While writing a manuscript entitled “Concerns
regarding the current state of patient safety initiative implementation in the
US: a conversation with Dr. LD Britt”, Dr. Douglas Paull, MD (Director, Patient Safety Curriculum, National Center for Patient
Safety) suggested to me that using the noun ‘team’
may not be appropriate in healthcare. He stated that we should be utilizing the
verb ‘teaming’ (coined by Amy Edmondson of Harvard). Dr. Paull stated "as
healthcare gets more complex,‘teaming’ may be what we strive for. Each member
of the organization knows CRM skills to be able to form team quickly, provide
both leadership and followership as necessarily, and communicate effectively.”
Considering the dynamic state most medical ‘teams’ exist in, utilizing Amy Edmondson's
concept of the action of 'teaming' in medicine rather than the formation of
teams (which is a more static concept) may be the way to go.
I considered the fact that even in the
Operating Room, the Intensive Care Unit, and the Emergency Department, teams
are rarely consistent. As case complexity changes or shifts change, the
construct of the team will vary. With this in mind I contacted Amy Edmondson (Professor
of Leadership and Management, Harvard Business School) about her
concept and book ‘Teaming:
Organizations Learn, Innovate, and Compete in the Knowledge Economy’, I
asked Amy C. Edmondson regarding her thoughts on using ‘teaming’ in medicine. .
QUESTIONS FOR AMY EDMONDSON:
The concept of a Traditional Team implies a static construct in the
membership of the team. Many years ago surgeons had the exact same team every
day all day long. Theoretically, if
successful, a traditional team has the same values, training, and understood
communication style. Such teams would be expected to be efficient and safe with
minimal extraneous communication need. However, excluding smaller surgery
centers and some inpatient operating rooms, the concept of having the same team
day-in and day-out went by the wayside decades ago and a surgeon will typically
have a different team construct different days and during the day (depending of
course on the volume of the medical center). During emergency cases or catastrophic changes
in the midst of a procedure there will almost assuredly be flux in the team.In general, in the Operating Room, the Intensive Care Unit, and
the Emergency Department, teams are rarely consistent. While OR administrators
(Nursing and Anesthesia) do their best to provide consistency in the team where
warranted, rarely does a surgeon have the same nursing and anesthesia staff.
Life in the OR reminds me often as a pickup game rather than an organized
sports team.
Is the concept of a Surgical
Team Archaic? Should we continue to use aviation as a model for healthcare or should
we totally revamp our methods for “team training”? If so, what should we be
doing?
Amy Edmondson: Medicine has a much higher complexity than
aviation. Aviation has a homogenous task compared to surgery. When we began to
investigate teamwork in healthcare, we saw a different answer to what exactly
was a “TEAM” in each area we investigated. I got a different meaning to the
definition in the lab, the intensive care unit, everywhere.
Is teaming more effective
than a stable team?
Amy Edmondson: Teaming is not
better or worse than a stable team – a stable team is likely better, but in
many situations you cannot have a stable team. In the OR, you can increase the
chance of a stable teams (in some medical centers), but sometimes it
unrealistic to organize staffing schedules for stable teams. If you train staff
in communication and leadership skills, any team –even a brand new one- can perform
well. With the 24/7 scheduling challenges in healthcare, you need to be able to
get people up to speed to coordinate and collaborate effectively with new work
partners.
What makes a team successful
or fail:
Amy Edmondson: There are many
aspects that determine the success of teams. Stability can be one of them, but
this is a hard thing to maintain. When people have multiple roles and do not
just do one thing anymore, we need to find ways to overcome a lack of familiarity
among team members. In short, it won’t work if anyone is crippled when “my
nurse is not around”.
Tell me about where this has
worked well:
Amy Edmondson: In a recent
ED study with Melissa Valentine, at Stanford, we assessed the use of Pods in
the ED. People were assigned randomly to a pod for that day’s shift. That created
some stability, compared to the usual ED staffing model.
Prior to Pods,
it was confusing and, for example, the nurses did not know who to go to when
they had questions or concerns. The pods behaved like a scaffolding structure
that helps temporary teams act like “real teams.” Valentine and I describe this well in a 2015
article called ‘Team Scaffolds’.
