Organizational factors to support collaborative care in Adult Congenital Heart Disease Programs

Organizational factors to support collaborative care in Adult Congenital Heart Disease Programs | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Organizational factors to support collaborative care in Adult Congenital Heart Disease Programs Seiji Ito, In Hye Park, Tonia C Carter, Pavan Zaveri This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9034016/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background: Collaboration among healthcare workers is critical for adult congenital heart disease (ACHD) programs to provide care to ACHD patients with complex needs. Objectives: This study aimed to describe ACHD programs’ organizational structure, environment, and indicators of collaboration. Methods: A cross-sectional survey among ACHD programs in the United States was conducted, including questions on characteristics, personnel, services, and ten indicators of collaboration using a model described by D’Amour. Results: The survey was sent to 86 ACHD programs, and 36 programs (41.8%) responded. The types of ACHD programs’ primary institution were combined adult and pediatric institution (61.1%, N=22), pediatric institution (27.8%, N=10), and adult institution (11.1%, N=4), and most ACHD programs had 1 to 3 healthcare organization(s) participating. The median number and interquartile range (IQR) of ACHD providers, advanced practice providers (APP), clinical coordinators, and administrative coordinators or assistants were 4 (IQR 3-5), 1 (IQR 1-2), 1 (IQR, 1-3), and 1 (IQR 1-2) respectively. Among the ten indicators of collaboration, leadership and connectivity were rated higher, and goals, centrality, formalization tools, and information exchange were rated lower. When analyzed by subgroups based on the types of primary institution, statistically significant differences in responses were demonstrated in support for innovation, formalization tools, and information exchange, showing higher levels of collaboration in the combined adult and pediatric institution group compared with the pediatric institution group. Conclusions: This study provided descriptions of the organizational structure and environment of ACHD programs. It also described organizational factors and suggested unique challenges and opportunities ACHD programs face. Adult congenital heart disease collaboration organization development specialty care program Figures Figure 1 Figure 2 Figure 3 Introduction The field of adult congenital heart disease (ACHD) evolved after the advent of neonatal repair of complex congenital heart disease (CHD) in the 1970s. Survival to age 18 years is expected for 90% of children, including ones with severe CHD in the current era. There is a rapid growth of the ACHD patient population, and 1.4 million ACHD patients were estimated to live in the United States in 2010, surpassing the number of children with CHD. 1 Over the course of their life time, many patients with CHD develop sequelae of either native CHD or surgical repair, including valvular heart disease, heart failure, arrhythmia, thromboembolism, endocarditis, and other medical comorbidities such as liver disease, pulmonary disease, kidney disease, and mental health disorders. Additionally, a large proportion of ACHD patients are of reproductive age, and female patients may undergo pregnancy with a higher risk of cardiac events, which could impact both maternal and fetal outcomes. ACHD patients frequently require multiple specialty care, which often includes care at more than single healthcare systems. Practice guidelines have been published to promote access to specialized ACHD care, standardization of care delivery, education of patients and their families, education of adult cardiovascular specialists and pediatric cardiologists, and liaison with regulatory agencies to meet the demand of the growing ACHD population. 2 – 4 ACHD programs were developed in major U.S. cities and expanded throughout the country to provide care to this unique, complex, and heterogeneous ACHD population and function as a resource for referring health care providers. In a publication from 2009, it was estimated that at least 150 ACHD specialized programs were required to care for 50% of the ACHD population with moderate to severe forms of CHD. 5 More recently, specialized ACHD care was independently associated with a significant mortality reduction. 6 The Adult Congenital Heart Association (ACHA) is a national organization founded in the United States as a patient and family community with its mission to empower the congenital heart disease community by advancing access to resources and specialized care and improving patient-centered outcomes. 7 ACHA maintains an ACHD clinic directory to improve access to ACHD programs, and the number of ACHD programs listed exceeds 100 programs in North America. In healthcare institutions, adult congenital heart disease programs are often organized as a subgroup in the cardiology division, although they are often named "programs." An innovative approach outside of traditional healthcare is necessary to accommodate accessible, seamless, comprehensive, and patient and family-centered care. Frequently, providers in the ACHD program see patients at multiple healthcare institutions from independent healthcare organizations with infrastructural support from each healthcare organization, including human resources and technology structure. Because each organization has unique organizational leadership, goal, vision, strategy, structure, environment, culture, and process, ACHD programs need to build collaborative structures and navigate the complex business environment. Collaboration, partnership, and coordination have increasing importance for ACHD programs to achieve the goal of providing the best care to ACHD patients. In the United States, the fragmented nature of the U.S. healthcare system challenges efficient collaboration and needs harmonized care coordination for healthcare service delivery. Healthcare professionals are confronted with a demand for inter-professional and inter-organizational collaboration among different disciplines and types of primary, secondary, and tertiary care institutions to achieve more effective care delivery and comprehensive services. From clinical practice perspectives, a patient-centered medical home has emerged as a model of a standard of care for all children and adults to provide coordinated, high-quality, compassionate, cost-effective, and patient- and family-centered care. Care coordination tools have been developed by numerous organizations, and the American Academy of Pediatrics published a policy statement on patient- and family-centered care coordination. 8 Quality of care coordination changed over time in medical homes for children with special health care needs, showing a change from being reactive to episodic needs to more systematically proactive and comprehensive. 9 From the systematic perspective on collaboration, horizontal and non-horizontal collaborations have been described, and hospitals generally operate in small horizontal collaborations, while nursing homes, disability care, and mental care services tend to have non-horizontal collaborations. 10 A literature review paper on core concepts and theoretical frameworks of interprofessional collaboration identified sharing, partnership, power, interdependency, and process as five concepts related to collaboration. 11 It also showed that the most complete models of collaboration seem to be based on a strong theoretical background and empirical data. A study evaluated inter-organizational collaboration in perinatal services demonstrated an association of strong leadership at the regional and local levels with higher levels of inter-organizational collaboration, which had more efficient services. 12 Factors contributing to collaboration in healthcare were sought in various collaborative settings such as healthcare providers, organizations, and integrated healthcare networks, and several factors were identified, including shared purpose, governance, finance, shared data, trust, and partnerships. 13 – 15 A practical model of collaboration between professionals in healthcare organizations was described via semi-structured interviews with healthcare managers and professionals. 16 This model has ten indicators (1. Goals, 2. Client-centered orientation vs. other allegiances, 3. Mutual acquaintanceship, 4, Trust, 5. Centrality, 6. Leadership, 7. Support for innovation, 8. Connectivity, 9. Formalization tools, and 10. Information exchange) from four dimensions (shared goals and vision, internalization, governance, and formalization). For each indicator, a three-level typology of collaboration was proposed as potential collaboration, developing collaboration, and active collaboration, with higher levels of collaboration in this order. Figure 1 demonstrates a concept map showing components of ten indicators of collaboration in the four-dimensional model. Although collaboration is critical for ACHD programs to achieve the goal of providing the best care to ACHD patients, there is a lack of literature to evaluate organizational factors for more collaborative work in ACHD practice. This study aims to evaluate organizational factors to support collaborative care in ACHD programs using the model by D’Amour. Methods An online cross-sectional survey was created, and study data were collected and managed using REDCap electronic data capture tools hosted at Children's National. 