COMPETENCIES FOR TEAM SPONSORS

The 3 elements of the team sponsor’s role serve well as categories of competencies for team sponsors. In order to design a team well, a sponsor must be able to establish its purpose, designate the composition of the team, and select a leader. Similarly, various competencies are necessary for effective evaluation and guidance of teams. When the team leader is performing well, many of the sponsor’s functions are not performed by the sponsor alone. In these situations, effective sponsor-leader pairs take many of these actions jointly. The competencies for team sponsors are shown in Table 12–2.

Designing the Team

Sheamus Doyle, MD, was an ENT surgeon (ear, nose, and throat surgeon) at Clarkdale Clinic, a large referral center that attracted patients with unusual medical problems from across the western half of the United States. He often saw patients referred for vertigo, a particular form of dizziness. Arriving at a diagnosis and treatment plan for these patients usually requires the participation of an audiologist. Dr. Doyle worked with audiologists daily; they were regular collaborators. However, occupational therapists, neurologists, neurosurgeons, and radiologists were also needed for some patients, and bringing together these other professionals was more difficult because they were located in other departments, whose schedules and priorities were different from those of the ENT Department. Dr. Doyle thought it would be useful to establish a Vertigo Clinic.

He explored his idea with many other people at Clarkdale, and eventually the idea was presented to the Clinical Services Committee of the medical center, which included the Chief Medical Officer (CMO), Chief Operating Officer, and the heads of the major clinical departments. The idea was well received, and soon the Committee considered the question of where the Vertigo Clinic should be placed in the organization’s management structure. The Committee decided that the new Clinic should be accountable to the Chief of Surgery, who was responsible for all surgical services. Alternatively, the Clinic might have been accountable to one or another of several people, including the CMO and the Chief of ENT Surgery. Part of the rationale for the choice of the Chief of Surgery was the rivalry between neurosurgery and ENT surgery in performing certain surgical procedures. The overall Chief of Surgery was well placed to manage any conflicts that might arise from this rivalry.

Yang Liu, MD, Chief of Surgery, was authorized by the Clinical Services Committee to establish the Vertigo Clinic. Not surprisingly, he appointed Dr. Doyle as its leader. Dr. Doyle was paired with an administrator to establish and run the Clinic. Together Dr. Liu and Dr. Doyle decided whom to invite to be members of the team: Dr. Doyle himself, a neurologist, a neurosurgeon, an audiologist, an occupational therapist, a physical therapist, a nurse with long experience in ENT, and the administrator for the new Clinic. These 8 people formed the new team. Dr. Doyle and Dr. Liu decided that a radiologist was not needed as a member of the team although most patients would have imaging studies done to investigate the causes of their symptoms. The team members would ordinarily be the ones to see the patients, but other clinicians would also work in the Clinic. Drs. Liu and Doyle also set the purpose of the Clinic. They decided to charge the team with diagnosing the causes of patients’ vertigo and formulating treatments plans but not with providing treatment. They would refer patients elsewhere for treatment, sometimes to the ENT Department, sometimes to Neurosurgery, sometimes to Neurology, sometimes to Adult Medicine (primary care). Although the topic of decision making never discussed, Dr. Doyle understood that he was to use consensus for team making decisions. This model was routinely used at Clarkdale, and the use of strong central authority or voting did not even occur to Dr. Liu or Dr. Doyle.

Drs. Liu and Doyle jointly designed this new team although the final authority, assigned by the Clinical Services Committee, rested with Dr. Liu. The process of establishing the new clinic illustrates the components of designing a team.

Is a Team Needed?

Before a team is designed, someone must determine whether a team is actually needed. In the case of the Vertigo Clinic, this question was addressed by the Clinical Services Committee at Clarkdale Clinic. Clarkdale had been operating for decades without a Vertigo Clinic. Dr. Doyle proposed the formation of this new team, but was it really needed? Maybe a better choice would be to continue providing services for people with vertigo through the various relevant clinical departments without creating any new team. How should this decision be made?

As mentioned in Chapter 1, some tasks are not suitable for teams (Hackman, 2002, pp. 43-44). For example, novels, poetry, and symphonies are properly written by individuals. Authors and composers may request critiques by other people, but they do not partner with them in the creative work. Other tasks outside of the art world are also suitable for individuals to perform, for example, creating a vision for a new children’s museum, crafting a proposal for the governance structure for a new philanthropic foundation, or designing buildings in a new architectural style. Individuals also perform better than teams in other less lofty tasks such as writing task force reports, political speeches, and book chapters. All of these tasks call for taking partially formed thoughts or dimly recognized feelings, synthesizing them, and expressing the newly formed ideas by using words, sound, or various visual means such as diagrams or sculpture. These are tasks that are performed well only within a single mind.

