The words “team” and “teamwork” are so widely used that most people tacitly believe they know what they mean. Actually, most teams have never explicitly taken the time to come to a common definition of the terms, as the insightful quote from Katzenbach and Smith clearly shows.
“The word team gets bandied about so loosely that many managers are oblivious to its real meaning—or its true potential. With a run-of-the-mill working group, performance is a function of what the members do as individuals. A team's performance, by contrast, calls for both individual and mutual accountability.”
Jon Katzenbach and Douglas Smith5
A clear definition with measurable and actionable elements is essential for understanding teams in healthcare. Without such a pragmatic definition, it is likely that the words of the late Peter Drucker, one of the world's great thinkers on leadership and management, will be as applicable to healthcare teamwork as they were to teamwork in business:
“Team building has become a buzzword in American business. The results are not overly impressive. Teams are tools. Teamwork is neither ‘good' nor ‘desirable'—it is a fact. Whenever people work together or play together, they do so as a team.”6
A “Team” is defined as 2 or more people who share a common goal and work interdependently to accomplish that goal.7 A group differs from a team in that members of the group may share a common goal but not work together to accomplish it. This is a subtle but crucial point as it is possible to assemble a group of healthcare providers in the ED who share the common goal of quality patient care but cannot achieve this goal because they do not function as a high-performance team.
While there are many formulations and definitions of effective teams (Boxes 12-2, 12-3, 12-4, and 12-5, Figure 12-1), perhaps the simplest is
To understand this definition of teams in healthcare, an exegesis of each element is necessary.
Common Sense of Purpose Shaped by Team Members
Healthcare is an enterprise, which can be quite confusing even to those involved daily in its provision. The first, best way to prevent such confusion is to ensure that each member of the team has a clear, succinct understanding of the purpose for which the team exists. While it may seem obvious that “excellence in patient care” is the primary purpose, team members often get distracted by process details and extraneous task-related issues. Thus it is necessary to constantly refocus on the common purpose.
Daily Reinforcement—Ritz Carlton
How often should that common sense of purpose be reinforced? In world class organizations, the answer is “Every day!” The Ritz-Carlton Hotels have a well-earned reputation for excellence in the hospitality industry. But lesser known is the “Why” of that reputation. In this context, 2 critical concepts are worth emphasis.
The first concept is the importance of having a clear vision for their staff, which succinctly states their purpose, known as the “Credo.”8 Some healthcare organizations have used this concept to help focus their staff on mission, vision, and purpose (Figure 12-2). The “Credo” in healthcare is an excellent idea, but it must be backed by a system that can be practically applied by the staff.
Many healthcare organizations have followed the example of the Ritz-Carlton Hotel brand and developed “Credo Cards” for their employees to remind them daily of the high purpose of their organization.
This leads to the second concept—a practical method to regularly deliver the stated common purpose and vision in the patient care setting. For that reason, Ritz Carlton and many highly successful hospitals and healthcare systems have adopted a “Daily Huddle.” The purpose of the huddle is to have a focused daily session across all units and departments that emphasizes a particular aspect of the Credo or common sense of purpose.
At Bon Secours Healthcare Richmond, the use of Daily Huddles has had dramatic results. As an example, one huddle focuses on “Anticipation—knowing what patients and families want before they ask for it.” This is one of many reasons that Bon Secours is considered a “world class health provider.” The huddle goes on to emphasize the importance of observing patient and family body language and using active listening as keys to building, loyal, engaged relationships. Each huddle ends precisely the same way for this faith-based system with these 3 questions and answers in Box 12-6.
Box 12-6 Bon Secours “Daily Huddle” Questions |Favorite Table|Download (.pdf)
Box 12-6 Bon Secours “Daily Huddle” Questions
- Where are We? We are on Holy Ground.
- Why are We Here? We are here to Serve.
- What are We? We are World Class.
Creating a Meaningful Vision
Each organization must discover or uncover its own deep sense of purpose, as well as give that purpose its own, unique voice. Successful teams share a sense of purpose that includes not only a commitment to excellence, but also an understanding that the rapid pace of change requires a constant spirit of innovation. “We've always done it that way” is a recipe for disaster for healthcare team members.
Finally, and perhaps most importantly, if the team is to have passionate commitment to the common sense of purpose, the team members themselves must actively help shape and articulate the sense of purpose. The phrase, “If they are not with you on the takeoff, they won't be with you on the landing” certainly applies here.
As team members change and new team members are “on-boarded,” each one should be oriented to the common sense of purpose and given the opportunity to discuss and improve it. The team's statement of purpose should reflect the organization's mission, vision, and values, discussed in more detail in Chapter 2.
