Teamwork Competencies

Section I of this book (Chapters 1–5) describes the concept of a work team, differentiates different types of teams in health care, introduces the professionals who comprise healthcare teams, and explains the roles of patients and administrators. This section introduces the team and the members of the team. It sets the stage for what follows. Sections II–IV then build on this foundation by examining how effective teams and team members work and how we can advance the effectiveness of teams throughout health care.

WHY HEALTHCARE TEAMWORK MATTERS NOW

Healthcare delivery is a specialized enterprise, and it promises to become more and more specialized as knowledge advances. Decades ago, most physicians in the United States were general practitioners. In 1940, 76% of physicians were general practitioners. By 1955, the proportion had declined to 56%; by 1969, it was 31% (Starr, 1982, pp. 358-359). In 2007, only 13.5% of physicians were family physicians or general practitioners, and 34.3% were practicing in all of the primary care fields combined—family medicine, general practice, internal medicine, and pediatrics (American Association of Medical Colleges, 2008). By then the American Medical Association was tracking counts of physicians in 33 specialties in addition to the primary care fields. Medicine has become highly specialized. Similar developments have occurred in nursing. Nursing now has registered nurses, licensed practical nurses, clinical nurse specialists in various fields, nurse practitioners, and doctors of nursing practice. Pharmacy has established specialties in nuclear pharmacy, pharmacotherapy, oncology pharmacy, and other fields. Social workers and physical therapists are also specialized. The care of most patients is provided by several people practicing different professions. This fragmentation calls for teamwork to assure that they work together effectively.

Calls for improved interprofessional teamwork date back to at least the mid-1950s (Garrett, 1955). However, progress has been slow for several reasons. First, in their training, physicians and nurses and many other clinicians are imbued with the notion that they are individually responsible for what happens to their patients and that performance must be flawless (Leape, 1994). Although a more complex and realistic viewpoint is now gaining sway, for more than a century, clinical professionals finished their training believing that good outcomes were the results of individual effort and that mishaps were caused by individual mistakes. Teamwork had nothing to do with it, or so it was believed. Second, the members of each healthcare profession are educated in isolation. Pharmacists are educated in Colleges of Pharmacy; nurses, in Schools of Nursing; physicians, in Medical Schools; and so on. They rarely meet. One result is that they embrace the values, vocabulary, and conceptual frameworks of their own professions without any exposure to this same socialization process as experienced by students in other healthcare professions (Hall and Weaver, 2001). These values, vocabulary, and concepts are different in different professions as explained in Chapter 3, and these differences hinder teamwork, especially when they are not understood. Separation during training also means that students do not learn how to work in interprofessional teams and are left to figure out teamwork (or not) once they are in practice. Change is stirring here too, but regular interprofessional education in the core curricula of healthcare professional schools is still distinctly uncommon. Third, rivalries between professions, especially medicine and nursing, have at times cooled enthusiasm for teams (Fagin, 1992). Controversy between physicians and nurse practitioners over leadership of medical homes (a team-based, patient-centered approach to primary health care in the United States) is a recent example of such rivalries (Lowes, 2012).

Nevertheless, the desirability of team-based care has not been seriously disputed in all these years. The problem has been that action was taken only in limited arenas—for example, mental health and developmental pediatrics—until the early 2000s. Interest in teamwork was reignited then by the widespread recognition that high quality health care is achieved not solely by the competent practice of individual healthcare professionals but also by the presence of systems—contexts, settings, processes—that enable and encourage good practice and protect against mishaps. A key event in building this recognition was the publication of To Err Is Human: Building a Safer Health System (Institute of Medicine, 2000). The foundation for that publication had been prepared by Donald Berwick, Paul Batalden, Lucian Leape, and others who had been writing and speaking for over 10 years about the importance of systems in determining the quality of health care (Batalden and Mohr, 1997; Berwick et al, 1990; Leape et al, 1995). To Err Is Human was widely discussed in newspapers, television, and radio—as well as in healthcare publications. Its impact was solidified by several other books issued by the Institute of Medicine over the next few years. Soon healthcare professionals across the country were discussing how systems might be changed to improve the safety and quality of care. And, of course, healthcare teams are important components of healthcare systems, as was emphasized in To Err Is Human. When To Err Is Human was published, interest in the quality and effectiveness of team-based health care increased, and it has continued to increase since that time.

