What Do Effective Team Leaders Do?

One simple but incorrect answer to this question is that effective team leaders make decisions and tell the other team members what to do. This is the notion of leader-as-commander. The error of this answer can be seen from the nature of teamwork in health care. Most healthcare teams are interprofessional. A person with one profession will not have sufficient knowledge to direct people in other professions properly. For example, physicians, with rare exceptions, know very little about social work and cannot instruct social workers on social work interventions. However, they can call on social workers to use their knowledge and skills to contribute to patient care, and ordinarily that is what physicians do when they are leading healthcare teams. Nurses and other team members interact with social workers in the same way. The notion that leaders tell other people what to do arises from a certain picture of team organization in which there is a clear hierarchy and orders are issued top-down by a highly knowledgeable leader. This view of the leader’s role is not tenable. First, it is based on an over-simplified military model of teamwork. In fact, it is doubtful that the military ever used this model. The military understands very well that a rigid top-down approach to team leadership is not effective (Marine Corps, 1996). Second, all effective healthcare teams have interdependent members who call on each other to take action, each member using his or her specialized skills. Those who prompt action from others adjust their own activities in response to that action. If team members were acting solely on the basis of orders from the leader, they would not be interdependent because each member would be dependent only on the leader. A team that functions in this way is in fact a dysfunctional team, as discussed later in this chapter.

If issuing orders is not what effective team leaders do, what do they actually do? The role of the leader can be summarized in 3 tasks (Hackman, 2002; West, 2012, pp. 61-63). Team leaders (1) create and maintain the conditions that enable the team to function effectively, (2) build and maintain the capacity of the team to do its work, and (3) coach the team to optimize its performance, or arrange for others to provide coaching. These tasks are listed in Table 8–1.

To create the necessary conditions for effectiveness means to enable the team to function at least at a minimal level of proficiency. The leader does not create the team or establish its goal. Those actions are taken by the team’s sponsor as discussed in Chapter 12. The only exceptions are teams that constitute the whole organization, for example, Mountain Lake Medical Group, described in one of the vignettes at the beginning of this chapter. In those cases, the team leader and the team sponsor are the same person. In all other teams, the leader’s role does not include creating the team or setting the goal. Assuming that the team has been created and its goal set, the leader’s first task is to establish and maintain the conditions necessary for the team to exist and to function. The team needs all members to understand the goal, it needs its membership to be well defined, and so on, as detailed below. The leader must see that all of these conditions are in place. In other words, the leader must assure that the team has all of the defining features of a work team as discussed in Chapter 1 and listed in Table 1–1.

Building the team means adding new members to augment the knowledge and skills available in the team. It also means fostering development of the team’s shared values, assuring that the team has the teamwork capabilities it needs to function well, and so on, as explained below. The leader does not exercise these capabilities himself or herself—at least not more than occasionally—but does make sure that the team has the capabilities that it needs.

Coaching the team means attending closely to how the team is performing, evaluating the performance, and providing advice and support for team members and for the team as a whole. Many team leaders provide coaching directly, but some leaders arrange for others to do it.

COMPETENCIES FOR TEAM LEADERS

The 3 tasks that define the team leader’s role serve well to categorize the competencies needed by leaders. Team leaders need to be able to perform the 3 tasks, and performance of each task requires certain competencies.

Enabling the Team

Breslo Medical Center is an integrated health system that employs 325 physicians, 825 registered nurses, and 52 nurse practitioners. It operates 12 clinics and 2 hospitals. The Breslo clinics are scattered throughout a metropolitan area of 2 million people. The clinicians are divided into a Primary Care Division and a Specialty Care Division. Both divisions are headed by a physician-administrator pair or dyad.

The Specialty Care Leadership Team meets monthly to deal with both strategic and operational issues in the division. The members of the team are Thomas Steward, MD, and Cari Rebold, MHA (the dyad that leads the whole division) plus the physician-administrator dyads for surgical specialties, for medical specialties, and for the large sub-specialty services such as general surgery and cardiology. However, the physician members of these various dyads rarely attend except for Dr. Steward and the physician heads for surgery and medical specialties.

