True Teams

The U.S. Preventive Services Task Force recommends screening for colorectal cancer beginning at age 50, using either colonoscopy or one of a few alternative methods. Sam Murphy turned 50 about a year ago. After some delay (not at all unusual), he decided to undergo colonoscopy after discussing the options with his general internist. His internist referred him to a gastroenterology group to have the procedure performed. After spending a largely sleepless night while prescribed laxatives cleansed his colon, Mr. Murphy arrived at the outpatient endoscopy facility early the next morning. There he met Kevin Leon, MD, the gastroenterologist to whom he had been referred. Dr. Leon performed the colonoscopy, working along with Susan Wallace, RN, and a technician expert in the function and maintenance of the equipment. Mr. Murphy later remembered nothing of the procedure itself since he was sedated with midazolam, administered intravenously by Ms. Wallace. After the procedure, Mr. Murphy recovered while attended by Ms. Wallace. He learned from her that she, Dr. Leon, and the technician had been working together for 5 years performing colonoscopies and other endoscopic procedures. Occasionally one of them is absent for various reasons, but whenever possible the same 3 work together. They prefer this approach even though it complicates scheduling because it has enabled them to know each other’s work preferences, communication styles, and skill levels for different procedures.

This colonoscopy team, like Red Family Medicine in Chapter 1, is a true team. True team is a technical term. Other writers have used the terms long-term teams (Joshi and Roh, 2009, pp. 610-611) or intact teams (Salas et al, 2008, pp. 909-910) for similar teams. The distinctive and defining feature of these teams is that, in addition to having all of the 7 attributes of work teams (Table 1–1 in Chapter 1), they possess stability of membership over time. They also have clear leaders. The characteristics of true teams are shown in Table 2–1 along with the characteristics of other types of clinical teams, which are discussed below.

True teams have many strengths, which, taken together, constitute an advantage for true teams compared with other teams. These strengths are listed in Table 2–2.

When people work together frequently over extended periods, they normally develop deep commitment to their shared purpose. This level of commitment usually comes only with time. Of course, some teams are dysfunctional and do not develop in this way, but a team of short duration never even has the opportunity, whether it functions smoothly or not. Members of stable teams also typically come to know one another in their work roles and to trust one another to a degree not possible at the outset.

The members of true teams usually come to know one another well. They learn about each other’s strengths, knowledge bases, values, and skills. They also learn each other’s vulnerabilities and limits of toleration for difficult situations. This knowledge permits true teams to develop advantages that can contribute to good performance.

Over time, the members of true teams also commonly develop high levels of trust in one another. This trust also provides the basis for tangible functional advantages.

Because they are work teams, true teams by definition share responsibility for achieving their goals, but the commitment, mutual knowledge, and trust that develop with time often enable the team members to go beyond simply sharing responsibility. They can come to hold one another accountable for performing their roles well. In other words, true teams often achieve mutual accountability. In the vignette, it is easy to imagine that Dr. Leon and Ms. Wallace could point out to each other without awkwardness or offense that he or she is about to take action without having gone through all the steps required for full safety. For example, Ms. Wallace might forget to state aloud (or “call out,” to use a common teamwork term) the dose of midazolam before administering it. If Ms. Wallace were to choose the wrong dose, “calling out” the dose would enable the other 2 team members to recognize the dose as atypical. One can imagine that Dr. Leon might tactfully remind her to call out the dose and that she would regard his prompt with gratitude, not annoyance. Mutual accountability is one of the marks of a particularly high-performing team. Some writers on teams regard mutual accountability as a defining feature of a work team (Katzenbach and Smith, 2006, pp. 60-61). Using this definition, a work group does not count as a team unless the members actually take action, when appropriate, to hold each other accountable for performance. This high standard commonly is not achieved in health care. True teams are more likely to rise to this standard than are teams with changing membership or short duration. The issue of mutual accountability is discussed more fully in Chapter 6.

Members of a team who stay together for a long period of time also often develop a strong sense of identification with the team and its goals, especially if the team’s activities comprise substantial parts of their work lives. Identifying with the team means that members see the team as a reflection of themselves. Under these circumstances, the value or esteem of the team becomes merged with the members’ self-esteem, and their motivation to perform well is heightened.