17 This study had oversight by the institutional review board at Children’s National, and it was determined that approval was not required as this study involves program evaluation and not human subjects. Items in this survey included characteristics of ACHD programs such as types of primary institution (pediatric, adult, or combined), year of program from the establishment, the number of partnering organizations, number of annual outpatient visits, number of ACHD cardiologists and advanced practice providers (APP) who are spending > 50% of time in ACHD, supporting staff, and various ACHD consultation services. For the ten indicators of collaboration, respondents were asked to assess the level of collaboration among professionals in their ACHD program on the three levels. The survey included descriptions of the ten indicators and potential barriers to each indicator as references (Table 1 ). The author asked three volunteers to pilot the survey and sought feedback to ensure internal validity and methodology, minimize potential bias, and maximize response. An effort was made to receive responses from many ACHD care center programs to maximize external validity. The final version of the survey was emailed to program directors or their associates of 86 U.S.-based programs listed in the clinic directory on the Adult Congenital Heart Association website ( https://www.achaheart.org/ ), after excluding 23 ACHD programs with inactive contact. Only ACHD programs in the United States were included because environmental factors such as business structure, legislation, and health insurance environment are relatively similar. Descriptive statistics were used for the characteristics of ACHD program, personnel, and consultation service by mean, median, range, or percentage as appropriate. Correlations between the numbers of various types of healthcare workers and outpatient visits per year were tested by Pearson correlation coefficient. Indicators of collaboration were analyzed using Fisher’s exact test or Kruskal-Wallis test to compare the distribution of the indicators across groups. The authors report there are no competing interests to declare. Table 1 Descriptions of ten indicators and potential barriers to each indicator Indicators Descriptions Potential barriers Goals Consensual values and goals shared by professionals and stakeholders (e.g., promoting patient-centered care). Conflicting goals. Mistrust. Prejudice. Lack of mutual acquaintanceship. Lack of opportunity to discuss goals and values. Goals and visions not well shared or set among professionals. Client centered orientation versus other allegiances Client-centered orientation shared by professionals and stakeholders. Professional, personal, and organizational interests hindering client or patient-centered orientation (e.g., protecting professional or organizational autonomy than patient-centered orientation). Mutual acquaintanceship Knowing each other personally and professionally. Sense of belonging to the group. Lack of opportunities to meet and socialize. Lack of joint projects or activities. Professionals do not know each other well. Trust Trust in each other’s competencies and ability to assume responsibilities. Conditional trust or lack of trust. Rapid turnovers of professionals. Professionals do not have solid trust in each other. Centrality Institution/organization- level leadership/authorities providing clear direction and playing a strategic and political role to implement collaborative process and structures. Lack of strong central leadership in providing clear direction to promote and support collaboration. Ambiguous political and strategic role or complete absence of such role. Institutional leadership not supporting program director’s effort toward collaborative work. Leadership Local leadership, either by position or emerging leadership to develop interprofessional and interorganizational collaboration. Unfocused or fragmented local (subgroup level) leadership to promote and support collaboration. Non-consensual, monopolistic leadership. Program director unable to focus or spend adequate time on program management to support collaborative work. Support for innovation Expertise and supportive environment in starting new practices or dividing/sharing responsibilities in different ways among professionals. Sporadic, fragmented, or little expertise or environment to support collaboration and innovative approach. Limited resource, environment, or professionals’ willingness to support new or modified practice. Connectivity Interconnectedness of individuals and organizations allowing discussion and participation for continuous adjustments to solve coordination problems. Limited information sharing and feedback system or discussion, such as regular meetings or working committees. Lack of communication or communication tools or forums. Ineffective communications among professionals. Formalization tools Formal rules and agreements clarifying responsibilities and sharing of responsibilities. Absence or limited details of interorganizational agreements, protocols, or information systems. Non-consensual agreement. Rules dictated by a certain group or professional. Limited policy or unclear rules regarding work and responsibilities among professionals. Information exchange Infrastructure to support information exchange among professionals. Incomplete or absence of infrastructure or mechanism for collecting or exchanging information. Lack of effective system for transferring or exchanging medical records or medical orders among different health care organizations or professionals. Results The survey was sent via email to 86 U.S.-based programs. Nearly half the programs (41.8%, N = 36) completed the survey. The types of primary institution were combined adult and pediatric institution (61.1%, N = 22), pediatric institution (27.8%, N = 10), and adult institution (11.1%, N = 4). The distribution of ACHD programs by annual outpatient visit volume is shown in Fig. 2 and characteristics of ACHD programs are shown in Table 2 . The median number and interquartile range (IQR) of healthcare organization(s) participating in providing ACHD care were 2 (IQR 1–3). The median number and IQR of ACHD providers, advanced practice providers, and all coordinators or assistants were 4 (IQR 3–5), 1 (IQR 1–2), and 1 (IQR 1–3), respectively. The median number of clinical coordinators was 1 (range 0–5, IQR 1–2), with the majority of clinical coordinators being registered nurses. The median number of administrative coordinators or assistants was 1 (range 0–5, IQR 1–2). Fourteen ACHD programs (38.9%) had no administrative coordinators or assistants spending > 50% of their time in the ACHD program, and this was observed in ACHD programs with a wider range of annual outpatient visits volume. Five ACHD programs (13.9%) answered they have no coordinators or assistants. These five programs had a relatively lower number of annual outpatient visits volume. For the number of healthcare professionals and supporting staff, there was a statistically significant positive correlation with annual outpatient visit volume in ACHD providers (R = 0.673, p < 0.001), APPs (R = 0.468, p = 0.005), and administrative coordinators or assistants (R = 0.596, p < 0.001), but not in clinical coordinators (R = 0.141, p = 0.442) (Fig. 3 ). Table 2 Characteristics of ACHD programs Year established Range Median Interquartile Range 1980–2023 2007 2001–2013 Outpatient visits per year 300–5200 1900 1000–2775 Number of healthcare organizations 1–10 2 1–3 Number of EMR systems 1–4 2 1-2.75 Number of credentials and privileges 1–16 3 1.25-5 Number of states and jurisdictions 1–4 1 1–2 Number of ACHD providers 1–14 4 3–5 Number of APPs 0–7 1 1–2 Number of all coordinators or assistants 0–10 1 1–3 Number of clinical coordinators 0–5 1 1–2 Number of administrative coordinators or assistants 0–5 1 1–2 ACHD cardiac surgery hospitals 0–3 2 1–2 ACHD obstetrics hospitals 1–3 1 1–2 ACHD cardiac catheterization hospitals 0–4 2 1–2 ACHD electrophysiology procedure hospitals 0–4 2 1–2 ACHD CMR or CCT hospitals 0–4 2 1–2 ACHD: adult congenital heart disease; APP: advanced practice provider; CCT: cardiac computed tomography; CMR: cardiac magnetic resonance imaging; and EMR: electronic medical record. For the ten indicators of collaboration, several ACHD programs either left unanswered or answered "unsure" for indicators including goals (N = 3), client-centered orientation versus other allegiances (N = 5), centrality (N = 3), and formalization tools (N = 4). These unanswered or unsure responses were removed from further analysis. The results are shown in number of responses and percentages by three levels of collaboration as all and three subgroups based on types of primary institution, combined adult and pediatric institution (N = 22), pediatric institution (N = 10), and adult institution (N = 4) (Table 3 ). Across ten indicators, more ACHD programs responded as active collaboration level in leadership (88%) and connectivity (86%), while fewer ACHD programs responded as active collaboration level in goals (67%), centrality (70%), formalization tools (69%), and information exchange (69%). When the three subgroups were compared, there were differences in responses with statistical significance for support for innovation (p = 0.011) and formalization tools (p = 0.024), showing lower levels of collaboration in pediatric institution group than the other two groups. We also conducted an analysis to compare combined adult and pediatric institution group and pediatric institution group given the small number of adult institutions, and differences in responses with statistical significance were identified in support for innovation (p = 0.009), formalization tools (p = 0.013), and information exchange (p = 0.040), showing higher levels of collaboration in the combined adult and pediatric institution group and lower levels of collaboration in the pediatric institution group. The comparison of ACHD programs with low volume (annual outpatient visit < 2000) and high volume (annual outpatient visit ≥ 2000) is demonstrated in Table 4 . There were no statistically significant differences observed in any of ten indicators, although the ACHD programs with high volume had more programs in active collaboration particularly in mutual acquaintanceship and centrality. Table 3 Indicators of collaboration. Results shown in number of responses and percentages by three levels of collaboration as all and subgroups based on types of primary institution. Levels of collaboration All (n = 36) Combined adult and pediatric institution (n = 22) Pediatric institution (n = 10) Adult institution (n = 4) p-value comparing all three subgroups a p-value comparing combined adult and pediatric institution to pediatric institution b Goals (No answer = 3) Potential 2 (6%) 1 (5%) 1 (11%) 0 (0%) 0.431 0.204 Developing 9 (27%) 4 (20%) 4 (44%) 1 (25%) Active 22 (67%) 15 (75%) 4 (44%) 3 (75%) Client centered orientation versus other allegiances (No answer = 5) Potential 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0.570 0.633 Developing 7 (23%) 4 (21%) 3 (23%) 0 (0%) Active 24 (77%) 15 (79%) 5 (77%) 4 (100%) Mutual acquaintanceship (No answer = 2) Potential 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0.557 0.384 Developing 9 (26%) 4 (20%) 4 (40%) 1 (25%) Active 25 (74%) 16 (80%) 6 (60%) 3 (75%) Trust (No answer = 1) Potential 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0.193 0.172 Developing 7 (20%) 3 (14%) 4 (40%) 0 (0%) Active 28 (80%) 18 (86%) 6 (60%) 4 (100%) Centrality (No answer = 3) Potential 5 (15%) 2 (10%) 3 (30%) 0 (0%) 0.155 0.076 Developing 5 (15%) 2 (10%) 3 (30%) 0 (0%) Active 23 (70%) 17 (81%) 4 (40%) 2 (100%) Leadership (No answer = 2) Potential 1 (3%) 0 (0%) 1 (10%) 0 (0%) 0.228 0.095 Developing 3 (9%) 1 (5%) 2 (20%) 0 (0%) Active 30 (88%) 19 (95%) 7 (70%) 4 (100%) Support for innovation (No answer = 2) Potential 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0.011 0.009 Developing 7 (21%) 1 (5%) 5 (50%) 1 (25%) Active 27 (79%) 19 (95%) 5 (50%) 3 (75%) Connectivity (No answer = 1) Potential 1 (3%) 0 (0%) 1 (10%) 0 (0%) 0.448 0.246 Developing 4 (11%) 2 (10%) 2 (20%) 0 (0%) Active 30 (86%) 19 (90%) 7 (70%) 4 (100%) Formalization tools (No answer = 4) Potential 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0.024 0.013 Developing 10 (31%) 3 (16%) 6 (67%) 1 (25%) Active 22 (69%) 16 (84%) 3 (33%) 3 (75%) Information exchange (No answer = 1) Potential 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0.082 0.040 Developing 11 (31%) 4 (19%) 6 (60%) 1 (25%) Active 24 (69%) 17 (81%) 4 (40%) 3 (75%) a Using Kruskal-Wallis test, b using Fisher’s exact test Table 4 Indicators of collaboration shown by low volume (< 2000) and high volume (≥ 2000) ACHD programs based on annual outpatient visits among 34 ACHD programs reported the volume. No statistically significant differences observed by Fisher’s exact test in any of 10 indicators. Levels of collaboration Low volume (n = 17) High volume (n = 17) p-value Goals (No answer = 3) Potential 1 (7%) 1 (6%) 0.836 Developing 3 (20%) 5 (31%) Active 11 (73%) 10 (63%) Client centered orientation versus other allegiances (No answer = 5) Potential 0 (0%) 0 (0%) 0.667 Developing 4 (31%) 3 (19%) Active 9 (69%) 13 (81%) Mutual acquaintanceship (No answer = 2) Potential 0 (0%) 0 (0%) 0.106 Developing 6 (40%) 2 (12%) Active 9 (60%) 15 (88%) Trust (No answer = 1) Potential 0 (0%) 0 (0%) 0.398 Developing 4 (25%) 2 (12%) Active 12 (75%) 15 (88%) Centrality (No answer = 3) Potential 3 (19%) 1 (7%) 0.197 Developing 4 (25%) 1 (7%) Active 9 (56%) 13 (87%) Leadership (No answer = 1) Potential 0 (0%) 1 (6%) 0.161 Developing 3 (19%) 0 (0%) Active 13 (81%) 16 (94%) Support for innovation (No answer = 1) Potential 0 (0%) 0 (0%) 1 Developing 3 (19%) 4 (24%) Active 13 (81%) 13 (76%) Connectivity (No answer = 1) Potential 1 (6%) 0 (0%) 0.402 Developing 2 (13%) 1 (6%) Active 13 (81%) 16 (94%) Formalization tools (No answer = 3) Potential 0 (0%) 0 (0%) 0.458 Developing 6 (40%) 4 (25%) Active 9 (60%) 12 (75%) Information exchange (No answer = 1) Potential 0 (0%) 0 (0%) 0.402 Developing 5 (31%) 5 (29%) Active 11 (69%) 12 (71%) Discussion The purpose of this study was to evaluate organizational factors to support collaborative care in ACHD programs. First, we provided descriptions of the heterogeneous nature of organizational structure and the environment in which ACHD programs are situated. It is expected that the complexity of organizational structure and environment will likely increase over time with increasing complexity of healthcare systems and care specialization. In this study, combined adult and pediatric institution was the most prevalent type of primary institution compared to pediatric or adult institution. It is unknown if there has been a shift in ACHD care from pediatric institutions to combined adult and pediatric institutions over time as the ACHD specialty field emerged and matured or vice versa. Also, it is possible that the regional environment and history surrounding healthcare institutions may be a significant determinant of the primary institution types on which ACHD programs are based. Second, this study described indicators of collaboration and their three-level typology among ACHD programs. Among the ten indicators, more ACHD programs responded as active collaboration level in leadership and connectivity, while fewer ACHD programs responded as active collaboration level in goals, centrality, formalization tools, and information exchange. This may reflect relatively stronger local leadership of ACHD programs and connectivity of core workers, and ACHD programs' perceived challenges in goals and strategies at the institutional leadership level as well as challenges in formalizing processes and sharing information. This may also be due to frequent challenges in caring for ACHD patients with unique and complex medical needs. When ACHD programs were analyzed by subgroups between combined adult and pediatric institution and pediatric institution as types of primary institution, there was a statistically significant difference in three indicators: support for innovation, formalization tools, and information exchange, showing higher levels of collaboration in the combined institutions and lower levels of collaboration in the pediatric institutions. This may reflect challenges in providing ACHD care and various specialty services for adult patients in pediatric institutions using innovative ways beyond traditional pediatric care practice, formalizing standard tools, and creating rules and agreements. It may also be due to ACHD programs with primary pediatric institutions facing more challenges in sharing or retrieving information among healthcare workers across multiple independent institutions. Although there were no statistically significant differences, our data suggested that ACHD programs with higher volume had more programs in active collaboration in mutual acquaintanceship and centrality compared with ACHD programs with lower volume, which are likely necessary features to develop and maintain larger volume ACHD programs. Future studies could focus on these indicators to further describe details and help understand barriers and opportunities for more collaborative work. There are several limitations of this study. First, the number of ACHD programs that participated in this survey was relatively small. Furthermore, there may be a selection bias as 23 ACHD programs could not be reached due to absence of active contact or person. The survey results are possibly skewed to represent larger size and long-established ACHD programs. There can also be recall bias in answering the survey. Second, the human resources supporting ACHD programs' daily functions, such as clinical coordinators and administrative coordinators and assistants, were thought to be difficult to capture accurately because titles and job descriptions of these workers are heterogeneous throughout ACHD programs. These workers can be full-time or part-time and are often shared by multiple subgroups of the division or department and not solely designated to work for ACHD programs based on the employment style and structure of the institution. Third, survey questions on the concept of indicators of collaboration and the three-level typology might have been challenging for respondents to understand and answer appropriately, due to difficulty in applying this conceptual framework to their real-world practice. In conclusion, this study provided descriptions of the organizational structure and environment of ACHD programs in the United States. This study also described organizational factors among ACHD programs, suggesting unique challenges and opportunities ACHD programs face. Abbreviations ACHA: Adult Congenital Heart Association; ACHD: adult congenital heart disease; APP: advanced practice providers; CHD: congenital heart disease; and IQR: interquartile range. Declarations Funding: none Disclosure statement: The authors report there are no competing interests to declare. Acknowledgment The authors appreciate all the ACHD programs that participated in this survey. We also appreciate the feedback provided from the ACHD programs through the pilot and survey study. Sources of Funding None. Disclosures All of authors have nothing to disclose. References Gilboa SM, Devine OJ, Kucik EJ, et al. Congenital Heart Defects in the United States. Circulation . 2016;134:101–109. DOI: 10.1161/CIRCULATIONAHA.115.019307 Warnes CA, Williams RG, Bashore TM, et al. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9034016","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":602976901,"identity":"5e79fac1-22ad-46af-845b-93ac9fce4295","order_by":0,"name":"Seiji Ito","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEUlEQVRIie3QsUrDQBzH8X/4w2X516xXLrSvcOFAESp5lRYhLhY6dugQENolkLVuPkrKQZ7BoUNKIS4OgkvBDF5bpQ5JpJvIfSFL4MPvnwDYbH8xNM8bZHQBwx9vYNJGEJylIeyb0IHI9hkkyOBE4BfSX3ir7WC29pk73mwn1bofupgXOwm9q/SplkiNqO7zkhi9KPU4L4ME2V2QSFD+c1FPEJkYx5oYj5joxNpJkC45SRgteVZ/2IMh10fiflClwz3pVi0EtCHO1woS06M9EYcVL276FhUkuSFUoujM9W2iWSR8yRXnDX8sXW2K3UyHnhs57+awm0Wq8+7rdNDjXsNhTZkJPjyPmM5dsdlstv/aJ8wOTnJcGe0AAAAAAElFTkSuQmCC","orcid":"","institution":"Children’s National","correspondingAuthor":true,"prefix":"","firstName":"Seiji","middleName":"","lastName":"Ito","suffix":""},{"id":602976902,"identity":"5f6b117a-2dfb-4505-b1f3-3b4dfa289800","order_by":1,"name":"In Hye Park","email":"","orcid":"","institution":"Children’s National","correspondingAuthor":false,"prefix":"","firstName":"In","middleName":"Hye","lastName":"Park","suffix":""},{"id":602976903,"identity":"d713280e-847c-482e-8e1e-a4c7325a168f","order_by":2,"name":"Tonia C Carter","email":"","orcid":"","institution":"Children’s National","correspondingAuthor":false,"prefix":"","firstName":"Tonia","middleName":"C","lastName":"Carter","suffix":""},{"id":602976904,"identity":"4c78f0b4-6cf7-476c-8945-149a56826f9a","order_by":3,"name":"Pavan Zaveri","email":"","orcid":"","institution":"Children’s National","correspondingAuthor":false,"prefix":"","firstName":"Pavan","middleName":"","lastName":"Zaveri","suffix":""}],"badges":[],"createdAt":"2026-03-04 22:08:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9034016/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9034016/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104387322,"identity":"5f552206-3202-45bb-b449-e3d2a7d63e06","added_by":"auto","created_at":"2026-03-11 08:57:33","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":163370,"visible":true,"origin":"","legend":"\u003cp\u003eA concept map showing components of ten indicators of collaboration in the four-dimensional model.