On one Thursday afternoon, the meeting was chaired as usual by Ms. Rebold. The topic of discussion was how to increase the proportion of primary care referrals going to specialists employed by Breslo Medical Center. For several years, 30% or so of referrals had been going to outside specialists—because of the long distances between some of Breslo’s primary care sites and the 2 specialty centers and because of the referral patterns that had been established for certain specialty services before Breslo hired specialists in those fields. Breslo was trying to keep more of this referral business inside its own walls. Linda Lawson, the administrator for medical specialties, proposed that primary care physicians and nurse practitioners simply not be allowed to refer patients outside of the group, that is, that procedures be established to assure that all referrals remained inside the group, permitting exceptions only when Breslo could not provide the specialized service needed. Ms. Rebold asked whether other exceptions might be permitted, for example, for patients for whom travel to a Breslo specialist would be a hardship or for patients who had long-established relationships with specialists outside of Breslo. Ms. Lawson responded by saying that Breslo was having financial difficulties and that, while the conveniences Ms. Rebold suggested would be fine reasons for exceptions in better times, Breslo could not afford them at present. Ms. Rebold responded by saying that the considerations she had mentioned were not merely matters of convenience for patients. She said that insisting that patients travel long distances or give up trusting relationships with specialists would worsen the patients’ experience of their health care. Dr. Steward added that the specialists at Breslo needed to find ways to appeal to the primary care clinicians and the patients so that more referrals would come their way. Dr. Steward then led a discussion of how Specialty Care might attract more referrals from Primary Care. He concluded the meeting by saying that he and Ms. Rebold would raise the issue with their superiors, the Clinical Services Administrator and Medical Director for Breslo, and explore with them how to achieve the goal.

In this team, Ms. Rebold and Dr. Steward provided genuine co-leadership. Although functional co-leadership can be difficult to achieve, using physician-administrator leadership dyads is increasingly common in larger medical groups and integrated health systems (Baldwin et al, 2011; Zismer and Brueggemann, 2010). At Breslo, the dyad of Ms. Rebold and Dr. Steward created and maintained the conditions that enabled their team to accomplish its goals. The competencies that leaders need to enable their teams’ effectiveness are listed in Table 8–2.

At the meeting described in the vignette, Ms. Rebold, supported by Dr. Steward, assisted the team by helping it to maintain its common sense of purpose. The team had a vision for its future, that is, a picture of what care provided by the Specialty Division would be when the Division was performing as well as it possibly could. In the meeting, Ms. Rebold responded to Ms. Lawson’s suggestion that patient-centeredness be compromised to serve the financial interests of the medical center. Her response reminded everyone that the goal of the team was to serve the patients’ interests as defined by the patients. As Dr. Steward stated, having made the patients’ interests the first priority, the team needed to seek a means to increase in-house referrals without coercing the patients. (The primary care physicians might have been coerced if the organization’s financial condition required that referrals be made in-house and if the patients were not adversely affected. That is a different matter. The interests of the clinical providers have lower priority than those of the patients. Coercion of the primary care providers would not have been an attractive option, but it would not have been inconsistent with Breslo’s goal of patient service.) Team leaders need to be able to remind team members of the team’s goal, clarify it when necessary, and fend off challenges to the goal when they arise. At best, all of this needs to be done without offensive preaching. And, if possible, it should be done in a way that inspires.

Although not illustrated in the vignette, the team leader must also be able to foster a sense of shared responsibility so that various team members help each other in pursuit of the goal. For example, within the Specialty Care Leadership Team a sense of shared responsibility might lead one administrator to help another in estimating costs for a budget. Or a physician leader for one of the specialty services might help another physician leader to think through how to resolve a conflict between a nurse and a physician whose dysfunctional behavior is disrupting smooth operations. Ideally, the team leader creates a sense of mutual accountability in the team, as discussed in Chapter 6. The Specialty Care Leadership Team is stable over long periods of time, and mutual accountability might be achievable. It would be worthwhile for Ms. Rebold and Dr. Steward to pursue it.

The leader also needs to be able to assure that the team has sufficient authority to do its work without needing to seek continual approval or direction from outside the team. The team needs to have authority to determine how to reach its goal and to be confident that it will retain that authority. At Breslo, threats to this condition for effectiveness might take the form of rigid instructions from the Clinical Services Administrator and Medical Director (to whom Ms. Rebold and Dr. Steward report) about such matters as times when department meetings can be held or methods for making appointments for patients. The co-leaders of Specialty Care need to be able to protect the team from such intrusions while remaining sensitive to the needs of the whole organization and continuing to work with others outside Specialty Care to meet the needs of Breslo overall. They need to be able to balance their responsibility to their team with their responsibility to the whole organization.