Individual effort is also appropriate for tasks that consist of decision making under time pressure and conditions of high uncertainty. When many factors pertain to a decision and these factors cannot be quantified, 2 (or more) people are likely to disagree or to make a joint decision only after long deliberation—even if their knowledge and values are very similar. Nonetheless, in some situations, a decision cannot be avoided and must be made in a short period of time. In these situations, a single decision maker is needed. Company presidents, political leaders, and military officers are examples of people who perform individual tasks of this second kind.

In contrast, a team is appropriate to a task when several individuals are needed to contribute expertise in different areas and to collaborate to achieve a goal. It is suitable for a team, rather than an individual, to perform a task if the task has both of the characteristics listed in Table 12–3:

1. To achieve the goal, the work must be done by individuals who possess knowledge and skills in different areas.

2. To achieve the goal, those individuals must work together interdependently, that is, as the work progresses, each individual must adjust what he or she does in response to what is done by other individuals.

A task that meets this twofold test has met the minimum requirements for a task that is appropriate for a team. However, in order for the task to be highly appropriate for a team to pursue, it must have some additional characteristics, as discussed below.

The Vertigo Clinic met the minimal test of appropriateness for teamwork. Diagnosing and treating people with vertigo requires people with knowledge and expertise in different healthcare fields, so the first requirement was fulfilled. Dr. Doyle’s efforts to create the team were triggered by his observation that achieving successful interaction of the different clinicians was very difficult under the prevailing arrangements. He sought to create a team so that the interdependent action of the various parties would flow more effectively and efficiently.

Having established that a team would be useful, one must also answer the question of whether the expense of the team is justified. Using a team is sometimes more expensive than having the work done by individuals working with lower levels of collaboration. More administrative time may be required if a team is created. Clinicians’ schedules may go unfilled if they spend time in a disease-specific clinic where open appointment slots cannot be used to serve patients with other problems. The person or committee deciding whether to establish a new clinical team needs to consider these financial issues as well as the question of whether a team would add benefits for the patients. Similar questions arise when considering whether to form new management teams.

Setting the Task

The sponsor needs to be able to delineate a task that will engage the team in performing well. Simply stating a task clearly is not sufficient. The task needs to have certain characteristics in order to be motivating. For many clinical teams, the task consists of providing clinical care; it is obvious, motivating, and requires no discussion. For management teams, the selection and clear delineation of the task is usually more difficult, for example, when the task is the formulation of a business strategy or the improvement of an equipment procurement process.

The team’s task needs to be significant in the eyes of the team members; and for the task to have this significance, the goal needs to be a complete piece of work (Hackman, 2002, pp. 95-105). For many tasks, doing part of the task is not sufficiently gratifying to the team members to motivate them or even to keep the team intact. For example, sorting surgical instruments to be sterilized is a poorly chosen task. Bundling this task together with related tasks, for example, sterilizing the instruments and assembling surgical equipment packs, enables the people doing the work to have a sense that they are contributing to good surgical care in some way that they regard as important.

The task also needs to be defined so that the team can have autonomy in pursuing its goal. If the team has this autonomy, it is more likely to experience a sense of responsibility for the outcomes of the team’s work. Without this autonomy, the team may pull back psychologically, feeling that success in achieving its goal is driven by forces outside of its control. For example, a team that handles bed assignments for patients entering a hospital may disengage from their task if their decisions are repeatedly overridden by physicians or nurses who redirect patients from one area of the hospital to another to balance out workloads or simply for their convenience.

And the task needs to be designed so that the team’s output can be evaluated. Of course, receiving feedback about progress and results enables the team to improve its performance. But the more fundamental consideration in task design is that feedback enables team members to know whether what they are producing is worthwhile. If they cannot answer this question for themselves, they are unlikely to be engaged for long. Team members have a need to know not only whether their particular task is completed but also whether they are producing value. Sometimes this need is met by making the task larger than first envisioned so that team members are involved in the process long enough to see the benefits of their efforts. For example, it might be tempting to move hospital nurses from ward to ward depending on immediate staffing needs. However, keeping nurses in the same ward most of the time enables them to follow patients through their hospital stays and to see their patients’ short-term outcomes.

Ideally, the task also affords opportunities for team members and the whole team to deepen their knowledge and learn new skills (West, 2012, p. 30). Teams that provide these opportunities are likely to be more engaged and more enduring than teams that do not.