As trust develops over time among team members, they become more deeply interdependent. In other words, as their confidence in each other’s skills and reliability grow, there is less need for the team members to second-guess and check each other’s work. This leads to faster action, less duplication, and more parallel action when possible. Because Dr. Leon has full confidence in the technician on his team, he does not need to watch the technician assemble the equipment or take it down; he can instead use this time to talk with the patient or to perform other tasks.

Members of true teams can also clarify their roles and communication routines over time, taking full advantage of the idiosyncrasies of the members’ personalities, knowledge bases, and skill sets. In a stable endoscopic team, it is not necessary for roles and routines to be fully defined in advance of each procedure. Early in the life of a true team, the speed with which members accomplish a procedure will be slower because they need to take time to clarify who does what. But eventually the assignment of tasks will fit the individual team members better than it would if the assignments were made in advance. For example, if the team in the vignette learns that Ms. Wallace is more effective in reassuring anxious elderly patients while Dr. Leon is more effective in reassuring middle-aged males, they can perform these more specialized roles routinely instead of one of them chatting with all patients before the procedure begins. They might even develop a means for signaling each other that an attempt to reassure a patient is not succeeding and that the other team member should take over the task because he or she is more likely to succeed. A team that is composed of different individuals each time it performs its task does not enjoy this opportunity to fit roles to individuals.

Health care has numerous teams that are composed of different individuals each time the teams go into action, for example, labor and delivery teams and many others as mentioned in Chapter 1. For many of these teams, there is no practical alternative to frequent changes in personnel. For staffing operating room (OR) suites, for example, frequently there are too many team members with duties in geographically dispersed places to be able to keep teams intact from one surgical procedure to another. Some observers have even suggested that these teams with variable composition are superior to stable teams because stable teams are vulnerable to complacency and other faults, leading to poor decision making and errors (Wachter, 2012, pp. 153-154). If we can extrapolate from the evidence in aviation, this suggestion is highly doubtful. Newly formed airplane cockpit crews experience more major accidents than do crews who have flown together before—in fact, many more (National Transportation Safety Board, 1994). Similarly, hospital-specific mortality rates for cardiac surgery are lower for surgeons who have performed more procedures recently at a given hospital, regardless of how many procedures they have performed recently at other hospitals. Operating consistently at one hospital improves a surgeon’s performance at that hospital but not at other hospitals, suggesting that stability of the OR team (and perhaps stability of the work setting) has a beneficial effect (Huckman and Pisano, 2006).

Writers on teams sometimes regard membership stability as a defining feature of teams (Thompson, 2011, p. 4). J. Richard Hackman, a prominent researcher on teams, regarded membership stability as so important that only stable teams were worthy of his label real teams (Hackman, 2002, pp. 54-59). (This was not Hackman’s only requirement for a team to be a real team.) As explained in Chapter 1, a definition drawn this tightly does not work well in health care because we have many groups plausibly called teams despite their routine turnover of membership. In health care, we have no choice about using many teams with fluctuating membership, and we can make them safe and effective—as will be discussed in the next section. Nonetheless, stable teams do have several advantages, and they should be used in preference to teams with variable membership when it is practical.

Even so, true teams are vulnerable in many ways, including some ways that do not pertain to variable teams. Outside of health care, true teams are the norm, and this had led to a great deal of research about their pitfalls. We consider these vulnerabilities in several later chapters. However, 3 points of vulnerability are so commonly encountered that they merit mention here (Table 2–3). First, all teams require effective leadership, and they may not have it. We deal with this topic in Chapters 8–11. Second, in a true team, it is important for decisions to be made in a way that secures team members’ support for the decisions. A team member who does not agree with an important decision will experience diminished identification with the team. If this happens occasionally, it will be unimportant. But, if there are frequent disagreements, over time the team member will cease to identify with the team and may become alienated. She may continue to perform in her customary role, but full engagement will be lost and performance quality is likely to suffer even if the loss of engagement is not overt. In fact, a disengaged team member often has reason to hide the change, for example, to avoid conflicts or to maintain employment. Third, true teams need to be able to resolve interpersonal or relationship conflicts. Relationship conflicts in short-lived teams often can be ignored—by the people who have the conflict and by others in the team. If there is an end in sight, team members can usually suppress their interpersonal disagreements. But in a true team, the members work together over long periods of time. Under these circumstances, the relationship conflicts are very likely, eventually, to cause dysfunction in the team.

