interpro- fessional conflicts, and (4) lack of communication. Communication may be one of the most important issues, and often most team members know very little about treatment goals for the individual patient. Lack of information, either medical or oth- erwise, does not allow for clear goal setting. Ker- stetter ~~ notes the oncology multidisciplinary conference can enhance exchange of information and unify oncology support services. Collabora- tion, not simply coordination, is essential for the formation of a joint care plan. All of these issues should be addressed at the outset.

The team members must develop standards of care appropriate for their respective disciplines and determine ways to meet those standards. Numer- ous resources are available and should be used by the team in developing the standards of care for the cancer program. For example, the Oncology Nurs- ing Society (ONS) has developed position state- ments for pain management and rehabilitation that might be helpful in the development of the standards. Whereas initially it may be the role of those with experience in the cancer setting to assist with

THE MULT1DISCIPLINARY TEAM 27

other disciplines in defining or assessing the needs of patients, the goal would be to expand their vision so they can assess the needs themselves. For example, if occupational therapy determines that "activities of daily living" needs should be as- sessed in all patients before discharge, they must meet that standard.

The importance of clinical team members cannot be minimized. Each team member brings a different focus and different skills to help the patient optimize their recovery. Education is critical to help team members understand the cancer patient. Many disciplines now have special interest groups within their professional organizations for members with an interest in cancer patient care. Team members should be encouraged to join these special interest groups and share information. In this manner the team as a whole can grow.

Once the clinical program is in place and functioning, many institutions find it necessary to organize the cancer program formally to help in future growth. Initially, management may identify the nurse manager or clinical specialist to begin the coordination of services. This is usually done in conjunction with a part-time medical director (often a physician in private practice). In smaller institutions with fewer cancer patients and no rapid changes this may be adequate. Additionally, if an institution expects only to maintain the cancer pop- ulation and not target the cancer program as a center of excellence, this structure will suffice. How- ever, in larger programs that are highly impacted by competition and in a state of growth, a full-time medical director and administrative director may be necessary. In addition to the coordinator/case manager (who can assist in the day-to-day opera- tion of the multidisciplinary team) the medical director and administrative director provide the leadership for future direction of the oncology program and interface with other administrative staff to determine how to fund the program and operational- ize the plans.

MEDICAL DIRECTOR ROLE

The role of the physician executive is to assist the health care organization take care of the "core business" (clinical medicine), help strengthen physician loyalty and participation, and bring a medical perspective to the team. 11 In the cancer program, the medical director's role includes these

aspects but goes even further. The medical director's responsibilities should be primarily medical based and vision based to determine what the future of the program is and how it will be achieved. Duties may include physician relations, research protocol interface, networking, visionary forecast- ing, medical education, clinical quality improvement, fundraising, and product differentiation (Dr Albert Brady, personal communication, Septem- ber 1991). The medical director should be the person who best understands and can impact the "onco-politics" (or hidden agendas) of an institution. What are the physicians trying to say to the management of the institution and vice versa? Why are the carders (payors) not responding to sugges- tions for change? The medical director must be seen as a peer to both physicians in the community and the administrative staff of the institution.

Additionally, the medical director plays an integral role in strategic planning with the administrative director and marketing department of the institution. The individual is thought of as the "visionary" and must have the big picture of the future of medical care as it relates to oncology. The medical director needs to be cognizant of national organizations (such as ACCC, American Society of Therapeutic Radiation Oncology, American Cancer Society, American Society of Clinical On- cology) and national issues. Determination of which new technologies/procedures are best suited for the cancer program and when to institute these technologies is another aspect of the job. For example, the positron emission tomography scanner may have vast implications for oncology but with an approximate $5 million price tag. It is the role of the medical director to help determine the needs of consumers (in this case, the oncologists) and direct the hospital board and administration in this decision. Additionally, the medical director must have knowledge of the changing reimbursement climate. As cancer care moves to outpatient set- tings or new technologies (such as colony- stimulating factors) change the way in which care is delivered, the medical director must be proactive in changing the care delivery system in the institution.

