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303 OctoberYDecember & 2017

Health care multidisciplinary teams: The
sociotechnical approach for an integrated
system-wide perspective

Marta Marsilio

Aleksandra Torbica

Stefano Villa

Background: The current literature on the enabling conditions of multidisciplinary teams focuses on the singular
dimensions of the organizations (i.e., human resources, clinical pathways, objects) without shedding light on to the
way in which these organizational factors interact and mutually influence one another.
Purpose: Drawing on a system perspective of organizations, the authors analyze the organizational patterns that promote
and support multidisciplinary teams and how they interrelate and interact to enforce the organization work system.
Methodology/Approach: The authors develop a modified sociotechnical system (STS) model to understand how the
two dimensions of technical (devices/tools, layout/organization of space, core process standardization) and social
(organizational structure, management of human resources and operations) can facilitate the implementation of
multidisciplinary teams in health care. The study conducts an empirical analysis based on a sample of hospital adopters
of transcatheter aortic valve implantation using the revised STS model.
Findings: The modified STS model applied to the case studies improves our understanding of the critical
implementation factors of a multidisciplinary approach and the importance of coordinating radical changes in the
technical and the social subsystems of health care organizations. The analysis informs that the multidisciplinary effort is
not a sequential process and that the interplay between the two subsystems needs to be managed efficaciously as an
integrated organizational whole to deliver the goals set.
Practice Implications: Hospital managers must place equal focus on the closely interrelated technical and social
dimensions by investing in (a) shared layouts and spaces that cross the boundaries of the specialized health care units,
(b) standardization of the core processes through the implementation of local clinical pathways, (c) structured
knowledge management mechanisms, (d) the creation of clinical directorates, and (e) the design of a planning
and budgeting system that integrates the multidisciplinary concept.

Key words: health care delivery processes, multidisciplinary teams, sociotechnical system, system-wide approach, technological innovation

Marta Marsilio, PhD, is Assistant Professor, University of Milan, Italy, and Centre for Research in Health and Social Care Management
(CERGAS), Bocconi University, Milan, Italy.
Aleksandra Torbica, PhD, is Assistant Professor, Centre for Research in Health and Social Care Management (CERGAS), Department of Policy
Analysis and Public Management, Bocconi University, Milan, Italy. E-mail: [email protected].
Stefano Villa, PhD, is Associate Professor, Department of Management, Catholic University, Rome, Italy, and Coordinator of field research projects at
CERISMAS (Research Centre in Health Care Management), Catholic University of Milano, Italy.
This material is based on research supported by the European Health Technology Institute for Socio Economic Research (EHTI) through an unrestricted
grant awarded to the Centre for Research in Health and Social Care Management (CERGAS). During the project execution, all authors were affiliated with
CERGAS, Bocconi University
The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article.

DOI: 10.1097/HMR.0000000000000115

Health Care Manage Rev, 2017, 42(4), 303Y314
Copyright B 2017 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.

mailto:[email protected]

304 Health Care Management Review OctoberYDecember & 2017

M
ultidisciplinary team-working is a complex pro-
cess that brings together a group of diverse health
care professionals to work and share their ex-

pertise, knowledge, and skills in to deliver patient
services (Mitchell, Parker, Giles, & Boyle, 2014; Nancarrow
et al., 2013). Evidence shows that multidisciplinary teams
play a significant role in generating a wide range of benefits,
such as increased learning and development of people and
institutions, better resource utilization, minimization of un-
necessary costs, improvements in job performance and work
quality, and more efficacious outcomes for patients and their
families (Andreatta, 2010; Atwal & Caldwell, 2005). Con-
sequently, well-coordinated collaboration within and across
the medical professions is likely to be an increasingly im-
portant part of meeting contemporary health care challenges
(Andreatta, 2010; McIntosh et al., 2014). Moreover, health
care teams showed to be more complex than nonmedical
teams, requiring more sophisticated knowledge of team dy-
namics and processes (Andreatta, 2010). This creates the
need to devise managerial strategies that promote an inter-
dependent collaborative approach among the professionals
in the health care environment to maximize the benefits of
multidisciplinary teams (Huckman & Pisano, 2006; Wholey
et al., 2013).