Because of these 3 vulnerabilities, true teams have 3 corresponding critical needs. Table 2–4 depicts the critical needs of true teams as well as the critical needs of the other types of clinical teams. The critical needs for each type of team arise from corresponding points of vulnerability that have special importance for that type.

We turn next to the second type of clinical team. These teams differ from true teams in that substantial changes in their membership are expected to occur often.

Template Teams

It was Friday night in the Emergency Department (ED). County General Hospital is located in a large, urban area. It is one of 4 Level I trauma centers serving a population of 3.5 million people. On this particular Friday evening, traffic on the area’s freeways was heavy and brisk. It was raining, and numerous traffic accidents had occurred in the vicinity of County General.

At 6:30 p.m., a middle-aged woman was brought in by ambulance. She had sustained trauma to her chest in a front-to-side collision. She was taken from the ambulance into the ED on a stretcher, attended by Patricia Sterns, RN, CNS. Almost immediately Ms. Sterns was joined by Roy Collins, MD, a trauma surgeon, and within minutes another nurse and 2 technicians joined them. Ms. Sterns listened to the patient’s chest with her stethoscope and found that no breath sounds were audible on the left, suggesting that the lung on that side was collapsed. A chest x-ray confirmed that fluid (not air) filled most of the left chest cavity. With the help of Ms. Sterns and one of the technicians, Dr. Collins inserted a chest tube between 2 of the patient’s ribs. Bloody, yellow fluid began to fill a drainage bag.

At 9:15 p.m., a 22-year-old man was brought in unconscious. The car he was driving had hit another car from behind. He was not using a seat belt and was thrown through the windshield of his car, sustaining injuries to his head, left shoulder area, and chest. Again, Ms. Sterns met the patient and the Emergency Medical Technicians (EMTs) at the door. This time she was joined by James Anderson, MD, a trauma surgeon. One more nurse and 2 technicians joined them shortly. One of the technicians had participated in the care of the woman brought in earlier; the other technician had not. Ms. Sterns checked the position of the head immobilizer put in place by the EMTs while Dr. Anderson did a quick physical examination and ordered a computed tomography (CT) scan of the patient’s head.

This ED, like all other EDs, uses template teams. Like true teams, template teams have all 7 attributes of a work team (Table 1–1 in Chapter 1). They also have clear leaders. What is distinctive about this type of team? In contrast to true teams, template teams do not have stable membership. In Table 2–1, the characteristics of template teams are compared and contrasted with the characteristics of other clinical teams. Template teams typically provide time-limited episodes of health care such as the episodes of emergency care described in the vignette. The defining characteristic of template teams is their changing membership. If a team repeatedly provides time-limited episodes of care without any change in the individuals who comprise the team, then it is a true team, for example, an emergency rescue team of EMTs that remains intact from one rescue to the next.

Although the individuals in a template team change and may change every time the team provides clinical care, the roles and procedural routines in template teams are stable. Each time a template team is called into action, it performs in essentially the same way even though the particular individuals comprising the team change. In this story of County General’s ED, 2 instances of a template team are described. The task of both teams was to provide health care to the patients who had traumatic injuries from car accidents. The composition of the team was the same in both cases, that is, as specified by the inclusion of 2 nurses, 2 technicians, and 1 trauma surgeon. However, the particular people on the team changed. Dr. Collins was the trauma surgeon on the first team, and Dr. Anderson had this role on the second team. One of the 2 technicians was on both teams, but the other slot was filled by one person on the first team and a different person on the second team.

The term template team, like true team, is technical. Other writers use different terms for this team type or similar types: short-term team (Joshi and Roh, 2009, p. 610), crew (Morey et al, 2002), fluid team (Wachter, 2012, p. 153), stable role-variable personnel team (Andreatta, 2010. p. 349), and ad hoc team (Salas et al, 2008, p. 910). The advantage of the term template team is that it suggests an analogy with a document template. In a document template such as a form letter, the format and most of the text are fixed, but crucial words or phrases used at particular points in the template are expected to change each time the template is used to produce a new document. Similarly, a template team remains much the same each time it is reconstituted, but the individual team members can change. The team is not entirely variable—far from it—but it is variable with respect to team composition. As one author aptly wrote, “teamwork is sustained by a shared set of teamwork skills rather than permanent assignments that carry over from day to day” (Morey et al, 2002, p. 1555). One might expand this comment to say that clear role definitions, standardized communication routines, common behavioral expectations, and shared values also contribute to sustaining teamwork in template teams despite turnover in the team’s membership.