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9034016/v1/26240643466dcfa501202942.png"},{"id":104387265,"identity":"65aef9af-4055-4929-93f4-f27a8af58e54","added_by":"auto","created_at":"2026-03-11 08:57:18","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":27455,"visible":true,"origin":"","legend":"\u003cp\u003eACHD programs by annual outpatient visit volume. Subgroups based on the types of primary institution are also demonstrated.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9034016/v1/65c6f6ca1fe8c4a01f6df417.png"},{"id":104387332,"identity":"de74d6fa-bc91-405d-9062-217ea4bcd400","added_by":"auto","created_at":"2026-03-11 08:57:36","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":34797,"visible":true,"origin":"","legend":"\u003cp\u003eNumbers of workers in ACHD programs based on annual outpatient visit volume. A: ACHD providers and APPs; B: clinical coordinators and administrative coordinators.\u003c/p\u003e\n\u003cp\u003eACHD: adult congenital heart disease; and APP: advanced practice provider.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-9034016/v1/8ccb56f967a747e911932bbf.png"},{"id":104387391,"identity":"797daf28-fcb4-4280-bec5-fe79c5def4f8","added_by":"auto","created_at":"2026-03-11 08:57:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":822053,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9034016/v1/b49343e3-b531-4d5a-a4d9-7f814f287238.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Organizational factors to support collaborative care in Adult Congenital Heart Disease Programs","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe field of adult congenital heart disease (ACHD) evolved after the advent of neonatal repair of complex congenital heart disease (CHD) in the 1970s. Survival to age 18 years is expected for 90% of children, including ones with severe CHD in the current era. There is a rapid growth of the ACHD patient population, and 1.4\u0026nbsp;million ACHD patients were estimated to live in the United States in 2010, surpassing the number of children with CHD.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Over the course of their life time, many patients with CHD develop sequelae of either native CHD or surgical repair, including valvular heart disease, heart failure, arrhythmia, thromboembolism, endocarditis, and other medical comorbidities such as liver disease, pulmonary disease, kidney disease, and mental health disorders. Additionally, a large proportion of ACHD patients are of reproductive age, and female patients may undergo pregnancy with a higher risk of cardiac events, which could impact both maternal and fetal outcomes. ACHD patients frequently require multiple specialty care, which often includes care at more than single healthcare systems.\u003c/p\u003e \u003cp\u003ePractice guidelines have been published to promote access to specialized ACHD care, standardization of care delivery, education of patients and their families, education of adult cardiovascular specialists and pediatric cardiologists, and liaison with regulatory agencies to meet the demand of the growing ACHD population.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e–\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e ACHD programs were developed in major U.S. cities and expanded throughout the country to provide care to this unique, complex, and heterogeneous ACHD population and function as a resource for referring health care providers. In a publication from 2009, it was estimated that at least 150 ACHD specialized programs were required to care for 50% of the ACHD population with moderate to severe forms of CHD.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e More recently, specialized ACHD care was independently associated with a significant mortality reduction.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e The Adult Congenital Heart Association (ACHA) is a national organization founded in the United States as a patient and family community with its mission to empower the congenital heart disease community by advancing access to resources and specialized care and improving patient-centered outcomes.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e ACHA maintains an ACHD clinic directory to improve access to ACHD programs, and the number of ACHD programs listed exceeds 100 programs in North America. In healthcare institutions, adult congenital heart disease programs are often organized as a subgroup in the cardiology division, although they are often named \"programs.\" An innovative approach outside of traditional healthcare is necessary to accommodate accessible, seamless, comprehensive, and patient and family-centered care. Frequently, providers in the ACHD program see patients at multiple healthcare institutions from independent healthcare organizations with infrastructural support from each healthcare organization, including human resources and technology structure. Because each organization has unique organizational leadership, goal, vision, strategy, structure, environment, culture, and process, ACHD programs need to build collaborative structures and navigate the complex business environment. Collaboration, partnership, and coordination have increasing importance for ACHD programs to achieve the goal of providing the best care to ACHD patients.\u003c/p\u003e \u003cp\u003eIn the United States, the fragmented nature of the U.S. healthcare system challenges efficient collaboration and needs harmonized care coordination for healthcare service delivery. Healthcare professionals are confronted with a demand for inter-professional and inter-organizational collaboration among different disciplines and types of primary, secondary, and tertiary care institutions to achieve more effective care delivery and comprehensive services.\u003c/p\u003e \u003cp\u003eFrom clinical practice perspectives, a patient-centered medical home has emerged as a model of a standard of care for all children and adults to provide coordinated, high-quality, compassionate, cost-effective, and patient- and family-centered care. Care coordination tools have been developed by numerous organizations, and the American Academy of Pediatrics published a policy statement on patient- and family-centered care coordination.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Quality of care coordination changed over time in medical homes for children with special health care needs, showing a change from being reactive to episodic needs to more systematically proactive and comprehensive.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eFrom the systematic perspective on collaboration, horizontal and non-horizontal collaborations have been described, and hospitals generally operate in small horizontal collaborations, while nursing homes, disability care, and mental care services tend to have non-horizontal collaborations.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e A literature review paper on core concepts and theoretical frameworks of interprofessional collaboration identified sharing, partnership, power, interdependency, and process as five concepts related to collaboration.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e It also showed that the most complete models of collaboration seem to be based on a strong theoretical background and empirical data. A study evaluated inter-organizational collaboration in perinatal services demonstrated an association of strong leadership at the regional and local levels with higher levels of inter-organizational collaboration, which had more efficient services.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Factors contributing to collaboration in healthcare were sought in various collaborative settings such as healthcare providers, organizations, and integrated healthcare networks, and several factors were identified, including shared purpose, governance, finance, shared data, trust, and partnerships.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e–\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eA practical model of collaboration between professionals in healthcare organizations was described via semi-structured interviews with healthcare managers and professionals.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e This model has ten indicators (1. Goals, 2. Client-centered orientation vs. other allegiances, 3. Mutual acquaintanceship, 4, Trust, 5. Centrality, 6. Leadership, 7. Support for innovation, 8. Connectivity, 9. Formalization tools, and 10. Information exchange) from four dimensions (shared goals and vision, internalization, governance, and formalization). For each indicator, a three-level typology of collaboration was proposed as potential collaboration, developing collaboration, and active collaboration, with higher levels of collaboration in this order. Figure\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e demonstrates a concept map showing components of ten indicators of collaboration in the four-dimensional model.