Interdependency of members is a defining feature of work teams. Without it, there is no gain in having people work together and surrender the flexibility of working independently. If there is to be a team, the leader must be able to create and sustain interdependency. This is done chiefly by designing the work so that individual members will draw on the knowledge and skills of other members and by encouraging members to make best use of what other members have to contribute. In the case of the Specialty Care Leadership Team, Ms. Rebold and Dr. Steward could, for example, partner pairs of department administrators so that cardiology and cardiac surgery scheduling routines are designed jointly or so that procedures for handling surgical specimens are designed jointly by the Pathology Department and the Surgery Department.

A team also needs clarity about who is a team member and who is not. On this point, the Specialty Care Leadership Team may have a problem. Most of the physician heads of the specialty departments do not attend the meetings regularly. Are they team members or not? They probably think that they are team members and that they may attend any meeting and participate in decision making. However, the other team members may resent and resist infrequent participation because the infrequent attenders are not well informed about the team’s methods of operation or its history of decisions made, that is, the precedents that shape the team’s on-going decision making. Ms. Rebold and especially Dr. Steward need to make it clear whether the rarely seen physician heads are team members or not, and, if they are not, to make it clear to these physicians that they may not attend the meetings. One solution might be to make attendance at meetings a condition of membership.

The leader also needs to keep the team unified, that is, to keep everyone accountable to the whole team for actions that affect the work of other people on the team. For example, the physician-administrator dyad in charge of gastroenterological services at Breslo should not make decisions that affect the operations of the general surgery department without the participation and agreement of those in charge of general surgery. The leader needs to be able to recognize when sub-groups are functioning with inappropriate independence and bring them back into collaboration with the whole team.

Finally, Dr. Steward and Ms. Rebold need to be able to relate effectively to the larger organization. The discussion at the meeting touched on this issue. The challenge at hand was how to increase in-house referrals. Dr. Steward spoke of seeking help to meet this challenge by consulting with the senior leaders of the whole clinical enterprise. Also implied was a desire to avoid provoking conflict with Breslo’s Primary Care Division. Another important aspect of relating to the larger organization did not come up at the meeting, namely, securing resources for the Specialty Care Division, for example, annual budget allocations and capital for major equipment purchases. Team leaders need to be able to secure funds and other forms of help from outside the team. They also need to assure that the team works smoothly with other parts of the organization and to obtain constructive evaluation of the team’s performance from outside the team, especially from the team’s sponsor, as discussed in Chapter 12.

Exercise of these 7 leadership competencies clustered under the heading of enabling the team establishes the possibility of effective team performance. However, for the team to move from possible to actual effectiveness, the team must also be developed and coached. We turn next to development of the team.

Developing the Team

George Mather, MD, was Medical Director of Cypress Medical Group. In 2002, he and the other leaders decided to establish a Mental Health Department. Prior to this time, the 63 clinicians in the group had referred patients outside of the group for treatment of depression, schizophrenia, and other mental and behavioral disorders. Dr. Mather hired William Chin, MSW, to chair the department. Mr. Chin was a mental health therapist with many years of experience as a therapist and as a leader of mental health teams.

Mr. Chin spent his first month at Cypress talking with family physicians, pediatric nurse practitioners, and other clinicians in the group about their perceptions of the needs for mental health services and of means that could be used to coordinate mental health services with general medical services. Then he began hiring. He first hired 2 psychiatrists, 1 PhD clinical psychologist, 1 RN, and 2 more therapists with Master of Social Work (MSW) degrees. He also hired 2 front desk clerks. More clinical staff members were added over the next 2 years. From the outset, the team had the help of a senior operations administrator at Cypress Medical Group. She was expert in handling appointment scheduling, use of the telephone system, and other routine aspects of the department’s day-to-day activities. But she was not considered a member of the team, at least not a member of the core team.

