healthcare has been described as a complex adaptive system ( cas ) that involves multiple , interdependent entities and organizational levels [ 13 ] .
such complexity poses a challenge for transformative change as relationships within a cas are nonlinear and unpredictable [ 4 , 5 ] .
this challenge is echoed by leaders in the field of quality improvement who have identified shortcomings , such as a lack of rigorous research methods , a failure to study contextual variables , and weak evaluation designs [ 68 ] .
these shortcomings are an indication that the interwoven processes of healthcare delivery are difficult for a single investigator to tease apart .
thus , a collaborative model that integrates multiple perspectives from several disciplines may help advance the field of improvement science and facilitate dissemination and implementation strategies .  
transdisciplinary collaboration is a potentially effective model as it brings together a diverse group of individuals who fully integrate theories , methodologies , and frameworks from their respective fields to work as a cohesive unit on complex issues .
this differs from multidisciplinary and interdisciplinary collaboration where multiple individuals work together but remain grounded in their respective ideologies [ 911 ] .
recently , a few studies have addressed the potential of transdisciplinary collaboration to develop effective interventions in healthcare [ 1214 ] . despite these efforts , research in healthcare improvement
has typically involved a single researcher studying an intervention at a single hospital or clinical unit .
this approach is ineffective as the complexity of organizational change and contextual influence can impact the implementation and effectiveness of an intervention [ 7 , 15 ] .  
the current consensus in the field of improvement science is that new methodologies are needed to address complex issues associated with healthcare delivery [ 6 , 16 ] .
specifically , researchers and clinicians need to adopt strategies that redefine relationships and establish new ways of communicating [ 6 , 1618 ] .
in fact , implementation science frameworks suggest that transdisciplinary interaction promotes effective and sustainable intervention programs .  
the shift from a single investigator / single site model to a transdisciplinary investigative team / multisite model calls for unique interactions between clinicians and researchers .
currently , there are few competencies and models for team performance ; especially in the context of building transdisciplinary teams for improvement .
this paper describes the adoption of a transdisciplinary model in a healthcare improvement research network and the impact of collaboration on the conduct of a national improvement study .
the results from this study show promise for enhancing research on improvement and uptake of best practices using transdisciplinary collaboration .
the guiding framework to implement and evaluate a transdisciplinary collaborative model in this project was grounded in principles from the science of team science ( scits ) .
scits is a hybrid scientific field that incorporates factors that facilitate and hinder scientific collaboration .
this field has generated the evidence to support the claim that transdisciplinary collaboration spurs innovation and accelerates scientific discovery [ 2224 ] .
additionally , scits is founded on evidence from human factors engineering and offers guidance on how investigative teams can be effective in studying healthcare improvement .  
the scits framework for this study was adapted from a previous review of factors contributing to collaborative success .
concepts were adopted by a healthcare research network based on the number of times they were referenced , how often they were used for an evaluation of collaborative work , and their relevance to long - distance collaboration .
the four concepts in the framework are as follows : ( 1 ) readiness for collaboration , ( 2 ) creating a shared mental model , ( 3 ) management and planning , and ( 4 ) virtual readiness .
these concepts are briefly described below .   in order for a collaboration to be successful ,
scientific teams need to be ready to collaborate on an individual , group , and organizational level .
this readiness comes in the form of one 's adaptability and flexibility , openness to diverse perspectives , communication skills , conflict resolution , respect for others , institutional support , and availability of reliable technology [ 27 , 28 ] .
a shared mental model is the organized knowledge that people use to interpret , explain , analyze , and predict what is happening around them .
a shared mental model helps collaborating researchers to coordinate with teammates , form accurate expectations about tasks , and understand and anticipate each other 's actions and needs .
teams make fewer mistakes than individuals , especially when each team member knows his or her responsibilities , as well as the responsibilities of other team members .
organizational researchers have observed that when team members have a shared mental model , it increases the overall team engagement and performance .  