The vast body of literature on the key enabling con-
ditions of multidisciplinary team-working in the health
care sector can be grouped into three main streams. The
first focuses on human resource management, exploring the
impact of organizational differences on the team learning
rate (Edmondson, 2003; Pisano, Bohmer, & Edmondson,
2001) and demonstrating how an interdependent team
leadership and an empowered team development, mini-
mizing the impact of professional identity, can successfully
frame the team learning process (Edmondson, 2003;
Mitchell et al., 2014; Wholey et al., 2013). Other scholars
found that relational coordination among cross-functional
care provider groups, through relationships of shared goals,
shared knowledge, and mutual respect, improved service
performance (Gittell et al., 2000). The second stream
identifies the powerful enabling tool of clinical pathways,
which incorporate the implementation of guidelines and
protocols into the core tasks and work processes of the
professions in to coordinate and promote a multi-
disciplinary approach in health care settings (Allen, 2009;
Bragato & Jacobs, 2003), also in the event of increased
uncertainty (Gittell, 2002). Finally, the third stream recog-
nizes the role of objects and the organization of space where
clinical procedure takes place (Barrett, Oborn, Orlikowski,
& Yates, 2012; Nicolini, Mengis, & Swan, 2012) as key
drivers in motivating and shaping cross-disciplinary collab-
oration and allowing participants to work across different
types of boundaries.

Although the current literature offers many suggestions
and implications, its main focus is on the singular dimensions

of the organization and not on how these influence each
other or how change management strategies need to be
designed using an integrated organizational lens. To narrow
this knowledge gap, the authors adopt a system perspective
of organization to develop a modified sociotechnical system
(STS) model and test it through the empirical analysis of
multidisciplinary teams in health care settings. A descrip-
tion of this conceptual framework is given in the following
section. The article then presents a multiple-case study
analysis to identify (a) which of the model_s social and
technical system patterns can better promote and support
multidisciplinary teams and (b) how the social and tech-
nical systems interrelate and interact to implement the
organization work system. The final sections discuss the
findings of the analysis, informs practicing health care
administrators and hospital managers about how to oper-
ationally apply the modified STS model, strengthens the
extant knowledge base of the multidisciplinary approach,
and points the way forward for future research.

Conceptual Framework

Several organization theory scholars have investigated
the role of the system perspective (Boulding, 1956; Von
Bertalanffy, 1969) defined as the analysis and design of
change processes that see the organization as a highly inte-
grated system. Indeed, focusing exclusively on the single
organizational subcomponents ignores the interaction be-
tween the diverse organizational dimensions and can be
misleading, even counterproductive. The evidence provided
by the health care management scholars shows that the
adoption of a system-wide perspective is critical to under-
standing change and process innovation, be it the intro-
duction of a new technology (Fitzgerald, Ferlie, Wood, &
Hawkins, 2002; Sugarhood, Wherton, Procter, Hinder, &
Greenhalgh, 2014) or the adoption of an innovative orga-
nizational model, for example, the lean approach (Mazzocato,
Savage, Brommels, Aronsson, & Thor, 2010).

The Sociotechnical System

The STS paradigm developed almost 60 years ago
(Pasmore, Francis, Haldeman, & Shani, 1982; Shani,
Grant, & Krishnan, 1992; Trist & Bamforth, 1951) has
proved to be a particularly useful framework for assessing
the system-wide implications of change and process in-
novation. The model considers each organization as a
social subsystem of people and a technical subsystem of
production process elements. The original technical sub-
system model comprises the structures, tools, and knowl-
edge needed to perform the work that produces products,
whereas the social system brings into play the atti-
tudes, beliefs, and relationships between individuals and
among groups.

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.

