Clinical Teams

The purpose of a clinical team is to deliver excellent health care to its patients, and so an effective clinical team is one that delivers high quality care. As discussed in Chapter 4, in 2001 the Institute of Medicine (IOM) set forth 6 aims for the improvement of health care (Institute of Medicine, 2001, pp. 39-60). The 6 aims are shown in Table 6–1. Taken together, they constitute a definition of quality in health care. An effective clinical team is one that achieves these aims.

Safety

Safe health care is care free of errors that cause injuries to patients (Institute of Medicine, 2000, pp. 18-40). A clinical team is a safe team if it avoids giving patients the wrong medication, failing to diagnose cancer or other diseases at an early stage, performing surgery on the wrong (unintended) body part, and so on. Many medical treatments carry known risk, for example, the risk of infection following high-dose chemotherapy for various cancers. When the risk is justified by the potential benefit for the patient, the occurrence of the unwanted consequence does not mean that the care was unsafe. Unsafe care is care that results from errors, that is, accidents or mistakes. Unsafe care resulting from an accident is either care that includes unintended actions or care from which components are unintentionally omitted, causing or threatening harm. An example of unsafe care due to an accident is surgery during which the surgeon removes the patient’s appendix but also unintentionally punctures the nearby small intestine. Unsafe care resulting from a mistake is care that includes actions that are intentional but are improperly chosen, causing or threatening harm. An example of unsafe care due to a mistake is a tonsillectomy performed on the wrong child because the child was improperly identified prior to surgery. The surgeon intentionally operated on the child, that is, the removal of the child’s tonsils was not an accident; but the identification of the child was mistaken.

Effectiveness

Effective health care is care that can be expected to prevent, cure, or alleviate the symptoms of a disease because the care is known to be successful in achieving one or another of these objectives, ideally on the basis of scientific evidence demonstrating the effectiveness of the diagnostic test or the treatment in question. Effective care achieves its objective of undoing the ill effects of physical or mental disease or of preventing the disease from occurring. At first blush, it may appear tautological and uninformative to define effective clinical teams in part as teams that achieve effectiveness; this would seem to be true by definition. But, of course, the word effectiveness is used here in a special sense. Effective clinical teams aim to achieve more than effectiveness in this narrow sense, for example, they aim to achieve patient-centeredness and other objectives noted below. Effective care, in this narrow sense, is care that repairs the biological machine—or repairs the mental machine, or prevents either one from needing repairs.

Patient-Centeredness

Patient-centeredness is discussed in detail in Chapter 4. Patient-centered health care is care that is focused on achieving the patient’s goals, is consistent with his or her values and preferences, and is attentive to his or her experience of health care.

Timeliness

Timely health care is care that is free of unnecessary delays. These delays include waits to obtain an appointment to see a clinician in a healthcare team, waits in the emergency room, waits to receive information about test results, waits for surgery to be done, and so on.

Efficiency

Efficient health care is care that uses the fewest resources possible to achieve the desired outcome, whatever it is. The essence of efficient care is absence of waste. Efficient care and low-cost care are not the same. Low cost can usually be achieved by accepting a lesser outcome, in other words, by withholding various services that are necessary to achieve the desired outcome. Under these circumstances, decreasing the cost would not result in high efficiency in achieving the original outcome because that outcome has been set aside. The care might be efficient in achieving the less desirable outcome, but that is a separate question; and this question is commonly of no interest because the lesser outcome is not desired.

Efficient care and high-value care are also not the same. Value is defined as outcome relative to cost as shown in Figure 6–1 (Porter, 2010). High-value health care is care that produces good results—as judged, for example, by the IOM 6 aims—for low cost so that the outcome “numerator” divided by the cost “denominator” yields a value “quotient” that is high. One could improve the value score for an episode of health care either by improving the outcome or lowering the cost. Also, the same value quotient could be achieved by combining a high-outcome numerator with a moderate-cost denominator or by combining a low-outcome numerator with a very low-cost denominator. In other words, high value could be achieved by sacrificing effectiveness as defined above, provided that the cost is low enough. For this reason, it is either incomplete or misleading to say baldly that clinical teams should aim to provide high-value care without saying something about quality and cost as separate considerations. The concept of value encompasses both quality and cost, and it conflates the contributions of the two. Efficiency is a less ambitious concept than value. Any claim of efficiency is made relative to a specified level of achievement of outcomes. Fully efficient care is simply care that is free of waste in achieving whatever outcome is under consideration.

