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C H A P T E R 8

T E A M W O R K A N D C O L L A B O R AT I O N

After reading this chapter, you will be able to do the following:

➤ Explain the role of teams in healthcare organizations

➤ Describe the importance of effective teams to patients and staff members

➤ Evaluate the impact of organizational culture on team success

➤ Identify characteristics of effective teams

➤ Understand the concept of groupthink

➤ Evaluate how peer review and teamwork help bring about better patient care

• Adjourning stage • Authoritarian leadership style • Collaboration • Democratic leadership style • Forming stage • Groupthink • Interprofessional team

• Laissez-faire leadership style • Norming stage • Organizational culture • Performing stage • Storming stage • Team • Teamwork climate

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Copyright 2019. Health Administration Press.

All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law.

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Ben Delozier, director of the stroke recovery unit at St. John’s Rehabilitation Institute, closed his office door and sighed. Most of the time, he liked his work. Helping someone lead as normal a life as possible after a stroke was gratifying. The patients exerted great effort to recover, and they appreciated his and his staff’s help in the rehabilitation process. Most of the time, he also liked the professional staff members with whom he worked. They were smart and worked independently, which allowed him to adopt a laissez-faire leadership approach, and the cul-ture of the recovery unit reflected this laissez-faire style. Most team members did their jobs without involving Ben directly. And, most of the time, this organizational culture that stressed independence and a team orientation worked well.

St. John’s staff members were divided into interprofessional teams that focused on each individual’s therapy. A nurse, a speech pathologist, an audiologist, a physical therapist (PT), and an occupational therapist (OT) would come together to plan, implement, and evalu-ate the specific rehabilitation treatment for a patient. The team members, who came from about the same hierarchical level, worked together to help the patient recover. “Restore the body, empower the spirit” is a philosophy to which the team members subscribed. That is, they subscribed to it most of the time.

Ben sighed again and said to himself, “Today is not one of those times.” Nurse Julie Turner, audiologist Amelia Torres, and speech pathologist Martin Smith had all come to him to discuss the behavior of two of their interdisciplinary team members: Joseph Sarducci from PT and Vince Antoni from OT. Amelia had explained that Joseph and Vince never get along with each other, although each one is great to work with individually.

Joseph is friendly and helpful. He was one of the first PTs St. John’s hired 30 years ago. He knows the rehab unit’s procedures better than anyone, and is a well-respected PT. He con-scientiously keeps up-to-date with treatments and protocol, and many of the other PTs come to Joseph for consultation. Joseph says he likes helping staff help patients “restore the body and empower the spirit.”

Vince Antoni is 26 years old and graduated from the local university’s OT program last year. This is his first full-time employment, and he is full of energy, full of ideas, and always ready to take on the next task. In fact, Vince sometimes gets so excited about an idea it is dif-ficult to get him to stop talking so others can express their opinions.

Martin told Ben that when Joseph and Vince work on the same team, they never get along. They argue about anything and everything. If Vince recommends a particular course of action, Joseph opposes it. And it is difficult for Joseph to get a word in, so when he does have the opportunity to talk, he ends up shouting at Vince. Their interaction does not help them help the patient.

Amelia added, “When we tell them to stop fighting and get back to discussing the patient, they pout and refuse to participate.”

Interprofessional teamA team that forms when two or more professionals from different disciplines collaborate to enable better patient outcomes.

c a S e S t u d y : B u t t I n g h e a d S

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Julie concluded by saying, “We just end up frustrated with the time wasted. They are both so busy trying to lead the team and telling everyone else what to do that we don’t accomplish as much as we could.”

In t r o d u c t I o n

We see in the case study the failure of collaboration among professionals who are supposed to work effectively on a team. Their failure is the opposite of what you read in chapter 4’s opening case about Maryland’s Local Overdose Fatality Review Teams (LOFRTs). The interprofessional team members of the LOFRTs exhibited mutual respect and trust, and they collaborated to share pertinent information. There does not seem to be any trust or respect between Joseph and Vince, and they are not able to collaborate because they are busy disagreeing with each other. Their failure to collaborate is also affecting the performance of other team members who cannot focus on providing patient-centered care because they are busy trying to cope in a dysfunctional team environment. Until Vince and Joseph come to a resolution so they may work together better, their fellow team members will find it more difficult to focus on their shared purpose of delivering patient-centered care and to perform their tasks timely and well, because time is wasted.