305 Multidisciplinary Teams and Modified STS

Regardless of type, each organization must align and
ensure the compatibility of these two subsystems in to
produce a product or a service of value to the environmen-
tal subsystem (customers included) that also achieves
market success. In other words, the concept underpinning
the STS approach is the joint optimization of the technical
and social subsystems that form the entire work system.
There are two reasons that make the STS model partic-
ularly appropriate to analyze the organizational enabling
conditions of health care multidisciplinary teams: (a) the
fact that the integration of people and technology is a key
driver of innovation and (b) the emphasis placed by the
system-wide approach to process redesign on the impor-
tance of the human aspects. Health care organizations can
be conceptualized as work systems in which people perform
multiple tasks using various tools and technologies in a
physical environment and under specific organizational
conditions; those system interactions influence care pro-
cesses and patient outcomes.

In devising the theoretical framework for this study, the
authors modified the social and technical subsystems of the
original STS model to factor in (a) the fundamental as-
pects that play a vital role in multidisciplinary team-working
(i.e., human resources, clinical pathways, and objects) high-
lighted by the scientific literature discussed above and (b)
the specific traits of the health care production processes
when applying general organizational theoretical frame-
works to the health care sector (Ackroyd, Hughes, &
Soothill, 1989; Lega, Marsilio, & Villa, 2013). These specific
traits include the long and diversified value chain of distinct
organizational settings and environments, the presence of
various stakeholders and subsystems with goals and expec-
tations not always aligned, the adaptation of people and
systems to local contingencies, the natural variability linked
to the unpredictability of the demand and to the extremely
high pace of product and process innovation, the relevant
role of clinicians who tend to focus on maintaining the status
quo and defending their professional autonomy as defined by
the professional community, and the key role of knowledge
creation and diffusion.

In the modified STS model, three key factors character-
ize the technical subsystem (Figure 1). Health care organiza-
tions adopt various types of devices/tools and technologies,
such as medical devices and health IT, to improve care

quality or safety or to reduce costs. The presence of different
stakeholders with different expectations is a key factor
when evaluating the introduction of a new technology:
for example, suppliers and patients usually push for a
fast introduction, managers and institutions are concerned
about the overall economic sustainability, whereas the
scientific community questions the appropriateness and
the actual clinical improvement in comparison to the
status quo. Second dimension regards layout/organization
of space where the services are being delivered. Health care
production processes are carried out in different spaces
within and outside the hospital (e.g., operating rooms
[ORs], hospital wards, outpatient clinics, rehabilitation
centers). The higher number of processes of care that cut
across different organizational settings (e.g., elderly and
chronic patients care programs) spawn a series of in-
terrelations and interdependencies between layouts that
must necessarily be governed and given direction. Finally,
core process standardization represents an important dimen-
sion of the technical subsystem. Core processes in health
care delivery organizations consist of all diagnosis, treat-
ment, and assistance activities done to patients. Evidence-
based clinical guidelines inform health care professionals
about caring for people with specific conditions. Defined as
one of the most appropriate and effective ways to treat
homogenous subgroups of patients, the accepted practice of
clinical pathways translates the clinical guidelines into
appropriate and effective organization core processes at the
local level. It is extremely important to factor in local
contingencies when implementing clinical pathways by
holding in-depth discussions about the specific professional
roles, the tasks involved, the decisions to be made, and the
settings of each phase. Furthermore, a distinction must
be made between natural variability (linked to the speci-
ficities of health care production processes) and artificial
variability (usually caused by bad management and process
malfunctions).

The social subsystem has three core dimensions as well
(Figure 1). Organizational structure refers to the Bhard[
drivers of people management (Gareth, 2012), such as the
formal assignment of roles and functions, the division
of work between different units, and all the mechanisms
that make the organization work, such as planning, bud-
get and control systems, and reward systems. The design of

Figure 1

A system-wide framework for investigating multidisciplinary approach in health care organizations

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306 Health Care Management Review OctoberYDecember & 2017

organizational structure in the health care sector is often
complicated by the fact that the clinical professionals say
that their job is to exclusively manage the patients and not
deal with organizational performance, making them averse
to organizational regulatory compliance. On the other side,
human resource management includes the Bsoft[ drivers such
as the mechanisms and processes by which the organization
generates and spreads knowledge to develop specific skills
and competencies (e.g., leadership, teamwork, training;
Gareth, 2012). The fast-paced changes in modern medi-
cine and ongoing technological innovation assign a lead
role to knowledge creation and diffusion in health care
organizations. Finally, the operations management defined as
the enabling mechanisms that support production processes.
More specifically, operations management applied to
health care means managing and optimizing the flow of
goods and patients across the different hospital production
units through scheduling and capacity planning, process
design and execution, and information systems (Vissers &
Beech, 2005).