Deep Respect among Team Members with Unique Roles and Responsibilities
High-performance teams require a common sense of purpose and an individual recognition of role The care of each patient in the ED requires multiple service handoffs among many different people (Figure 12-3) from highly variable educational backgrounds and training, ranging from high school graduates to nurses and physicians with many years of professional training. And yet there is a common sense of purpose. Team members are well prepared to accomplish their own responsibilities and to work adaptively with other team members who have different roles. They expect to do their jobs well, just as they expect others team members to do so. Like members of a sports team
- Each person knows what is expected of them and what is expected of others on the team.
- The “playbook” changes depending upon the specific circumstances and demands of the moment.
- The energies and capabilities of the team and its members are different in the “1st Quarter” (the beginning of the shift) than they are in the “4th Quarter” (the end of the shift, particularly a busy, stressful shift).
Teams in the ED have multiple service handoffs and transitions from various members of the team to others, even in the simplest of clinical presentations, as illustrated here.
High-performance teams ensure that service transitions are handled in a positive and proactive manner. Using effective scripts to manage that transition is extremely helpful. For example, a triage nurse stating, “Janice will be your primary nurse—she's one of our best!” primes the patient and family to feel that they will be well cared for in a professional fashion. These types of verbal skills assure patients and families that the service transition has been anticipated and handled well. Quint Studer refers to this as “managing up.”9 Box 12-7 shows other examples of this technique.
Box 12-7 Leading Up-Managing Expectations |Favorite Table|Download (.pdf)
Box 12-7 Leading Up-Managing Expectations
Teams can dramatically assist in service handoffs by leading or managing up for the next team member through these verbal approaches, which ensure that the patient and their family approach the next team member with a positive attitude:
- “Janet is your nurse today and she's the best we have.”
- “Let me introduce you to Dr Smith, who is my partner who will be taking over your care. I have briefed him on your care and he will take great care of you.”
- “Unfortunately, the bone is broken. The good news is Dr Theiss is on call and he is a great one.”
- “You will need to be admitted. I spoke to your doc and he want our specialist in Hospital Medicine to care for you. Dr Rodriquez will be taking care of you and he is excellent.”
Contrast the triage nurse's comment above with a different person greeting the patient, who simply says, “Have a seat. Someone will call you.” The first message communicates, “I care and we are prepared to treat you with excellence.” The second message communicates, “I/We don't care.”
A critical responsibility of ED leaders is to ensure that all team members know the roles and responsibilities of others and that a culture of mutual trust and appreciation exists. This knowledge and trust accelerate and accentuate the team's effectiveness. Perhaps Rudyard Kipling said it best:
“For the strength of the pack is the wolf and the strength of the wolf is the pack.”10
Dr James Adams, Chair of Emergency Medicine at Northwestern University, shares this vignette of the dramatic value of teamwork.11
A patient presented to triage when no beds were available. Per protocol, an electrocardiogram (ECG) was performed at triage by an ED technician, whose responsibility it was to take the ECG to an emergency physician in the acute care area. The quiet and unassuming ED technician expected the worst when he took the ECG to a particularly acerbic, gruff emergency physician. The emergency physician snatched the ECG tracing out of the tech's hands, quickly read it, and diagnosed an acute anterior MI. The patient was quickly rushed into the treatment area and then onto the cardiac catheterization lab. But not before the emergency physician sought out the ED tech and said, “You just saved that guy's life.”
Not only did that tech feel incredible and in that moment recognize his unique sense of purpose, but also the story became a part of the lore of the ED. That's the power of teamwork and the way in which it strengthens “the pack.”
A System of Value-Added Processes to Deliver Specific, Measurable Results
Develop Effective Measurable Processes
Good teams rarely “make it up as they go.” Excellent, high-performance teams never do. Instead they develop clearly delineated and mutually understood processes, which all team members know and which are designed to produce measurable results.
The Indianapolis Colts NFL team ran the “no-huddle” offense to near perfection. Quarterback Peyton Manning, center Jeff Saturday, and the entire team were able to set the offensive formation, snap count, and specific play, all of which were designed to maximize the chance of success against the defensive set they encountered on that specific down and distance. A complex set of hand signals, verbal calls, and last minute adjustments and audibles were used to choreograph maximum productivity out of the offense. (The verbal signals have been described as so complex that some claim, inaccurately, that they are in the Celtic language.)12
Among the highest performing sports teams, there is variability of performance from play to play, series to series, and game to game. The same is true of high-performance ED teams, in which the system is extremely well known to the team members and is designed to deliver specific, measurable results. As the Colts have found, changing even a single, albeit critical, team member, can dramatically change team results.
Similarly, the high-performance ED team carefully designs processes intended to add value (to the patient, family, and providers of care) while predictably and reliably producing measurable results in diverse areas (clinical, service, financial, patient safety, and so on). The processes all combine for the good of the patient and for those who care for the patient.