Template teams have several strengths, which are listed in Table 2–5. Because of their standardized roles and processes, they can have highly reliable processes and outcomes. As described by Meyerson and colleagues (1996), they also have the capacity for swift trust. In other words, when members of a template team assemble, assuming that they are familiar with the purpose of the team and the roles of the various team members, they can quickly establish trust that is adequate for the team to perform well. In general, template teams need little lead time to respond to the needs of the patients whom they serve. And template teams are resistant to deterioration in their performance when they undergo changes in personnel.

Template teams also have characteristic vulnerabilities, which are listed in Table 2–6. First, like true teams, template teams need effective leadership, and may not have it. But the role of the leader in a template team is different from that of a leader in a true team. Briefly, in a template team, the leader usually deals directly with short-term, operational issues. A template team leader is ordinarily an operational manager rather than a true leader. This difference is discussed in Chapter 8. Also, despite the urgent circumstances under which template teams commonly operate, the leadership is often shared. For example, the surgeon and anesthesiologist often share the leadership in an OR team.

Second, unlike true teams, template teams do not enjoy the luxury of being able to refine the members’ roles over time. When a motor vehicle accident victim is brought into the ED, there is no time to work out who will put in the intravenous line, who will measure the patient’s blood pressure, and so on. All of these tasks need to be assigned in advance. Even in situations in which time pressure is not so great, for example, at the beginning of an elective surgical procedure such as a mastectomy, it would be quite inefficient to work out the assignment of tasks anew each time the operation is done. Surgeons, scrub nurses, circulating nurses, and nurse anesthetists all know their roles in considerable detail before they enter the OR, and they have no need to negotiate their roles with the other team members. This standardization permits different OR teams to be composed of different people. At the same time, standardization of roles carries with it a degree of rigidity that is unnecessary in true teams and would often hinder achievement of optimal performance. Recall that over time Dr. Leon and Ms. Wallace in the earlier vignette about colonoscopy had the latitude to define their different roles in reassuring different groups of patients undergoing colonoscopy. They could even switch roles on short notice. In contrast, template teams have a higher need for clear and reliable role definitions from task to task.

Third, template teams are especially vulnerable to inadequate training. New template team members must be brought into the pool of team members with close attention to their orientation and initial training. All team members need periodic updates or refreshers of their training. In ED teams, surgical teams, and most other template teams, important parts of the necessary role definitions arise from professional education. Physicians perform certain tasks; nurses perform other tasks; pharmacists perform their tasks; and so on. However, educational differences do not fully assure that role differences in a template team will be clear because there are significant overlaps in what people in the various professions do. For example, both physicians and nurses do physical examinations of patients. It is only through training that team members acquire a clear and common understanding of their roles in a template team—as well as the role of the leader.

Standardization of communication processes is one important objective of template team training. Through training, various techniques become legitimized and expected. For example, check-backs become established as expected behavior. A check-back is a repetition by one team member of the answer just received from another team member. In other words, the person who asked for an important piece of information, say, how many units (bags) of blood are needed for a transfusion, repeats back to the person answering the question what that person said. The purpose of this routine is to confirm that the answer was received and that it was received correctly. With training, check-backs become an expected mode of behavior. Without the training, repeating someone’s answer might seem puzzling, awkward, or even sarcastic. The use of several other communication routines can also help in assuring that communication is standardized and reliable.

Communication routines are concrete and easily explained and taught. More abstract lessons can also be conveyed through team training, namely, behavioral expectations and the values underlying them. For example, in teams with steep hierarchy gradients, the junior members often will be reluctant to challenge the senior members because such challenges might be taken to imply disrespect. To cite an example from education, a freshman student in a chemistry laboratory session will be reluctant to tell the chemistry professor that she is about to add the wrong solution to a beaker, even if the risk at hand is a fire. Similarly, in an OR, a young and inexperienced circulating nurse may be reluctant to raise the question of whether the surgeon is about to operate on the wrong knee. Through training, everyone—including surgeons, nurses, and technicians—can come to understand that the good of the patient requires people to voice their concerns when they see an error in the making and that suggesting that an error might occur does not imply disrespect for anyone.