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAlthough collaboration is critical for ACHD programs to achieve the goal of providing the best care to ACHD patients, there is a lack of literature to evaluate organizational factors for more collaborative work in ACHD practice. This study aims to evaluate organizational factors to support collaborative care in ACHD programs using the model by D’Amour.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eAn online cross-sectional survey was created, and study data were collected and managed using REDCap electronic data capture tools hosted at Children's National.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e This study had oversight by the institutional review board at Children’s National, and it was determined that approval was not required as this study involves program evaluation and not human subjects. Items in this survey included characteristics of ACHD programs such as types of primary institution (pediatric, adult, or combined), year of program from the establishment, the number of partnering organizations, number of annual outpatient visits, number of ACHD cardiologists and advanced practice providers (APP) who are spending \u0026gt; 50% of time in ACHD, supporting staff, and various ACHD consultation services. For the ten indicators of collaboration, respondents were asked to assess the level of collaboration among professionals in their ACHD program on the three levels. The survey included descriptions of the ten indicators and potential barriers to each indicator as references (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). The author asked three volunteers to pilot the survey and sought feedback to ensure internal validity and methodology, minimize potential bias, and maximize response. An effort was made to receive responses from many ACHD care center programs to maximize external validity. The final version of the survey was emailed to program directors or their associates of 86 U.S.-based programs listed in the clinic directory on the Adult Congenital Heart Association website (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.achaheart.org/\u003c/span\u003e\u003cspan class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e), after excluding 23 ACHD programs with inactive contact. Only ACHD programs in the United States were included because environmental factors such as business structure, legislation, and health insurance environment are relatively similar. Descriptive statistics were used for the characteristics of ACHD program, personnel, and consultation service by mean, median, range, or percentage as appropriate. Correlations between the numbers of various types of healthcare workers and outpatient visits per year were tested by Pearson correlation coefficient. Indicators of collaboration were analyzed using Fisher’s exact test or Kruskal-Wallis test to compare the distribution of the indicators across groups. The authors report there are no competing interests to declare.\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003ctable id=\"Tab1\" border=\"1\"\u003e \u003ccaption\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptions of ten indicators and potential barriers to each indicator\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003c/colgroup\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\"\u003e \u003cp\u003eIndicators\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eDescriptions\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003ePotential barriers\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eGoals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eConsensual values and goals shared by professionals and stakeholders (e.g., promoting patient-centered care).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eConflicting goals. Mistrust. Prejudice. Lack of mutual acquaintanceship. Lack of opportunity to discuss goals and values. Goals and visions not well shared or set among professionals.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eClient centered orientation versus other allegiances\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eClient-centered orientation shared by professionals and stakeholders.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eProfessional, personal, and organizational interests hindering client or patient-centered orientation (e.g., protecting professional or organizational autonomy than patient-centered orientation).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eMutual acquaintanceship\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eKnowing each other personally and professionally. Sense of belonging to the group.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eLack of opportunities to meet and socialize. Lack of joint projects or activities. Professionals do not know each other well.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eTrust\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eTrust in each other’s competencies and ability to assume responsibilities.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eConditional trust or lack of trust. Rapid turnovers of professionals. Professionals do not have solid trust in each other.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eCentrality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eInstitution/organization- level leadership/authorities providing clear direction and playing a strategic and political role to implement collaborative process and structures.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eLack of strong central leadership in providing clear direction to promote and support collaboration. Ambiguous political and strategic role or complete absence of such role. Institutional leadership not supporting program director’s effort toward collaborative work.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eLeadership\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eLocal leadership, either by position or emerging leadership to develop interprofessional and interorganizational collaboration.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eUnfocused or fragmented local (subgroup level) leadership to promote and support collaboration. Non-consensual, monopolistic leadership. Program director unable to focus or spend adequate time on program management to support collaborative work.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eSupport for innovation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eExpertise and supportive environment in starting new practices or dividing/sharing responsibilities in different ways among professionals.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eSporadic, fragmented, or little expertise or environment to support collaboration and innovative approach. Limited resource, environment, or professionals’ willingness to support new or modified practice.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eConnectivity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eInterconnectedness of individuals and organizations allowing discussion and participation for continuous adjustments to solve coordination problems.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eLimited information sharing and feedback system or discussion, such as regular meetings or working committees. Lack of communication or communication tools or forums. Ineffective communications among professionals.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eFormalization tools\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eFormal rules and agreements clarifying responsibilities and sharing of responsibilities.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eAbsence or limited details of interorganizational agreements, protocols, or information systems. Non-consensual agreement. Rules dictated by a certain group or professional. Limited policy or unclear rules regarding work and responsibilities among professionals.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eInformation exchange\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eInfrastructure to support information exchange among professionals.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eIncomplete or absence of infrastructure or mechanism for collecting or exchanging information. Lack of effective system for transferring or exchanging medical records or medical orders among different health care organizations or professionals.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/table\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe survey was sent via email to 86 U.S.-based programs. Nearly half the programs (41.8%, N\u0026thinsp;=\u0026thinsp;36) completed the survey. The types of primary institution were combined adult and pediatric institution (61.1%, N\u0026thinsp;=\u0026thinsp;22), pediatric institution (27.8%, N\u0026thinsp;=\u0026thinsp;10), and adult institution (11.1%, N\u0026thinsp;=\u0026thinsp;4). The distribution of ACHD programs by annual outpatient visit volume is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and characteristics of ACHD programs are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The median number and interquartile range (IQR) of healthcare organization(s) participating in providing ACHD care were 2 (IQR 1\u0026ndash;3). The median number and IQR of ACHD providers, advanced practice providers, and all coordinators or assistants were 4 (IQR 3\u0026ndash;5), 1 (IQR 1\u0026ndash;2), and 1 (IQR 1\u0026ndash;3), respectively. The median number of clinical coordinators was 1 (range 0\u0026ndash;5, IQR 1\u0026ndash;2), with the majority of clinical coordinators being registered nurses. The median number of administrative coordinators or assistants was 1 (range 0\u0026ndash;5, IQR 1\u0026ndash;2). Fourteen ACHD programs (38.9%) had no administrative coordinators or assistants spending\u0026thinsp;\u0026gt;\u0026thinsp;50% of their time in the ACHD program, and this was observed in ACHD programs with a wider range of annual outpatient visits volume. Five ACHD programs (13.9%) answered they have no coordinators or assistants. These five programs had a relatively lower number of annual outpatient visits volume. For the number of healthcare professionals and supporting