Consider the cascade of processes used at triage, which vary according to the specific circumstances and demand-capacity constraints at the time of service to the individual patient. In the traditional triage model, each patient presenting ambulatory to the triage area was “triaged” at the entry point, after which only the high-acuity patients were sent directly to the treatment area. Far more commonly, patients were sequentially sent to the waiting room following triage, then registration in a cubicle, the waiting room again, and then called by the primary care nurse, who placed the patient in a room. The “waiting” journey continued as the patient was subjected to “secondary triage” and a further waiting until the emergency physician arrived to begin the evaluation and treatment.
ED teams began to evaluate these processes from the patients' perspective and to implement the critical concept of adding value and eliminating unnecessary waste (Figure 12-4). It became abundantly apparent that a “cascade” of more innovative processes could be put in place for the good of the patient and for the good of those taking care of the patient. Bedside registration, triage bypass (also known as “pull until full” and direct bedding), advanced triage orders and treatment, and Team Triage™ are all examples of variable processes used according to demand-capacity circumstances, which are mutually conceived, widely understood, and put to use for the good of the patient.
There is a cascade of potential options that teams can utilize to add value to the patients' experiences at triage, including these innovative approaches.
As the play call varies for a sports team, the specific process used by the high-performance ED team may vary according to the specific circumstances the team faces and the resources available at the time. Triage bypass is an excellent process when there are ED beds available. When all of the ED beds are full, standing medical orders for advanced triage and treatment becomes the preferred process or “play call.” When all ED and hospital beds are full and there are hospital borders occupying ED beds for extended periods of time, Team Triage™ is another example of a high-performance ED team adaptive process. Team Triage consists of placing an emergency physician and nurse, often along with registration and a medical scribe in the triage area to manage patients until beds become available in the treatment area. Well-prepared and effectively coached teams, whether in sports or in the ED, have prepared in detail (and together) to address these types of challenges. It is a fundamental and nondelegable responsibility to have “thought these issues through” (Peggy Noonan regarding Presidential leadership.13 Similarly, Coach John Wooden said:
“Failing to prepare is preparing to fail.”14
High-Performance Teams Can Become Increasingly Effective: Teamwork Requires Both Execution and Agility
(Figure 12-5) Execution encompasses much more than efficiency. It is the ability to consistently, reliably, and efficiently produce desired results (value added) with the minimal amount of waste, despite obstacles. The more long-term and ultimately more satisfying benefit is the creation of agility—the talent and capability to change and adapt systems, processes, disciplines, and behaviors in ways, which allow the healthcare team to create a new and more sustainable future. High-performance teams that can execute with agility can provide excellence in patient care while improving the system and its processes to benefit the patient and those who care for the patient. Any ED team which has designed new processes, such as the triage “cascade”, mentioned previously, has felt this effect.
Teams always have a dynamic tension between execution (keeping the current system working) and agility (the ability to develop change that adds value despite resistance).
Thus, essential features of high-performance ED teams include both the agility to change over time and a system of value-added processes designed to reliably and predictably produce measurable and defined results.
Culture of Team Success with Accountability through Coaching and Mentoring for Improvement
Many wise and experienced people have said, “Culture eats strategy for lunch.” That is certainly true in healthcare and in the ED in particular. Further, culture is not “governed” by the leaders or “potentates.” Rather, both the leaders and the followers determine culture. Chris Argyris wisely noted the difference between the “espoused theory” versus the theory in use.15 The former is typically a piece of paper or a poster while the latter is the manner in which leaders and the teams, for which the leaders are responsible, actually perform their day-to-day duties. To be effective, leaders must continually share the vision describing their intended culture prior to creating a plan of action. With an understanding and commitment to the vision, even in the face of adversity, a team can reach great heights. As Friedrich Nietzsche said:
“He who has a strong enough why, can bear almost any how.”16
One of the simplest examples of this dynamic tension of a stated and enacted culture is the following. Complete this statement of culture:
“The Few, the Proud, the …”
Most people would immediately answer, “The Marines.” In part, that is testament to the terse and excellent message the United States Marine Corps has projected to the public. But it is also a message which is embodied daily in the culture of the nearly 300,000 Marines worldwide, whose goal it is to show “Honor, Courage, and Commitment” in their every action.17
What is the culture of the ED and do the leaders and members of the team embody that culture in their every action? Culture lives in the hearts and minds of those who provide the service to the patients. It must be exemplified from both a “Top Down” and “Bottom Up” perspective. If the culture is not defined and effectively articulated in an inspirational vision and if leaders at every level do not embrace and consistently embody that compelling culture in their every action, there is little chance of having a high-performing, highly reliable organization.