Equity

Equitable health care is care that is delivered without regard to considerations that are irrelevant to health needs, for example, gender, race, ethnic group, or urban versus rural location. Seeking equity in health care means pursuing reductions in disparities across different populations defined by income level and other factors that ought to be irrelevant to the care provided and the quality of care provided. Seeking equity also means providing care at the same level of quality to individuals without regard to these irrelevant factors considered as personal characteristics of the individual.

Assessing a Clinical Team’s Effectiveness

Although the burden of measurement would be great, one could in theory determine the effectiveness of a clinical team by measuring its activities and outputs across the 6 IOM aims. Clinical teams vary with respect to the emphasis they place on different IOM aims, but all 6 aims are important for all teams. For example, a team of nurses and social workers staffing a hospital ward typically will be focused heavily on patient-centeredness, but safety, effectiveness, and timeliness also will be important parts of their goal. In measuring team effectiveness, adjustments would be needed to take account of the disease burden in the population of patients served by the assessed team. For some measures, the circumstances under which the team operates would also need to be taken into account, for example, whether a rural hospital has the equipment to handle certain rare emergencies. Making these adjustments would be no small matter. But even without an operational method for measuring effectiveness, the concept of effectiveness—based on the IOM aims—is clear in its application to clinical teams. In other words, clinical teams are effective insofar as they achieve the 6 aims.

Management Teams

All clinical teams are alike in their aims, but different management teams have different aims. All clinical teams aim to provide high-quality health care to their patients. Some management teams aim to devise effective business strategy for healthcare systems; other management teams have a specific time-limited objective, for example, implementation of a new billing system; other management teams provide advice to decision makers but do not take action themselves. Some management teams work to provide good health care in a particular operational unit such as an intensive care unit (ICU), but the operational team for an ICU works only through those who deliver care directly, namely, the clinical ICU team. While the IOM 6 aims define the purpose of the clinical ICU team, they do not define the purpose of the ICU’s operational team considered as a separate component of the whole. The IOM aims would not be helpful in determining the operational team’s contribution to the success of the entire unit. Other management teams are aimed at more abstract objectives such as financial security or a favorable community reputation for an integrated health system. Again, the IOM aims will not serve to define their purposes. For a management team, as with a clinical team, the touchstone of effectiveness is achievement of its purpose. These purposes can be specified for individual management teams in a way that permits assessment of their effectiveness, but little can be said about how to specify the aims of management teams in general.

CHARACTERISTICS OF EFFECTIVE TEAMS

An effective team is one that achieves its purpose; and when achievement of purpose can be measured, this approach to assessing effectiveness is superior to all others. However, adequate information on achievement of purpose is often difficult to obtain or cannot be obtained within a workable time frame. And so it is useful to have additional measures of effectiveness. Fortunately, many additional measures are available. When achievement of purpose cannot be measured, one can assess the quality of a team by examining characteristics that are conducive to achievement of purpose. This approach is analogous to measuring clinical quality by measuring process measures instead of outcome measures. The approach is sound if the processes measured are known to contribute to achieving the outcomes of interest. In the case of clinical teams, these outcomes are one or more of the IOM 6 aims. In the case of management teams the outcomes depend on the purpose of the team.

Those who come to the topic of teamwork with a background in clinical science, especially pharmacists and physicians, will want empirical evidence for claims that certain team attributes and processes lead to achievement of the team’s goals. In medicine, pharmacy, and other clinical fields, best evidence commonly comes from controlled trials, often randomized, controlled trials. But teamwork (including clinical teamwork) is a management topic, not a clinical topic. Unlike evidence-based practice in health care, evidence-based management is in its infancy. Sometimes the desired evidence is available, and some of that evidence is cited in Chapters 1 and 2. For some claims, however, the only evidence available comes from case studies or the experience of managers. Given the usual impracticality (or impossibility) of doing controlled trials, the complexity of organizational systems, and the difficulty of generalizing from one setting to another, we may never reach the level of evidence for management decision making that we already have for making many clinical decisions (Begun, 2009). In the workaday world, one has no choice but to move forward using what is available while pressing for more evidence and sometimes gathering it along the way.