Are there
any skills we can learn or teach that improve teaming?
Amy Edmondson: We can teach
certain skills that improve performance in these worlds. For instance, knowing someone’s
name improves coordination and teaming, especially in critical circumstances. You
can lean towards stability when it is feasible for your scheduling constraints,
but that is not going to be the model forever. What you most need is an
awareness of interpendence on others. It is obvious in the OR that you need
specific functions and specialties. It is not as clear in other areas such as
in clinic. If I just do my job and don’t consider how it intersects with other’s
jobs, and say the patient ends up waiting too long between steps, the patient
is not getting optimal care or customer service. You ought to be asking how to
improve handoffs throughout the care delivery process.
How do
you train healthcare staff to function in a “teaming” model?
Amy Edmondson: If I am about
to put salt in the sugar bowl, it would be great if someone would speak up and
stop me from doing that. In other words, no one is infallible. All of us need
input and feedback. As a leader I need to constantly remind people of
interdependence and of the need to speak up and to listen intently to each
other, so that we can deliver care and improve and innovate.
After this I purchased her 2012 book ‘Teaming: How Organizations Learn, Innovate, and Compete in the
Knowledge Economy’.
Teaming reflects the activity of
working together as an active (not static) process. It represents “a fluid
network of interconnected individuals working in temporary reams on
improvement, problem solving and innovation.” This concept relies on differing
perspectives to become successful. For this to work effectively the members
must rely on their affective and cognitive skills. This concept originally was
conceived for the performance of temporary or urgently constructed teams for
the purposes of brainstorming or managing an unexpected catastrophe. For
decades, this concept would not likely apply to the static environment most
healthcare workers resided in. Surgeons had the same nurses and techs on
virtually all procedures. In fact, these
days many may feel a bit (or a lot) reticent about this concept of teaming
functioning well in a hospital. With all the short staffing, high turnover,
ingrained silos, push for production in the OR, ward etc, it is hard to imagine
that healthcare institutions can find the motivation to function in the same
capacity as these highly motivated and innovated business teams. It is also
more difficult to motivate an institution to move to a model that differs from
the perspective that they have an ingrained traditional hospital structure. Add
to this the fact that it is not as easy to measure ‘Teaming’ and in this day
and age if you cannot measure it, you are instructed to move on. But, adopting
the concept of teaming is likely exactly what needs to happen. Healthcare is
more dynamic than ever with new innovations and the need to respond to dynamic
uncertain situations on an ever increasing basis. Sure great teams consist of
stable organized units, but we simply do not have that luxury anymore it
appears in healthcare. This flexibility in mindset will initially be difficult
by healthcare staff not quite used to that idea, but in reality this dynamic
environment is already here to stay.
Does teaming eliminate the need for
standard team skillsets? No, those skillsets of interdependence, trust, and
coordination are still necessary. What is not necessary is the need to build
the foundation of personal history and experience while working together. Now
workers will be required to work to communicate frequently, rapidly and clearly
to assure comprehension.
Perhaps the greatest pressure may actually be placed on
institutional administration. For teaming to be effective, administration may
need to be less managerial (less top-down) in its mindset. Past practice of
relying on fear to control employees is not effective in this environment. If
administration desires dynamic and adaptable staff then management will need to
become dynamic and adaptable and relinquish control. This management style will
need to rely on learning rather than coercion.
This methodology is a drastic change in many places as it requires the
allowance of SPEAKING UP, ASKING QUESTIONS, SHARING IDEAS OPENLY without
humiliation or punishment, allowing for EXPERIMENTATION, Constructive FEEDBACK
and open discussion of MISTAKES. This mindset defies human nature. It requires
one to take risk and humility. This is not easy in the current litigious,
competitive environment. On top of that, the traditional leadership model is
one where everyone expects the leader to be infallible and have all the
answers. In this environment, you are rewarded for success and punished for
failure.
What happens when you have interdependent teams and individuals
but without the teaming skills? In many cases, things go fine with no problems.
