Cleft Lip & Palate: From Origin to Treatment, 1st Edition

24. Developing a Cleft Palate or Craniofacial Team

Ronald P. Strauss

Cleft palate and other craniofacial conditions are widely cared for in the context of a multi-specialty healthcare team (Strauss, 1999). Various types of healthcare team organization exist, and effective team-based healthcare delivery has the ability to address the fragmentation and dehumanization that can result when a spectrum of specialists and disciplines are needed to provide assessment and technical care. The organization and delivery of cleft palate and craniofacial health services vary according to national and health system characteristics. Economic development and sociopolitical structures define the resources and health delivery system within which craniofacial care is rendered. In developed nations, organized healthcare teams largely deliver craniofacial care, although individual specialists outside of the team context render some care. In some nations, regional or national centers of clinical care have been organized to aggregate clinical service delivery and facilitate regionalization. In recent years, efforts such as the “Eurocleft” study have resulted in more regionalized care delivery. In many nations, such as the United States, a competitive market system exists that allows as many teams to develop as the market for services will bear. Reimbursement mechanisms, cultural factors, and health system characteristics define the craniofacial health delivery system.

Healthcare Teams

Research has examined the roles (Horwitz, 1970; Furnham et al., 1981; Logan and McKendry, 1982; Nason, 1983; Temkin-Greener, 1983; Ovretveit, 1996; Jones, 1992) and ideology (Nagi, 1975; Brill, 1976; Dingwall, 1980; Kane, 1980; Payne, 1982; Feinstein, 1983; Margolis and Fiorelli, 1984) of the interdisciplinary healthcare team as well as the settings for interdisciplinary team practice (Briggs, 1980; Campbell and Whitenack, 1983; De Santis, 1983). The cleft palate or craniofacial team has been studied as an organization (Koepp-Baker, 1979; Day, 1981; MacGregor, 1982; Strauss and Broder, 1985, 1990; Nackashi and Dixon-Wood, 1989; Ellis, 1993) with specific focus on issues related to team communication (Lillywhite, 1957) and function (Mason and Riski, 1982; Noar, 1992). In particular, the mental health and support functions of the interdisciplinary healthcare team have been examined (Lonsdale et al., 1980; Webb and Hobdell, 1980; Cluff and Cluff, 1983; DeSpirito and Grebler, 1983; McKeganey and Bloor, 1987; Strauss and Ellis, 1996; Strauss, 1997).

Cleft palate and craniofacial care has been described as optimally delivered by organized teams (Strauss and Ellis, 1996). The benefits of healthcare teams include the ability to coordinate complex services, meet the psychological and social needs of families, and provide multifaceted evaluations (Koepp-Baker, 1979; Morris et al., 1978; Nackashi and Dixon-Wood, 1989; Pannbacker et al., 1992; Strauss, 1997). Typically, cleft or craniofacial teams include medical, surgical, speech, psychosocial, and dental professionals; but large sample profiles of these organizations did not appear in the literature until recently (Strauss and The ACPA Team Standards Committee, 1998).

The literature on healthcare teams suggests that there is little agreement on what comprises a healthcare team, how it is organized, and what its goals and objectives should be. However, the need for integrating various specialized disciplinary perspectives in the care of persons with complex health issues results in increasing numbers of clinical settings in which teamwork is employed. Attention has been paid to team decisionmaking, the authority structure of teams (Nagi, 1975), and team cost effectiveness in terms of personnel and other resources (Strauss and Broder, 1985). Research on the attitudes and perspectives of team professionals (Noar, 1992) suggests that most teams function by agreement or consensus, even though each profession may view the needs of patients differently. Healthcare teams form when a sizable number of professionals and other health workers become involved in complex patient care that demands the insights and skills of various specialists. Teams, such as cleft palate or craniofacial teams, are a response to increasingly specialized knowledge and to the advancing technology of medicine. Teams are organized when a variety of specialists are required for the treatment of patients, as occurs in facial birth defects. Some have hypothesized that the availability of intensive care units and life support for newborns with craniofacial conditions has improved their survival and resulted in greater and more specialized treatment demands on the cleft or craniofacial team (Strauss and Ellis, 1996). If such is the case, the future model of team care delivery will need to fit increasingly complex clinical needs. Teams may find themselves incorporating professionals with expertise in swallowing disorders, pediatric anesthesiology, pulmonary function, neuropsychology, dental implantology, and intensive care medicine. This elaboration of team function will depend on the healthcare system providing resources and a payment mechanism. Market forces, including managed care, may limit the ability to expand the services of the team as they seek to control the costs of team care.