The aim of the study is to investigate the robustness of
the modified STS model and to identify which social and
technical system patterns/tenets can better promote and
support multidisciplinary teams in health care settings. The
analysis also explores the interrelational dynamics to un-
derstand how the two subsystems interact to enforce the
organization work system.

Methods

Research Design

To empirically investigate these propositions, the case
study method has been adopted as deemed the most appro-
priate by the scholars to conduct an in-depth investigation
of a contemporary phenomenon within its real-life context
(Yin, 2014). Along with the other drivers of the multi-
disciplinary approach, the study examines the adoption of
innovative medical technology as a typical primary engine
of health care multidisciplinary team-working. The intro-
duction of new technologies has a significant impact on
health care organization work processes (Edmondson,
Bohmer, & Pisano, 2001), disrupting the existing bound-
aries and routines that distinguish the several professional
domains challenging organizational relationships and
demanding new and alternative ways of interaction (Korica
& Molloy, 2010). Several authors (Attewell, 1992; Orlikowski,
2000), beginning with Barley_s (1986) pioneer work, un-
derscore how a multidisciplinary approach to team-working
can determine the implementation benefits of new tech-
nology. The transcatheter aortic valve implantation (TAVI)
technology and procedure were identified by a focus group
of 12 health care experts (industry representatives, poli-
cymakers, and scholars) as a typical case (Yin, 2014) of

innovative medical technology that challenges routines
and demands the efficacious implementation of a multi-
disciplinary team in clinical practice. TAVI is a highly
technological, complex, and intensive procedure devel-
oped as a less invasive procedural alternative to surgical
valve replacement for aortic stenosis in elderly or high-risk
patients who are not suitable candidates for conventional
open-heart surgery treatment (Feldman & DiSesa, 2014).
TAVI implementation requires the hospital to create a well-
organized multidisciplinary team, as set out in the most
recent clinical guidelines issued by the relevant professional
societies (Vahanian & Alfieri, 2013). Ideally, the multi-
disciplinary teams has broad expertise in structural and
valvular heart disease, cardiovascular imaging, and post-
procedure care and is composed of cardiac surgeons, cardi-
ologists, radiologists, anesthesiologists, and trained nurses.
The experts also recommend performing the procedure in a
Bhybrid[ OR installed with the equipment and staffed
required for both image-guided catheter-based intervention
and open-heart surgery (Vahanian & Alfieri, 2013). TAVI
technology is an Binterventionist[ procedure, situated
midway between the two specializations of cardiology and
cardiac surgery, that is, it straddles the boundary but belongs
to neither one nor the other. Traditionally, patients with
heart valve problems are treated by cardiac surgeons, but
the fact that TAVI is a catheter-based technology means
that the skills of a cardiologist-interventionist are also
needed. Moving the patients from the surgeon to the
cardiologist in such a high-volume procedure poses at least
two challenges: the technological and procedure-learning
challenge for the cardiologists and the cardiac surgeons, and
the organizational challenge whereby diverse profession-
als (cardiologists, cardio surgeons, anesthesiologists, and
nurses) must learn and work together as a multidisciplin-
ary team.

Data Collection and Analysis

The data were collected in 2012 from the Italian National
Health Service (INHS) hospital-adopters of TAVI, that is,
those using the TAVI procedure since it was introduced in
Italy in 2007. In 2011, Italy performed 14.9% of total
European implants, ranking second by TAVI take-up rate.
In 2012, when the data were sourced, 80 hospitals across
Italy had already completed a total of 1,855 TAVI pro-
cedures. The number of procedures varied significantly
from hospital to hospital: More than 50 hospitals (62.5%)
recorded less than 20 TAVI procedures, whereas 11 hospitals
(13.5%) completed over 45 procedures. The results of a
new technology or procedure have been widely shown
to improve in step with the learning curve experience
(Edmondson, Winslow, Bohmer, & Pisano, 2003) The
international guidelines that specifically address TAVI
suggest that, for a single hospital to achieve the optimal
results, it needs to treat at least 40Y50 cases per year. In