This chapter begins our exploration of teamwork in health care by dealing with several foundational issues. How is the word team to be understood in the context of health care? What benefits do teams bring to health care, and what are the risks of working in teams? What evidence do we have that teams are more effective in making decisions and providing care than individuals working alone? What values must various people in clinical practices and hospitals have in order for healthcare teams to function well? What knowledge must these individuals have? What must team members be able to do? We begin by considering what a team is.

WORK GROUPS AND WORK TEAMS

To begin at the beginning, it is important to understand the word team. In ordinary conversation, the word is used to describe a wide variety of groups of people jointly engaged in one activity or another. There are sports teams, management teams, surgical teams, and so on. In some organizations, every employee is regarded as a team member so that the team consists of thousands of people, many of whom have never seen each other. For example, if you pick up a customer service telephone at a Target store and ask for help, you are told that a team member will be with you shortly. All of these uses of the word team make sense in their contexts, but in order to understand teamwork in health care, it is useful to define a term that refers to teams as they are encountered in the workplace, that is, teams of the kind that can provide team-based health care and can make decisions in healthcare organizations. We will call these teams work teams; and in this book, the term team means work team. It is somewhat arbitrary to use the phrase work team instead of work group for these entities. For the sake of clarity, we choose to think of work group as the name of a class or genus of groups of people and to think of work team as the name of a sub-class or species within that class (Figure 1–1).

It is Monday morning. The Chief Executive Officer (CEO) of Memorial Hospital has called a meeting to make an important announcement. The hospital is going to merge with another hospital across town. Attending the meeting are the Chief Nursing Officer (CNO), the Vice President of Medical Affairs, the Medical Staff President, the Chief Financial Officer (CFO), and about 25 others, including the head of the housekeeping service, the nurse manager of the emergency room, a prominent orthopedist who performs surgery at Memorial, and the hospital’s in-house legal counsel. Everyone has known for months that merger talks are in progress, and many in the room have participated in them. However, only a small group knew before this meeting that the talks had reached a successful conclusion over the weekend.

The response to the announcement of the merger is jubilation. The merger will be very good for Memorial. The CFO and in-house counsel smile broadly and shake hands. The CNO and the Medical Staff President exchange looks of satisfaction—mingled with relief. All around there are signs of collegiality, pride, and anticipation of good things to come.

All of the people attending the meeting in the vignette work at Memorial Hospital. In some sense they are all on the same team. They may even call each other team members, meaning that they are all colleagues. There is no doubt that they all work together and that they all depend on each other to do their best so that Memorial can provide excellent health care to the people it serves.

But are they really a team? Describing the group of people at Memorial as a team stretches the concept. For example, many of the people do not interact. The CFO may recognize the head of housekeeping, but she never meets with him or communicates with him in any way. The group seems to be too large to be called a team. Within the broad scope of activity in the hospital, the people present in the room have specific objectives that they work toward each day without needing to know what many of the others are doing. Only some of them work interdependently on a daily or weekly basis.

Still, the Memorial Hospital employees and medical staff share a common general purpose, which is to provide health care, either directly or by supporting those who provide it directly. Each of them plays his or her part to serve that purpose. They collaborate in various sub-groupings. They identify with Memorial in its successes and difficulties. The group receiving the good news this Monday is certainly a work group.

But they are not a team except in some watered-down sense of the word. Why are they not a team? How does a work team differ from other work groups?

WHAT IS A WORK TEAM?

