Applying Agile Principles to Collaborative Healthcare Teams

Rubina Lakhani, Benjamin Eze and Liam Peyton

Faculty of Engineering, University of Ottawa, 800 King Edward Street, Ottawa, Canada

Keywords: Collaborative Healthcare Teams, Performance Management, Agile, Treatment Plan, Dashboard, ADHD.

Abstract: In this paper, we demonstrate how agile principles can be applied to collaborative healthcare teams. We

provide a generic Agile Healthcare Process, and two associated artifacts, the Agile Treatment Plan, and the

Agile Dashboard using a theoretical Attention Deficit Hyperactivity Disorder case study. The paper describes

these in detail and shows how healthcare teams can measure the success of their collaboration through

actionable metrics. Our hypothesis is that providing a process in which collaboration factors are identified

and associated with specific performance metrics that can be collected and analyzed, can improve

coordination of collaborative healthcare teams. We demonstrate how agile methodology can be applied to

manage the treatment of chronic conditions such as ADHD. Our approach anchors around the Agile Treatment

Plan and the Agile Dashboard. We show how the KPIs associated with these artifacts can be used to quantify

healthcare team collaboration and performance.

1 INTRODUCTION

Medical errors – from poor communication,

misdiagnosis, poor judgement, and inadequate skills

- account for 30% of patient deaths in the US

(Anderson & Abrahamson, 2017; Makary & Daniel,

2016). Medical errors can be systematic or linked to

individual care providers, but approximately 75% of

these errors are the result of teamwork failures (Mayo

& Woolley, 2016). While most medical errors are

unintended, the negative impact on quality of care can

be very significant and sometimes result in the death

of the patient.

Chronic health conditions like Attention Deficit

Hyperactivity Disorder (ADHD) pose a huge

challenge since managing the condition requires

collaboration and coordination between healthcare

professionals, school authorities, community support

and caregivers (Carpentier, 2012). These long-term

chronic conditions are most susceptible to medical

errors because of the number of different individuals

involved in patient care. Therefore, the high incidence

of chronic health conditions and the associated

benefits of team-based care delivery is one of the

major drivers for collaboration (Kuziemsky, 2016).

Collaboration can be especially challenging. In

addition to clinical domain complexity, care team

members tend to have very different roles,

perspectives and training (family health, mental

health, community health, and therapies) (Ezziane et

al., 2012). Additionally, healthcare policy and

regulation pose challenges to team collaboration. In

general, healthcare collaboration is complex, which

can make coordination, cooperation and

communication difficult. These factors make

measuring teamwork performance particularly

challenging (Sicotte, D’amour, & Moreault, 2002).

In this paper, we discuss performance

management for collaborative healthcare teams by

using a theoretical ADHD case study. The case study

is developed using empirical observation, theoretical

research and consultation with experts. We establish

the advantages of treating healthcare processes as

agile processes guided by an agile treatment plan and

dashboard that is managed across the healthcare team,

and 2) show that healthcare teams can measure the

success of their collaboration through actionable

metrics.

It is our hypothesis that if we provide a framework

in which a holistic set of collaboration factors and an

associated set of specific performance metrics is

collected, analysed and communicated effectively,

then, care teams will be more effective in

coordinating care. This should result in outcome

improvements to quality of care that will exceed those

from traditional practice.

506

Lakhani, R., Eze, B. and Peyton, L.

Applying Agile Principles to Collaborative Healthcare Teams.

DOI: 10.5220/0008984105060513

In Proceedings of the 13th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2020) - Volume 5: HEALTHINF, pages 506-513

ISBN: 978-989-758-398-8; ISSN: 2184-4305

2 BACKGROUND

Managing chronic disease conditions is complex, long-

term, and requires multifaceted responses from multi-

disciplinary healthcare teams comprised of doctors,

nurses, social workers, physiotherapists and other

health professionals that provide collective

intelligence, over multiple domains for the purposes of

diagnosis and treatment (Nolte, Knai, & McKee,

2008). While team collaboration has the potential to

improve patient care, in many instances it can have the

opposite effect if the teams do not collaborate

effectively (Havyer et al., 2014; Zwarenstein,

Goldman, & Reeves, 2009). Further, there is a great

focus on integrating clinical workflows, with less

emphasis placed on team-based collaboration (Eikey,

Reddy, & Kuziemsky, 2015).