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307 Multidisciplinary Teams and Modified STS

to minimize any variations in technical competence
driven by the volume of use, the authors focused exclusively
on the 11 Bstrong adopters[ of TAVI, starting with those
hospitals that performed the most procedures. Consistent
with replication logic (Yin, 2014), the analysis was halted
at the theoretical saturation point with reasonable in-depth
knowledge of the variance in technical and social dimen-
sions previously identified in the model (Guest, Bunce, &
Johnson, 2006). This selection process resulted in using the
top four hospitals of the 11 short-listed health care facilities
as case studies (Table 1).

The case study methodology relies on multiple sources of
evidence with data that must converge and benefits from
the prior development of theoretical propositions to guide
the data collection and analysis (Yin, 2014). In to
understand the TAVI technology and procedure, the au-
thors interviewed the industry representatives of the two
medical device companies operating in the Italian market
in 2012. A structured interview protocol of 38 open-ended
questions split into sections according to the modified STS
domains was then designed to obtain the relevant infor-
mation from each health professional involved in the pro-
cedure; the questionnaire was subsequently tested in a pilot
study with four professionals. A total of 27 interviews were
held over a 6-month period with different staff at each
hospital whose roles assigned them responsibility for key
aspects of the TAVI procedure (Table 1). Two members of
the research team were present at each interview: one of
the three authors accompanied by their research assistant.
Questions on factual issues aimed to get the multiple re-
spondents at each site to give their diverse perspectives of
the individual roles; the responses were then cross-checked
to optimize data validity. The interviews were tape-recorded
and transcribed verbatim (9400 pages of written mate-
rial). A direct content analysis approach was used to ana-
lyze and codify the transcribed text (Hsieh & Shannon,

2005). The content analysis followed different steps. First,
using the modified STS categories, the researchers iden-
tified key concepts or variables as initial coding categories.
The three authors then independently reviewed the
material and highlighted all text that initially appeared to
refer to a key social or technical element. The next step
entailed coding all the highlighted passages according to
the predetermined categories. Text that eluded this coding
scheme was given a new code. The researchers compared
notes and reconciled any deviations from their initial
coding and then used the consolidated checklist to in-
dependently code all the text and reach an acceptable
level of reliability of the coding. The coded data set enabled
the comparison of specific features across the four hospitals
to facilitate cross-case analysis.

Findings

The modified STS model developed and applied by the
authors to the case study analysis produced the following
findings, also summarized in Table 2 (technical subsystem)
and Table 3 (social subsystem).

Technical Subsystem

Devices and tools. The TAVI procedure replaces the dis-
eased aortic valve by inserting a technologically inno-
vative valve into the heart via catheter. This minimally
invasive development has radically changed the man-
agement of aortic valve heart disease. The complex TAVI
procedure involves many interlocking steps organized by
each hospital in three main phases: (a) diagnostic testing
and evaluation of the patient_s risk profile and eligibility
for TAVI, (b) TAVI insertion, and (c) postsurgical re-
covery of patients in the intensive care unit (ICU) and
regular floors. In the first phase, the patient undergoes

Table 1

Sample characteristics

Hospital 1 Hospital 2 Hospital 3 Hospital 4

Ownership Private Public Private Public
Size (no. of beds) 1,373 1,285 136 1,230
Annual volume. of TAVI 142 47 49 54
procedures (2011)

Members of TAVI Heart Team 12 10 10 10
No. of individuals interviewed 8 6 6 7
Positions of individuals interviewed 2 cardiologists 3 cardiologists 3 cardiologists 1 cardiologist

2 cardiac surgeons 2 cardiac surgeons 1 cardiac surgeon 1 cardiac surgeon
1 technician 1 nurse 1 nurse 2 nurses
2 nurses 1 technician 1 anesthesiologist
1 nurse manager 1 technician

