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