Drs. Liu and Doyle set the task for the Vertigo Clinic. (They set the task after they decided the team’s composition, but the order could have been reversed.) The general nature of the task for the Clinic was clear without any discussion. The Clinic was intended to provide clinical service to people with vertigo. However, making the task explicit led to a realization that there was a choice to be made. The Clinic could provide diagnostic services only, or it could also provide treatment. Dr. Liu decided that the goal should be limited to diagnosis and treatment planning. A major factor in his thinking was the political risk that would be incurred if the Clinic also provided treatment. The head of the Clinic was going to be an ENT surgeon, Dr. Doyle. If the Vertigo Clinic provided treatment, it might be regarded by the neurosurgeons as a biased mechanism for routing surgical cases to the ENT Department or perhaps to Dr. Doyle himself. Having the Clinic refer patients for treatment would mean that referrals would be distributed impartially unless the patient’s clinical characteristics called for a particular surgeon or other physician. The pattern of referrals could be easily audited if questions arose. A question to be considered here was whether stopping with diagnosis and planning made the team’s task too small to be regarded as significant in the eyes of the team members. Without any discussion, Drs. Liu and Doyle both knew that this task was substantial enough.

Establishing the Composition of the Team

The sponsor needs to be able to specify the initial composition of the team. Establishing the composition requires considering the technical knowledge and skills needed among the members, the teamwork competencies needed in the team, diversity within the team (of age, educational backgrounds, personality, and so on), and the size of the team (Hackman, 2002, pp. 115-129).

Knowledge and Skill: Technical knowledge and skill are obvious requirements in any healthcare team. Both Dr. Doyle and Dr. Liu knew that the team needed an ENT surgeon, a neurosurgeon, and a few others with well-defined capabilities. There was a question about whether a radiologist was needed as a direct team member, but this was quickly resolved. Settling these issues is ordinarily quite straightforward for clinical teams. For management teams, the decisions are often less clear. For example, a project team charged with investigating the feasibility of a new heart care center in a hospital could include a wide range of management personnel and clinical specialists. For both clinical and management teams, the key to determining the necessary skill mix is the nature of the work the team is expected to do.

Teamwork Competencies: In sharp contrast to technical skills, teamwork competencies are often ignored in composing clinical teams. Every team needs to have some members who are adept at working in teams. Without these competencies, the team is likely to have difficulty organizing its work, settling relationship conflicts, making durable decisions, and carrying out many other tasks. If it can be envisioned that one or more of the team members is especially incompetent at working in teams and is likely to be disruptive, the need for other qualified people is even more important. It is the responsibility of the sponsor, working with the leader, to assure that the proposed team membership will provide enough teamwork competencies for the team to function well. If not, someone tentatively chosen for the team because of certain technical skills may need to be dropped in favor of someone who has those skills as well as teamwork competencies. Of course, teamwork competencies are also important for management teams. But here there is ordinarily less difficulty in meeting the need since managers have commonly acquired some degree of facility in teamwork through their education or experience.

Diversity: Diversity within the team also needs to be considered. Some age diversity appears to improve team performance, but there is some evidence that extreme age diversity results in instability, that is, in higher rates of members leaving the team (West, 2012, p. 56). Diversity of educational backgrounds within a single profession may be helpful in some clinical teams, especially when the approach to patients with a given condition cannot be evidence-based because evidence is lacking and different approaches are taught in different medical schools, nursing schools, or other professional schools. Diversity of history in working together, however, is often undesirable in healthcare production teams (for example, emergency cesarean delivery teams) since teams composed of people who have worked together in the past perform established tasks better than teams composed of people new to each other, as discussed in Chapter 2. On the other hand, in teams that do creative work, some diversity of history in working together is beneficial, as discussed in Chapter 10.

Consideration of cultural and ethnic diversity is more complex. Cultural and ethnic diversity results in diversity of perspective, which boosts creativity in both clinical and management teams, as discussed in Chapter 10. However, for the purpose of assuring smooth internal operations of a team, a low level of cultural diversity is useful. Still, for clinical teams this consideration is fairly unimportant. The values and roles of clinicians are fully and firmly instilled during education and training, as discussed in Chapter 3. These values and roles are reasonably uniform within any single profession, and they tend to override differences in the clinicians’ ethnicity or country of origin. In management teams, ethnic diversity may carry more risk for smooth operations. Seeking a balance between no diversity and extreme diversity would appear to be prudent because some degree of diversity fosters creativity, while too much diversity slows down decision making and development within the team (Hackman, 2002, pp. 122-124; Watson et al, 1993). And yet, one must also consider the population of patients served. A clinical team that serves a diverse patient population will be more effective if the team is also diverse, that is, if the team has diversity in race, language, and ethnicity that approximates the diversity in the patient population. Diversity would also benefit the administrative team of a healthcare institution serving a diverse population. Several different factors need to be considered in determining the extent of cultural and ethnic diversity that will be most suitable for a new team.