staff, there was a statistically significant positive correlation with annual outpatient visit volume in ACHD providers (R\u0026thinsp;=\u0026thinsp;0.673, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), APPs (R\u0026thinsp;=\u0026thinsp;0.468, p\u0026thinsp;=\u0026thinsp;0.005), and administrative coordinators or assistants (R\u0026thinsp;=\u0026thinsp;0.596, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), but not in clinical coordinators (R\u0026thinsp;=\u0026thinsp;0.141, p\u0026thinsp;=\u0026thinsp;0.442) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of ACHD programs\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eYear established\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eInterquartile Range\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1980\u0026ndash;2023\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2007\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2001\u0026ndash;2013\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutpatient visits per year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e300\u0026ndash;5200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1900\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1000\u0026ndash;2775\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of healthcare organizations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of EMR systems\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1-2.75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of credentials and privileges\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.25-5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of states and jurisdictions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of ACHD providers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u0026ndash;5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of APPs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of all coordinators or assistants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of clinical coordinators\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of administrative coordinators or assistants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eACHD cardiac surgery hospitals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eACHD obstetrics hospitals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eACHD cardiac catheterization hospitals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eACHD electrophysiology procedure hospitals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eACHD CMR or CCT hospitals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eACHD: adult congenital heart disease; APP: advanced practice provider; CCT: cardiac computed tomography; CMR: cardiac magnetic resonance imaging; and EMR: electronic medical record.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFor the ten indicators of collaboration, several ACHD programs either left unanswered or answered \"unsure\" for indicators including goals (N\u0026thinsp;=\u0026thinsp;3), client-centered orientation versus other allegiances (N\u0026thinsp;=\u0026thinsp;5), centrality (N\u0026thinsp;=\u0026thinsp;3), and formalization tools (N\u0026thinsp;=\u0026thinsp;4). These unanswered or unsure responses were removed from further analysis. The results are shown in number of responses and percentages by three levels of collaboration as all and three subgroups based on types of primary institution, combined adult and pediatric institution (N\u0026thinsp;=\u0026thinsp;22), pediatric institution (N\u0026thinsp;=\u0026thinsp;10), and adult institution (N\u0026thinsp;=\u0026thinsp;4) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Across ten indicators, more ACHD programs responded as active collaboration level in leadership (88%) and connectivity (86%), while fewer ACHD programs responded as active collaboration level in goals (67%), centrality (70%), formalization tools (69%), and information exchange (69%). When the three subgroups were compared, there were differences in responses with statistical significance for support for innovation (p\u0026thinsp;=\u0026thinsp;0.011) and formalization tools (p\u0026thinsp;=\u0026thinsp;0.024), showing lower levels of collaboration in pediatric institution group than the other two groups. We also conducted an analysis to compare combined adult and pediatric institution group and pediatric institution group given the small number of adult institutions, and differences in responses with statistical significance were identified in support for innovation (p\u0026thinsp;=\u0026thinsp;0.009), formalization tools (p\u0026thinsp;=\u0026thinsp;0.013), and information exchange (p\u0026thinsp;=\u0026thinsp;0.040), showing higher levels of collaboration in the combined adult and pediatric institution group and lower levels of collaboration in the pediatric institution group. The comparison of ACHD programs with low volume (annual outpatient visit\u0026thinsp;\u0026lt;\u0026thinsp;2000) and high volume (annual outpatient visit \u0026ge; 2000) is demonstrated in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. There were no statistically significant differences observed in any of ten indicators, although the ACHD programs with high volume had more programs in active collaboration particularly in mutual acquaintanceship and centrality.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIndicators of collaboration. Results shown in number of responses and percentages by three levels of collaboration as all and subgroups based on types of primary institution.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLevels of collaboration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAll\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCombined adult and pediatric institution\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePediatric institution\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAdult institution (n\u0026thinsp;=\u0026thinsp;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep-value comparing all three subgroups\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ep-value comparing combined adult and pediatric institution to pediatric institution\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eGoals\u003c/p\u003e \u003cp\u003e(No answer\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePotential\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (11%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.431\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.204\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeveloping\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (27%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (44%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (25%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eActive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (75%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (44%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3 (75%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eClient centered orientation versus other allegiances\u003c/p\u003e \u003cp\u003e(No answer\u0026thinsp;=\u0026thinsp;5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePotential\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.570\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.633\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeveloping\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (23%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (21%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (23%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eActive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (77%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (79%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (77%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eMutual acquaintanceship\u003c/p\u003e \u003cp\u003e(No answer\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePotential\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.557\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.384\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeveloping\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (26%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (40%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (25%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eActive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (74%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (80%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (60%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3 (75%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eTrust\u003c/p\u003e \u003cp\u003e(No answer\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePotential\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.193\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.172\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeveloping\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (40%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eActive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (80%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 (86%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (60%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eCentrality\u003c/p\u003e \u003cp\u003e(No answer\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePotential\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (15%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (30%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.155\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.076\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeveloping\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (15%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (30%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eActive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (70%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (81%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (40%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eLeadership\u003c/p\u003e \u003cp\u003e(No