The specialization and complexity of health professional practice have been seen as causing fragmentation of care, with dehumanizing results (Feinstein, 1983). To humanize care, teams often include several psychosocial specialists, such as social workers, psychologists, therapists, and nurses. Commenting on the complex nature of craniofacial problems and the need for specialists to work together, Nackashi and Dixon- Wood (1989) point out that the cleft lip and palate rehabilitative process includes medical, social, psychological, and vocational factors and that a holistic approach to the patient or client is needed.

When medical or human problems cluster in a family (Nagi, 1975), they need to be treated in a way that integrates both medical and social interventions (Phillips and Whitaker, 1979; Dingwall, 1980). McKeganey and Bloor (1987) argue that teamwork emerged particularly in those specialties where social problems are most evident. Teamwork in healthcare delivery has sometimes evolved as a result of the recognition by healthcare professionals of the social and behavioral aspects of medical conditions (Ovretveit, 1996; Cluff and Cluff, 1983; Day, 1981, 1984; MacGregor, 1982, Brantley and Clifford, 1979).

Cleft palate and craniofacial teams have been developed around the appreciation that all professionals, as well as patients and their families, can make meaningful contributions to treatment and management. MacGregor (1982) notes that all team healthcare workers must demonstrate an awareness of the behavioral and social structural aspects of the sickness experience; this function cannot be the exclusive concern of behavioral professionals. It is important to involve family members, especially parents, in craniofacial team decisionmaking and treatment planning (Hill, 1956; MacDonald, 1979; Temkin-Greener, 1983; Jones, 1992). Craniofacial teams have formed to efficiently meet the clinical and psychosocial needs of a complex patient population. The health outcomes of craniofacial team management have not as yet been established in the research literature, though clinicians and administrators report many advantages of team-based care over fragmented, community-based, multispecialty care.

Models of Team Organization

There has been disagreement about whether or not a health team is a distinct social unit (Temkin-Greener, 1983; Margolis and Fiorelli, 1984; Strauss and Ellis, 1996). Most health teams are established and operate for particular and specialized purposes (Campbell and Whitenack, 1983; Nason, 1983; Ellis, 1993, Logan and McKendry, 1982). Specific organizational or institutional arrangements may also force some professionals to work together as a “team” (Furnham et al., 1981). Distinctions are drawn by some between intradisciplinary, multidisciplinary, and interdisciplinary teams (Briggs, 1980; DeSpirito and Grebler, 1983; Horwitz, 1970; Kane, 1980; Ovretveit, 1996). The exact disciplinary composition of the team specialties may determine the categorization of a team. Furthermore, team categorization has to do with cohesiveness, level of cooperation between members, quality of relationships, and maintenance of professional authority and autonomy.

An intradisciplinary team is composed of more or less similar specialists within a very narrow field of specialization.

It has been described as a team in which each discipline makes an initial independent assessment, information is later shared, and team members are not permitted to cross over traditional role boundaries between disciplines (Nackashi and Dixon-Wood, 1989). An intradisciplinary team operates with a narrow focus and has members whose orientation is to one discipline but who speak to different aspects of that discipline (Brill, 1976).

Multidisdplinary teams may be specifically set up to allow a number of professionals to cooperate in a particular area while maintaining autonomy from each other (Payne, 1982; Bardach et al., 1984; Ovretveit, 1996; Jones, 1992; Strauss and Ellis, 1996). Nackashi and Dixon-Wood (1989) indicate that on multidisciplinary teams the members work independently because they involve established, defined roles for the professional and permit only limited communication among professionals. Multidisciplinary teams may be seen as work units where a number of varied professionals are involved in a treatment situation (Temkin-Greener, 1983). They form a loose collection of specialists treating various aspects of a patient's clustered problems without constructing mutually agreed on plans. Payne (1982) calls these “work groups,” as distinguished from a “collaborative team.”

In comparing interdisciplinary and multidisciplinary teams, Day (1981) suggests that a multidisciplinary approach may involve isolated evaluations by a series of disciplines and does not imply the merger of thinking or the formation of a shared treatment plan. An interdisciplinary team is one in which a number of professionals from related, but not necessarily similar, disciplines are involved in conducting a joint evaluation and developing a treatment plan in which expertise is pooled and decision-making is collective (Day, 1981; Strauss and Broder, 1985). Nackashi and Dixon-Wood (1989) indicate that interdisciplinary teams meet often to plan, with each professional member forming an independent opinion, followed by the sharing of findings, the construction of recommendations, and the writing of a report summarizing all recommendations. The team leader facilitates and coordinates the treatment plan and then communicates this to the patient and family.