(Eikey et al., 2015) develop a Collaboration Space

Model that is based on four main concepts:

1) Technology - used by care providers,

2) Context – refers to the collaborating teams,

3) Processes – refers to collaborative processes,

workflows, communication, and information

exchange, and

4) Outcomes – represent the goals for achieving the

desired patient outcomes. While collaboration must be

designed to incorporate these four concepts, there is the

gap to ensure that outcomes are in line with the desired

patient outcomes.

Agile methodology encompasses well-defined

methods for organizing collaborative work processes

and for measuring performance in software

engineering and other fields. Agile methodology is

heavily used in managing software development

projects and teams (Duka, 2013). It involves breaking

up development activities into vertical slices that allow

for the incremental release of software to the customer

at the end of each sprint (Agile Methodology, 2008;

Upadrista, 2015). The strength of agile methodology is

that it enables continuous, measurable feedback that

gets communicated back to the teams, so priorities and

goals are constantly adjusted to be in congruence with

the customer needs.

Some early results in the literature show the

potential benefits of applying this approach to the

healthcare domain (Mayo & Woolley, 2016)

(Williams, 2016). Applying agile methodology

principles to collaborating healthcare teams means that

patient outcomes are continuously evaluated by the

collaborating teams. Feedback from the patient and

caregivers is received in a timely manner by the teams

so medical errors are minimized while the feedback

from the patient results in tuning treatment plans to

meet the desired patient outcomes. Based on the work

of James Reason (Reason, 2000), Figure 1, shows that

each of the collaboration space model concepts is

affected by various issues like cognitive overloads,

misaligned goals, communication breakdown, and

ineffective coordination. These dark (active) holes

constitute negative incidents or errors, while the others

are latent. When several active holes line up, patient

harm occurs through a cascade of these errors.

Figure 1: Swiss Cheese Diagram of Collaboration Failure

(Reason, 2000).

A key component of agile methodology is the

ability to provide measurable outcomes. This requires

collaborating healthcare teams to define metrics for

measuring success in forms of Key Performance

Indicators (KPIs)

In order to monitor care processes, data must be

collected and reported to measure how well they are

meeting quality of care goals dictated by

organizational, governmental, and accreditation

regulations. These measures need to be presented and

reported to care teams in a simple format such as a

dashboard or report that assists them in decision

making (Azvine, Nauck, & Ho, 2003).

Shared outcomes and goals for patient health are

measured and evaluated in a methodical manner and

inform the accountability and efficiency of the team.

The agile mindset encompasses values, goals and

attitudes for the benefit of the customer, as opposed to

the benefit of the bottom line (Denning, 2016). It

involves continuous improvement and transparency on

an ongoing and daily basis. The communication is

egalitarian, open and conversational and occurs

independently of hierarchy or position within the

organization. The workplace, including the physical

workspace, is open and lends itself to collaboration

(Denning, 2016)

Applying Agile Principles to Collaborative Healthcare Teams

507

3 A GENERIC AGILE PROCESS

FOR COLLABORATIVE

HEALTHCARE TEAMS

Agile methodology may be applied to situations

where complexity and uncertainty are high. This

uncertainty can be related to the scope or even

whether a product or service meets customer and

market needs (Samaniego & Deters, 2016). Agile

methodology can be applied to many aspects of

healthcare service delivery involving multiple

collaborative healthcare teams. For example, teams

within a department in a hospital may work very

efficiently. However, when they are required to

interact with the greater community (inside and

outside the hospital), there is a higher likelihood of

issues. (Tolf, Nyström, Tishelman, Brommels, &

Hansson, 2015) describe three types of environmental

uncertainties that face hospitals, which can be

generalized to healthcare organizations: 1) general

uncertainties that deal with changing demographics,

technology, political and socioeconomic realities; 2)

task uncertainties related interaction with other care

organizations or individuals such as community care,

social care, patients and suppliers; and 3) work

uncertainties that describe scientific elements related

to the nature of care itself such as certainty of

diagnoses, and the ability to routinize diagnoses.

Our generic agile process for collaborative teams

leverages agile artifacts as shown in the list below.

This list summaries some of the mappings between

the terminologies used by collaborative healthcare

teams and agile methodology.