The organizational culture that favors a team orientation with laissez-faire leadership may be contributing to the problem. Perhaps Ben should reflect on two outcomes of his leadership style. First, he has not provided direction to his teams regarding his support for innovative patient care. Second, his hands-off approach has contributed to the growth of a competitive environment between two team members. Competition is not necessarily a negative variable among team members; however, if the competition affects their ability to collaborate on behalf of the patient, it is a problem that warrants attention.

In the last chapter, we saw that managers’ clear communication skills are vital for a healthcare organization to serve patients effectively, efficiently, and safely. This chapter will address the healthcare management practice of employing teams and discuss the importance of team development and management to providing quality patient care. You will learn how to create teams comprising professionals who work toward the common goal of providing patient-centered care, as well as how to overcome barriers for effective collaboration. On a more personal level, you will read about the importance of your responsibility to create and sustain an organizational culture that lets teams operate well.

he a lt h c a r e te a m S a n d or g a n I z at I o n a l cu lt u r e

It is standard practice for healthcare organizations to use teams. Dedicated clinical teams administer patient care, and management teams develop and implement a healthcare

CollaborationWorking together to achieve designated goals.

TeamA group of people who work toward a shared task and hold themselves mutually accountable for effective performance.

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organization’s strategy, rules, and protocol—all with the goal of improving the healthcare system and the delivery of healthcare services.

Discussing the history of team development in the US healthcare system, Heinemann (2002) noted that in the 1900s physicians initiated the use of teams as a strategy for com-municating about the patient. By the 1930s, nurses—via their state associations—officially supported the team approach to coordinating patient care (Washington State Nurses Asso-ciation 2018). Interdisciplinary healthcare professionals continued to endorse the use of teams in clinical practice. By the end of the twentieth century, The Joint Commission had mandated that patient care plans document interdisciplinary input and included teamwork as one of its corporate values (Joint Commission 2009):

We believe that a productive work environment requires teamwork, active collaboration, and clear and open communication within and across organization units.

Collaboration and cooperation among professionals on a healthcare team have resulted in improvements in patient care. In a review of the literature, Lemieux-Charles and McGuire (2006) found a positive relationship between the presence of teams and patients’ clinical outcomes (Caplan et al. 2004; Cohen et al. 2002).

Members of healthcare teams adhere to the principle that quality improvement is achiev-able by the way healthcare is delivered. To illustrate, let us examine the practice of providers who wash their hands before and after seeing a patient, as they know this reduces infection risk (Polacco et al. 2015). The World Health Organization (WHO) offers recommendations for providers to wash their hands through their “Save Lives—Clean Your Hands” promotion (WHO 2017). Healthcare team members who exhibit appropriate handwashing, as recom-mended by WHO, and encourage team members to do so as well exemplify improved quality of patient care, which, in turn, positively affects patient satisfaction and patient outcomes.

This focus on teams adopting quality improvements to improve patient care is sup-ported by healthcare organizations such as the American Society for Quality (ASQ), an international organization focused on continuous quality improvement in various organi-zations. Its mission is to “increase the use and impact of quality in response to the diverse needs of the world” (ASQ 2018). Applied to the healthcare environment, this quality phi-losophy focuses on the fact that patients’ satisfaction depends on outstanding performance and requires input from all the healthcare professionals involved in their care. In fact, ASQ (2018) notes that the overall goal of quality improvement is to

engage all members of an organization to participate in improving processes, products, services, and the culture in which they work.

Quality improvement will be more fully discussed in chapter 14. For now, let us look at an example of quality improvement and teams. Virtua, a four-hospital system serving

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southern New Jersey and Philadelphia, reduced length of stay for congestive heart failure (CHF) patients by adopting a model of quality improvement known as Six Sigma (Ettinger 2001).