Team Leadership

The scientific literature deals with team organization by describing hierarchical and egalitarian teams (Nagi, 1975). Horwitz (1970) distinguishes between a “leader-centered coordinated” team and a “fraternally oriented integrated” team, or a “hierarchical” and a “participative” team. It appears that teams might be divided into those with a structured hierarchy of authority and power and those which share authority, allocating power to the group. Hierarchical teams may be considered efficient because individual disciplines can maintain autonomy and conflicts are limited, while egalitarian teams allow for joint participation and decision-making (Strauss and Broder, 1985; Ellis, 1986). There are important implications of team structure on team communication and cooperation. Multidisciplinary teams are often assumed to be hierarchical and interdisciplinary teams to be egalitarian in nature. Temkin-Greener (1983) questioned the existence of egalitarian interdisciplinary teams, claiming that the structure of teams reflects traditional status arrangements in which physicians dominate. Bardach et al. (1984) also regarded certain medical specialists as “cornerstones” of the team, while others were portrayed as contributing less central, but necessary, “support and treatment.”

The role of the physician/surgeon is often critical to the function of healthcare teams. Some may expect that physicians will dominate on healthcare teams (Nagi, 1975). For instance, on a surgical operating team, a hierarchy of professionals may be engaged but final authority and decision-making may be given to the surgeon (Dingwall, 1980). Medicine's traditional authority and status among the professions usually account for the strength of physician influence. The effects of medical training, the doctor-patient relationship, and the bureaucratic structure and technological nature of hospitals and medical schools reinforce status and power relationships on teams (Strauss and Ellis, 1996). A subservient and auxiliary role for other nonphysician professionals may occur on some healthcare teams (Mason and Riski, 1982; De Santis, 1983). The interdisciplinary team may present a direct challenge to physician dominance as it emphasizes “role blurring” (Kane, 1980). This does not mean that differences between team specialists are eliminated with respect to roles. Legal accountability mandates specific disciplinary roles and a clear division of labor (Logan and McKendry, 1982). Ambiguous professional or team member roles may lead to team conflict. The need for shared understanding and acceptance of role definitions is important to healthcare team function (Strauss, 1994). A lack of such understanding can cause suspicion about other specialists and their methods (Lillywhite, 1957). An ethical concern has arisen about where responsibility resides when a group or team renders care. It is important that a team leader be seen as ultimately responsible for the outcomes and complications or care and that this person be identified clearly to the family.

On contemporary cleft palate and craniofacial teams, there have been interprofessional tensions related to common domains of expertise. Such overlapping expertise may occur between mental health and psychosocial professionals, such as psychologists, social workers, and nurses. Most commonly, interprofessional boundary disputes have occurred between surgical specialties in the United States. The oral-maxillofacial surgeon, the plastic/reconstructive surgeon, and the otolaryngologist may be trained and capable in performing cleft palate and craniofacial surgery. In centers where all three disciplines coexist, there may sometimes be rivalry for access to patients and tensions may erupt along professional boundaries. Such tensions have the potential for being detrimental to the team process and to the quality and continuity of patient care. Successful resolutions of interprofessional rivalries may require mediation by disinterested parties and will depend on the various professionals holding high-quality patient care as a prime value.

Some observers hold that treatment decisions are often made unilaterally by team leaders, often physicians, who hold a dominant place on the hierarchy of the team (Bardach et al., 1984; Mason and Riski, 1982). Others have found that joint decision-making takes place when teams have more egalitarian and collegial structures (Strauss and Broder, 1985). In the case of joint decision-making, there is sharing of status and knowledge with colleagues and a willingness to learn about other disciplines (Ellis, 1986). To achieve true interdisciplinary function, it is necessary that communicative openness and a shared vocabulary exist (Lillywhite, 1957; Margolis and Fiorelli, 1984; Koepp-Baker, 1979).

Where the formulation of a joint plan of action is the desired team goal, as in interdisciplinary teams, insistence on the dominance of one specialty can become counterproductive. Leadership on healthcare teams can vary according to the nature of the team, the patient's problem(s), the institutional set-up, personal leadership style, and individual personalities. Horwitz (1970) viewed team leadership primarily as “facilitating the achievement of common goals.” Margolis and Fiorelli (1984) also viewed the leader as an “impartial facilitator,” who ensures efficiency in the team's operation. Logan and McKendry (1982) referred to a coordinator, rather than a leader, whose role should be clearly distinguished from the professional roles on the team, to avoid being dominating. Leadership can also be granted to the person who serves as the administrator of the team.

In some craniofacial team settings, team leadership is rotated between disciplines and their various members (Strauss and Broder, 1985; Horwitz, 1970). This style may reduce interprofessional barriers and assist in diminishing professional status hierarchies. The rotation of the position of team leader assures that several disciplines experience being at the helm of the team. They will certainly become more aware of the challenge of leadership and will appreciate how hard it is to develop an interprofessional plan at the team conference.