• Sprint Planning: Sprint Planning

• Agile Treatment Plan: Project Backlog

• Intervention/Action: Task

• Ongoing Collaboration: Daily Stand-up

Meeting

• Final Case Conference: Sprint Retrospective

• Agile Dashboard: Agile Dashboard

In order to illustrate the agile process for

collaborative healthcare, we will assume that the

patient has been diagnosed with ADHD, and the team

is in the process of determining the drug of choice, as

well as implementing behavioural modification

strategies for learning.

Figure 2 shows how an agile process would see

the creation of a virtual team consisting of the

physician and psychologist. The teams would create

the activities that are part of their treatment as user

stories to a scrum backlog. The team would agree on

an initial treatment plan at a “Sprint Planning

Meeting”, by moving activities from the cross-team

“Project Backlog” into the current sprint or Agile

Treatment Plan (ATP).

Figure 2: Agile Process.

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This initial meeting could include other players

such as the patient and parents. At the end of the sprint

planning meeting, a treatment plan for the sprint is

produced reflecting a commitment made by all teams

involved. This plan would organize and prioritize

specific interventions related to the broad areas of a

patient’s life, for example, home, school, friends and

peers.

In our example (Figure 2), we focus on learning at

school. The treatment plan includes medication

which would help reduce the symptoms of ADHD.

Therapy is prescribed to help with coping strategies,

as well as possibly tutoring help with schoolwork. A

variety of interventions would be articulated in the

treatment plan to help with the child’s development

(Jellinek & Mcdermott, 2004).

4 ADHD CASE STUDY

Dysfunction of the cerebellar-striatal/adrenergic-

prefrontal brain results in the core symptoms of

ADHD which involve developmentally inappropriate

and functionally impairing inattentiveness and

hyperactivity-impulsivity (Solanto, Arnsten, &

Castellanos, 2001). ADHD is difficult to diagnose

because the core and secondary symptoms of ADHD

are exhibited in many childhood disorders.

Additionally, many view ADHD symptoms as a kind

of variation of normal childhood development.

(Rapport, Timko, & Wolfe, 2006). Whatever the

etiology, the prevalence of the diagnosis of

ADHD/ADD has exploded over the past two decades.

Parents become aware of behavioural issues that

manifest in a child’s or adolescent’s education or

social interactions and, justifiably, look for solutions

to help them.

In current practice, the healthcare team for a child

who has been diagnosed with ADHD is the primary

care physician, parent(s), teacher, and if possible, the

child. Each of these team members plays a role that

yields the most effective outcomes for the child.

The role of the physician is to diagnose, prescribe

medication, recommend community resources for

behaviour and support (such as psychologists), and

on-going monitoring of the child’s progress

(Canadian ADHD Practice Guidelines, Third

Edition, 2011).

The role of the educator is to implement, enforce

and document academic and behavioural strategies

during school hours. Once ADHD is successfully

diagnosed, there is strong evidence that treatments

with high acceptability and adherence yield the best

outcomes for school-aged children with ADHD.

ADHD is a disorder that is best treated with a

combination of drugs and behavioural therapy (MTA

Cooperative Group, 1999; Subcommittee on

Attention-Deficit/Hyperactivity Disorder & Steering

Committee on Quality Improvement and

Management, 2011).

The role of the parent is to execute

recommendations of the family physician and

psychologist, to monitor the effectiveness of the

administered medication, to act as an intermediary

between the school and the healthcare system, to

advocate for the child, and to be a contributing

member of the agile team.

The team in this scenario includes the family

physician Dr. Jones, the psychologist, Dr. Martin,

Mary Smith, the patient, and Mary’s mother. The

educator has been excluded for simplicity.

Due to the collaborative nature of treatment,

ADHD is used as a case study to elaborate on our

model and validate its applicability. We aim to

assess/evaluate whether or not care teams will be

more effective in coordinating care if they adopt or

generic agile process for collaborative care.

4.1 Agile Treatment Plan

The Agile Treatment Plan (ATP) is a document that

establishes the roles and responsibilities of each team

member. This helps in clarifying the importance of

the role of the patient in the process and set

expectations. For example, if the patient is not

compliant in taking the medications, then the process

is deemed a failure and will not be marked as

complete – allowing the team to try a different

approach in subsequent sprints. In addition, an ATP

would specifically outline what drug is being titrated,

as well as the expected reaction to the drug. It could

also specify a meeting plan which would be agreed

upon by all team members.