As the new people joined the department, Mr. Chin brought them together as a team. At first the team had extended discussions of their values and operating philosophy. Then came efforts to establish operating procedures and behavioral norms. These efforts were accompanied by some jockeying for position and power within the team. At one point the psychologist attempted to use her credentials to assert authority over all matters of psychotherapy. The psychiatrists did not immediately object, being interested primarily in diagnosis and the use of medications. But the social workers rejected the psychologist’s foray. Fortunately the episode was brief, and there were no damaging effects. Within 8-9 months the team had settled down into a highly functional and collaborative team, using regular case conferences and frequent informal consultations within the team.

Mr. Chin held a monthly operations meeting, attended by everyone in the department, including the clerks. Initially Mr. Chin chaired the meeting, but he turned this duty over to Dr. Green, one of the psychiatrists, an able chairperson, after a few months.

In the first 2 years, the mental health services clinical staff went off-site for an entire day twice annually to review what was going well and what problems the team was having in delivering service. The product of each of these off-sites was an action plan for the next year, to be revised in 6 months. As part of the planning, the team used 2 or 3 methods for brainstorming when they needed to solve particularly difficult problems. Conflicts were also addressed. Once the RN and social workers had a disagreement about the role of the RN in medication follow-up. The disagreement was worked through in a well-planned group discussion involving all of the clinicians.

During the first year, Mr. Chin met monthly with Dr. Mather, the team’s sponsor. They discussed the team’s rising capacity to receive new patients. Some new patients sought care directly, and others were referred from other departments at Cypress. Dr. Mather was frustrated that the capacity of the Mental Health Department was not increasing faster. Mr. Chin did his best to hasten development of the team’s patient care operations, relying for some issues on the senior administrator provided to the department. Dr. Mather and Mr. Chin also discussed the pace of new additions to the clinical staff and began planning to remodel the department’s consultation rooms to make them more suitable for psychotherapy. The rooms previously had been used as examination rooms for general medical care.

At the 2-year mark, all things considered, both Dr. Mather and Mr. Chin judged the venture to be a success. Mr. Chin had assembled and shaped an excellent team, all of whom made their own contributions to the team’s development. Dr. Mather had provided excellent sponsorship.

Team leaders need to be able to develop their teams. The individual competencies required by a leader to develop a team are listed in Table 8–3. Mr. Chin’s adept development of the Mental Health Department illustrates most of these competencies.

Establishing how many people will be on a team is a task usually performed by the team sponsor and team leader working together, as discussed in Chapter 12. Sometimes the sponsor also has a role in determining the mix of professions on the team. From that point onward, the leader needs to be able to recruit team members, assure their orientation to the team, and oversee the melding of the team members into a unified team. Mr. Chin showed his competence in these functions as he determined which professionals should comprise the team, hired them directly, and orchestrated a series of events to form them into a team. Adding new members to a team remains a central responsibility of the team leader throughout the history of the team. In teams of 12 or fewer people, the leader ordinarily should do the hiring directly to assure that each new member embraces the team’s goal, shares the core values of the team, and fits well with the people already on the team. In larger teams—which are both unusual and riskier, as discussed in Chapter 12—some portion of the hiring process may be delegated to others, but even then hiring needs to be closely supervised by the leader. In either case, other team members should participate in the interviews that are part of the hiring process, especially members who have the same profession as the person to be hired. As the team grows, clarity needs to be maintained about who is a core team member and who is associated with the team but is a peripheral member or a resource for the team. As he built the Mental Health Department, Mr. Chin was clear about the senior operations administrator from Cypress Medical Group being a resource rather than a team member. She did not attend off-site meetings, and at the monthly operations meeting she was regarded as a respected advisor rather than a direct participant in decision making.

The process of team formation is something that the team leader must know well and be able to guide. While it is useful for the team members also to understand the process, commonly in clinical teams the members do not know the process, and this rarely makes a difference. Teams progress through a sequence of stages as they become competent as integrated units. This sequence has been characterized in different models proposed by various researchers in organizational behavior. The most commonly used model is the one devised by Bruce Tuckman. Its stages are memorably named forming, storming, norming, and performing (Tuckman, 1965; Tuckman and Jensen, 1977; West, 2012, pp. 89-91). This model is shown in Figure 8–1.