Team leadership often implies the ability to resolve team conflict. Conflicts resulting from the structural constraints of a team organization can be dealt with by a team leader who can arbitrate differing positions (Lonsdale et al., 1980); however, conflicts that reflect larger interprofessional rivalries, or “turf battles,” may be more difficult to resolve on a team-specific basis. On teams where plastic surgeons, otolaryngologists, and oral-maxillofacial surgeons try to negotiate their specific boundaries and responsibilities, conflicts may occur over the division of labor in patient care. The team leader must recognize such conflicts, but their resolution may actually depend on the role definitions of the specific professionals involved and the “turf” definitions supported by professional organizations.

The team interaction approach to conflict resolution allows the leader to facilitate team members in the settling of their differences, thus reducing role clashes, conflicting professional judgments, and class, cultural, and gender differences (Strauss and Broder, 1985; Strauss, 1985; Nason, 1983). Tensions within the team and in team deliberations may be natural, inevitable, and productive. The expression of tension may, if carefully managed, enhance the probability of emerging with superior patient care plans (Margolis and Fiorelli, 1984). Nonprofessional actors in team deliberations are the patient, the family, and the funder of care. Their perspectives will often be woven into the team deliberations, and in some settings patients or parents may sit in on team discussions. In other team settings, an interpretive meeting is held between a designated team member and the parent or patient, to transmit the treatment plans and team findings. Both strategies allow for parents or patients to voice their concerns and to determine if the team has responded to their questions. Teams that meet with patients only in a group or that do not find time to interpret findings and recommendations may fail to meet consumer expectations.

The healthcare funder has increasingly been perceived as a party to the team's decisions about care. In the United States, managed care organizations and other funders have increasingly mandated treatment options and even have determined which team professionals will be engaged in a patient's evaluation and treatment (Herelinger, 1997).

The cost and quality of cleft palate and craniofacial care are receiving increasing attention in the health policy arena (Strauss, 1994). Little has been written about the emergence of managed care into the care of persons with cleft and craniofacial conditions in the United States. The managed care organization has sometimes been seen as providing effective levels of gatekeeping to assure that overutilization of care does not occur (Kutner, 1998). The managed care organization generally will guide entrance to team services for their clients and will restrain clinical activism. The managed care organization has much at stake in preventing unnecessary procedures, radiographs, or laboratory tests. In the name of controlling costs, the managed care organization has sought to limit the number of professionals that evaluate a person with a health condition (Kutner, 1998; Nelson, 1997). Furthermore, they may mandate that only their own providers can evaluate clients of their managed care organization. In the case of “closed-panel” managed care organizations or health maintenance organizations, there is often a reluctance to allow a client to seek services or evaluation “out of system.” The primary care provider assigned to, or selected by, the client is portrayed as serving in an advocacy role, wherein the provider seeks needed services for the client. Critics of the managed care organization point out that there are often incentives for the primary care provider to reduce the number of specialty referrals made, especially “out of system.” In some managed care organizations, there are direct economic disincentives for specialty referral, even for evaluation purposes (Povar and Moreno, 1995; Simon and Emmons, 1997). Clients of some managed care organizations report that they have a difficult time accessing their primary care physician due to the long wait for nonemergency appointments or consultations. Some cleft palate and craniofacial teams work with managed care organizations that wish to “unbundle” the team evaluation. In other words, they seek to use several team professionals and several of their own in-house professionals. Some teams have resisted this move by arguing that they function effectively when they can work as an experienced and complete unit or team. Another challenge associated with the current health system relates to the ability of patients to access comprehensive coverage for craniofacial conditions (Strauss, 1994). Some states have passed legislation to mandate coverage, but the results have been uneven across the United States. One issue that has arisen is when health coverage is provided by an employer who self-insures workers (Nelson, 1997). In that situation, the insurer is often not covered under state-specific insurance legislation and cannot be affected by state legislation. National legislation has sought to permit Americans portability of health insurance and to protect them from denial of coverage when changing jobs (Kutner, 1998). Some managed care organizations have been selective in who they enroll. When this occurs, it has been called “skimming the cream,” in that the lowest-risk patient population is covered while more complex populations are left uncovered. To deal with this, many states have begun to cover Medicaid services (care for primarily low-income persons) under managed care. Thus, poor adults and children may also receive care under the guidelines of a managed care organization. The advent of managed care may have fundamentally changed the relationship between the patient and the provider by inserting the managed care organization between them (Povar and Moreno, 1988; Reinhardt, 1993; Emmanuel and Dubler, 1995).

Issues of the quality of care (Inglehardt, 1996) have also emerged as the healthcare system in the United States changes. The National Committee for Quality Assurance has taken on the role of evaluating and accrediting managed care organizations and health plans using specified outcome measures and parameters of care (Inglehardt, 1996). Such standards of care and clinical pathways or guidelines have been developed to rationalize care patterns. The emphasis on evidence-based practice suggests that technological advances will need to demonstrate their effectiveness and that outcomes research will guide future clinical practices.