Six Sigma encourages team members to watch for variances in performance, with the goal to reduce or eliminate inefficiencies in patient-care processes (Spath 2018). To accomplish this goal, the team determines the problem that needs improvement, analyzes the way the services are currently being delivered, identifies ways to improve, implements those improvements, and assesses the outcomes. By following these steps, the team at Virtua identified a problem with length of stay for CHF patients.

CHF patients tend to be elderly, and exposure to unfamiliar surroundings and germs in a healthcare facility increase their risk for negative health outcomes. By working together and identifying potential causes of extended inpatient stays, the Virtua team could discuss, and then implement, best-practice solutions that reduced hospitalizations.

When they analyzed current processes, the team identified four factors that affected length of stay: family expectations and education regarding CHF, nursing protocol for patient care, specific care procedures, and post-hospital care instruction. Implementing changes in communication to educate families and in nursing protocol reduced the average length of a patient’s stay from 6.2 days to 4.6 days, which improved outcomes for the older patients. These changes and effective teamwork also benefited the Virtua organization, thanks to the use of more efficient processes.

For another example of the importance of effective clinical teams on patient out-comes, let us consider the impact of the teamwork climate. Researchers or interested human resource administrators may measure teamwork climate by surveying health professionals’ responses to questions about the quality of their collaboration with one another. The Agency for Healthcare Research and Quality supported research regarding the creation and use of the Safety Attitudes Questionnaire that has become widely accepted to assess the culture of safety among healthcare teams (Pronovost et al. 2003; Sexton et al. 2006; Smits et al. 2017). The survey includes a section on teamwork climate and asks respondents to rate their agreement with the following statements in the intensive care unit (ICU) setting (Sexton et al. 2006, 7):

◆ It is easy for personnel in this ICU to ask questions when there is something they do not understand.

◆ I have the support I need from other personnel to care for patients.

◆ Nurse input is well received in this ICU.

◆ In this ICU, it is difficult to speak up if I perceive a problem with patient care.

◆ Disagreements in this ICU are resolved appropriately (i.e., not who is right, but what is best for the patient).

◆ The physicians and the nurses work here together as a well-coordinated team.

Teamwork climateHow well healthcare team members perceive they work together to provide patient care.

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Other research has found that a strong teamwork climate is associated with better patient care. For instance, teamwork climate is associated with lower rates of healthcare-associated infections in very low birth weight infants (Profit et al. 2017), and with outcomes for adult patients in the ICU (Huang et al. 2010; Pronovost et al. 2008).

In particular, a study by Pronovost and colleagues (2008) examined whether the Comprehensive Unit-Based Safety Program (CUSP) improved the teamwork climate in ICUs and led, in turn, to improved safety culture and better patient care. First, clinical profes-sionals working on ICU teams answered the Safety Attitudes Questionnaire to determine a baseline teamwork climate. Then, evidence-based research on ways to improve patient safety was introduced to the teams, and members identified potential problems in their respec-tive ICUs that might have a negative effect on patient care. Senior leadership was asked to prioritize and provide support for actions that might be taken to improve safety. Clinical staff monitored and assessed any actions taken to improve safety conditions and they, along with senior leaders, conducted a “culture checkup” that examined and reflected on ways to improve teamwork (Pronovost et al. 2008). In the end, the study found that exposure to CUSP improved teamwork climate scores in the ICU setting. And, this improved teamwork climate positively affected patient care.

Given these findings, research has also examined how healthcare managers can help create and sustain the culture of an effective teamwork climate. This research is based on the premise that organizational culture affects healthcare professionals’ perception of their workplace climate, which in turn affects patient care quality.

