Gap analysis of strategies for promoting interprofessional teams in healthcare units

teamwork in medical centers


Introduction
The signi cance of interprofessional teams in healthcare has gained momentum in recent times [1].These teams comprise diverse professionals who work in tandem to deliver superior care to patients.Research indicates that effective collaboration among these professionals can enhance clinical practice and elevate patient outcomes [2].The value of teamwork extends beyond healthcare, as it is also crucial in organizational environments where employees work together to attain shared objectives while prioritizing the interests of their organization [3].On the other hand, Healthcare providers are facing multiple challenges due to biomedical and technological advancements, changing public perceptions, shortage of healthcare workforce, increasing costs, and the rising prevalence of chronic diseases [4].These factors are causing a transformation in the organizational structures of healthcare, with a renewed focus on collaboration.For example, The COVID-19 pandemic has further highlighted the importance of healthcare teams in providing safe and effective services.To reduce the transmission of the virus and ensure continuity of services, there is a growing need for innovative healthcare solutions and faster changes in interprofessional teams worldwide [5].
At the start of each shift, healthcare teams convene to discuss patient matters, safety protocols, and operational updates [6].These professional conversations cultivate a culture of communication and collaboration, strengthening working relationships and ultimately improving e ciency.By creating time and space for such exchanges, healthcare teams enhance their capacity to eliminate patient harm and uphold the highest standards of care [6].Research has found that patients and healthcare providers experience greater satisfaction when working together as a team [7,8].In recent years, healthcare organizations have shifted away from the traditional hierarchical model of treatment staff towards a more collaborative and horizontal team structure that emphasizes accountability [9].The healthcare industry recognizes the importance of teamwork and the Code of Professional Conduct for Nurses stresses the need for nurses to work closely with others in a team [10].Consequently, there has been a notable increase in team building training and efforts to promote a culture of teamwork within the healthcare sector over the past decade [11].
The quality of teamwork in health care systems plays a crucial role in how these systems affect people's lives [12].While effective teamwork can greatly improve organizational performance, research shows that some organizations struggle to create successful teams that meet their needs, leading to challenges in team activities [13].Communication between health professionals from different disciplines is complex and requires careful management [4].While teamwork can bene t patients, health systems, and health workers, it can also lead to con ict and negatively impact health services if not managed effectively.Lately, there has been a surge in the number of instances where healthcare professionals from different disciplines have been at odds with each other in the workplace [14].These con icts can be quite disruptive and are encountered across all levels of healthcare delivery.In severe cases, they can even escalate to physical altercations between interdisciplinary professionals [4].
While there is a growing body of literature on teamwork in healthcare settings, particularly in developed countries and there are unique opportunities to contribute to the science of team building in medical units [12], there has been little research on optimizing team collaboration in treatment units in developing countries where collaboration pressures may be more prevalent [4].By identifying the effective components of teamwork improvement, researchers and organizational psychologists can make a positive impact on this evolving industry for both those who work in it and the people whose health depends on it.As such, this research aims to analyze the gaps in strategies for promoting interprofessional teams in healthcare units.

Materials and Methods
This study utilized a mixed-method approach to systematically review qualitative and quantitative studies aimed at identifying strategies for improving interprofessional teams in healthcare units.The researcher employed an Importance Performance Analysis (IPA) to evaluate the current and desired situation in four specialized clinical training centers, in Hamadan province, Iran.The study's required information was extracted from PubMed, Scopus, Web of Science, and ScienceDirect databases using relevant keywords such as "Team*", "Health*", "Challenge*", "Barrier", "Hospital", and "Medicine".Inclusion criteria consisted of articles that identi ed the components of teamwork in health organizations, while exclusion criteria included non-English publications, books, conferences, letters, errata, meeting abstracts, notes, short surveys, and reviews.The study also excluded articles or materials that did not result from research work, such as personal opinions or hypotheses.

Evaluation of the quality
Two evaluators utilized the STROBE checklist [15] to assess the reporting quality of articles extracted from the designated databases using the provided keywords.The initial evaluation was conducted on 5 articles by the two evaluators to reach a consensus.Subsequently, each evaluator assessed the remaining articles independently, and if any uncertainty arose, a third party with greater expertise in methodological matters was consulted.