Evaluating the Characteristics of Teams

The American Cleft Palate-Craniofacial Association (ACPA) (1993) has revised its mechanism for listing teams in the ACPA Membership-Team Directory (2001). This began when it became apparent that public funding agencies and many health insurance or managed care providers would set criteria for cleft palate and craniofacial team care. Believing that a professional association should provide leadership in such matters, the ACPA initiated efforts to define basic and minimal standards for team listing that include categorization of teams. The resulting ACPA Team Self-Assessment Instrument employs specific criteria to list teams. Team categorization is achieved through a self-rating process with no examiners or site visitors. Standards for listings permit the specification of two principal types of team, the cleft palate team and the craniofacial team. A given center may be listed in either or both of these categories. Strauss and The ACPA Team Standards Committee (1998) reported that all known (n - 296)

North American cleft and craniofacial teams were contacted for team listing purposes using a self-assessment method developed by an interdisciplinary committee of national stature. Team clinical leaders classified their centers and provided data on team care. The response rate was 83.4% (n = 247), and the distribution of listed teams was 105 (42.5%) cleft palate teams, 102 (41.3%) craniofacial teams (includes craniofacial teams that are both cleft palate and craniofacial teams), and 12 (4.9%) geographically listed teams. There were 28 (11.3%) other teams that included interim cleft palate teams (new teams of less than 5 years' duration), low-density teams (teams in states with low population density), or evaluation and treatment review cleft palate teams (teams that provide no direct clinical treatment but only evaluation and quality assurance). They noted that 85% of all teams systematically collected and stored clinical data on their team's patient population in the past year. Furthermore, 50% of all North American teams had a quality assurance program in place to measure treatment outcomes. Other findings included the annual number of face-to-face team meetings; new and follow-up patient censuses; and surgical rates for initial repair of cleft lip/palate, orthognathic/osteotomy procedures, and intracranial/craniofacial procedures. The authors concluded that two out of five North American teams classify themselves as having the capacity to provide both cleft palate and craniofacial care. An additional two out of five teams limit their primary role to cleft palate care.

TABLE 24.1. American Cleft Palate-Craniofacial Association (ACPA) Standards for Listing the Cleft Palate Team (CPT)*