It is the healthcare managers’ responsibility to help shape an organizational culture that allows for effective teamwork. Edgar H. Schein, social psychologist and noted scholar on organizational culture, proposed that organizational culture may be analyzed at three levels (Schein 2010, 53):

1. Visible artifacts;

2. Espoused beliefs, values, roles, and behavioral norms; and

3. Tacit, taken-for-granted, basic underlying assumptions.

The term visible artifacts refers to what you can see, such as the uniforms worn by various staff members in a healthcare setting, the layout of the nurses’ station on hospital floors, and the appearance of patient waiting rooms in a clinic. Espoused beliefs, values, roles, and behavioral norms all refer to what employees learn about the organization and adopt as organizationally sanctioned. This does not mean all employees will accept these as their own beliefs, values, or norms, but those who do not may risk “excommunication” (Schein 2010, 26) from the group. For instance, if managers at a teaching hospital support the inclusion of students as interns but do not encourage departmental employees to serve as preceptors, then the behavior contradicts what the espoused beliefs state. Also, if an employee refuses

Organizational cultureThe shared values, beliefs, and taken-for-granted assumptions of an organization’s employees.

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to serve as preceptor when management has endorsed student interns, then that employee risks management and peers perceiving she is not a good team member.

The last level identified by Schein (2010) regarding organizational culture refers to the taken-for-granted, or the unspoken expectations. As you learn about an organization’s culture, you may see that these taken-for-granted, underlying assumptions about the way employees conduct themselves, what senior management considers important regarding employee behavior, and how work is actually done can help you predict how the organization may respond in future circumstances. You can, thus, determine your actions accordingly.

For example, the firm Medical Management (MedMan) illustrates the importance of culture and effectiveness in the workplace. Jim Trounson (2018a) founded MedMan in 1977 with the thought that managing medical clinics was best conducted by a team, not an individual. If the MedMan team managed the physician practice, then the physicians could devote their time to their patients. Today, 11 MedMan managers and seven corporate-based officers are responsible for ten medical groups located in Idaho, Oregon, Washington, Montana, Wyoming, and Utah.

The MedMan culture rests on the principles of respect, integrity, loyalty, and sharing (MedMan Medical Management 2018):

Respect—We constantly strive to earn and express respect for ourselves, our clients and our employees;

Integrity—We do the right thing;

Loyalty—We build the trust required of a high-performance team; and

Sharing—We improve each other’s performance through aggressive information transfer.

Given that these culture statements are published on MedMan’s website, you know the firm is built on the principles of effective teams and active individual participation. But are they an accurate indicator of the true culture? The sharing habits among MedMan’s managers and employees tell us more.

Since the firm’s managers are located in six states, it is not possible for them to gather at a conference table frequently to share. To ensure they do meet face-to-face on a scheduled basis, MedMan holds annual retreats. Trounson (2018a) explained:

We are a virtual company spread all over the Northwest. The retreat is one way to create a sense of company, to encourage a team spirit without people having a collective “water cooler” to gather around.

MedMan also holds “think tanks” through video conferencing. Better than mere con-ference calls, these let managers share documents and see one another—in real time—which

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improves communication. Staff members often participate in think tanks three times a day regarding committee meetings, problem-solving sessions, or task force updates.

Each week, MedMan also holds 30-minute meetings through video conferencing, during which each manager talks about what is going on in her clinic and describes some-thing she is proud of or something she is worried about. For example, recruiting was the topic of a March 2018 weekly meeting. One manager was having difficulty recruiting an appropriate nurse practitioner (NP) or physician assistant (PA) for her practice. A fellow manager provided the contact information for a reputable recruiting company she had used successfully to recruit an NP. Another manager reported he knew a PA that was looking for a position in that area and thought they would work well together. Thus, the 30 minutes spent by MedMan team managers talking with each other offered solutions to a pressing problem.

Monthly one-hour educational colloquiums also are held to share knowledge that may be of interest to managers. During the March 2018 session, the focus was on generational challenges and how to effectively manage employees from different cohorts (e.g., baby boomers, Generation Xers, millennials), who all have different expectations and work behaviors. The colloquium described each group and identified what managers might face at different times, such as during recruiting. For example, millennials, born between 1982 and 2004, often want to work at a company that has purpose and will help make the world a better place. Thus, a manager can address how MedMan may fit that profile when discussing corporate culture.