Data extraction
To begin the data extraction process, a form is created that includes essential details such as the author's name, publication year, study location, objective, study type, participants, health system area under investigation, and ndings.Initially, three articles were used to experimentally extract data and address any issues with the form.All published articles and reports were considered for selection, regardless of the time frame, as long as they met the input criteria.After eliminating articles based on exclusion criteria, a total of 48 relevant articles were reviewed in detail.The extracted research was organized and criteria were applied using Endnote X9 software.

Important-Performance Analysis
The IPA technique is a derivative of gap analysis, which was rst introduced by John Martilla and John James in 1977 [16].The technique is widely recognized as an effective tool for evaluating an organization's competitive position, identifying areas for improvement, and designing strategies that enable the provision of targeted services [17].The analysis is presented in a twodimensional network comprising of four distinct quadrants, each with a speci c strategy that can aid the decision-making process.This matrix serves as a vital resource for understanding the level of priority for various indicators.
In Fig. 1, the IPA is divided into four areas based on the importance and current performance of each indicator.
The rst quadrant.is the area of weakness or de ciency, and it consists of variables that have high importance but low performance.This indicates the weak points of the organization and highlights priorities for improvement and investment.
The second quadrant.is the acceptable or optimal area, and it consists of variables that have high importance and high performance.This indicates the strengths and competitive advantage of the organization, and it is recommended to maintain the current strategy.
The third quadrant.is the area of indifference or low priority, and it consists of variables that have low performance but high importance.While the current situation is not considered a threat, it is not necessary for survival.Therefore, it is advised to ignore and not invest.
The fourth quadrant.is the area of waste of resources or the focus of attention, and it consists of variables that have low importance but high performance.This indicates the waste of resources allocated to these characteristics, and it is recommended to make better use of the available resources in another eld.Being in this area requires immediate action.
Data analysis in the performance gap analysis section was done through SPSS 19 and Microsoft Excel 2019 software.

Results
According to the PRISMA ow chart (Fig. 2), among the 2569 related articles found, 739 duplicate articles have been removed, then 244 studies have been excluded based on the type of work, and 1586 articles are left to review the title.After reviewing the titles, 1035 unrelated studies were excluded based on the exclusion criteria, and 551 studies were evaluated based on the abstract text in the next step.In this step, 212 studies were excluded from the study, and 339 studies were left to review the entire text.Based on the exclusion criteria, 48 articles related to the objectives of the study were included and fully reviewed.The characteristics of the reviewed articles are given in (Table 2).Financial and non-nancial incentives to enhance motivation [23] Performance of quality improvement teams and associated factors in selected regional referral hospitals

Selfadministered questionnaires
Training; Communication; Roles and responsibilities; Team size and composition; Self-assessment and learning; Management support; Team cohesiveness [24] Dealing Semistructured interviews Teamwork support; Team leadership/decision-making; Communication in Team and managers.[30] Barriers and facilitators to implementing an urban coresponding policemental health team Content analysis of qualitative focus groups Team building exercises.[31] Nurses' perceptions of multidisciplinary team work in acute health-care

Direct observation
Acquisition of team-playing skills [32] An Interprofessional Team Performance Training Program for the Care of Vulnerable Patients in the Ambulatory Setting

Inductive coding and comparison
Meeting practices (standardizing time and processes for collaborative care using checklists); Understanding team members' roles and responsibilities, and how to improve care; Building humanistic relationships with patients and team members, and communicating respectfully.[33] " Using thematic analysis, similar cases were combined and the strategies for promoting interprofessional teams in medical centers were categorized into seven groups according to (Table 3).Teams given authority to make process changes [39] Organizational aspect The external environment/ Immersive work spaces [20,33,42,45,47,59] To ensure privacy and security of health data [36,53] Climate/ enjoyment [37,45] Enable to speak freely without fear [44] Finding To assess the effectiveness of strategies for promoting interprofessional healthcare teams, we have employed the IPA model framework.In this framework, each component is assigned a code to facilitate its positioning on the importance-performance matrix.
We have collected data to analyze the performance gap and have calculated and analyzed the average importance and performance of each component.