Basic Criteria 1. The CPT meets face-to-face for regularly scheduled meetings for treatment planning and case review, at least six times per year, with at least four specialties represented. 2. The CPT evaluated at least fifty new or recall patients with cleft lip/palate in the past year. 3. The CPT keeps a central and shared file on each patient. 4. The CPT has at least an actively involved Surgeon, Orthodontist and Speech-Language Pathologist, who attend team meetings. As a minimum, patients evaluated by the CPT are seen by these specialties plus at least one additional team specialty that attends the CPT meetings. 5. The CPT assures that each child has health evaluation by a primary care Physician (Pediatrician, Family Physician or General Internist) in the community or on the team. The CPT uses the findings from the health evaluation to guide its treatment planning and team meeting deliberations. 6. Evaluations at the CPT include a screening hearing test and tympanogram. All patients with clefts of the palate, or hearing concerns, or abnormal tympanograms or hearing tests, are referred to an Otolaryngologist (E.N.T.) for examination, consultation or treatment. 7. At least one Surgeon on the CPT operated on ten or more patients for primary repairs of a cleft lip and/or cleft palate in the past year. 8. For patients requiring facial skeletal surgery, the CPT has or refers to a surgeon whose education, training and experience has adequately prepared him/her to provide facial skeletal surgery (bone graft, orthognathic surgery) and who has performed ten or more major maxillary or mandibular osteotomies in the past year (not necessarily on patients with cleft lip and/or cleft palate. Additional CPT Criteria 1. The CPT has a Speech-Language Pathologist(s) who attends team meetings and whose education, training and experience have adequately prepared him/her for the diagnosis and treatment of patients with cleft lip/palate. 2. At least one Speech-Language Pathologist on the CPT provided speech therapy and/or a complete speech and language evaluation to a minimum of 10 patients (team or other patients) with cleft lip/palate in the past year. 3. The CPT Speech-Language Pathologist performs a structured speech assessment during team evaluations. 4. The CPT uses clinical speech instrumentation (such as endoscopy, pressure flow, videofluoroscopy, etc.) to assess velopharyngeal function, when indicated. 5. CPT has an Orthodontist who attends team meetings and whose education, training and experience have adequately prepared him/her for the diagnosis and treatment of patients with cleft lip/palate. 6. At least one Orthodontist on the CPT provided orthodontic treatment for a minimum of 10 patients with cleft lip/palate in the past year. 7. The CPT refers patients requiring orthognathic treatment to an Orthodontist(s) whose education, training and experience have adequately prepared him/her for the provision of orthodontic care as a part of orthognathic treatment. 8. Orthognathic surgical treatments are adequately documented with intraoral dental casts, facial and intraoral photographs, and appropriate radiographs. 9. Orthognathic surgical planning and outcomes are routinely discussed at the CPT meetings for patients requiring such care. 10. The CPT has, or refers to, a Pediatric Dentist/General Dentist/Prosthodontist(s) whose education, training and experience have adequately prepared him/her for the dental diagnosis and treatment of patients with cleft lip/palate. 11. CPT has a Surgeon(s) who attends team meetings and whose education, training and experience have adequately prepared him/her for the diagnosis and treatment of patients with cleft lip/palate. 12. The CPT has a Psychologist, Clinical Social Worker, or other Mental Health Professional(s) who evaluates all patients on a regular basis. 13. The CPT routinely tests or screens patients for learning disabilities and developmental, psychological, and language skills. 14. The CPT collects school reports and other information relative to learning in school-age patients, when indicated. 15. The CPT has a nurse or other trained professional who regularly provides supportive counseling and instruction (feeding, developmental) to parents of newborns. 16. The CPT sponsors or makes referrals to a parent support group or parent network in the community (if available), as desired by families. 17. The CPT regularly provides supportive counseling and instruction to parents and patients pre- and post-operatively. 18. The CPT provides for formal genetic counseling or a clinical genetic evaluation for parents and patients. 19. The CPT evaluation includes a hearing test by an Audiologist(s) beginning before one year of age. 20. The CPT has an Otolaryngologist(s) whose education, training and experience have adequately prepared him/her for the diagnosis and treatment of patients with cleft lip/palate. The Otolaryngologist provides examination, consultation and treatment to patients evaluated by your team. 21. The CPT evaluation includes ear examinations by an otolaryngologist(s) on a routine basis beginning before one year of age. 22. After a CPT evaluation, the patient and family have an opportunity to ask questions and discuss the treatment plan with a team representative. 23. The CPT routinely (for each evaluation) writes reports or summary letters, containing a treatment plan, which are sent to the family in a timely manner. 24. CPT reports are routinely sent in a timely manner to the patient's care providers in the community (schools, health department, local professionals) with the family's permission. 25. The CPT record includes a diagnosis(es). 26. The CPT team record includes a complete medical history. 27. The CPT record includes a treatment plan or goals which are reviewed periodically on a formal basis. 28. The CPT record includes a social and psychological history. 29. The CPT record includes dental and orthodontic findings and history. 30. The CPT makes intraoral dental casts on patients, when indicated. 31. The CPT takes facial photographs on patients in treatment or evaluation. 32. The CPT obtains appropriate radiographs, including lateral cephalometric radiographs on patients, when indicated. 33. The CPT has an office and coordinator or secretary. 34. The CPT supports, encourages, or offers continuing education in cleft lip/palate care for its members. 35. The CPT provides case management (follow-up, referral, and coordination of care) and benefits advocacy/assistance (help families obtain financial or programmatic support), as needed. *The CPT provides coordinated and interdisciplinary evaluation and treatment to patients with cleft lip and/or cleft palate. The CPT meets the 8 basic criteria defined by the ACPA Committee on Team Standards, plus 30 of the 35 additional criteria. Source: American Cleft Palate-Craniofacial Association. Parameters for evaluation and treatment of patients with Cleft Lip/Palate or other Craniofacial Anomalies. Pittsburgh: American Cleft Palate-Craniofacial Association, 1993.

In evaluating a team, one might consider the questions included on the ACPA Team Self-Assessment Instrument (Strauss and The ACPA Team Standards Committee, 1998). As shown in Tables 24.1 and 24.2, there are different criteria for cleft palate teams and craniofacial teams. In developing a team, a potential team leader might use these criteria to guide planning.

As the U.S. health system changes, it is predictable that increasing attention will be paid to the rationale and value of cleft and craniofacial teams. Health planners are likely to ask the following:

1. How can cleft/craniofacial teams be most productive?

2. Are limitations on the numbers of cleft/craniofacial teams in a region effective at controlling cost and improving the quality of care?

3. Is team care more cost-effective than fragmented care? Does it result in improved outcomes for patients?

4. What constitutes a minimal team? an excellent team?

The cleft palate and craniofacial team can be understood as a way to organize complex, multi-specialty care in a humanistic and cost-effective manner. It is not difficult to endorse the vision of teams of professionals working together to reduce fragmentation and to make specialized care more personal. It is clear that getting a group to work together, e.g., to perform several different surgical procedures with one hospitalization and one anesthesia in one operating room, makes intuitive sense. A team approach reduces costs, minimizes school and work time loss, and promotes a more comprehensive view of care. The team approach implies quality peer review on a continuous basis. Constructing the most effective team possible is a challenge, but the rewards lie in the shared group interaction, the es-prit-de-corps, and the families and patients who express satisfaction with the experience and outcomes of care.