The most overlooked quality of a medical director is the ability to relate to members of the multidisciplinary team. The medical director must respect the unique contribution of each team member. The role of the medical director is to

28 MARSHA JEAN FOUNTAIN

bring the medical perspective to the team meetings and integrate that perspective with the plan of care. The role may also be to educate the team on medical cancer care. Program failure may result if the importance of team members is not recognized.

The majority of current medical directors are part-time.12 Table 1 outlines the phases of cancer program development. In phases one and two, a part-time medical director may be useful. Part- time medical directors generally spend less time on management duties associated with the position and more time on clinical matters. Keeping current with clinical skills is essential to maintain a relationship with physician peers. One alternative when recruiting a full-time medical director is to allow a small clinical focus by negotiating responsibility for a rural outreach clinic or serving as a second opinion physician for patients selected for clinical trials. Medical directors recruited by a hos-

Table 1. Phases of Cancer Program Development

First Phase

Registry Cancer committee

Tumor board Diagnostic/treatment capabilities

ACoS approval No financial data

Cancer program coordinator Part-time medical director

Second Phase

Professional and lay education Oncology unit

Hospice/home care NCI research Networking

Multidisciplinary team Cancer program manager Part-time medical director

Third Phase

Prevention programs Full rehabilitation programs

All services Full financial data Quality standards

Division of oncology Subspecialists

Program administrator Full-time medical director

Abbreviations: NCI, National Cancer Institute.

pital and allowed to start a clinical practice may experience the feeling of competition from the other physicians on staff. This issue should be addressed up front because it can set the medical director up for failure if there is not support from the medical staff.

In most cases, the medical director is a medical oncologist but that is certainly not a requirement. More importantly, the medical director must have the important characteristics necessary to get the job done. These include energy, zealousness, desire for perfection, the ability to work with a high degree of chaos and ambiguity, strong clinical, negotiating, and leadership skills, and excellent communication skills. Most important, there must be a desire to pursue and to enjoy the job. As with nurses who leave the bedside for management, the medical director must recognize those things that are being left (clinical practice) and achieve com- fort with the new role. It is a career change that takes introspection and understanding. Finally, the medical director should be capable of promoting and stimulating enthusiasm that culminates in the product of excellent cancer care.

The medical director must also be willing to take a back seat to the success of the program and allow others the rewards at times. It is often difficult to recruit successfully internally. Many cancer program medical directors have been recruited from other hospitals. A medical director from outside the institution may be better received, just as hav- ing an outside consultant can be better received by employees than an internal manager. This often requires more time before the person proves wor- thy but the wait will be rewarded in the long term.

ADMINISTRATIVE DIRECTOR ROLE

The differences in the jobs of the medical director and the administrative director are intermingled and often overlap (Table 2). The medical director and administrative director should report in a peer fashion. That is, they should each have responsibilities distinct from the other, and should relate as peers. Often the administrative director reports to the medical director, but the relationship should be such that there is respect for the differences each brings to the program. The administrative director often reports to an operational vice president or the Chief Executive/Operational Officer for the day- to-day operations of the program. Many believe it


Table 2. Roles/Responsibilities of Medical Director and Administrative Director

29

Role~Responsibility Person Responsible

Strategic planning Development of standards of care Compliance with accrediting agencies Coordination & facilitation of patient care New program development Marketing plan Quality assurance/improvement Development of budget Evaluation of financial performance Evaluation of interdepartmental protocols Determining of applicability of new technology Liaison with medical committees Mediation of MD/staff differences Development & implementation of education/screening Payor relations Development of outreach clinics Research development Recruitment of subspecialists Fundraising Public relations Contributions to national cancer effort Coordination of data collection/manipulation (eg, registry, financial, etc)

A,M A,M A,M

A A,M A,M A,M

A A A M M M

A,M A,M A,M

M M

A,M A,M

M A

Abbreviations: A, administrative director; M, medical director.

is not beneficial to have the medical director report to the chief executive officer and the administrative director report to a vice president without some distinct division of the responsibilities of each.