We deal with more aspects of communication, behavior change, and other aspects of team training in Chapter 14. Training is central to achieving the “set of teamwork skills” mentioned earlier as necessary for sustaining teamwork in template teams.

The existence of these 3 vulnerabilities of template teams—poor leadership, unclear role definition, and inadequate training—implies corresponding critical needs. In Table 2–4, the critical needs of template teams are compared and contrasted with the critical needs of teams of other types.

Beyond their differences with respect to needs for upfront role definition and training, the differences between true teams and template teams are less pronounced. As mentioned, both true teams and template teams require effective leadership. True teams can eventually develop deep commitment to their goals among their members, and many template teams can also enjoy deep commitment—even immediately, simply because of the nature of the task. It is difficult to imagine that the commitment of trauma teams would increase with time. The urgent needs of the patients engender strong commitment straightaway.

In true teams, team members achieve familiarity and mutual knowledge over time. Template teams can also achieve familiarity and mutual knowledge, especially if the pool from which the team members are drawn is relatively small and stable. For example, an ED might employ 30 nurses, 35 technicians, and 15 physicians. These professionals constitute the pool from which various individuals are drawn to make up the specific template teams providing care to the stream of patients arriving at the ED. Over time, all of the members of the pool will work with all of the other members; if necessary, this interaction can be deliberately planned. By working together, the members of the pool will become familiar with each other even if this happens more slowly than it would in a stable team of 5 or 6 who always work together. As the size of the pool increases, achieving this familiarity becomes more difficult.

Template teams are capable of swift trust, but deeper levels of trust are largely determined by mutual knowledge. This mutual knowledge—assuming that competence and reliability are present in the various team members—engenders confidence in each member that every other member can be relied upon even if he or she is departing from his or her customary role in the team. Since the potential for mutual knowledge is present in template teams, they can also achieve trust in addition to the high levels of commitment noted earlier. If the hierarchy gradient can be made less steep, through training or otherwise, template teams can also achieve mutual accountability. Mutual accountability is harder to achieve in template teams than in true teams because of the residual unfamiliarity of team members in most template teams, but it can be achieved. If it is not achieved throughout the whole team, it can sometimes be achieved between various pairs of team members who have worked together more frequently and for a longer duration.

Strong identification with the team and its goals can also be achieved by template teams, especially if the pool of team members is relatively small and stable. Those who work in an ED, for example, do develop a sense of identification with their ED. They are identifying not with specific template teams in which they participate but instead with the whole pool of people from which the specific teams are drawn. If the size of the whole group is large or if the group experiences high turnover, this identification will be more difficult to achieve.

Finally, the factors that determine whether mutual accountability is achieved also affect the level of interdependency in a template team. If commitment, mutual knowledge, and trust are high, then the level of interdependency will be high. As in true teams, this results in faster action, decreased second-guessing, and decreased duplication of effort.

Knotworks

Most clinical teams are either true teams or template teams. However, these 2 categories do not account for all clinical teams. There are 2 other categories of clinical teams, although these other teams are not fully team-like as they do not have all of the 7 attributes of work teams (Table 1–1 in Chapter 1). The teams in one of these 2 additional categories are called knotworks (Engeström et al, 1999).

Hakim Ghazzi was a 45-year-old Iraqi refugee who presented to George Walker, DO, his family physician, with weight loss and vague abdominal pain that sometimes went through to his back. Physical examination and a CT scan of his abdomen quickly established that Mr. Ghazzi probably had a cancer of his pancreas. The diagnosis was confirmed by taking a biopsy, that is, sampling tissue from his pancreas. Several additional tests were performed. None of them showed any spread of the tumor outside of his pancreas.

Mr. Ghazzi felt that he had lost much of his life to the turmoil in Iraq and that he had only recently been able to start again after a long hiatus. He was determined to undergo any treatment that might extend his life, regardless of how unlikely the treatment was to be successful.