Work Team Defining Characteristics Revisited

In Chapter 1, the defining characteristics of a work team are discussed. In exploring the effectiveness of teams, it is assumed, of course, that these teams are real teams, with all 7 defining characteristics. Some of the characteristics of effective teams are particularly robust or well-developed versions of these defining characteristics, which are listed in Table 1–1 in Chapter 1. Briefly, the characteristics are (1) the presence of a shared goal for the team, (2) shared responsibility for achieving the goal, (3) defined team membership, (4) possession by the team of sufficient authority to achieve its goal, (5) interdependency of team members in accomplishing their tasks, (6) absence of sub-groups that operate without accountability to the whole team, and (7) accountability of the team to the larger organization in which it works (if there is a larger organization).

Effective Team Characteristics

Going beyond these initial 7 characteristics, effective teams can be described with more richness by considering their attributes under 5 categories: (1) structure of the team, (2) focus of the team on the patient, (3) orientation of team members to the team, (4) collaborative work done by the team, and (5) management of the team. The different types of healthcare teams are discussed in Chapter 2. The types of clinical teams are listed in Table 2–1, and the types of management teams are listed in Table 2–9. The characteristics falling under each of the 5 categories of effectiveness apply to true clinical teams and template clinical teams. Only some of the characteristics apply to clinical knotworks. This limitation is not surprising since knotworks do not have all 7 defining characteristics of work teams and are team-like groups rather than full-blown teams. The characteristics under each of the 5 categories also apply to management teams, that is, to operational teams, project teams, consultative teams, and leadership teams. Figure 6–2 depicts the 5 categories, considered as clusters of components of effective team performance.

Team Structure

David Ziegler, MD, was leading rounds in the surgical ICU on Wednesday morning. The ICU was part of a teaching hospital in Washington State. Dr. Ziegler was the head of the unit. With him were 2 surgical residents, a clinical pharmacist, a physician assistant, and 3 medical students doing their clerkships in surgical intensive care (6-week training periods). The head nurse sometimes joined the group on rounds, but she was attending an administrative meeting that morning. Sometimes the social worker attached to the unit also joined the group, but that morning she was meeting with the family of a critically ill patient. As the group moved from patient to patient, the critical care nurse caring for each patient joined the discussion. When the clinicians were seeing a patient who could participate in the discussion, they included the patient too—although most of the patients were either sedated or too ill to join in. Dr. Ziegler frequently asked questions of the other members of the group. One or the other of the 2 residents had primary medical responsibility for each of the patients, and for each patient Dr. Ziegler asked the responsible resident for the details of the patient’s progress and for the test results obtained since the group had rounded the evening before. He asked the medical students more general questions about the patient’s medical problem or the significance of various test results. Throughout these interactions it was clear that Dr. Ziegler was in charge. The residents answered his questions quickly and respectfully, avoiding any extraneous comments. They also offered their viewpoints freely and showed no signs of hesitation in stating their views. The medical students answered as well as they could, but sometimes they did not know the answers. All 3 of them looked nervous but not intimidated. When a medical student could not answer a question, Dr. Ziegler would either answer the question himself or redirect it to one of the residents. He never belittled the students for answering incorrectly or for not being able to answer his questions. The pharmacist was often asked for information and judgments about the drugs being administered, and she often volunteered comments unprompted. The critical care nurses usually offered comments on the patient’s progress after the resident responsible for that patient had summarized the key events during the past 18 hours or so. The critical care nurses often commented on whether the patient was agitated and whether the family members had visited. Dr. Ziegler’s manner was purposeful and earnest. However, he did offer light-hearted remarks from time to time, especially when talking with patients who were able to converse with him.

Dr. Ziegler’s team was a well-structured clinical team. The structural characteristics of effective teams are shown in Table 6–2.

First, like all other effective teams, the members not only had a shared goal but understood it very well and could have stated the goal clearly if asked (Thompson, 2011, p. 76). The first priority was to provide safe and effective care so that patients could quickly move through the ICU to a regular surgical unit in the hospital. In addition, they aimed to provide for the psychological and emotional needs of the patients and their families. For this second purpose the team relied especially on the nurses and the social worker.