John Kimpell, MD, is a family physician. He works in a large medical group. His immediate colleagues are 3 other family physicians, Anna Gomez, MD, Allen Lewis, DO, and Jane Pearson, MD, and 1 nurse practitioner, Sarah Harris, RN, CNP. Penny Mills, RN, is a nurse who works closely with the physicians and the nurse practitioner. She receives patients’ telephone calls and e-mail notes and assesses their needs for care, often meeting their needs herself without the need for a face-to-face visit. There are also 2 receptionists, who make appointments and greet patients as they arrive in the clinic, and 3 medical assistants, who bring patients to the examination rooms, take vital signs, and help the clinicians in other ways. This group of 11 cares for approximately 9000 patients who are registered with them. In the clinic, Dr. Kimpell and his colleagues are referred to as Red Family Medicine. There are 3 other similar family medicine groups functioning within the medical group.

Dr. Kimpell, Dr. Gomez, and the others in Red Family Medicine are a team. They work together to provide health care to the patients who see them in their clinic. What is it about them that makes it fitting to describe them as a team—as opposed to a group of people who simply work near one another in the same organization? A work team is commonly defined as a work group with several characteristics that mark it more specifically as a team (Hackman, 2002, pp. 41-59; Katzenbach and Smith, 2006, p. 45; Reeves et al, 2010, pp. 37-42; Scholtes et al, 2003, pp. 1-2; Sundstrom et al, 1990, p. 120; West, 2012, pp. 27-28, 65). There are 7 defining characteristics of a work team, listed in Table 1–1.

First, the members of the team have a shared goal or a set of goals. They are not pursuing their own individual aims while working nearby one another. Instead they are jointly seeking to achieve the same aim or perhaps a set of aims. In the case of Dr. Kimpell and his colleagues, the aim is to provide primary health care to the patients seen in the clinic. All of their work is oriented toward the task of achieving this aim.

Second, the team members share responsibility for achieving the goal. If the goal is reached, then all of the members share the credit for the achievement. And if the goal is not reached, all members of the team bear the burden of not succeeding. If Red Family Medicine provides health care with good outcomes, good patient experience, and efficient use of resources, then all of the individuals will share the credit, despite the fact that the roles of the various team members are different. All also will share the satisfaction.

Third, the membership of the team is “bounded” (Hackman, 2002, pp. 44-50). In other words, it is clearly established and understood who the members of the team are. The membership may change over time, of course; but at any given time, it is clear who is a member and who is not. The membership of Red Family Medicine is clear. Those who interact directly with patients and their families are team members. There are 11 of them. Various other people support the team, for example, those who clean the offices in the evening. However, they are not members of Red Family Medicine. They are members of a different team.

Some writers on teams go further to say that a group larger than a certain size cannot be a team (Katzenbach and Smith, 2006, pp. 45-47; Reeves et al, 2010, p. 61; West, 2012, pp. 28). Sometimes this upper bound is said to be 25; some writers say that a team can be no larger than 10 or even smaller. We have more to say about the important consideration of team size in Chapter 12 where we consider the design of teams.

Fourth, the team has authority to carry out its task without needing to obtain approval for its decisions from someone outside of the team. In other words, it has autonomy in execution (West, 2012, pp. 27-28, 65). The team has sufficient capability in the pursuit of its goals to be able to take action without routinely seeking help and permission from people outside of the team. It has responsibility for achieving its goals, and it also has accountability as discussed below.

Fifth, the members of the team are interdependent. In order for the team to achieve its goal, the individuals depend on each other to carry out various portions of the work. Moreover, their dependency on one another is interactive. Dr. Gomez can do her work only if the medical assistants in Red Family Medicine do their work well, and her actions are often performed in response to what a medical assistant has done. For example, if a medical assistant brings a patient to an examination room but does not take the patient’s blood pressure because the patient is agitated at that moment, then the assistant will tell Dr. Gomez, who will take the blood pressure later. The medical assistant has served the patient’s psychological needs and has intentionally not gathered important physiological information with the usual timing, so Dr. Gomez fills the gap later. In health care, there is almost always some degree of skill specialization across the team members so that the members are not interchangeable, and the specialization makes the interdependency quite obvious. In other arenas other than health care, there are teams that consist of members who all have essentially the same skill set and do different pieces of the work depending on what is needed. For example, a carpentry crew erecting the structure for a new house could consist wholly of people who could substitute for each other if someone happens to be absent. In health care, teams with this ability to substitute team members are distinctly unusual, and so the dependence of one team member on another exercising his or her skills is usually very clear.