answer\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePotential\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.228\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.095\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeveloping\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eActive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (88%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (95%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (70%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eSupport for innovation\u003c/p\u003e \u003cp\u003e(No answer\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePotential\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003e0.011\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003e0.009\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeveloping\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (21%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (25%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eActive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (79%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (95%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3 (75%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eConnectivity\u003c/p\u003e \u003cp\u003e(No answer\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePotential\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.448\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.246\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeveloping\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (11%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eActive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (86%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (90%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (70%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eFormalization tools\u003c/p\u003e \u003cp\u003e(No answer\u0026thinsp;=\u0026thinsp;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePotential\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003e0.024\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003e0.013\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeveloping\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (31%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (16%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (25%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eActive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (69%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (84%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3 (75%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eInformation exchange\u003c/p\u003e \u003cp\u003e(No answer\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePotential\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.082\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003e0.040\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeveloping\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (31%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (19%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (60%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (25%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eActive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (69%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (81%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (40%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3 (75%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e\u003csup\u003ea\u003c/sup\u003e Using Kruskal-Wallis test, \u003csup\u003eb\u003c/sup\u003e using Fisher\u0026rsquo;s exact test\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIndicators of collaboration shown by low volume (\u0026lt;\u0026thinsp;2000) and high volume (\u0026ge; 2000) ACHD programs based on annual outpatient visits among 34 ACHD programs reported the volume. No statistically significant differences observed by Fisher\u0026rsquo;s exact test in any of 10 indicators.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLevels of collaboration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLow volume (n\u0026thinsp;=\u0026thinsp;17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHigh volume (n\u0026thinsp;=\u0026thinsp;17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGoals\u003c/p\u003e \u003cp\u003e(No answer\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePotential\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.836\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeveloping\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (31%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eActive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (73%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (63%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eClient centered orientation versus other allegiances\u003c/p\u003e \u003cp\u003e(No answer\u0026thinsp;=\u0026thinsp;5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePotential\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.667\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeveloping\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (31%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (19%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eActive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (69%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (81%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eMutual acquaintanceship (No answer\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePotential\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.106\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeveloping\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (40%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (12%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eActive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (60%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (88%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eTrust\u003c/p\u003e \u003cp\u003e(No answer\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePotential\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.398\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeveloping\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (12%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eActive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (75%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (88%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eCentrality\u003c/p\u003e \u003cp\u003e(No answer\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePotential\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (19%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.197\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeveloping\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eActive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (56%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (87%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eLeadership\u003c/p\u003e \u003cp\u003e(No answer\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePotential\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.161\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeveloping\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (19%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eActive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (81%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (94%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eSupport for innovation\u003c/p\u003e \u003cp\u003e(No answer\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePotential\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeveloping\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (19%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (24%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eActive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (81%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (76%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eConnectivity\u003c/p\u003e \u003cp\u003e(No answer\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePotential\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.402\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeveloping\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (13%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eActive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (81%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (94%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eFormalization tools\u003c/p\u003e \u003cp\u003e(No answer\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePotential\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.458\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeveloping\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (40%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eActive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (60%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (75%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eInformation exchange\u003c/p\u003e \u003cp\u003e(No answer\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePotential\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.402\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeveloping\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (31%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (29%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eActive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (69%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (71%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe purpose of this study was to evaluate organizational factors to support collaborative care in ACHD programs. First, we provided descriptions of the heterogeneous nature of organizational structure and the environment in which ACHD programs are situated. It is expected that the complexity of organizational structure and environment will