Gap Analysis: Importance-Performance Matrix
In order to determine how close the performance level of each component is to its importance level; we used a formula (I-P).We subtracted the average importance of each component from the average performance and calculated the performance gap.To check if the difference between the average importance and the average performance of each component is signi cant, we used the paired comparison test at the 5% error level.If the performance gap is signi cant, it means that the component's performance level is far from the ideal situation (level of importance).We presented the results of the paired comparison test of the analysis of the performance gap between the existing and desired situation for all seven indicators (contextual, strategic, communication, organizational, individual, human resource management, and environmental factors) in Table 2.According to the results, there is a signi cant gap in the performance of various factors such as contextual, organizational, individual, and human resource management (Sig ≤ 0.05) when compared to the ideal situation.The eld of human resource management has the biggest performance gap (1.243), followed by the organizational aspect (0.588), individual aspect (0.499), and contextual aspect (0.496) respectively.On the other hand, there was no signi cant difference between the current situation and the desired situation (signi cance of the indicator) for indicators related to strategic, communication, and environmental aspects (Sig > 0.05).
Figure 3 displays the IPA for the primary research indicators.The experts at the medical centers were interviewed concerning the abilities and capabilities of the centers, and based on their inputs, the threshold limit for the current performance has been set at 3 out of 5. Additionally, a score of 3.60 out of 5 in terms of the level of importance.has been assigned to the components related to the promotion of interprofessional teams.The communication, contextual, individual, and organizational aspects are within the acceptable range.However, the aspect of human resource management is lacking and needs improvement to reach an acceptable level of performance.Although the environmental aspect is in the area of resource wastage, it is in an acceptable state due to its relatively lower level of importance compared to other aspects.
According to the pairwise comparison test in Table 2, there is a notable performance gap between the current and desired conditions for 36 components related to the main indicators.Speci cally, the background factors of "culture of respect" and "humility" exhibit a signi cant difference (Sig ≤ 0.05).Additionally, the "team alignment with organizational goals" component shows a signi cant difference from a strategic aspect (Sig ≤ 0.05).In terms of communication, there is a signi cant difference (Sig ≤ 0.05) between the current and desired status of "Communications," "Role clarify," and "Con ict Resolution Support."Furthermore, there is a signi cant difference (Sig ≤ 0.05) between the current and desired situation for the organizational aspects of "leadership support" and "facilitation in team innovative processes." Table 2 shows the results of the pairwise comparison test of the analysis of the performance gap between the current and desired conditions for 36 components related to the main indicators.There is a signi cant difference between the current and desired situation in the group of background factors of "culture of respect" and "humility" (Sig ≤ 0.05).From the strategic aspect of the "team alignment with organizational goals" component, there is a signi cant difference between the current and desired situation (Sig ≤ 0.05).From the aspect of communication, there is a signi cant difference (Sig ≤ 0.05) between the current and desired status of the components "Communications", "Role Transparency" and "Con ict Resolution Support".From the organizational aspect of "leadership support" and "facilitation in team innovative processes," there is a signi cant difference between the current and desired situation (Sig ≤ 0.05).From the individual aspect of the "roles and responsibilities", there is a clear discrepancy between what is currently in place and what is desired (Sig ≤ 0.05).In terms of human resource management, there are signi cant differences between the current and desired situations regarding "Financial resources to support work," "Partner resources (skills, expertise, and networks)," and "Incentives/rewards/pay attention to workforce needs" (Sig ≤ 0.05).Looking at the "Enable to speak freely without fear" from an environmental perspective, there is also a signi cant difference between the current and desired conditions (Sig ≤ 0.05).
Figure 4 presents the IPA for teamwork promotion sub-indicators in medical centers.The results indicate that the components "Enable to speak freely without fear" (g5), "Teams given authority to make process changes" (c5), and "Training/Education/teaching program" (f5) are in the indifference zone.This means that the current performance is satisfactory, and there is no need for improvement.On the other hand, certain components contribute to resource waste, including "having a shared vision" (b4), a "proactive employment strategy" (b2), "ensuring the privacy and security of health data (g3), "giving teams the authority to make process changes" (c6), "the external environment/immersive workspaces" (g2), and "climate/enjoyment" (g4).While the medical centers' performance is good, these components are not given priority in terms of importance, leading to a waste of resources.Lastly, the components "Incentives/ rewards/ pay attention to workforce needs" (f4), "Roles and responsibilities" (e3), "Financial resources to support work" (f1), "Facilitate team-initiated innovation" (d4), "Culture of respect" (a1), "Partner resources (skills, expertise and networks)" (f2), and " Leadership support"(d1) are in the weak area.Since these components are highly important, it is necessary to improve the current situation until reaching the ideal performance level.