Second, all of the team members understood that they shared responsibility for achieving their goal, that is, providing excellent health care for their patients.

Third, the membership of the team was well defined (Hackman, 2002, pp. 44-50), and the members’ roles were well defined (Thompson, 2011, p. 79; Mitchell et al, 2012, pp. 9-13). The team consisted of Dr. Ziegler, the residents, the critical care nurses, the head nurse, the pharmacist, the physician assistant, the social worker, and the health unit coordinator (a clerical staff member). The coordinator never participated in rounds but did participate in other team functions. The medical students were not core team members. They might be regarded as peripheral or secondary members. They were present to learn, not to care for the patients; and everyone understood this distinction. Although each patient was a member of his or her care team, in this case the patients’ participation was quite limited because of their medical conditions. In many cases, family members served as surrogates in making decisions about care. In total, the core team had 10-13 members, depending on the number of critical care nurses working at any given time. In other words, it was small enough for all of the members to interact directly with all of the other members and have complex, detailed conversations when such conversations were required for good patient care. We discuss the important question of team size, especially the advantages of small size, in Chapter 12 when discussing the design of teams.

Fourth, the team had a clear leader in Dr. Ziegler, and he was acknowledged by all other team members to be the leader. This feature of the team is implied by the clear roles for the members, but it merits special mention because of its importance, which is well recognized in health care (Firth-Cozens and Mowbray, 2001). The leadership need not be vested in one person. Some teams are genuinely co-led by 2 people. Co-leadership by 3 people usually reflects a political compromise, and is usually not functional for a long period of time—unless the arrangement is actually rotating leadership and not true co-leadership. This ICU care team in fact had rotating leadership since the attending surgeon changed every month. Dr. Ziegler would be replaced by another surgeon when his month as ICU head was completed.

This ICU team was led by a physician as is commonly the case for clinical teams. Must the leader of a clinical team always be a physician? Many physicians think so. For example, in the statement of principles for patient-centered medical homes, issued in 2007 jointly by 4 national physician associations, the second principle is that a medical home is a “physician-directed medical practice” (American Academy of Family Physicians et al, 2007). Many advanced practice nurses do not agree. In Chapter 8, we take up the contentious question of whether clinical team leaders must be physicians.

Fifth, the team had a steep enough hierarchy to provide for its needs. Hierarchies of authority enable decisions to be made quickly. Hierarchies also enable teams to maintain order and give people an understanding of what authority they have in the team (Leavitt, 2003). In this ICU team, Dr. Ziegler had final decision-making authority for treatment decisions requiring quick action, for example, decisions about whether rapidly deteriorating patients need to return to the operating room for the management of postoperative complications such as bleeding inside the chest. On the other hand, Dr. Ziegler did not demand frequent acknowledgements of his superior standing, and he welcomed information, opinions, and suggestions from the pharmacist, the nurses, and other team members—although probably not the medical students. All teams need some hierarchy of authority to maintain order; authority differences beyond the minimal level required to maintain order need to be justified because differences in status and authority within teams threaten communication as discussed in Chapter 2.

Sixth, the team had clear authority to do its work (Thompson, 2011, pp. 76-77). The team was expected to provide health care for the patients in the ICU without seeking input or approval from anyone except for the patients and their families, whom they regarded as team members in any case. Ultimately, the ICU, represented by Dr. Ziegler, the head nurse, and the unit’s administrator, were accountable to the senior leadership of the hospital (the Chief Medical Officer, Chief Nursing Officer, and Chief Executive Officer), but this accountability did not imply the need for any action by the senior leaders in the care of individual patients.

Seventh, the team had some degree of membership stability. As in all teaching hospitals, there was turnover in the team according to a calendar known to everyone well ahead of any changes. Dr. Ziegler was the attending surgeon this month, but there were 5 other surgeons who also served as attending surgeons, rotating each month. The residents changed every other month. Meanwhile, the head nurse, the other critical care nurses, the pharmacist, the social worker, and the health unit coordinator changed only rarely. As discussed in Chapter 2, stability of team membership is conducive to good performance. Thus even greater stability would likely make the team more effective. However, the attending physicians also had other duties to fulfill, and the residents were in training and needed to gain experience in surgical areas besides the ICU. Changes every month or two are preferable to changes every week. The team was as stable as it could be, given the other responsibilities of the surgeons. It was not a true team like the primary care team in Chapter 1 or the colonoscopy team in Chapter 2, but neither was a rapidly changing template team like the emergency room teams described in Chapter 2. It was somewhere in between. One might call this team a slow-turnover template team.