TABLE 24.2. American Cleft Palate-Craniofacial Association (ACPA) Standards for Listing Craniofacial Team (CFT)*

1. The Operating Surgeon(s), Orthodontist(s), Mental Health Professional(s) and Speech-Language Pathologist(s) on the CFT meet face-to-face at a scheduled team meeting or conference to evaluate patients with craniofacial anomalies or syndromes at least six times per year. The meeting may or may not coincide with CPT meetings. 2. The CFT evaluated at least 20 patients with craniofacial anomalies or syndromes in the past year. 3. The CFT assures that each child has health evaluation by a primary care Physician (Pediatrician, Family Physician or General Internist) in the community or on the team. The CPT uses the findings from the health evaluation to guide its treatment planning and team meeting deliberations. A community or team-based primary care Physician evaluates all patients prior to craniofacial surgery. 4. Craniofacial surgical treatments are adequately documented with facial and intraoral photographs, and appropriate radiographs. 5. Craniofacial treatment plans and treatment outcomes (results) for patients with craniofacial anomalies or syndromes are discussed at CFT meetings. 6. The CFT has a Surgeon(s) who attends team meetings and whose education, training and experience have adequately prepared him/her for the diagnosis and treatment of patients requiring craniofacial surgery. 7. At least one Surgeon on the CFT provided craniofacial surgical treatment (surgical procedures in which the intracranial approach to the midfacial segment -includes the orbit and/or supraorbital rim-is used) for a minimum of 10 patients with craniofacial anomalies or syndromes in the past year. 8. The CFT has an Orthodontist(s) who attends team meetings and whose education, training and experience have adequately prepared him/her for the orthodontic diagnosis and treatment of patients with craniofacial anomalies or syndromes. 9. At least one Orthodontist on the CFT provided orthodontic evaluation or treatment for a minimum of 10 patients with craniofacial anomalies or syndromes in the past year. 10. The CFT has a Speech-Language Pathologist(s) who attends team meetings and whose education, training and experience have adequately prepared him/her for speech and language diagnosis and treatment of patients with craniofacial anomalies or syndromes. 11. At least one Speech-Language Pathologist on the CFT provided speech therapy and/or a complete speech and language evaluation to a minimum of 10 patients (team or other patients) with craniofacial anomalies or syndromes (or cleft lip/palate) in the past year. The CFT Speech-Language Pathologist performs a structured speech assessment during team evaluations. 12. The CFT uses clinical speech instrumentation (such as endoscopy, pressure flow, videofluoroscopy, etc.) to assess velopharyngeal function, when indicated. 13. The CFT has a Mental Health Professional(s) (Psychologist, Social Worker, Developmental Pediatrician, Psychiatrist) who attends team meetings and whose education, training and experience have adequately prepared him/her for the psychological and psychosocial diagnosis and treatment of patients with craniofacial anomalies or syndromes. 14. The CFT has a Mental Health Professional(s) who evaluates all patients on a regular basis. 15. The CFT routinely tests or screens patients for learning disabilities and developmental, psychological, and language skills. 16. The CFT collects school reports and other information relative to learning in school-age patients, when indicated. 17. The CFT has a nurse or other trained professional who regularly provides supportive counseling and instruction (feeding, developmental) to parents of newborns. 18. The CFT sponsors or makes referrals to a parent support group or parent network in the community, as desired by families. 19. The CFT regularly provides supportive counseling and instruction to parents and patients pre- and post-operatively. 20. The CFT has a Neurosurgeon(s) whose education, training and experience have adequately prepared him/her for the neurosurgical diagnosis and treatment of patients with craniofacial anomalies or syndromes and who provides examination, treatment and consultation for CFT patients with craniofacial anomalies or syndromes. 21. The CFT has an Ophthalmologist(s) whose education, training and experience have adequately prepared him/her for the ophthalmological diagnosis and treatment of patients with craniofacial anomalies or syndromes who provides examination, treatment and consultation for CFT patients with craniofacial anomalies or syndromes. 22. The CFT has an Otolaryngologist(s) whose education, training and experience have adequately prepared him/her for the otolaryngologic diagnosis and treatment of patients with craniofacial anomalies or syndromes and who provides examination, treatment and consultation for CFT patients with craniofacial anomalies or syndromes. 23. The CFT evaluation routinely includes hearing evaluation by an audiologist and\or otologic evaluations by an otolaryngologist. 24. The CFT has a Radiologist(s) whose education, training and experience have adequately prepared him/her for the radiological evaluation of patients with craniofacial anomalies or syndromes and who provides examination and consultation for CFT craniofacial anomalies or syndromes. 25. The CFT facility has C.T. capability and access to M.R.I. 26. The CFT obtains lateral cephalometric radiographs (or the equivalent) on patients, when indicated. 27. The CFT has a Pediatric Dentist/General Dentist/Prosthodontist(s) whose education, training and experience have adequately prepared him/her for the dental diagnosis and treatment of patients with craniofacial anomalies or syndromes and who provides examination, treatment and consultation for CFT patients with craniofacial anomalies or syndromes. 28. The CFT makes intraoral dental casts on patients, when indicated. 29. The CFT has an Audiologist(s) whose education, training and experience have adequately prepared him/her for the audiologic diagnosis and treatment of patients with craniofacial anomalies or syndromes and who provides examination, treatment and consultation for CFT patients with craniofacial anomalies or syndromes. 30. The CFT has a Geneticist(s) whose education, training and experience have adequately prepared him/her for the genetic diagnosis and treatment of patients with craniofacial anomalies or syndromes and who provides examination, treatment and consultation for CFT patients with craniofacial anomalies or syndromes. 31. The CFT provides for formal genetic counseling or a clinical genetic evaluation for parents and patients. 32. The CFT facility has a Pediatric Intensive Care Unit (P.I.C.U.) in the facility where they perform craniofacial surgery. 33. After a CFT evaluation, the patient and family have an opportunity to ask questions and discuss the treatment plan with a team representative. 34. The CFT (for each evaluation) writes reports or summary letters, containing a treatment plan, which are sent to the family in a timely manner. 35. CFT reports are sent in a timely manner to the patient's care providers in the community (schools, health department, local professionals) with the family's permission. 36. The CFT keeps a central and shared file on each patient. 37. The CFT record includes a diagnosis(es). 38. The CFT record includes a complete medical history. 39. The CFT record includes a treatment plan or goals which are reviewed periodically. 40. The CFT record includes a social and psychological history. 41. The CFT record includes dental and orthodontic findings and history. 42. The CFT takes facial photographs on patients in treatment or evaluation. 43. The CFT has an office and coordinator or secretary. 44. The CFT supports, encourages, or offers continuing education in craniofacial care for its members. 45. The CFT provides case management (follow-up, referral, and coordination of care) and benefits advocacy/assistance (help families obtain financial or programmatic support), as needed. *The CFT provides coordinated and interdisciplinary evaluation and treatment for patients with a range of craniofacial anomalies or syndromes. For the purposes of the categorization, craniofacial anomalies or syndromes are defined as congenital conditions other than cleft lip/palate, unless cleft lip/palate is a feature of another condition, anomaly or syndrome. The specific definition of craniofacial surgery being used states that “craniofacial surgery consists of the diagnosis, treatment planning, and surgical procedures in which the intracranial approach to the midfacial segment (includes the orbit and/or supraorbital rim) is used.” The CFT meets all of the following criteria defined by the ACPA Committee on Team Standards. Source: American Cleft Palate-Craniofacial Association. Parameters for evaluation and treatment of patients with cleft lip/palate or other craniofacial anomalies. Pittsburgh: American Cleft Palate-Craniofacial Association, 1993.