the success of a project is dependent on the way the work is organized and carried out in a scientific team . structuring and monitoring are necessary to maintain scientific rigor and protocol fidelity especially in multisite studies . without proper management ,
the project may not meet its objectives , or results generated from a study may not be reliable due to variations in study implementation and data collection .
virtual collaboration requires a high quality , well - functioning technical infrastructure that is designed to fit the nature of the work [ 22 , 27 ] .
research suggests that user - centered technology , such as access to email , web space for sharing documents , and a centralized databases , is essential features for long distance collaboration [ 25 , 33 ] . without a stable technical infrastructure to support virtual collaboration , readiness to collaborate , shared mental models , and management planning are ineffective in multisite , transdisciplinary teams .
the main research questions for this study were ( 1 ) does an scits framework facilitate transdisciplinary collaboration in a healthcare improvement research network ? and
( 2 ) what impact does a transdisciplinary model have on the conduct of a national , multisite improvement study ?
this project was approved by the university of texas health science center san antonio ( uthscsa ) institutional review board ( irb ) .
the objectives of this project focused on transdisciplinary collaboration within a multisite study conducted by the improvement science research network ( isrn ) .
the isrn is a national hospital - based research network comprised of approximately 200 partners from academic and practice settings across the nation that have an interest in studying quality improvement .
demographic information for the isrn membership at the time of this study is presented in table 1 . the majority of the membership consisted of nurses working in various fields in acute care settings or at academic institutions .
doctorate prepared members represented a variety of fields including nursing research , health services research , public health , translational science , quality improvement , and implementation science .   from the isrn membership ,
each network study is supported by a research infrastructure modeled after practice - based research networks ( pbrns ) and multisite clinical trials .
the research infrastructure supports a virtual collaboratory , or center without walls , that allows a team of scientists to work on common problems regardless of location [ 25 , 34 ] .
the cornerstone of this infrastructure is a set of national research priorities that serve as a common rallying point to attract diverse perspectives and integrate paradigms from multiple disciplines in order to study improvement .
these priorities were developed through a national stakeholder survey and include transitions of care , high - performing clinical systems and microsystems approaches to improvement , evidence - based quality improvement and best practice , and learning organizations and culture of quality and safety .  
isrn studies are supported through a cyber infrastructure equipped with appropriate communications technology ( virtual meeting platforms and teleconference lines ) , a dedicated web space for sharing information and a central database for data entry .
this technology platform is backed with sufficient bandwidth , electronic networking capabilities , and technical support .
adequate capacity for data security , integrity , privacy , rapid retrieval , and long - term archiving are also integrated into the isrn infrastructure to support data entry and storage .   for this study ,
the average hospital size was 425 beds ( range : 120665 ) with an average daily census of 74.7% ( range : 60%100% ) .
each site had at least one principal investigator ( pi ) and one research coordinator .
both pis and research coordinators had nursing backgrounds with educational experiences that ranged from bachelor 's to doctorate levels .
although the collaborative team also consisted of two study pis ( a doctorate - prepared nurse and a physician , both with extensive research backgrounds ) and two research scientists ( both phd prepared with backgrounds in psychology and physiology ) , they were not included in the data collection due to their proximity to the evaluation and interpretation of results .
scits principles were used to develop the key isrn resources to facilitate the conduct of network studies .
these resources included training meetings to build readiness and a shared mental model , a protocol implementation kit to facilitate study management , and a robust technical infrastructure to support long distance collaboration .
sites on the investigative team were required to complete capacity building exercises , including a training session on participating in a research collaborative .
this 2-hour training session consisted of an overview of the isrn mission and research priorities , a review of the study objectives , an introduction to the protocol , an explanation of data entry procedures , and a presentation of how to work as a collaborative team .
sites were also asked to review recorded isrn presentations from experts in the fields of team science and virtual collaboration .
concepts from these presentations were discussed during study meetings . finally , sites were given a resource guidebook on building successful research collaboration .