The value of membership stability is particularly well recognized in primary care (Willard and Bodenheimer, 2012), but stability is valuable for any team, for reasons detailed in Chapter 2. This has important implications for the scheduling of physicians, nurses, and other clinicians in template teams. Specifically, scheduling of whole teams is preferable to scheduling individuals separately because separate scheduling of individuals to comprise template teams results in constantly changing membership (Hackman, 2002, pp. 54-59). There are many factors that stand in the way of scheduling of whole teams in health care, and these factors are not unique to health care: tradition, union contracts, desires of clinicians to set their own schedules, and concerns about costs—although experience in some other industries indicates that costs are often reduced by scheduling whole teams (Hackman, 2002, pp. 58-59). If institutions continue to prefer scheduling individuals, they should at least acknowledge that this practice is second-best, and they should keep template teams intact whenever possible.

As depicted in Figure 6–2, a sound structure is the platform or foundation that enables a team to function well in the 4 areas to be discussed next. If pieces of the platform are missing, the team will be hampered in its performance. For example, if the membership of the team is not well defined, then the team will have difficulty in making decisions that last over time. And if a team is not stable, then it will be difficult for the team to develop a sense of identity.

Team Focus

The Chief Executive Officer (CEO), Chief Nursing Officer (CNO), Chief Medical Officer (CMO), Director of Pharmacy, attorney for the hospital, and Theresa Fournier, MD, were meeting on a Wednesday morning in 1992 to discuss the care of Bobby Harrington, a 5-year-old boy with leukemia, specifically, acute lymphoblastic leukemia (ALL). Dr. Fournier was a pediatric oncologist at a children’s hospital in North Carolina. She and her team had been treating Bobby.

Bobby had developed fatigue and severe nosebleeds about 6 weeks earlier. Investigation quickly revealed that he had ALL. His white blood count at the time was extremely high, placing him at higher risk of death than other children of similar age with ALL. Mr. and Ms. Harrington wanted to understand all they could about the disease and the treatment options available for Bobby. The initial treatment was evidence-based and well established. It consisted of chemotherapy aimed at achieving control (remission) of the disease in the short run, to be followed by other treatment aimed at achieving cure in the long run. Assuming that control would be achieved, the next step in Bobby’s treatment might include eradication of Bobby’s bone marrow, followed by bone marrow transplantation with disease-free bone marrow. This step, which carries considerable danger, warranted serious consideration because of Bobby’s high white blood cell count at the time he was found to have ALL. In other words, Bobby’s higher than usual risk of death from ALL warranted consideration of more aggressive treatment early in the disease to prevent the disease from recurring in a form that would be resistant to further treatment. Mr. and Ms. Harrington spent many hours reading and talking with one of the pediatric oncology nurses on the team, Dr. Fournier, a clinical pharmacist, and a radiation oncologist (who might be involved in the bone marrow transplant if that treatment pathway was chosen). Bobby’s parents anticipated deliberating with Dr. Fournier and other team members about whether a bone marrow transplant should be done. The decision would be made after it was known how Bobby responded to the initial treatment. In the meantime, the pediatric oncology team was engaged in supporting both Bobby and his parents as they coped with the disease.

Bobby’s initial treatment regimen included intravenous (IV) vincristine, a potent anticancer drug. Three weeks prior to the meeting of the CEO and others, Bobby had been given 10 times the intended dose of vincristine. The error had originated in the pharmacy, where 10 times the required amount of the drug was mixed with IV fluid in the plastic bag used in administering the drug. It was unclear how the error had occurred. The bag was transferred to the patient care area with the amount of the drug indicated on the bag’s label. Despite the label showing the high dose of vincristine, the oncology nurse treating Bobby that day had administered the drug.