Acknowledgements

Team standards criteria were developed by the ACPA Team Standards Committee: Samuel Berkowitz, DOS, MS (Orthodontics, Miami, FL); Philip J. Boyne, DMD, MS (Oral and Maxillofacial Surgery, Loma Linda, CA); Arthur Brown, MD (Plastic Surgery, Camden, NJ); John Canady, MD (Plastic Surgery, Iowa City, IA); Marilyn Cohen, BA (Team Coordinator, Speech Pathology, Camden, NJ); Linda Hallman, DOS, PhD (Orthodontist, Washington, DC); Robert Hardesty, MD (Plastic Surgery, Loma Linda, CA); Marilyn Jones, MD (Pediatrics and Genetics, San Diego, CA); Kathleen Kapp-Simon, MA, PhD (Psychology, Chicago, IL); Pat Landis, MA (Speech Pathology and Administration, Baltimore, MD); James Lehman, MD (Plastic Surgery, Akron, OH); Lynda Power, RN (Nursing, Toronto, Canada); Craig Senders, MD (Otolaryngology, Sacramento, CA); Helen

Sharp, MS (Speech Pathology/Ethics, Iowa City, IA); Barry Steinberg, DDS, MD, PhD (Oral and Maxillofacial Surgery, Ann Arbor, MI); Ronald P. Strauss, DMD, PhD (Dentistry and Sociology, Chapel Hill, NC, Chair); Timothy Turvey, DDS (Oral and Maxillofacial Surgery, Chapel Hill, NC); Duane VanDemark, PhD (Speech Pathology, Iowa City, IA). The ACPA Team Standards Committee conducted this work with the assistance of the ACPA National Office. The Allegheny Marketing Group (Pittsburgh, PA) performed data entry and data management.

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