this guidebook synthesized essential qualities for succeeding in research collaboratives for healthcare improvement .   to facilitate the study implementation and ensure the protocol fidelity , sites were given a protocol implementation kit ( pik ) .
the pik was designed with two goals in mind : ( 1 ) systematic implementation of the study protocol across multiple sites to yield analyzable / reliable data and valid study outcomes ; ( 2 ) guidance for site pis to facilitate the conduct of the study .
the pik provided a structured overview of various topics related to the study including : forming the project team , preparing for irb submission , establishing project timelines , identifying participating staff members , using data collection materials , submitting data to the isrn , and understanding results from the study .   
finally , sites were given access to a variety of technical resources , including a shared web space , access to conference lines , and a centralized database .
; santa barbara , ca ) and a teleconferencing line were used for real - time meetings and presentations .
lastly , a centralized database was created and maintained by the uthscsa department of epidemiology and biostatistics using the informatics data exchange and acquisition system ( ideas ) , a robust web - based human studies research informatics data management framework .  
variables that best represented measures of collaboration readiness , study management , and the presence of a strong mental model were selected for analysis .
these variables included ( 1 ) the number of protocol deviations ( study management ) , ( 2 ) meeting attendance percentage ( shared mental model ) , ( 3 ) number of study timeline adjustments ( readiness ) , and ( 4 ) number of questions received from pis and coordinators regarding study objectives ( study management , shared mental model , and readiness ) which were all collected from regulatory documents ( e.g. , protocol deviation logs ) , study meeting notes , and email communication .  
additionally , site pis ( n = 16 ) and research coordinators ( n = 14 ) were surveyed on isrn coordinating center services and resources .
the survey was designed in survey monkey ( surveymonkey.com , llc ; palo alto , ca ) , and a link to access the survey was emailed to site pis and research coordinators .
respondents were asked to rate the importance and quality of isrn features and services on 6-point likert scale .
the number of protocol deviations , number of email correspondence , number of timeline adjustments , and meeting attendance percentage is broken down by site in table 2 . on average , collaborating sites reported six protocol deviations .
examples of deviations reported were study instruments turned in after data collection period ended and data collected from unconsented participants .
a review of the study notes revealed that a total of ten sites ( 70% ) successfully adhered to study timelines .
study timeline delays were due to late irb approvals , accreditation visits , or a change in health information technology systems .
the average number of email correspondences per site was 55 emails ( range : 20101 emails ) .
the majority of questions from site pis and coordinators pertained to the conduct of the study , including irb regulations , participant recruitment , data collection , and data entry .
few questions ( < 1% ) were directed towards the study 's goals or the function of the collaboration .
finally , the attendance on conference calls averaged 94% with sites being absent due to scheduling conflicts or unexpected emergencies .  
a survey on the quality and importance of isrn coordinating center services and resources was sent to a total 30 site pis and coordinators .
each respondent had previous experience participating in studies as a part of a formal investigative team ( mean : 6 studies per respondent , range : 120 studies ) . on average , half of these studies involved professions other than nursing ( mean : 3 studies per respondent , range : 015 studies ) .
results from survey items specific to providing a collaborative environment are presented in table 4 .
most services and resources were positively rated in terms of quality , but those related to organizational structure , study objectives , and communication were rated highest by respondents ( > 90% ) .
the present study described the adoption of a transdisciplinary collaborative model in a multisite improvement study .
resources developed using best practices from scits facilitated the study 's conduct as evident by consistent protocol implementation , active engagement , and focused task completion .
the impact on productivity could have implications on identifying effective improvement strategies that lead to rapid uptake and spread .
improvement scientists and clinicians in the field need to engage in systems change to support team science and adopt resources , such as research collaborative guidebooks and training modules on scits principles , to build capacity for transdisciplinary collaboration . in the context of collaboration readiness ,
individuals who demonstrate high levels of readiness are less likely to make mistakes , communicate effectively , and complete objectives in a timely manner .