Over the next 3 weeks, Bobby had lost sensation in his feet and had developed some difficulty walking because of weakness in his lower legs and inability to lift his feet normally. The symptoms had advanced gradually and had been plainly evident for only 2 days prior to the Wednesday meeting. The loss of sensation was discovered only after the muscular weakness was noted by his parents. Bobby, being only 5 years old, had said nothing about his feet being numb.

The question addressed at the Wednesday meeting was what to tell Bobby’s parents—and how and when. The attorney raised the possibility of saying nothing and waiting out the symptoms, which were likely to resolve completely with time. The CEO, who was an administrator without a clinical background, responded firmly that hiding the error was out of the question. He told a brief story about being counseled 15 years earlier by an attorney to disclose nothing to the parents of a child who had died because of a surgical error. After talking with the child’s parents without acknowledging the error, he had pondered what had happened and vowed that he would never again mislead or lie to parents in dealing with a healthcare error causing harm. The question, said the CEO, was simply how and when to tell Mr. and Ms. Harrington what had caused their son’s symptoms.

The meeting was short. Dr. Fournier offered to speak with Bobby’s parents. She and the CEO met with Mr. and Ms. Harrington that morning and explained in detail what had happened. Dr. Fournier took the lead in the discussion. She told Bobby’s parents what the future might hold for Bobby, acknowledging that no prediction could be made with certainty. She pledged that the hospital would do everything possible to see that the error did not occur again—in Bobby’s care or in the care of any other patient. By his presence, the CEO conveyed to the parents that the hospital accepted responsibility for the error and stood with Dr. Fournier in dealing with the consequences. He apologized on behalf of the hospital. Bobby’s parents expressed their anger about what had happened, but they strongly emphasized their gratitude for being told promptly and openly what caused the problem. They asked what was being done to assure that the error was not repeated, and they expressed their confidence in Dr. Fournier and the other members of the pediatric oncology team who were caring for Bobby.

This pediatric oncology team was squarely focused on the interests of Bobby Harrington and his parents. Actually, there were 2 teams at work here, a clinical team and a management team. Both teams were effective in interacting with Bobby and his parents. The characteristics of effective teams as they focus on patients and families are listed in Table 6–3.

Despite the serious medication error, Dr. Fournier and her clinical team were able to maintain an effective relationship with Bobby and his parents. The senior leadership team of the hospital, which was a management team, also had a good relationship with the parents. The CEO was directly involved. He did not leave the handling of the calamity to the CNO or CMO. What accounts for both teams being able to maintain good relationships in this highly regrettable situation?

First, all of the healthcare people involved—including the attorney, who felt obliged to play devil’s advocate briefly—respected Bobby’s parents (and Bobby) as persons and set their interests ahead of those of the hospital and everyone who participated in Bobby’s care. The clinicians and administrators sought to understand not only the parents’ and Bobby’s goals but also the parents’ experience of Bobby’s health care. They sought to provide for the parents’ wants as defined by them. Before the medication error, they responded without reservation to the parents’ wishes for information and for discussion of the available treatment options. After the error, their dedication to Bobby’s and the parents’ interests was even more obvious. As voiced by the CEO in the Wednesday morning meeting, the hospital’s interest was less important than giving the parents what they wanted, namely, the truth about what had happened. In 2012, this approach to dealing with a medical injury is becoming common worldwide although there are still obstacles and nay-sayers (Iedema et al, 2011). In 1992, providing full and prompt disclosure was unusual, even courageous. At that time, fear of litigation and damage to reputation commonly led both administrators and clinicians to put their own interests and the interests of their organizations ahead of the interests of the patients and their families. In contrast, Dr. Fournier and her colleagues put the patient’s and family’s interests first.

Second, the oncology team succeeded in garnering the trust of Bobby and his parents. Clinical teams face this challenge with every new patient and family. (Management teams are not often called on to gain the trust of specific patients and their families although they need to do so occasionally, as in this case.) If this trust in the team had not existed prior to the medication error, it is doubtful that good relations would have prevailed when the causes of the error were disclosed. During the process of diagnosis, treatment planning, and initiation of treatment, the team had engendered in Bobby’s parents the belief that the team had both competence and integrity. These 2 components of trust are separate, and both are necessary. A healthcare team might bring a patient to believe that the team is competent but prone to hide shortcomings or even to lie to avoid blame. In that case, the team would not have succeeded in generating the full trust that is achieved by an effective team. On the other hand, a team might generate in the patient the belief that the team has high integrity but not generate the belief that the team can perform its technical tasks reliably. In that case, full trust would also not be present. If Bobby’s parents had had doubts about the team’s integrity, they most likely would not have accepted the explanation of the error as true or complete. If they had had doubts about the team’s competence, they would have had difficulty accepting Dr. Fournier’s pledge that the error would not be repeated. Either way, ongoing care for Bobby and his parents would have been compromised.