1 radiologist

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308 Health Care Management Review OctoberYDecember & 2017

Table 2

Main dimensions of the technical system: Findings from the case studies

Dimensions Hospital 1 Hospital 2 Hospital 3 Hospital 4

DEVICE AND TOOLS
Insertion procedure TR SG TR SG TR SG TR SG
(% of cases
over total)

70% 30% 75% 25% 80% 20% 80% 20%

LAYOUT AND SPACE
a) Pretreatment Dedicated TAVI hemodynamic Specific slot for TAVI Specific slot for TAVI patient Specific slot for TAVI patient

diagnostic phase outpatient rooms patient in the aortic in the hemodynamic in the hemodynamic
stenosis outpatient room outpatient rooms outpatient rooms

b) Insertion Hemodynamic Cardiac Hybrid room Hemodynamic Cath Lab Hemodynamic Cath Lab
procedure phase Cath Lab Surgery OR

c) Postsurgical TAVI beds in ICU and in ICU and ICU and ICU and Cardiology ICU and ICU and
recovery Cardiac Surgery ward Cardiology Cardiac ward beds Cardiology Cardiac

ward beds Surgery ward beds Surgery
ward beds ward beds

PROCESS STANDARDIZATION
TAVI clinical Full definition and Definition and No formalization Full definition and

pathway implementation implementation only implementation
for the insertion
procedure phase

Note. TR = transfemoral procedure; SG = surgical operation; OR = operating room; ICU = intensive care unit.

intensive medical examinations and tests (e.g., ulcer, cho-
rography, orthography), and the health care unit allocates
the specific resources (e.g., radiology, special software on
the CT scan). Patient assessment is crucial to deciding
whether the patient is eligible for TAVI and what the
best access route to the aortic valve (i.e., second phase) is,
or whether the mainstream procedure is more appro-
priate. TAVI may be inserted in the heart in different
ways, and the choice of the route has important con-
sequences on the composition of the operating team.
According to the TAVI_s most recent clinical guidelines,
access to the aortic valve may be transluminal through a
large artery (typically the femoral or subclavian artery; a
percutaneous or endovascular approach) or surgical via a
minithoracotomy with an apical puncture of the left
ventricle (transapical approach). Most TAVI hospital
patients (70% in Hospital 1 to 80% in Hospitals 3 and 4)
were treated with transluminal access through the femoral
artery, which the practitioners refer to as the transfemoral
approach.

Layout and organization of space. Each phase took
place in the different spaces assigned to the specific clinical
processes, which in hospital practice are organized and
managed as diverse units. Each hospital carries out the
pretreatment diagnostic phase in the spaces of the hemo-
dynamic unit. Some hospitals elected specialized TAVI
areas to meet the procedure_s specific needs and demands.
Hospital 1 assigned one of its four hemodynamic outpatient
rooms exclusively to TAVI screening activities. Hospital
2 set up an outpatient room for the treatment of aortic

stenosis with a specific slot for TAVI patients. Hospitals
3 and 4 did not arrange specific facilities but assigned
three afternoons per week for TAVI diagnosis and screen-
ing in the regular hemodynamic outpatient units. The
TAVI-eligible patients then proceed to the next two phases
according to the type of TAVI access treatment recom-
mended. A Bhybrid[ OR furnished with the relative equip-
ment and the medical staff qualified to conduct both image-
guided catheter-based interventions and open-heart surgery
is the preferred TAVI procedure setting indicated by the
clinical standards (Vahanian & Alfieri, 2013). Of the
three hospitals to assign a specific setting for the TAVI
procedure, only Hospital 2 has a hybrid room. Hospital 1
divided its setting rooms according to the access route,
using the hemodynamic Cath Lab for the transfemoral
procedures and the cardiac OR for the surgical approach.
Hospitals 3 and 4 assigned all TAVI procedures to the
hemodynamic Cath Lab.

The decision of these two hospitals to use the hemo-
dynamic Cath Lab for all TAVI procedures led the pro-
fessionals involved to take conflicting positions. For
example, a radiologist from Hospital 4 told us that the
Cath Lab is …