Sixth, the team functions as an undivided unit in working toward its goal. In other words, a work team does not have sub-groups operating separately, nor does it have an internal structure. This does not mean that sub-groups never meet or make decisions by themselves. Obviously, the 5 physicians and nurse practitioner in Red Family Medicine must decide how many of them can be on vacation and how many must be in the clinic to see patients each day. However, in making this decision they do not operate autonomously in that they are accountable to the team as a whole for their decision. For example, it is reasonable, even expected, that Ms. Mills, the registered nurse in the team, or one of the medical assistants would raise a question about staffing being too low for a given week because the clinicians have overlooked the fact that spring school vacation will mean that more children than usual will be brought in for care.

If what seems to be a team does have operational sub-groups, then each of these sub-groups is a team and the whole is a pair or a cluster of teams. If there is an internal structure through which some individuals are accountable to others but not to the team as a whole, then some individuals are not actually team members or there is more than one team at work. The members of Red Family Medicine all interact frequently. Although there is differentiation of function, no subgroup operates separately from the rest of the team.

Seventh, regardless of its authority and responsibility for carrying out its purpose, a work team is accountable to the larger organization of which it is a part. Dr. Kimpell’s team is accountable for the team’s performance, including its quality of care and its financial performance, to the head of primary care in the medical group and ultimately to the president of the medical group. The only exception to this rule is a team that is the whole organization, for example, a small primary care practice that is freestanding. But even then the team is accountable to the practice’s governing board or partnership committee.

A work group is a work team only if it has all 7 of the characteristics listed in Table 1–1. This is not to say that a team with all 7 attributes is necessarily an effective team or a good team in any other sense. This is a separate question, one that is addressed in Chapter 6. For the moment, we are simply getting clear on what counts as a team, good or bad.

WORK TEAMS AND LOOK-ALIKES

Defining a work team as a work group with these 7 characteristics has several implications. Some of them may not be immediately obvious.

A group of individuals, each producing a product or service that contributes to a final goal, is not a team unless the individuals work interdependently, that is, unless the individuals adjust their outputs depending on the actions of other group members. In the vignette about Red Family Medicine, this adjustment is illustrated by the interactions of Dr. Gomez and the medical assistant with whom she works. In contrast, the individuals who wash and sterilize the laundry in a hospital, those who sterilize surgical instruments, and those who clean the operating rooms all contribute to effective, safe surgery, but they are not a single team because the members of each group work separately from all of the people in the other groups. Individuals performing the cleaning and sterilization of laundry, surgical instruments, and operating room cleaners constitute 3 separate teams.

Similarly, a group that appears to be an organizational leadership team may actually be a group of individual contributors and not a genuine team. The difference can be quite subtle. Leadership team members can meet together regularly and appear to be a team while they are actually performing their own functions without attending to the actions of the other team members and without any adjustment to assure that their respective portions of the organization work together effectively (Lencioni, 2002). A hospital leadership team consisting of a Vice President for Patient Care, a Chief Medical Officer, a Director of Human Resources, and others may function in this way. If they do, they are not a team; they are some other kind of work group.

Because a team has the authority to carry out its task, a work group is not a team if it is closely supervised from outside the group. Thus, a group of nurses is not a team if they are given repeated, detailed direction by a supervisor who is not a member of the unit. This group does not have the latitude to work together collaboratively because individual members of the group are not permitted to interact with one another to make joint decisions and act on them.

Some large groups that are sometimes labeled teams are not work teams. For example, a football team is not a work team. Its large size and separation of players into different sub-units are inconsistent with the requirement that a team does not have components that operate independently. Within a football team, normally there are 3 sub-groups: an offensive group, a defensive group, and a special-teams group. A football team is a cluster of 3 teams, perhaps more. For similar reasons, the medical staff of a hospital is not a work team and a hospital’s nursing staff is not a work team. And the employees of a Target store are not members of one work team; at any Target store there are multiple work teams.