During the stage of forming, the members learn the team’s goal and what will be expected of them as individuals. They also become acquainted with the leader and the other team members. Mr. Chin used an off-site, 2-3 operations meetings, and 2-3 case conferences to take the team through this stage. Of course, there were also numerous one-on-one conversations involving many different pairs of team members. During the stage of forming, members determine for themselves whether they will commit wholeheartedly to the team. Commonly new members have not reached a firm decision on this issue before joining the team because they lack adequate information. If a member decides that the team is not a good fit, he or she may depart or may hold back psychologically, perhaps for a long period of time. Part of the leader’s task during the forming stage is to convince the team members that the team’s goal is worthy and that it can be achieved.

During the stage of storming, team members engage in testing assumptions about the team, and they may engage in outright conflict. The leader’s conception of the goal and her or his competence are tested. Various members challenge the roles assigned to them and to others. Members elbow one another (hopefully not literally) to determine who has what knowledge and skills and who will have what authority as the team moves forward. In the preceding vignette, the psychologist’s attempt to assert her authority in the new mental health team was characteristic of this stage. The social workers might have accepted some form of this authority, but they rebuffed her and insisted on their own independence as practitioners.

In the norming stage, team members establish the functional basis for doing the team’s work. Norms of behavior are established, usually through group discussion, and people begin functioning in their roles. At this point, the leader needs to pull back and let the other team members resolve questions about communication routines and behavioral norms.

As the team settles into doing its regular work, it enters the stage of performing. The common understanding of the team’s goal, the refinements of roles, the norms of behavior, and other results of the previous stages are put to work as the team becomes a functional and productive unit. The leader’s direction of particular members usually decreases to a very low level from this time onward, rising again only when certain events occur, for example, individual actions that depart from team values or crises in staffing or financial support.

Although not originally included in the model, Tuckman, in response to work by other researchers, later added a fifth stage to the model, which he called adjourning (Tuckman and Jensen, 1977). In this stage the team completes its work and may celebrate achievements or catalog lessons learned. Team members acknowledge each other’s contributions and say their good-byes. This stage is especially important for teams that include members who will work together again in some other team or in some other way in the organization. To sustain the prospect of good working relationships in the future, the team members need to close out their work and depart on good terms, sometimes expressing their sense of loss if the team has been particularly important to them. The Mental Health Department, of course, did not go through this stage since it was an on-going team. However, management project teams and time-limited consultative teams routinely do go through this stage and need to manage it well. (These and other types of teams are discussed in Chapter 2.) Clinical template teams usually do not attend to adjourning, but some probably would benefit from doing so, for example, surgical teams that carry out extended and complex procedures such as the multi-hour procedures done to remove certain cancers. Many clinical knotworks would also benefit from deliberate adjourning, but the opportunity to adjourn a knotwork is distinctly unusual.

The progression through Tuckman’s stages is not a predictable march, invariable from team to team. In fact, Drinka and Clark (2000, pp. 18-27) hold that team development in health care usually has a different sequence of stages. The stages in the Drinka-Clark model are forming, norming, confronting, performing, and leaving (Figure 8–2). Forming and performing are the same in this model as they are in the Tuckman model, and the stage of leaving is equivalent to Tuckman’s adjourning. The difference between this model and the Tuckman model lies in the second and third stages. In both the Tuckman model and the Drinka-Clark model, norming is a stage of clarifying roles, team procedures, and behavioral norms; but the discussions are pursued in the Drinka-Clark model without the benefit of a storming stage. In the Drinka-Clark model, the storming stage is passed over in the hope of avoiding all conflict. The reason offered for this behavior is that “health care practitioners do not like conflict and use many excuses for ignoring it” (Drinka and Clark, 2000, p. 26). But, of course, personal rivalries, doubts about the leader’s vision for the team, and other sources of disagreement or conflict do not disappear. In time, the team members challenge one another and come into disagreement over goals, roles, and individual authority in daily operations. The term for this stage in the Drinka-Clark model is confronting instead of storming. The word confronting is apt because it suggests that disagreement is often more personal when it is openly expressed after having been suppressed for a time. In both models, a stage of conflict and negotiation occurs. Such a stage must occur for a team to develop into a unit that functions well. This stage can occur before norms are set, as in the Tuckman model, but if the team avoids this stage and proceeds directly to norming, team will need to go through a confronting stage later on. None of the stages can be omitted.

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