Each person brings support and ideas distinctly different from the other. The major role of the administrative director is operationalizing the vision and program. In a survey done by this author in 1990, the major responsibilities of the administrative director were marketing, education, program planning, and construction renovation. Ma- jor challenges were competition for market share and relations with oncology physicians. 13 Most cancer programs had a matrix organization in which the administrative director had few departments reporting directly. The administrative director and medical director must have control over the issues that affect cancer patients, which may include standards of care, program development, quality issues, and staffing requirements to name a few.

The educational background of the administrative director is varied. Most often it is a nurse with an advanced degree. However, this is not a requirement. Some individuals believe that the role of cancer program administrator is best suited for an individual with a Masters degree in Health Ad- ministration or Business Administration. The

strength of a program is a reflection of the leadership. A clinical background may be important to understand the various factors impacting the program. However, if strong clinical personnel are available, it may be appropriate to have nonclinical directors. Minimally, the administrative director should have had some experience dealing with the components of the cancer program and have strong management skills.

The nurse progressing into an administrative director position must prepare for the role of high- level manager in an organization. This includes learning financial management, developing profor- mas and business plans, and strategic planning. Nurses bring the important perspective of nurtur- ing and the desire to have the patient's best inter- ests at heart. This is a perspective that an individual with a business degree traditionally does not have. It is also important to look at solutions to problems and new programs within the context of fiscal constraints while understanding the needs and input of others. A global view of the situation is required to be successful in this position.

Settlemyre 14 describes six critical leverage points of leadership, which may also be applied to the skills necessary for directors of cancer programs:

1. Operations--zealousness to make things work fight the way the patient wants it.

30

2. Meaning--leaders share information because it provides a context for understanding why change is occurring and how to respond.

3. Morale--leaders manage morale by manag- ing communications effectively.

4. Attention leaders reward good performance and develop people who are good performers.

5. Perceptions--leaders provide forums where vision and values can be discussed openly.

6. Ambiguity--leaders can tolerate high degrees of uncertainly without fear. If these are necessary factors for leadership, it is obvious that advanced prepared nurses are well prepared to assume this leadership position.

A major role (and challenge) of the administrative director and medical director is that of forming a unified view of the future. Liz Johnson (personal communication, March 1992) recommends the fol- lowing steps in planning the view of the future:

1. Tell yourself the truth, not what you want the truth to be. No problems can be solved if members of other disciplines tell people what they would like to hear, not the way it truly is.

2. Define the future as you want it now, not in 2 to 5 years. Decide what cancer care in your community should look like today and make it happen. Looking too far into the future will delay impact.

3. Plan the means and resources. 4. Decide how to measure and implement. The leader must continually focus on what the

truth is and focus on what is best for the consumer. The process of management must meet the patient's needs, not fit the patient to the management's needs.

A variety of types of individuals are qualified to manage a cancer program. An appropriate exercise to consider may be a Myer Briggs-type indicator (a tool to measure personality types and determine how people receive and react to information) on each team member, particularly the key roles of administrative director and medical director. For example, a rapidly changing program would not want both persons to be "judging," which is de- f'med as those who want to make a decision, come to closure and then carry on. One of the members could be a "perceiving" type, which is defined as spontaneous and keeps options open. Similar to the "fight brain/left brain" needs of team members, it would be desirable that the members of the team included o n e " sensing" person who can work with a great deal of facts and be careful with detail, and

MARSHA JEAN FOUNTAIN

one who is "intuitive," who looks at the big picture and values imagination and inspiration. In composing the team, it would be worthwhile to use the Myer Briggs personality trait to determine the best way to work together. ~5

TERRITORIAL CONSIDERATIONS

The issues of territory or " turf" are important. No department manager wants an "outsider" to tell them what to do. The organization of the cancer program defines which departments report to the program administrators. Often, there are many cancer services that do not report to but collaborate with the program administration. On the other hand, it is important to discuss and to understand the customer's stated and latent needs. This often requires the team approach to solve the problems or merely to identify the needs.

