JAMIAMay/June03 I

Design: 18 clinical teams, consisting of 180 clinicians from three Australian hospitals, were identified and studied. Teams were categorized as small (≤ 15 members) or large (> 15). Measurements: Clinical team functioning was assessed using the Team Climate Inventory (TCI). Awareness, use, and impact of an online evidence retrieval system were measured using a self-administered questionnaire. The relationships between TCI scores and awareness, use, and impact were examined using t-tests and one-way ANOVAs. Chi square analyses were used to examine differences between small and large teams. Results were interpreted within a diffusion of innovations framework. Results: Clinical team functioning was not related to awareness or use of the online evidence retrieval system. However, clinical team functioning was significantly associated with the impact of online evidence in terms of reported experience of improved patient care following system use. Clinicians in small teams (≤ 15 members) had higher levels of system awareness compared to large (> 15) teams. Conclusions: Team functioning had the greatest impact on the fourth stage of innovation diffusion, the effective use of online evidence for clinical care. This supports Rogers’ diffusion of innovation theory, to the effect that different types of communication about an innovation are important at different stages in the diffusion process. Members of small teams were more aware of the system than members of large teams. Team functioning is amenable to improvement through interventions. The findings suggest that the role of team climate in the diffusion of information systems is a promising area for future research. ■ J Am Med Inform Assoc. 2003;10:244–251. DOI 10.1197/jamia.M1285. 245 Journal of the American Medical Informatics Association Volume 10 Number 3 May / Jun 2003 not working in teams, and individual mental health increases as team functioning improves.1 Such findings have led to research aimed at identifying the attributes of good clinical teams and understanding aspects of team functioning that result in improved performance. Factors shown to contribute to effective teamwork include team composition, size, and organizational factors. For instance, systematic reviews have concluded that multidisciplinary teams can deliver improvements in patient care compared with standard care in a range of settings and patient groups.5,7,8 Optimal team size for effective communication has been reported to be 11–15 members; larger teams tend to fragment into sub-teams.9 Team Climate for Innovation One of the hypothesized reasons for improved performance of some teams is their ability to be innovative. Innovative teams are characterized by high levels of support and challenge; team members feel able to share and implement new ideas and have a clear mutual perception of the tasks and objectives of the team.10 After studying 148 teams from a range of health care and industrial settings, Anderson and West11,12 developed a measure of team functioning, the Team Climate Inventory (TCI). This tool measures the four factors that they found were related to team effectiveness and innovation: • Participative safety: how participative the team is in its decision-making procedures and how psychologically safe team members feel it is to propose new and improved ways of doing things • Support for innovation: the degree of practical support for innovation attempts contrasted against the rhetoric of professed support by senior management • Vision: how clearly defined, shared, attainable and valued are the team’s objectives and vision • Task orientation: the commitment of the team to achieve the highest possible standards of task performance, including the use of constructive progress monitoring procedures Several studies have subsequently demonstrated the utility of the TCI as a way of examining health care teams’ support for innovation.1,10,11,13–15 Results have shown that effective teams, as judged by external raters, have higher TCI scores than poorly functioning teams. TCI scores are also related to an increased level of innovative practice and improved quality of care.1,16 In a study of health service management teams, innovative practice was measured through tape recordings of team meetings over a 12-month period, from which a heterogeneous list of 125 innovations was derived. Experts rated these innovations using Damanpour’s17 typology of technical and administrative innovations on six dimensions of magnitude: radicalness, novelty, benefit to patient care, benefit to patients, benefits to staff wellbeing and benefits to administrative efficiency. The TCI was shown to have predictive validity, accounting for 45% of overall innovativeness and 42% of the variation in innovation magnitude.12 One of the most significant innovations to health care practice in recent years is the introduction of sophisticated clinical information and decision support systems provided at the point of clinical care. Examples include physician order entry systems and online clinical evidence retrieval systems. The relationship between clinical team functioning and the adoption and diffusion of such IT innovations has not been previously examined. Diffusion of Innovation The conceptualization of diffusion of innovation has developed over many years, with empirical research encompassing a diverse range of technologies, products, and processes. Diffusion of innovation can be seen as an orderly process, progressing through predictable stages, or as an unpredictable and chaotic process.18,19 Rogers’ seminal work describes the “innovation-decision process” in five stages: knowledge, persuasion, decision, implementation, and confirmation. Van der Ven et al.18 describe the “innovation journey” as having three main periods: initiation, development, and implementation/termination. Common to both models is considerable support for the importance of social networks in endorsing and enabling the diffusion of innovation.18,19 Integral to this approach is the view that knowledge does not flow vertically or in structured ways; instead, it flows back and forth within complex networks and relationships. In health care, the importance of social networks in the diffusion of innovations has been a consistent finding.20,21 Ash20 posits that greater diffusion will occur in organizations that encourage communication. This suggests that clinical team functioning plays an important role in IT uptake and use because within health care organizations the clinical team is one of the most important organizational levels at which information is communicated and work is negotiated. This layer of the organizational structure is rarely examined explicitly as a possible diffusion vehicle, with most studies concentrating on either individual or organizational characteristics. Other psychological theories of change such as social learning theory22 or the stages of change model,23 also concentrate only on how social interactions and cognitive processes influence individual change. Although the links between innovative practice and team processes are extensively discussed in West’s work,24 the links to diffusion of innovation theory are not clearly delineated. We sought to investigate the relationship between clinical team functioning as measured by the TCI and diffusion of a specific IT innovation, a 24-hour, point-of-care, publicly funded, online evidence retrieval system. The State Health Department in New South Wales* (NSW), *NSW, located on the east coast of Australia with the capital city of Sydney, has a population of 6.4 million, approximately one-third of the Australian population. Australia has a universal health insurance system similar to those of Canada and the United Kingdom. Public hospitals provide the vast majority of inpatient care in the country. Many privately insured patients are also treated in the public hospital system. Australia implemented this online evidence system, called the Clinical Information Access Program (CIAP), in all public hospitals in 1997.25 The online address is . The aim of CIAP is to improve the access of clinicians (doctors, nurses and allied health staff) to up-to-date evidence to support patient care decisions. The CIAP website provides access to a wide range of bibliographic and other resource databases (Table 1). Using a password, clinicians can access CIAP at work, with multiple terminals typically available on wards and in clinician offices, and at home. CIAP is available to approximately 55,000 clinicians across the state, yet there is considerable variation in the rates of use by individual hospitals.26 Past studies have shown low rates of use of information resources, with physicians reporting more use than other clinical groups.27–29 Technical factors such as access to, and speed of, computers explain only a proportion of the variation in CIAP uptake.30 The aim of the current study was to determine at what point in the diffusion process team functioning influences clinicians’ awareness and use of the online evidence system. Specifically, we sought to examine the relationships between clinical team functioning and (1) clinicians’ awareness of the innovation, (2) clinicians’ use of the innovation, and (3) the effective use of the innovation to improve health care.