These considerations are important because understanding the performance of a hospital or healthcare practice—or a football team or a Target store—requires attention to the real work teams in the organization and to those small groups that aspire to be work teams but have not yet succeeded. Attending to a cluster of work teams as if it were a single work team will obscure the function of the component work teams and frustrate attempts to improve the performance of both the component teams and the whole.

TRUE TEAMS

The reader may have noticed that stability of team membership is not among the characteristics listed in Table 1–1. Why not? Surely, a group of strangers who come together, carry out a task for an hour or less, and part company forever cannot be regarded as a team. Surprisingly, though, health care has many teams that function in exactly this way: code blue teams, emergency cesarean delivery teams, and even some routine operating room teams. To rule out these groups as teams would mean neglecting a good deal of health care. It is because of such teams that membership stability is not a defining feature of healthcare work teams.

Nonetheless, stability is a desirable team characteristic, something to encourage and maintain when circumstances permit. Teams that persist over time but must contend with ever-changing membership usually do not achieve levels of commitment and interdependency that are characteristic of the most highly performing teams. Moreover, only teams that are stable over long periods of time are likely to be able to attain mutual accountability; that is, only the members of stable teams are likely to actively hold each other accountable for their performance. And only stable teams are likely to develop in their members a sense of identity with the team and its goal. The advantages of stability in a team are discussed more fully in Chapters 2 and 6.

Red Family Medicine—with its long-serving members—does seem to be more fully a team, more like a genuine team than one that forms and carries out a task over an hour or even a month, then disbanding. Because Red Family Medicine has the 7 defining characteristics of a work team and, in addition, has stable membership, it is an example of an important archetype among healthcare teams. Our label for this type of team is true team. In Chapter 2, this archetype is contrasted with other team archetypes.

BENEFITS OF TEAMS

Why are teams used to provide health care? For many episodes of health care, given the specialization discussed earlier, there is no other way to provide the needed care. To meet the needs of many patients, the expertise of several people is required so that all of their expertise can be brought to bear on the problem, expertise that no one person has or could have. But beyond this consideration, what value do teams bring—generally and to health care in particular? What are the justifications for using teams in situations in which the work could be done by individuals working alone? There are actually many reasons for using teams (Katzenbach and Smith, 2006, pp. 15-19; West, 2012, pp. 17-20). Let us consider 4 important ones.

Bay Medical Group provides primary care to people of all ages in a coastal community 100 miles north of San Francisco. Its staff includes general internists, pediatricians, nurse practitioners, and many others. It is unusual in having a psychologist and a social worker therapist in the group. These 2 clinical professionals were added 2 years ago to improve the care provided for adults with mental health problems. Prior to that time, a patient with depression, for example, would be treated with medication by one of the physicians or would be referred to a mental health group nearby. There was nearly always a delay in getting an appointment for the patient with the mental health group. Often the information transferred would be incomplete, requiring another delay as the mental health provider obtained the information needed. Similarly, the information transferred back to Bay Medical Group was often incomplete or delayed.

Now that the primary care providers work as a team with their own mental health care providers, the sequence of events is much faster and easier. A patient presenting to a nurse practitioner with serious depression can usually be seen by the psychologist for brief initial assessment the same day. The primary care providers can seek guidance informally by walking down the hallway for a brief conversation with the psychologist or social worker. Often they learn then and there that a visit with a mental health provider is not needed because the problem can be handled by the primary care provider. Sometimes they learn that the situation is more urgent than they realized and that mental health care is needed immediately.

Teams are faster in performing many tasks. This advantage is graphically illustrated by the team arrangement at Bay Medical Group. When the care was provided by the various professionals providing their items of care serially, everything took much longer. The rapid interaction of people working in a team often saves both time and money.

Teams also enable individuals and organizations to learn. By working together closely, the primary care providers and mental health care providers at Bay Medical Group have learned a great deal from each other about providing high quality mental health care. They also have learned many routines for working together smoothly and effectively.