Lastly, each quarter Trounson leads a town hall meeting over video conferencing. In March 2018, the topic was the business of MedMan—its stock price, the opportunity for employees to buy into the firm, and succession planning, as Trounson was preparing to retire after 41 years of leadership. In addition, all practice financial information is posted so each manager knows how well his or her clinic is performing compared to all the other MedMan clinics. Managers also may discuss who needs support or training.

Given all these opportunities for managers to share information, you might surmise that sharing is indeed a taken-for-granted, underlying core of the MedMan culture. However, what happens when the sharing helps clinics do well also is an important indicator of the firm’s culture. At MedMan, salary increases are tied to client satisfaction scores. The clients, usually a physician group, are the owners of the clinics. And, the salary increases of MedMan managers are partially based on client scores from all the firm’s clients. The rationale for this compensation practice rests on the assumption that clinic performance improves with good teamwork, advice, and solutions offered. Thus, sharing is not only tied to the face-to-face or online opportunities to talk with each other; the salary policy underscores the importance to MedMan of communicating and sharing well.

A strong culture like this is characterized by employees’ devout commitment to the organization’s values, beliefs, and taken-for-granted assumptions regarding the way things are done. Organizational culture affects healthcare professionals’ perception of their work-place climate, which in turn affects patient care quality. And, as we turn our attention to characteristics of effective teams, it is important to note that a strong culture also promotes better outcomes for staff working on effective teams.

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Research regarding the team approach supports beneficial outcomes not only for patients, but also for staff members. Collaboration and cooperation among healthcare team members are positively associated with job satisfaction; in addition, recruitment and reten-tion are influenced by the organizational environment. If upper management supports team efforts, if team leaders are positive regarding the team, if communication is clear regarding the team’s goals, and if communication among members supports the charge’s importance to organizational success, positive outcomes are more likely (Amos, Hu, and Herrick 2005; Anderson 1993; Barczak 1996; Borrill et al. 2000; Korner et al. 2015; Weisman et al. 1993).

ch a r a c t e r I S t I c S o f ef f e c t I v e te a m S

Given the positive outcomes associated with teamwork, researchers have investigated the characteristics of effective teams. For example, Hellriegel and Slocum (2003) developed a self-assessment tool to determine team effectiveness. Team members are asked if they

◆ know why the team exists,

◆ have a procedure for making decisions,

◆ communicate freely among themselves,

◆ help each other,

◆ deal with conflict among themselves, and

◆ identify and address ways to improve the team’s functioning.

Looking back to this chapter’s opening case study, if Julie, Martin, Amelia, Joseph, and Vince completed this self-assessment, their team probably would score poorly. While the team members understand why the team exists, the evidence indicates they do not communicate freely among themselves. Vince and Joseph do not help one another, Joseph dismisses Vince’s ideas, and Vince resists allowing others to speak. In addition, the team members do not deal with conflict among themselves; Julie, Amelia, and Martin all turned to Ben, their supervisor, for help.

The Academic Health Center Task Force on Interdisciplinary Health Team Develop-ment (1996) lists ten competencies team members should strive to achieve. These compe-tencies form the basis for team self-assessment:

1. Do team members focus on the patient as their first priority?

2. Have the members established common goals regarding patient outcomes?

3. Do the members understand the roles of other team members from different professions?

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4. Do the members have confidence in each other’s abilities?

5. Are members flexible in their roles to accommodate team goals?

6. Do the members share group norms and expectations?

7. Do they deal with conflict among themselves?

8. Do members communicate freely among themselves?

9. Do team members share responsibility for actions made by the team?

10. Do the members evaluate themselves and their team performance?

If we apply the assessments of Hellriegel and Slocum (2003) and the Academic Health Center Task Force on Interdisciplinary Health Team Development (1996) to the interdisciplinary team of Julie, Martin, Amelia, Joseph, and Vince, we would conclude that this team is not as effective as it could be. Their uncooperative behavior has resulted in the team’s accomplishing less than it could. Their team lacks the needed communication and conflict-management skills to address the problems that have occurred. Hence, members have turned to Ben for help.