The trust at issue here is trust in the whole team. Of course, the behavior of individuals determines whether trust is achieved, but the flawless behavior of most team members will ordinarily not compensate for the flawed performance of 1 or 2 members. Some patients and families will differentiate among team members, but most will not and probably should not for 2 reasons. First, the team members operate interdependently so that the poor performance of 1 or 2 members affects the results achieved by the whole team. Second, as patients with knowledge of behavior in organizations will know, the performance of any and all members of the team is heavily influenced by the systems or context in which they work. So poor performance by 1 or 2 members may well indicate a flaw in the forces that affect the whole team. In Bobby’s case, the initial error was made by a pharmacist or pharmacy technician. This may have been a matter of poor individual performance, or it may have resulted from a system defect within the pharmacy. Regardless, others also participated in Bobby’s care and contributed to the injury. The error is best attributed to the whole team, including its system or processes for doing its work. The question on Mr. and Ms. Harrington’s minds is whether they can trust the whole team.

Third, the oncology team demonstrated its commitment to serving the parents’ interests by supporting the parents in their desire to be partners in Bobby’s care. As soon as Bobby was found to have ALL, his parents expressed their desire to learn as much as they could about the disease and Bobby’s treatment. They did not want to be in charge (like the lawyer with coccidioidal meningitis in Chapter 4), but they did want to be actively involved in making the decision about whether a bone marrow transplant should be done and in making any other decisions that lay ahead. The team showed that it understood the parents’ viewpoint, respected it, and was willing and able to support Mr. and Ms. Harrington in their chosen role in Bobby’s care.

In other situations, supporting patients as partners would also include providing them with assistance for self-management as discussed in Chapter 4. Patients with chronic diseases such as rheumatoid arthritis need more than information if they are to manage their own diseases day-to-day. They need skills in identifying and solving problems. When serving patients with these needs, additional activities are manifest in effective teams, for example, motivational interviewing and referrals to programs providing self-management education.

The ultimate purpose of any healthcare team—whether it is a clinical team or a management team—is to protect and restore the health of the people who are served, or, if prevention or cure is not possible, to minimize symptoms and decrease suffering. To say that effective teams are focused on the patient is simply to say that they are focused on the purpose of health care without distraction or compromise by secondary goals. As shown in Figure 6–2, team focus is the second element needed for a team to be effective. Focus provides the aim for the rest of the team’s activities. We turn next to how effective teams function to achieve the object of their focus.

Team Orientation

Dr. Kimpell, Dr. Gomez, Penny Mills, RN, and their colleagues provide primary care to about 9000 people in a large clinic in North Dakota. They were introduced in Chapter 1 as the members of one of 4 primary care groups in their clinic. There are 11 members of the team, including physicians, a nurse practitioner (NP), a registered nurse, medical assistants, and receptionists. They are known throughout the medical group as Red Family Medicine or the Red Team.

Red Family Medicine meets once monthly. The main purposes of the meetings are to troubleshoot operational issues and to keep the team’s process improvement projects moving forward. Dr. Kimpell always wants everyone on the team to attend the meetings. The only exception is that one of the 2 receptionists needs to be at the front desk to answer the telephone and help any patients or parents who arrive unexpectedly. The 2 receptionists alternate this duty every other month. Having everyone attend the monthly meetings is important to Dr. Kimpell and the other team members because it repeatedly reminds everyone that all team members are important for the team’s success in providing patient care.