A sample Agile ADHD Treatment Plan is shown

in Figure 3. In a typical Agile Scrum sprint, the “Daily

Stand-up Meeting” takes place every day for 15

minutes; however, this is highly unfeasible.

Therefore, we adapt the process for the team to meet

on a regular basis at a mutually agreed-upon time, for

a short duration (15 min), to answer three agile-based

questions as needed:

a.What did you do previously?

b.What are you doing currently?

c.Are there any impediments in your way?

Each member of the team provides information or

other assistance to help with impediments as needed.

The team is flexibly agile and governs itself around

the treatment needs of the patient. It should be noted

Applying Agile Principles to Collaborative Healthcare Teams

509

Figure 3: Agile ADHD Treatment Plan.

that each member of the team becomes a source of

expertise in their own discipline, with a recognition

that success can only occur when all members are

fulfilling their responsibilities. The treatment plan is

updated according to feedback from the regular

meetings as necessary. Because of regular sprint-like

meetings, the team becomes agile and can be

responsive to issues that arise from drug

incompatibility for example. Iteration may occur, and

once successful, a final case conference will be held

where there will be an agreement regarding the

outcomes and next steps.

4.2 Agile Dashboard

The objective of this artifact is to provide a snapshot

status at any time before, during or after a sprint. The

elements of the dashboard are the iteration number,

the sprint number and the status of each

Intervention/Action of the current sprint. Figure 4

shows an example of the beginning and middle of a

sprint. The status of the intervention is indicated by

red=fail, yellow=jeopardy, and green=good.

The Agile Dashboard (AD) provides a

mechanism to monitor the status of all the KPIs

associated with the overall treatment plan. It provides

not only the quick operational summary of the

treatment, but it also flags the risks, and blockers so

early intervention can be put in place to mitigate

against those.

Agile Treatment Plan

Name: Mary Smith DOB: July 1, 2006 Current Date: October 11, 2019

Problem/Symptom:

Current symptoms of ADHD include periods of inattentiveness, frustration, irritability and poor self esteem. In addition, over the past few

months Mary has had difficulty coping with stressors; she has reacted to stressors with a brief increase in depressive symptoms, including

increased sleep, suicidal thoughts, and loss of interests.

Long Term Goal:

Symptoms of ADHD will be significantly reduced and will no longer interfere with Mary’s functioning at school.

Short Term Goals/Objectives:

Date Established

Projected Completion

Date

Achieved

1. Alleviate physiological symptoms of ADHD September 1, 2019 June 1, 2019

2. Help Mary be successful at school for current school year September 1, 2019 June 30, 2019

Intervention/Action:

Responsible Person

Short Term

Goals/Objectives:

Status of

Intervention

1. Determine best medication for Mary and monitor her

progress.

Dr. Jones

1. Alleviate

physiological

symptoms of ADHD

Ongoing

2. Mary will take medications on a regular basis as prescribed

and report on how she is feeling.

Mary’s Mother

1. Alleviate

physiological

symptoms of ADHD

Ongoing

3. Dr. Martin will outline and execute a plan to help Mary

success at school.

Dr. Martin

2. Help Mary be

successful at school

for current school

year

Ongoing

4. Mary will work with Dr. Martin and diligently apply the

recommendations from Dr. Martin.

Dr. Martin

2 Help Mary be

successful at school

for current school

year

Ongoing

Review Meetings:

Date: Oct. 11, 2019

Reported by: Dr. Martin

Short Term Goals/Objectives: 1

Intervention/Action: 3,4

STATUS: YELLOW

Mary has not been responding well to current therapy. As a result, I am initiating a new assessment to

determine if there are any underlying issues. At the current time, I recommend a case-conference be held

with Mary’s parents as well as her teacher and guidance councillor. I believe that an Individual Education

Plan (IEP) should be initiated in order to help Mary access the curriculum.

Date: Oct. 11, 2019

Reported by: Dr. Jones

Short Term Goals/Objectives: 2

Intervention/Action: 1,2

STATUS: YELLOW

Mary has demonstrated no change in symptoms. I am increasing titration to 15mg methylphenidate.

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Figure 4: Agile Dashboard at the Beginning (a) and Middle

(b) of a Sprint.

5 PERFORMANCE

MANAGEMENT OF

HEALTHCARE

COLLABORATIVE TEAMS

The Agile Treatment Plan and Agile Dashboard are

useful

tools

for

enabling,

standardizing

and

automating communication between the different

actors in the collaborative healthcare team.