Part of the role of the administrative and medical director is to decrease the territorial battles wher- ever possible. Such is the importance of allowing all involved departments the opportunity to help write the vision and participate in the business plan development. Achieving support after the fact is a wasted effort at best unless the most altruistic person is in charge.

The traditional "keeper of the flame" for cancer patients has been the nursing division, directed by nursing administration. The nurse administrator (manager/supervisor) may or may not be responsible for other areas (medical, surgical) as well. Un- fortunately, in many cancer programs the nurse administrator and the administrative director may seem to have similar roles simply because they are both nurses, and tension may develop. This is es- pecially true when the administrative director is an advanced prepared nurse from outside the system. The role of the nurse administrator and the relationship in the team cannot be overlooked or minimized. Nursing administration has the role of as- sisting with developing and operationalizing of the vision for the advancement of nursing care and should play an integral part in the revision of the business plan for the cancer program (as it relates to nursing services, staffing, etc). The nurse administrator may have insight into the politics of the hospital and relationships with the physicians and other department managers and therefore can fore- see barriers that might arise and can assist in less-


ening their impact. Just as the medical director brings a medical perspective to the planning, the nurse administrator brings the nursing perspective.

The medical director and administrative director need to be consulted on any issue or any hiring that directly affects the care of cancer patients. These positions include nurse manager, clinical nurse specialist, oncology pharmacist, dietician/clinical nutritionist, nurse practitioners for specialty programs, radiation therapy manager, and outpatient chemotherapy manager. Whereas these positions may not report to the cancer program administrative staff, it is important that the leaders of the cancer program have some input and retain veto power.

31

CONCLUSION

Many hospitals find that the process of formal cancer program development starts with (1) assess- ments of departments according to national standards (eg, ONS, ACCC, ACoS); (2) focus groups comprised of patients, the public, and physicians; and (3) determination of the unmet needs and program deficits. This assists in the development of a camaraderie of effort to meet the needs of the consumer. In this way, no one person is telling the managers what needs to be done, the consumers are. Issues of territory are also kept to a minimum if everyone is willing to share in the success of developing a quality program.

REFERENCES

1. Coile RC: Cancer: #1 Center of excellence for the 21st century. Hosp Strategy Rep 2:7, 1990

2. Enck R: ACCC standards: Past, present and future. J Cancer Prog Manag 2:11-20, 1987

3. American College of Surgeons Commission on Cancer: Cancer Program Manual. Chicago, IL, American College of Surgeons, 1991

4. Ducanis AJ, Golin AK: The Interdisciplinary Health Care Team, A Handbook. Germantown, MD, Aspen Systems, 1979

5. Goldberg R, Tull R, Sullivan N, et al: Defining discipline roles in consultation psychiatry: The multidisciplinary team approach to psychosocial oncology. Gen Hosp Psychiatry 6:17- 23, 1984

6. Schull D, Tosch P, Wood M: Clinical nurse specialists as collaborative care managers. Nurs Manag 23:30-33, 1992

7. Mayer D, O'Connor L: Rehabilitation of persons with cancer: An ONS position statement. Oncol Nurs Forum 16:433, 1989

8. Dudas S, Carlson CE: Cancer rehabilitation. Oncol Nurs Forum 15:183-189, 1988

9. Frymark S: Rehabilitation resources within the team and community. Semin Oncol Nurs 8:212-218, 1992

10. Kerstetter NC: A stepwise approach to developing and maintaining an oncology multidisciplinary conference. Cancer Nurs 13:216-220, 1990

11. Joseph T: Greater future roles seen for physicians, physician executives. Physician Executive 17:3-7, 1991

12. Mannisto MM, Ney MS: Cancer program medical directors: Growing in number and importance. Oncol Issues 4: 15-22, 1989

13. Fountain MJ: A survey of cancer program administrators. Oncol Issues 6:20-22, 1991

14. Settlemyre JT: Health executive and leader. Today's cardiology administrator. Cardiovasc Manage 2:46-50, 1991

15. Myer I: Introduction to Type. Palo Alto, CA, Consulting Psychologist Press, 1990

key roles and issues of the multidisciplinary team

Documents