likely increase over time with increasing complexity of healthcare systems and care specialization. In this study, combined adult and pediatric institution was the most prevalent type of primary institution compared to pediatric or adult institution. It is unknown if there has been a shift in ACHD care from pediatric institutions to combined adult and pediatric institutions over time as the ACHD specialty field emerged and matured or vice versa. Also, it is possible that the regional environment and history surrounding healthcare institutions may be a significant determinant of the primary institution types on which ACHD programs are based. Second, this study described indicators of collaboration and their three-level typology among ACHD programs. Among the ten indicators, more ACHD programs responded as active collaboration level in leadership and connectivity, while fewer ACHD programs responded as active collaboration level in goals, centrality, formalization tools, and information exchange. This may reflect relatively stronger local leadership of ACHD programs and connectivity of core workers, and ACHD programs' perceived challenges in goals and strategies at the institutional leadership level as well as challenges in formalizing processes and sharing information. This may also be due to frequent challenges in caring for ACHD patients with unique and complex medical needs. When ACHD programs were analyzed by subgroups between combined adult and pediatric institution and pediatric institution as types of primary institution, there was a statistically significant difference in three indicators: support for innovation, formalization tools, and information exchange, showing higher levels of collaboration in the combined institutions and lower levels of collaboration in the pediatric institutions. This may reflect challenges in providing ACHD care and various specialty services for adult patients in pediatric institutions using innovative ways beyond traditional pediatric care practice, formalizing standard tools, and creating rules and agreements. It may also be due to ACHD programs with primary pediatric institutions facing more challenges in sharing or retrieving information among healthcare workers across multiple independent institutions. Although there were no statistically significant differences, our data suggested that ACHD programs with higher volume had more programs in active collaboration in mutual acquaintanceship and centrality compared with ACHD programs with lower volume, which are likely necessary features to develop and maintain larger volume ACHD programs. Future studies could focus on these indicators to further describe details and help understand barriers and opportunities for more collaborative work.\u003c/p\u003e \u003cp\u003eThere are several limitations of this study. First, the number of ACHD programs that participated in this survey was relatively small. Furthermore, there may be a selection bias as 23 ACHD programs could not be reached due to absence of active contact or person. The survey results are possibly skewed to represent larger size and long-established ACHD programs. There can also be recall bias in answering the survey. Second, the human resources supporting ACHD programs' daily functions, such as clinical coordinators and administrative coordinators and assistants, were thought to be difficult to capture accurately because titles and job descriptions of these workers are heterogeneous throughout ACHD programs. These workers can be full-time or part-time and are often shared by multiple subgroups of the division or department and not solely designated to work for ACHD programs based on the employment style and structure of the institution. Third, survey questions on the concept of indicators of collaboration and the three-level typology might have been challenging for respondents to understand and answer appropriately, due to difficulty in applying this conceptual framework to their real-world practice.\u003c/p\u003e \u003cp\u003eIn conclusion, this study provided descriptions of the organizational structure and environment of ACHD programs in the United States. This study also described organizational factors among ACHD programs, suggesting unique challenges and opportunities ACHD programs face.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eACHA:\u0026nbsp;Adult Congenital Heart Association; ACHD: adult congenital heart disease; APP: advanced practice providers; CHD: congenital heart disease; and IQR: interquartile range.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eFunding: none\u003c/p\u003e\n\u003cp\u003eDisclosure statement: The authors report there are no competing interests to declare.\u003c/p\u003e\n\u003cp\u003eAcknowledgment\u003c/p\u003e\n\u003cp\u003eThe authors appreciate all the ACHD programs that participated in this survey. We also appreciate the feedback provided from the ACHD programs through the pilot and survey study. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSources of Funding\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003eDisclosures\u003c/p\u003e\n\u003cp\u003eAll of authors have nothing to disclose.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eGilboa SM, Devine OJ, Kucik EJ, et al. Congenital Heart Defects in the United States. \u003cem\u003eCirculation\u003c/em\u003e. 2016;134:101\u0026ndash;109. DOI: 10.1161/CIRCULATIONAHA.115.019307\u003c/li\u003e\n \u003cli\u003eWarnes CA, Williams RG, Bashore TM, et al. 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The conceptual basis for interprofessional collaboration: core concepts and theoretical frameworks. \u003cem\u003eJ Interprof Care\u003c/em\u003e. 2005 May;19 Suppl 1:116-31. doi: 10.1080/13561820500082529.\u003c/li\u003e\n \u003cli\u003eD\u0026apos;amour D, Goulet L, Pineault R, et al. Comparative study of interorganizational collaboration in four health regions and its effects: the case of perinatal services. June 2003. https://www.semanticscholar.org/paper/Comparative-study-of-interorganizational- in-four-%3A-D%27amour-Goulet/a50b0c374ef78356d1f8f0b5effc0449b0442b44\u003c/li\u003e\n \u003cli\u003eLanford D, Petiwala A, Landers G, et al. Aligning healthcare, public health and social services: A scoping review of the role of purpose, governance, finance and data. \u003cem\u003eHealth Soc Care Community\u003c/em\u003e. 2022 Feb;30(2):432-447. doi: 10.1111/hsc.13374.\u003c/li\u003e\n \u003cli\u003eLarsson LG, B\u0026auml;ck-Pettersson S, Kyl\u0026eacute;n S, et al. A national study on collaboration in care planning for patients with complex needs. \u003cem\u003eInt J Health Plann Manage\u003c/em\u003e. 2019 Jan;34(1):e646-e660. doi: 10.1002/hpm.2680.\u003c/li\u003e\n \u003cli\u003eLewis, VA, Tierney, KI, Colla CH , et al. The new frontier of strategic alliances in health care: New partnerships under accountable care organizations. \u003cem\u003eSoc Sci Med\u003c/em\u003e. 2017 Oct;190:1-10. doi: 10.1016/j.socscimed.2017.04.054.\u003c/li\u003e\n \u003cli\u003eD\u0026apos;Amour D, Goulet L, Labadie JF, et al. A model and typology of collaboration between professionals in healthcare organizations. \u003cem\u003eBMC Health Serv Res\u003c/em\u003e. 2008 Sep 21;8:188. doi: 10.1186/1472-6963-8-188.\u003c/li\u003e\n \u003cli\u003eHarris PA, Taylor R, Thielke R, et al. Research electronic data capture (REDCap)-- a metadata-driven methodology and workflow process for providing translational research informatics support. \u003cem\u003eJ Biomed Inform\u003c/em\u003e. 2009 Apr;42(2):377-81. doi:10.1016/j.jbi.2008.08.010.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"pediatric-cardiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pedc","sideBox":"Learn more about [Pediatric Cardiology](http://link.springer.com/journal/246)","snPcode":"246","submissionUrl":"https://submission.nature.com/new-submission/246/3","title":"Pediatric Cardiology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Adult congenital heart disease, collaboration, organization development, specialty care program","lastPublishedDoi":"10.21203/rs.3.rs-9034016/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9034016/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Collaboration among healthcare workers is critical for adult congenital heart disease (ACHD) programs to provide care to ACHD patients with complex needs.\u003c/p\u003e\n\u003cp\u003eObjectives: This study aimed to describe ACHD programs’ organizational structure, environment, and indicators of collaboration.\u003c/p\u003e\n\u003cp\u003eMethods: A cross-sectional survey among ACHD programs in the United States was conducted, including questions on characteristics, personnel, services, and ten indicators of collaboration using a model described by D’Amour.\u003c/p\u003e\n\u003cp\u003eResults: The survey was sent to 86 ACHD programs, and 36 programs (41.8%) responded. The types of ACHD programs’ primary institution were combined adult and pediatric institution (61.1%, N=22), pediatric institution (27.8%, N=10), and adult institution (11.1%, N=4), and most ACHD programs had 1 to 3 healthcare organization(s) participating. The median number and interquartile range (IQR) of ACHD providers, advanced practice providers (APP), clinical coordinators, and administrative coordinators or assistants were 4 (IQR 3-5), 1 (IQR 1-2), 1 (IQR, 1-3), and 1 (IQR 1-2) respectively. Among the ten indicators of collaboration, leadership and connectivity were rated higher, and goals, centrality, formalization tools, and information exchange were rated lower. When analyzed by subgroups based on the types of primary institution, statistically significant differences in responses were demonstrated in support for innovation, formalization tools, and information exchange, showing higher levels of collaboration in the combined adult and pediatric institution group compared with the pediatric institution group.\u003c/p\u003e\n\u003cp\u003eConclusions: This study provided descriptions of the organizational structure and environment of ACHD programs. 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