High-performance team cultures seek and celebrate team success, not just success for the individual members. Sports team analogies abound in this regard. A quarterback or running back may have a great game from a statistical standpoint, but that counts for nothing if the team loses. Hall of Fame and six-time NBA champion Bill Russell repeatedly said that his numbers counted for nothing if his team did not win the championship.18 And John Wooden, whose teams won more NCAA Division I men's basketball titles than any coach in history, never, ever mentioned “win” to any of his players—only that they perform to their very best as a team.19
Similarly, ED teams should be focused on team results and team success, not just on parameters affecting individuals or subgroups of the team. For example, statements like those in Box 12-8 are evidence that the team is not functioning as a team.
Box 12-8 “Nonteam” Statements |Favorite Table|Download (.pdf)
Box 12-8 “Nonteam” Statements
- “That's not a ‘doctor' problem, it's a ‘nurse' problem.”
- “That's not a ‘nurse' problem, it's a ‘doctor' problem.”
- “That's not our problem, it's a radiology (or lab, registration, inpatient, etc) problem.”
- “Our patient satisfaction scores are fine. It's the doctors (or nurses or lab, etc) who are pulling us down.”
- “That's not in my job description!”
- “Nobody told me…this is the first I've heard about it!”
These statements are evidence that teamwork has broken down and individuals or groups of individuals have failed to embrace the interests of the team and the patients the team serves. High-performance team leaders are sensitive to the early signs that the team structure and morale are breaking down and are prepared to deal with it. (See “What to Do When the Team Breaks Down” later.)
Other signs of ineffective teams include an inability to deal constructively with conflict by “making conflict personal” or by assuming areas of conflict are resolved when they have simply been described, but in reality ignored.
An effective team building approach involves raising and discussing an area of concern or conflict. Each team member is asked to take copious notes on the deliberations, particularly the decisions and resolutions discussed during the meeting. At the end of the meeting, the team leaders(s) collect the notes and confidentially review the notes and the conclusions of the team members. Even in high-functioning teams, there is often discrepancy among what is recorded in the notes. In poorly functioning teams, there may be minimal overlap in the notes, reflecting the inability of the team to share a common vision or recognize common deviations from that vision. This discrepancy may be particularly pronounced on a team with members driven by individual success rather than team success. (See “Conflict Management” later.)
It is the nature of a team that individual team members have variable levels of talent, ability, motivation, and results. As the Danish philosopher Soren Kierkegaard noted, “I write with steadfast love, but variable ability.”20 Team members may be motivated by a steadfast love for the team and the work it does, but they will have varying (different) abilities. Effective team leaders create both a culture and a climate in which coaching and mentoring are part of the fabric of the organization. There will always be “A Team” and “B Team” as well as some “C Team” members in the mix. Does the team have both the culture and the wherewithal to provide a path for those who are currently low performers to raise their performance? The Studer Group refers to these as “High, Middle, and Low Performers” and provides specific suggestions on how to deal with them.21
Coaching and mentoring are essential for individual and team accountability. If a culture of accountability does not exist, there is no need for coaching and mentoring. Individual accountability leads to and is a precursor of team accountability. This concept of individual accountability may seem paradoxical since the focus is on the team. However, the actions of the individual team members comprise, collectively, the performance of the team. If individual team members cannot be depended upon to do their jobs consistently well, the team can never perform at the high levels demanded of EDs. As Spinoza noted, “Excellence is what we strive for, but consistency is what we demand.”22 Delivering consistently high levels of performance over time requires mutual accountability.
There is a wealth of literature on coaching and mentoring23-25 and Box 12-9 lists several simple concepts that are particularly pertinent.
Box 12-9 Coaching and Mentoring Tips |Favorite Table|Download (.pdf)
Box 12-9 Coaching and Mentoring Tips
- Ensure that the culture of performance as well as the concept of coaching and mentoring are well known to and widely accepted by the team
- Make performance about metrics, not opinions
- Make team-based performance and the associated metrics the rule, not the exception
- Ensure accountability is a function of both the members and leaders of the team
- Identify mentors (see below) who are willing and able to assist in the process
- Pair B Team members with A Team mentors over the course of several shifts
- During the coaching and mentoring effort, point out specifically what the A Team members are doing that makes them so widely admired
- And if all else fails, act on behalf of the team to remove low performers who will not change (“there are some people you want to get away from!”)
Four Common Traits of Healthcare Teams
In summary, teams in healthcare share these 4 common features:
A common sense of purpose shared by team members
Deep respect among team members with unique roles and responsibilities
A system of mutually-known, value-added processes to deliver specific, measurable results
A culture of team success with mutual accountability through coaching and mentoring for improvement