this level of readiness can create a fertile environment for multiple disciplines to come together , blend knowledge , and create a new intellectual space . both researchers and clinicians
the importance of this concept is further validated by the development of standardized evaluations that directly assess readiness in scientific teams , including the national cancer institute 's transdisciplinary research on energetics and cancer ( trec ) survey and the collaboration success wizard [ 29 , 37 ] .
currently resources do exist such as national research priorities in improvement science , frameworks for implementation science , and national methodology conferences [ 6 , 15 , 3841 ] ; yet , more is needed to help build transdisciplinary scientific teams for research .
for example , experts have called for the establishment of professional organization for improvement and implementation science .
attention has also been called to taxonomy development for an overarching language in hybrid fields . in the present study ,
the isrn research priorities and mission were intended to help create a shared mental model that kept research partners engaged in conducting the study . without a mental model ,
the observed level of engagement would have decreased and impacted the quality of study outcomes .
the present study also demonstrated the effectiveness of the isrn research infrastructure , in particular , the management of a multisite study with standardized approaches .
a protocol implementation kit was shown to be an effective tool for ensuring protocol fidelity .
the use of such a tool helps meet a need in the field for rigorous research and standardized implementation methods [ 6 , 16 , 39 ] .
a failure to ensure consistent implementation and protocol fidelity can decrease the reliability of research findings and thus impact translation into multiple clinical settings .   the move from research to clinical practice requires scaling - up quality improvement initiatives to large - scale network studies .
doing so may yield more effective improvement and implementation strategies , improve dissemination of knowledge , and ultimately change policy .
an example of transdisciplinary collaboration is in the numbers associated with the isrn study evaluated for this paper .
the dataset consisted of 24,014 data points reported by 716 acute care medical - surgical nurses across 14 hospitals .
a team - based approach enabled this particular study to capture a representative national sample to enhance the quality of research and raise scientific rigor .
this is an indication of a need for established evaluation tools for transdisciplinary collaboration in improvement and implementation research .
in fact , there is a nonhealthcare specific tool that is designed to identify potential barriers to collaboration and provide recommendations for improvement .
the collaboration success wizard ( csw ) was developed to evaluate virtual collaborations based on 15 years of evidence that has identified factors that predict collaborative success .
an external evaluation of the same isrn study described in the present paper revealed that the project was well positioned for successful collaboration using the csw .  
the present study was also limited in its ability to measure the impact of transdisciplinary collaboration on dissemination and implementation .
thus , more research and funding are needed to demonstrate the impact of transdisciplinary research on spread and uptake of evidence - based quality improvement uptake . given the magnitude of data collected from improvement studies using this approach , it can be inferred that rigors methods and generalizable results may speed uptake and spread ; however , data are still needed to justify this claim .
this project demonstrated the effectiveness of a transdisciplinary model for academic and clinical scientists that are interested in studying improvement .
indications are that national improvement studies are positively assisted by the guidance gleaned from scits .
further research is needed on the causal relationship between team - based research and dissemination and implementation of evidence - based quality improvement . with advances in team research and increased funding opportunities to investigate dissemination , implementation , and improvement strategies in healthcare , the gap between what works and what is actually practiced will narrow to raise the quality of care delivery .
 healthcare is a complex adaptive system , and efforts to improve through the implementation of best practice are well served by various interacting disciplines within the system . 
 as a transdisciplinary model is new to clinicians , an infrastructure that creates academic - practice partnerships and builds capacity for scientific collaboration is necessary to test , spread , and implement improvement strategies . 
 this paper describes the adoption of best practices from the science of team science in a healthcare improvement research network and the impact on conducting a large - scale network study . 
 key components of the research network infrastructure were mapped to a team science framework and evaluated in terms of their effectiveness and impact on a national study of nursing operations . 
 results from this study revealed an effective integration of the team science principles which facilitated the rapid collection of a large dataset . 
 implications of this study support a collaborative model for improvement research and stress a need for future research and funding to further evaluate the impact on dissemination and implementation . 