In many circles in health care, diversity of personality is believed to contribute to improved team performance. Self-administered questionnaires can be used by team members to characterize their behavioral styles and personality traits. There are many profiling tools available, including StrengthsFinder, Insights Discovery, DiSC, and the Myers-Briggs Type Indicator (MBTI). These tools are discussed in Chapter 15; they are often used in team building. Having a mix of personality types represented on the team, as determined by one or another of the profiling questionnaires, is thought by some to bring benefit by assuring that many different cognitive approaches and behavioral dispositions are put to use, resulting in heightened creativity, improved decision making, and better team performance. While it is plausible that teams would benefit from balance across different personality types, there is no evidence to support this belief (West, 2012, pp. 43-45, 55).

Team Size: Team size is a consideration of paramount importance, in large part because sponsors (and leaders) almost routinely err on the side of making teams too large. Adding more members to a clinical team can be tempting because more skills will be immediately available for performing the task. In the case of management teams, sometimes many people or departments seek representation on the team so that their interests can be protected or advanced. Keeping teams small is often difficult, but there are strong reasons for holding the line.

First, interpersonal relationships, coordination, and communication become more cumbersome as the size of the team increases. The number of dyadic (2-person) interpersonal relationships in a team increases geometrically as the size of the team increases (Figure 12–1). A team of 6 has 15 interpersonal relationships (15 different pairs of people). A team of 15 has 105 relationships. Also, as team size increases, meetings become more difficult to schedule, meeting space becomes harder to find, and communication becomes more burdensome and less reliable.

Second, a large team has more difficulty functioning internally. It struggles more to achieve a common understanding of its purpose, to reach agreement, and to make decisions in general (Katzenbach and Smith, 2006, pp. 45-47). Large teams are more susceptible to groupthink (McCauley, 1998). They also experience disruptive relationship conflicts more often (Aubé et al, 2011). Because of these difficulties, they are vulnerable to establishing a hierarchy within the team, with subgroups operating independently of the whole—thus ceasing to be work teams and becoming instead small organizations of their own with policies and procedures replacing team decision making.

Third, the quality of deliberation deteriorates in teams larger than about 12. In teams of 12 or fewer, rapid, detailed analytical discussion is possible, enabling the team to consider multiple options carefully when they are making decisions. In larger teams, members are more likely to interrupt each other. Humorous critical remarks, even sarcastic remarks, are more common. Relationships are less immediately personal, and members are more likely to disrupt teamwork by jockeying for position in the informal status hierarchy of the team. These behavioral effects of larger team size make complex analysis and weighing of choices more difficult.

Fourth, larger groups are more prone to social loafing, as discussed in Chapter 1.

So, what size is best for a team? At the lower end, by definition, a team must have at least 2 members. With regard to the upper bound, different researchers give different answers. Although Hackman stated that teams can have various sizes, his short answer to the question was that ordinarily the best size is about 6 members (2002, p. 119). West says teams should generally have 6 to 8 members and rarely more than 15 (2012, pp. 28, 65). Katzenbach and Smith accept higher numbers, saying that teams can have 2 to 25 members (2006, p. 45). Thompson says that as a rule teams should have 9 or fewer members (2011, p. 35).

Of course, there is no single best size. The size of the team needs to correspond to the needs of the team. Some teams require more members because they require a wider variety of skills. Organizational politics sometimes dictate that several constituencies must be represented. Sometimes management teams, for example, planning teams, need to be able to proceed very quickly, necessitating very small teams of, say, 3-4 people. There is no general rule for determining team size, but team sponsors will be well served by remembering that “small is beautiful” and that the best size for a team is commonly smaller than the size first considered. If a team needs to be larger than 10 or 12 for political reasons or so that people with the necessary skills can be included, the sponsor (as well as the leader) needs to be aware that the team will have more difficulty in deliberation, in making decisions, and in other ways and that these difficulties will increase as the size of the team increases. If the size is more than 25 members, the team will not be functional. Below that size, skillful leadership and chairing of meetings can mitigate some of the difficulties.

In the vignette about the Vertigo Clinic, Dr. Liu, with Dr. Doyle’s agreement, decided that the Clinic team would have 8 members (7 clinicians and an administrator), a workable number of members. He was aware that more than 7 clinicians would see patients in the Clinic, and Dr. Liu might have been tempted to include 2 ENT surgeons, 2 neurosurgeons, and so on. This would have been a mistake because the team would have become too large. Keeping the decision-making body for the Clinic to 8 members was characteristic of a good team designer.