Discussion
Through a systematic review, this research identi ed the dimensions and components required to improve interprofessional teamwork in health systems.Afterward, a gap analysis was conducted to evaluate strategies for promoting interprofessional teams in medical centers.The analysis was carried out on a case-by-case basis in four specialized medical training centers in Hamadan, Iran.A total of 2569 related articles were initially found, but only 48 articles that fully met the study's objectives were analyzed in full text.The solutions for promoting interprofessional teams were then categorized into seven categories, which included contextual, strategic, communication, organizational, individual, human resource management, and environmental aspects.These categories encompass 36 components in total.
The gap analysis results indicate a notable performance gap between the current and ideal state of contextual, organizational, individual, and human resource management factors (Sig ≤ 0.05).The eld of human resource management shows the largest performance gap (1.243), followed by the organizational aspect (0.588), the individual aspect (0.499), and nally, the contextual aspect (0.496).
Based on the IPA results, human resource management is an area of weakness despite its high importance.Its performance is signi cantly below the ideal level and needs improvement to reach an acceptable standard.Medical centers must invest in this eld to enhance their performance.On the other hand, the environmental aspect is relatively less important and falls under the category of resource wastage.Nevertheless, it currently maintains an acceptable level of performance.Based on the IPA results, it is evident that the sub-indices, " Enable to speak freely without fear" (g5), "Teams given authority to make process changes" (c5), and 'Training/Education/ teaching program" (f5), are all within the indifference range.
It has been observed that certain factors are contributing to the wastage of resources.These factors include having a shared vision, a proactive employment strategy, ensuring the privacy and security of health data, giving teams the authority to make process changes, the external environment/immersive workspaces, and climate/enjoyment.Although the medical centers' overall performance is good, these components are not given priority in terms of importance, leading to a waste of resources.Moreover, some components such as incentives/rewards/attention to workforce needs, roles and responsibilities, nancial resources to support work, facilitate teaminitiated innovation, the culture of respect, partner resources (skills, expertise, and networks), and leadership support are in the weak area.As these components are highly important, it is necessary to improve the current situation until reaching the ideal performance level.
Incentives, rewards and nancial resources to support teamwork It has been found that reduced resources and budgets have limited the effectiveness of health teams and decreased the motivation of team members to maintain success.Budget constraints, such as funding delays, the effort required to submit grant applications, and the threat of budget-related staff cuts, play a more important role than leadership skills attributes [65].Another study by Mantell et al. (2022) found that the motivation of teams to support health promotion and education has been reduced due to the decrease in salary and bonus levels.As a result, the level of health services in the eld of mother and child health, tuberculosis, HIV, and other chronic diseases has decreased [22].
Based on a study by Sakyi et al. (2011), providing motivational incentives to regional health management teams was found to be a crucial element in promoting decentralization [35].The study [66] found that when individual performance is easily measurable, differential rewards based on the situation lead to greater job satisfaction.For long and complex projects, team rewards based on results also have a positive impact on team performance.Hence, it is recommended that medical center o cials prioritize teamworkbased payments, nancial and non-nancial incentives, and rewards in their nancial and non-nancial planning to boost the motivation and performance of teams.
Effective programs require well-designed reward systems to keep interprofessional teams motivated and focused on achieving their goals even after receiving their rewards [67].A survey conducted in health centers revealed that incentives offered to health service providers are often inadequate.Providers may not be interested or motivated to participate unless the incentives are worth their while.
To ensure the effectiveness of incentives, they should be based on a comprehensive and valid performance measurement system.The measurements should be reliable, valid, and clear, while the performance comparisons between the members of interprofessional teams should be unbiased.However, achieving this ideal point in the current system of performance in the medical centers of Iran seems almost impossible due to the current conditions.