In the hospital setting, individuals and teams appear to perform successfully
the majority of the time. Occasionally, however, there is lack of understanding
leading to lack of coordination, which leads to missed opportunities, which
leads to incrementally intensification of the effects of individual mistakes,
and finally an adverse or even worse, a sentinel event. In those cases where
timing is crucial, a leader needs to recognize that the situation mandates
teaming and needs to gather the players together so they understand why this
situation is different. When this scenario comes up, it is no longer simply
that “everyone just needs to do their job”. If a dynamic situation arises,
Silos simply do not support a dynamic situation and real time teaming is needed
to be successful. In great hospitals, the employees are rewarded for skills
such as ingenuity, judgment, intelligent experimentation and resilience. In
many places, these characteristics are discouraged and scoffed at. More so, you
cannot measure these skills.
How does one initiate a teaming
concept? It begins with the recognition that we need to break down the silos
and acknowledge we are interdependent. It takes a new mindset. It requires open
communications. It requires institutional leadership acceptance that the current
process is not successful. Only then will people begin to speak up,
collaborate, experiment and reflect. This requires that people escape the
stigma of speaking up and discussing their mistakes. Healthcare staff are
already stressed and in conflict, so breaking out of the potential embarrassing
emotional aspect of speaking up when you see something wrong or an opportunity
for improvement with potential for being shamed. This will take respect. This
will also require that we face our personal cognitive biases when our personal
view just seems so right that no other view can possibly be accurate. This is compounded by our view that everyone
else likely shares our view and that one individual may be deliberately
clashing with our view with no merit. This becomes an opportunity for
leadership to cool conflict and make it psychologically safe where people feel
free to express relevant thoughts without fear of penalty. For teaming to be
successful, everyone must suspend their assumption that their perspective is more
accurate than that of others, but unfortunately people tend to focus on their
own task failing to account for the relationship that their tasks have with the
overall picture. Leadership must
acknowledge that with psychological safety, comes additional conflict but that
is expected when staff are encouraged to speak up and that goes against the
grain of typical human emotions where we don’t want to be told we are wrong in
public venues.
One of the most important facets in Amy
Edmondson’s book to me is the concept of Framing. As a leader, how we construct the picture of
our vision of the team’s mission and goals could theoretically make or break
the probability of success. The process of motivational framing allows the
members to collect the signals they are receiving and maintain a positive
outlook.
Unfortunately, leaders typically let
that moment slip by, losing the opportunity to frame the assumptions and
preconceptions in a positive manner. After that, the members will interpret
situations and signals in their own personal manner. One example is when we
utilize performance measures to motivate staff. When not framed in a positive
manner, staff become risk aversive and unwilling to persist through obstacles
compared to if the project was framed as a learning situation. Amy Edmondson
relates a study performed in 2001 assessing motivational techniques utilized by
Surgeon Leaders in implementing a minimally invasive cardiac surgery program in
four institutions. When the leader framed the project as a learning potential
for the benefit of the patients as well as an opportunity to develop a teaming
partnership with mutual respect, the staff were motivated to succeed. When the
leader sat back in an office framing the project as a set of goals where they
were the leader and every member had their own duties which they were expected
to perform flawlessly to support the surgeon, the teams tended to fail. In the
later example, staff tend to not believe that they can make genuine
contributions to the success of the project.
Kenneth A. Lipshy, MD, FACS
Melissa A. Valentine, Amy C. Edmondson (2015) Team Scaffolds: How
Mesolevel Structures Enable Role-Based Coordination in Temporary Groups.
Organization Science 26(2):405-422. http://dx.doi.org/10.1287/orsc.2014.0947
- Edmondson AC. Teaming: How Organizations Learn, Innovate, and Compete in the Knowledge Economy. John Wiley & Sons 2012.
- Edmondson AC. Framing for learning: Lessons in successful technology implementation. California Management Review.2003; 45 (2): 34-54
- Edmondson AC. Bohmer, R.M., and Pisano, G.P. Disrupted routines: Team learning and new technology implementation in hospitals. Administrative Science Quarterly, 2001;46: 685-716.
- Pisano G, Bohmer R, and Edmondson A. Organizational differences in rates of learning: Evidence from the adoption of minimally invasive cardiac surgery. Management Science, 2001;47 (6): 752-768.
- Edmondson A, Bohmer R, and Pisano G. Speeding up team learning. Harvard Business Review,2001;79 (9): 125-134
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