Dr. Liu’s possible temptation raises a final issue concerning team size. Some large groups appear to be teams when a sub-group is the actual team. The surgical intensive care unit (ICU) team described in Chapter 6 illustrates this point. The team consisted of the senior surgeon, the surgical residents and several others, including medical students. Someone observing the group on rounds might regard the whole group as a team, but in fact the medical students were not team members. Alternatively, one might say that they were peripheral or secondary members. In establishing many teams in health care, it is important to distinguish the core members from peripheral members. Core members can rightfully expect to participate in all team activities including, in particular, decision making. Peripheral members do not have the same rights although they usually participate in some activities and may be consulted about decisions. In the case of the surgical ICU, the medical students were peripheral members because of their lower status. In the Vertigo Clinic, the designated ENT surgeon, neurosurgeon, and so on constituted the team’s core membership (8 people in total). The other clinicians seeing patients in the Clinic were peripheral members of the team even though their status was the same in the larger organization as the status of those on the team. The rationale for considering them to be peripheral rather than core members was that the team needed to be kept small in order to function well in managing the Clinic. Dr. Doyle expected the neurosurgeon in the core team to confer with any other neurosurgeons working in the Clinic when the team considered any decision that would affect the neurosurgeons significantly. And he expected the same of the neurologist, occupational therapist, and others as they related to other Vertigo Clinic clinicians in their respective fields.

Appointing the Team Leader

As part of designing the team, the sponsor also needs to be able to select an effective leader. As discussed in Chapter 8, the primary qualification to be a team leader is the possession of the competencies needed by leaders. In other words, the leader needs to be able to establish the conditions that enable the team to function well, to develop the team, and to provide coaching for team members about how they perform as team members.

As also discussed in Chapter 8, in a clinical true team the leader’s particular clinical skill set is not relevant, and the leader need not be a physician, a nurse, or any other individual identified by his or her particular healthcare profession. (In contrast, as also discussed in Chapter 8, a clinical template team leader does not have the customary role of a team leader. A clinical template team leader is an operational manager, and some template teams require leaders who have a particular profession in order for them to be able to direct the operations of the team.) Regardless of her or his profession, the leader needs to garner the respect of the other team members, and normally this requires the leader of a clinical team to exhibit excellence in his or her clinical role, whatever that role may be. However, a mistake commonly made in choosing a clinical leader is to regard excellence in clinical performance as the foremost requirement for being a leader. Thus some superb physicians, nurses, and other clinicians are appointed leaders of their teams even though they cannot lead. Such appointments lower team performance, and eventually they usually cause distress for the leader as well as the others on the team. Despite these risks, the sponsor is sometimes severely restricted in selecting the leader because very few people (maybe only one) want to serve in the leadership role and have the necessary level of respect in the eyes of the other team members. In these situations, the appointment of the leader amounts to confirming a choice dictated by circumstances.

In management teams, of course, this confusion of clinical excellence with leadership excellence is not a problem. In management teams too, what matters is the leader’s ability to lead.

Sponsors should consider a candidate’s formal education relevant to leadership, but the possession of a management degree does not assure effective leadership. Many physicians, for example, earn Master of Business Administration degrees or other management degrees; and while the subject matter studied in the degree programs is helpful, it is not sufficient to make someone an effective leader. Most clinical leaders do not have management degrees, and they are not required. On the other hand, some experience in leadership positions, even in very limited roles such as chairing a committee or leading a time-limited project, is ordinarily necessary.

Personal attractiveness or charisma also is not necessary. Some experts on leadership argue, in fact, that the most effective leaders are not charismatic but are instead humble and self-effacing while also being extremely determined (Collins, 2005). Others would say that charisma is useful but not essential.

In short, a team leader needs to be able to lead. In assessing whether someone will be a suitable leader, sponsors can usefully consider whether the candidate has the competencies needed by a leader, discussed in Chapter 8. These competencies, listed under the headings of enabling, developing, and coaching, constitute a checklist for use in assessing potential leaders (Table 12–4). Not all potential leaders will have strength in all of the competencies listed. Often, in fact, especially when designing clinical teams, the best choice for a leader is deficient with respect to some or even many leadership functions. In that case, the burden of coaching is higher for the sponsor. Organized courses can also be useful, as discussed in Chapter 14. Many clinicians, however, do not have the time to pursue leadership courses or do not want to take the time. In that case, the sponsor needs to provide the necessary training informally or arrange for it. Unfortunately, finding the time to carry out this function is difficult for many sponsors.

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