Culture of respect
Teamwork in healthcare requires active participation from different professionals to exchange experiences and knowledge.This is often done through team meetings [68].Professional respect is an important aspect of workplace interactions between coworkers and signi cant others, such as supervisors.Unlike peer support or social relationships, professional respect is evaluative and re ects the value of work and the level of participation in the community..From a contextual aspect, research [33] emphasizes the importance of a culture of respect among team members as a key factor for effective teamwork.Showing respect among team members can improve team performance [27].In order for mobile crisis intervention teams and rst response unit o cers to interact effectively with service recipients, they must respect each other's roles [58].Therefore, it is recommended that healthcare center management focus on promoting a culture of respect and humility through team leadership interventions.

Roles and responsibilities
Group performance is determined by the way team members share resources, roles, and responsibilities.When individual roles are clearly de ned, especially in teams where every member knows their role, everyone is aware of what they are supposed to do, and they understand their boundaries, which helps them focus their thinking and move in the right direction [28].However, even when all members of the clinical team are willing to develop a common practice, misunderstandings and con icts about roles are common and signi cant obstacles to the integration and practice of physicians and nurses [64].
When nurses have clearly de ned roles, there is agreement on how patient management duties are divided, the skills of each team member, and the scope of practice, as well as the distinctions and similarities between roles [69].Research [58] indicates that recognizing the distinct roles of nurses and police o cers within interprofessional teams is crucial for providing optimal services.The interpretation of research ndings [26] suggests that managers need to have a thorough understanding of the key elements for successful group performance in order to facilitate it.Therefore, it is advisable that managers communicate information in a way that allows team members to have a clear understanding of their roles and responsibilities, as well as what is required of them to complete tasks and meet deadlines.

Facilitate team-initiated innovation
Innovation thrives in an environment that fosters employee questioning of organizational practices [70], encourages creative expression, and enables risk-taking, experimentation, and seizing opportunities [71].In complex systems like hospitals and healthcare centers, middle managers are essential to implementing healthcare innovations effectively.Speci cally, middle managers play a critical role in disseminating and combining information related to innovation implementation, mediating between strategy and daily activities required by interprofessional teams [26].Research shows that issues such as nancing, information governance, interoperability, strict regulations, procurement, and the systemic challenge of encouraging and scaling innovation are central to enhancing innovation in the medical eld [72].Regardless of their roles, team members recognize the importance of managers in promoting innovation or change.In highly effective teams, where change was implemented successfully, employees reported that managers facilitated the innovation process, allowing them to initiate change in their service line.Meetings with managers are an excellent opportunity for all members of interprofessional teams to share their innovative ideas.One crucial piece of advice that team members in all roles agree on is the need for managers to coordinate changes across all disciplines when implementing change.

Conclusion
Research has shown that effective health care relies heavily on teamwork to meet patients' needs and promote overall health [73].The World Health Organization emphasizes the importance of health care professionals from diverse backgrounds working together to achieve health goals and provide top-quality care [74].Since the outbreak of the COVID-19 pandemic, there have been some notable changes in the medical profession.Studies such as [75,76] have identi ed common traits among medical staff, including greater collaboration in interprofessional teams, increased trust in one another, and greater empowerment and independence to effect positive change.Nonetheless, the complexity of the structures and the variety of specialist employees involved in health care can make implementing teamwork challenging.Future research should investigate the impact of strategies that promote interprofessional teams on enhancing the quality of healthcare services in medical centers.Importance_Performance Matrix for main criterias

Figures
Figures Figure 1

Table 1
To develop a shared understanding of the domain; To establish a common understanding of key concepts among the project participants; To involve the end-users in the research and development process; To collaborate across sectors; To ensure privacy and security of health data; To obtain the right timing of activities according to project dependencies.

Table 2
Dimensions and components of promotion of interprofessional teams

Table 3 :
Pairwise comparison test in order to gap analyze the indicators

Table 4 :
Pairwise comparison test in order to gap analyze the Sub-indicators