Over the years, largely through decisions made at the monthly meetings, the team has developed a standardized approach to doing its work. For example, telephone calls from patients seeking healthcare advice are normally directed to Ms. Mills. However, any patient who requests to speak with a physician is either connected with a physician or, more often, is told that a physician will call the patient back within 4 hours. Also, laboratory test results are reviewed first by the physician or NP who ordered the test. In the days before the electronic health record, the medical assistants reviewed all test results first and passed along to the ordering clinicians only those results that were abnormal. This routine delayed action on abnormal results but saved time for the clinicians in handling the paperwork for normal results. This same sequence was used briefly after the records were automated, but it became apparent quite soon that with the electronic record this routine saved very little time for the clinicians. The delays in acting on abnormal results could be eliminated without any significant inefficiency for the clinicians.

In conversation inside and outside of the team, the members of the team identify themselves as members of Red Family Medicine. They can easily say what is distinctive about their group and how they fit into the larger whole. Being members of the team largely defines their work lives and their places in the larger organization. Last year one of the medical assistants came to work one Tuesday wearing a red scarf. She suggested that every Tuesday should be Ruby Tuesday and that people should wear something red to celebrate the team. The other medical assistants, Ms. Mills (the registered nurse), and the receptionists quickly joined in as did Dr. Gomez. The other physicians and the NP were a bit embarrassed by this idea, but Dr. Kimpell did wear one or another red tie each Tuesday for a while. Eventually the idea died out except for the occasional red sweater or tie.

Dr. Kimpell is the leader of the team. He is very attentive to what he calls the morale of the team. Others call it the social climate. Every summer he invites all of the team members and their families to his home, which is located on a river west of town. He and his wife host a picnic; and toward the end of the afternoon, the team members give each other joke awards. One year, Dr. Gomez, who is well known in the team for becoming agitated when things do not go smoothly in the clinic, was given “an Ativan (antianxiety drug) the size of a hockey puck,” in other words, a hockey puck painted white. She enjoyed the ribbing as much as everyone else. It was all in good fun. Members of the group rarely miss these picnics. They appreciate both the fun and the contribution that the social interaction makes to the functioning of the team.

Red Family Medicine also engages in behavior that often surprises other physicians and nurses who happen to visit the unit. The team members point out each other’s omissions and mistakes. For example, one afternoon after the clinic session was finished, Carrie Tanaka, CMA, one of the medical assistants, saw Dr. Lewis walking away from her down the hallway with his overcoat on and briefcase in hand. “Just a minute,” she said and then reminded him that earlier in the day he had said that he would telephone one of their patients himself to report that the patient’s Pap smear was mildly abnormal and needed to be repeated. Both Ms. Tanaka and Dr. Lewis knew the patient well and knew that she would be upset by the news, even though the abnormality was very unlikely to be an indication of anything serious. They also knew that she would be put at ease more fully by hearing the explanation of the test result from Dr. Lewis rather than Ms. Tanaka or anyone else because she had a particularly strong relationship with Dr. Lewis. With a quick thank-you to Ms. Tanaka, Dr. Lewis went straight to the telephone. On another occasion, Dr. Pearson was preparing to inject an anti-inflammatory medication (methylprednisolone) into the knee joint of a patient with severe arthritis. April Simpkins, CMA, another medical assistant, was working with Dr. Pearson, and had just returned to the procedure room with a new vial of the medication. Ms. Simpkins noticed that Dr. Pearson had placed a packet of iodine (Betadine) swabs on the instrument stand. The swabs were to be used to clean the patient’s skinned knee prior to inserting the needle into her knee. Flustered, Ms. Simpkins could think of nothing else to do except to ask Dr. Pearson to come with her to take an urgent telephone call. In the hallway, Ms. Simpkins explained that there was no telephone call. She recalled for Dr. Pearson that the patient had suffered a severe allergic reaction to iodine when she was in the hospital for surgery last year, as Dr. Pearson knew but had overlooked on this busy day in the clinic. Dr. Pearson thanked Ms. Simpkins for preventing a mistake that could have been quite serious. A different antiseptic solution was used in doing the knee injection.

The members of Red Family Medicine are oriented to being members of a team. They continually think about the performance of the whole team, and its capacity to perform well. They appreciate that simply carrying out their own individual tasks well will not be enough to meet the needs and wants of the patients, and they know that they need to spend time contributing to the team as well as time performing their own tasks. Table 6–4 lists the characteristics of teams whose members are effectively oriented to being a team.

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