Moreover, these routines for referral, information transfer, and the like have become codified in the operation of the clinic. When the providers turn over as various people move away or retire, the lessons learned will be retained by the team even though the team members have changed. The team serves as a repository of useful knowledge.

Teams are also sources of innovation. When the psychologist and social worker first joined Bay Medical Group, they were disappointed that they were not consulted more frequently on an informal basis. In meetings with the primary care providers, the psychologist and social worker voiced their disappointment. This led to exploration of the issue and eventually to a discussion about the causes and solutions for a problem of lost opportunity. It was revealed that when the primary care providers began seeking informal consultation they had become frustrated because the mental health care providers seemed never to be available. The principal solution chosen was to schedule the mental health providers less tightly so that they had slack time available to be interrupted as their days progressed. This solution would have been unlikely to be discovered if the primary care and mental health care providers had been working separately.

Despite these and other advantages for teams, it is, however, important to note that not all tasks are suitable for teamwork. Some examples of tasks suitable for one person are obvious from the nature of task. A portrait painted by 2 people is likely to suffer from the division of labor rather than being enhanced—unless the styles of the 2 painters are identical (for example, because one painter trained the other). A prosthetic aortic valve can be sewn into place by only 1 surgeon. But even some tasks commonly performed by teams are often better done by individuals. Task force reports written by teams sometimes are stigmatized as “camels,” that is, horses designed by committees. The decision as to whether a given task should be carried out by a team is an important consideration in designing teams. In other words, the first decision to make when designing a team is whether a team should be created for the task at hand. This issue is discussed more fully in Chapter 12.

RISKS OF TEAMS

Working in teams also carries some risks. The most frequently noted risk often is called social loafing (Thompson, 2011, pp. 28-31). Primarily because teams commonly have more than one person who can perform a given task, it becomes tempting for team members to stand by while someone else does the work. For this reason, teams can have a demotivating effect on individual members. This problem is also called freeloading or free riding. The risk of social loafing is higher with larger teams since responsibility is diffused more widely when there are more people who might do the work.

In addition, decision making and action by individuals may be degraded when individuals work in a team rather than alone. A common cause of this problem is domination by hierarchy or personality so that team members set aside what they think is best and instead do what they think is expected of them by those they perceive to have more power in the team (Jelphs and Dickinson, 2008, p. 68; Reeves et al, 2010, pp. 60-61). Thus, in the operating room, where the surgeon and the anesthesiologist are the acknowledged leaders, often other members of the surgical team are reluctant to disagree with them. It is likely that some cases of wrong-site surgery could be prevented if team members did not feel inhibited about voicing their doubts about the course of action being taken (Clarke et al, 2008). So too, a physician with a forceful personality may intimidate the nurses and others with whom she works so that the other clinicians set aside their own insights into what would best serve the patient’s interest—even if the physician would be most dismayed if she understood the effects of her manner on team performance.

Despite being sources of innovation, teams can actually be less creative than individuals working alone (West, 2012, pp. 23-25). Again, there are several causes for this diminished creativity. One of the most obvious causes is that offering novel ideas in a group carries the risk that one will be ridiculed (or criticized in gentler ways) because the idea offered is unfamiliar and, at least at first blush, implausible. A particularly interesting second cause goes by the name of production blocking. Despite the enthusiasm often expressed for the practice of multitasking, it is in fact not possible to switch back and forth between different trains of complex thought and maintain the quality of both (Thompson, 2011, pp. 212-215). In group discussions, the production of truly new ideas gets blocked when those who are formulating a novel thought get diverted by the need to attend to what other members of the group are saying. Production blocking is discussed further in Chapter 9. Still, innovation is fueled by the pooling of facts and insights that no one person possesses before the discussion begins. Fortunately, there are methods for overcoming fear of criticism, production blocking, and the other threats to team creative thinking and problem solving. We explore those methods in Chapter 10, which deals with creativity.

Table 1–2 summarizes the benefits and risks of teams.

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