Dr. Walker set about arranging for Mr. Ghazzi to see a surgeon and a medical oncologist, who would talk with him about treatment options. Although Mr. Ghazzi spoke English reasonably well, he requested to see specialists who spoke Arabic because he anticipated that the discussions would be complex and because he wanted his wife to join in the conversations. His wife spoke almost no English. Fortunately, Mr. Ghazzi lived in a large urban area, and Dr. Walker was able to identify suitable Arabic-speaking specialists. Appointments were made with both the surgeon and the medical oncologist. Dr. Walker agreed to continue as the coordinator for Mr. Ghazzi’s care.

Within 3 weeks, Mr. Ghazzi underwent surgery. The surgeon then referred him to a radiation oncologist for radiation therapy. (The radiation oncologist did not speak Arabic.) After the radiation therapy was completed, he received chemotherapy from the medical oncologist for several months. During this time, Dr. Walker continued to receive reports from the other physicians, and Mr. Ghazzi saw him every few weeks so that Dr. Walker could monitor him to detect signs and symptoms of depression or other complications.

Mr. Ghazzi’s physicians and the nurses who worked with them were working as a team—more or less. However, this was not a template team and certainly not a true team. The 4 physicians came together specifically to pursue the goal of eliminating Mr. Ghazzi’s pancreatic cancer. The surgeon and radiation oncologist had shared patients many times in the past, but the group as a whole had never worked together before and most likely would never work together again. They constituted a knotwork, tied together temporarily as the word knot suggests.

By definition, a knotwork has shared responsibility for the care of a patient but does not have a clear leader or stable membership. These characteristics are depicted in Table 2–1 along with the characteristics of true teams and template teams.

Knotworks are very common in health care. The example described here is largely within one profession, but there are many interprofessional knotworks as well. For example, a knotwork could be composed of a general internist, psychiatrist, clinical nurse specialist, and psychologist who do not work together normally but who have come together to provide care for a patient with bipolar disorder. Another interprofessional knotwork might be comprised of a pediatrician, pediatric neurologist, psychologist, and social worker, all caring for an autistic child and the child’s family—again, assuming that they have joined together to serve this particular child and family and do not ordinarily work together. A teacher at the child’s school might also be a member of the knotwork. A knotwork serving a teenager with disruptive behavior disorder might include police officers as participants.

Knotworks differ from true teams and template teams in several ways. As mentioned, they lack clear leaders and stable memberships. In addition, while some knotworks have all of the characteristics of a work team, most of them lack one or more of these characteristics. A knotwork does have a shared goal, shared responsibility for achieving the goal, authority for taking action, and interdependency of members. However, a knotwork’s membership is often not clearly defined. In Mr. Ghazzi’s story, the original team did not include a radiation oncologist, who was invited in by the surgeon without foreknowledge or approval by the family physician or medical oncologist although, of course, they would not have objected and did not object later. Similarly, as Mr. Ghazzi’s illness progresses, a psychologist, a visiting nurse, or various other professionals might be added to the knotwork, all in response to Mr. Ghazzi’s needs as perceived by him and by one or another member of the existing knotwork. In knotworks, there is also often independence of sub-groups, that is, sub-groups who are not accountable to the whole team. For example, the medical oncologist and the visiting nurse might make various decisions together without seeking the agreement of the family physician even though the family physician might want to participate. For some decisions, the oncologist and the nurse might not even notify the surgeon, and the surgeon might not expect to be notified since he might regard his work for Mr. Ghazzi as finished. And knotworks often are not accountable to anyone outside of the knotwork because commonly the group crosses organizational boundaries and there is no supervisor or governing board to which all of the members are accountable.

The group caring for Mr. Ghazzi is in fact not a team as defined in Chapter 1. Instead it is an appropriately fluid group, evolving over time. Whether or not they are regarded as work teams, it is desirable for knotworks to achieve teamwork if the patients’ interests are to be well served. For this reason, knotworks warrant discussion along with genuine work teams. In fact, knotworks frequently are thought to be teams but are not distinguished from template teams, leading to neglect of how knotworks’ special characteristics affect their performance.

Knotworks have certain strengths, which are listed in Table 2–7. First, they are highly flexible. New knotwork members can be added easily, normally at the request of one of the existing professional members and sometimes at the request of the patient or family. Second, because of their flexibility, knotworks are quickly responsive to the needs of patients and families. No team decision-making process needs to be followed to revise the membership of the knotwork or its plan of care. In fact, often there is no unified plan of care. Instead, individual knotwork members or pairs of members commonly have separate plans.

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