Table 1: Healthcare Agile KPIs.

KPI Description Unit Example

WoS Workflow on

Schedule

Yes Team is meeting as agreed

No Team is not meeting as

reed u

Jeopardy There is a risk that the team

is not meeting as agreed

Unknown Schedule not updated due

to technolo

failure

Mod Modality % self Patient administering care

to self

% in

erson

Care being given by the

arent

% remote Care being monitored by

sician

SS Success

Status

Green Task complete and

successful

White Task incomplete

Yellow Task incomplete – in

ard

Red Task complete and

unsuccessful

DB Dashboard Mixed All KPIs would be shown

on the dashboard in

addition to technology

effectiveness

TEC Technolo

Success Tools workin

Fail Tools not workin

The data from these artifacts can be useful for

performance management of Healthcare

Collaborative teams. Performance management in

this context would help professionals analyse how

effective their interventions/actions are for the

individual as well as over a large swath of patients,

without actually monitoring their actual treatment.

Accordingly, performance metrics are related to team

collaboration, and not individual team member

performance. Some examples are shown in Table 1.

We specifically chose KPIs related to

collaboration, while avoiding those related to specific

areas of clinical expertise such as “appropriate

diagnosis” or “effective medication” for example.

The objective is to measure key aspects of team

performance such as whether they were meeting

regularly, how are they meeting (in person or

remotely), whether they thought they were being

successful and whether the technology they are using

is working for them. Other KPIs can include whether

the workflow is on schedule, how often the

technology breakdown and causes problems.

6 DISCUSSION AND FUTURE

WORK

In this paper, we have shown how agile methodology

can be applied to making collaborative healthcare

teams more effective. Our approach revolves around

the Agile Treatment Plan and the Agile Dashboard.

The application of agile principles results in

several improvements. For example, team members

are aware on a daily basis of patient status in terms of

what is being done (Agile Treatment Plan) and how

the patient is progressing (Agile Dashboard). Rather

than each individual team member having their own

treatment plan, and ad hoc measurements of

indicators for progress, this approach provides

conformity and continuity between modalities and

treatments. Team consensus is established at the

beginning of what the goals are and how they will be

measured (dashboard) in a formalized way.

Importantly, the process of care follows a simple

structured template rather than being ad hoc and

adverse event-driven. Another important factor is

that the composition of the team is flexible and

configurable (for example, the patient, parent or

teacher or pharmacist can be part of the team).

Different members with different roles and

knowledge can easily plugin. Finally, performance

management is now enabled and quantifiable.

Applying Agile Principles to Collaborative Healthcare Teams

511

There are several challenges to the application of

an agile methodology to healthcare processes. For

example, the ATP represents yet another form for

practitioners to be concerned with. An Agile

Dashboard will have the same issue since there are

several support tools. Hence the adoption of these

artifacts may be an issue due to cognitive overload,

management of information, hosting and other IT

issues. A further issue is on reaching agreement on

KPIs, their meaning and use.

An area of the agile methodology that would

improve collaboration is a common language and

terminology. There are several ways that this could be

achieved. Firstly, placing an emphasis on the

functionality of the patient, rather than the disease,

may be an effective way to enable common ground

through common language use. This would also shift

the emphasis from treatment to management and

creation of healthy living within the context of illness.

Secondly, in order to further create a common

understanding, we believe that an ontology for

collaborative healthcare that consists of actors, their

relationships, how communication occurs, what

information is communicated, and what is done with

this information, be developed.

7 CONCLUSION

In this paper, we have shown how agile methodology

can be applied to manage the treatment of chronic

conditions such as ADHD. Our approach anchors

around the Agile Treatment Plan and the Agile

Dashboard. We have shown how the KPIs that form

these artifacts can be used to quantify healthcare team

collaboration and performance. We also articulated

some areas of improvement that could be evident

should if an agile approach is used. Finally, we

articulated some challenges and the need for an

ontology and common communication based on

functionality, rather than ailment or disease.

In summary, the application of Agile

methodology to healthcare would require

managers/administrators to empower knowledge

workers to find solutions, rather than control the

team. It requires healthcare teams to become self-

organizing, autonomous, and have the ability to

function as a network of teams. Coordination of work

would occur in an iterative manner, free of

bureaucracy, while at the same time being structured.

Practices would be customer-focused, and mission-

critical.

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