The problem confronting Ben Delozier from the opening case study is that he has a team that lacks collaboration and cooperation. Ben has three concerns to address: the con-flict between Joseph and Vince; the potential effect of this conflict on other team members’ commitment; and, most important, the conflict’s potential interference with patient care. In addition, Ben should be aware that these team dynamics have developed in part because he has not created and established a culture that supports mutual respect and sharing. Ben knows the conflict is a barrier to effective team performance, and he has several options for addressing this problem.

First, he can reassign responsibilities so Joseph and Vince are not on the same interdis-ciplinary team. Second, he can talk with them separately to ascertain why the conflict exists and to develop a plan to address their concerns effectively. Third, he may choose not to get involved and let team members address the conflict themselves. Ben rejects the first option, because St. John’s Rehabilitation Institute is about patient care. The staff members need to learn how to behave in a professional manner to help patients. At the same time, however, Ben knows the context in which the team operates needs to be addressed to prevent this problem from happening again. He needs to rally the team and help establish a department-wide culture that encourages effective team construction and maintenance. Ignoring the problem is not a viable option. Ben needs to work on the immediate issue regarding Joseph and Vince, who, in turn, need to work on a plan of corrective action. But Ben also needs to devote time to communicating his vision of how the department teams should work, and he should create opportunities for employees to communicate more effectively. Ben could take some lessons from the MedMan culture.

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St r at e g I e S f o r de v e l o P I n g te a m ef f e c t I v e n e S S

Team effectiveness depends on how well team members work together. Tuckman (1965) and Tuckman and Jensen (1977) propose that individuals move through stages of team development and behavior. These stages are forming, storming, norming, performing, and adjourning. The forming stage is an orientation phase in which members are given their charge or purpose for the team. During this stage, team members learn about one another’s personalities. The storming stage is characterized by conflict and emotional issues that may inhibit a team’s progress toward performing the task with which it was charged. How effec-tively (or not) team members learn to work with one another depends on their personalities.

The St. John’s Rehab team is stuck in this storming stage. Joseph and Vince have allowed their conflict to overshadow work efforts, and the other team members are frustrated by the time that has been wasted. The ultimate concern is that Joseph and Vince are more focused on their conflict than they are on developing, implementing, and evaluating the patient’s rehabilitation care plan.

If this team is able to move forward, it will experience the norming stage that Tuck-man (1965) proposed. In this stage, team members agree upon working styles and make compromises. Conflict is reduced as the team unifies. The energy that had been directed toward the conflict is now devoted to the charge of patient care. The team then enters the fourth stage, performing, and they work productively together. The final stage is adjourn-ing, during which the team goes over its successes and individuals disengage from the team. As the patient is discharged from the rehabilitation unit, the team regroups to focus on a new task, or a new team is created, and the process begins again.

Managers can establish an organizational context that is conducive to team success. They communicate the team’s charge clearly; set the stage for a positive and supportive environment; and focus on the team’s goal. Staff members expect managers to take the lead to establish a positive work environment (Harmon, Brallier, and Brown 2002). During the forming stage of the rehab team, Ben could have met with the members and reviewed the team’s purpose, discussed the patient load for the team, and endorsed a positive work environment in which team members treat one another with respect, listen to one another’s ideas, and allow one another to contribute.

Moreover, at this stage of team formation, a shared mental model may be identified. Shared mental models give team members a common understanding of the work at hand (Weller, Boyd, and Cumin 2014). The team gains a sense of the treatment plan and each member’s individual role and responsibilities. Without a shared mental model, team mem-bers are less likely to contribute to decision-making about a patient or to solve problems (Stout et al. 1999).

To move the St. John’s team out of the storming stage, Ben needs to decide how to deal with the problem before it escalates or leads to poor patient care. As mentioned earlier, he could ignore the problem, but this action would only encourage the team members

Forming stageThe first stage of teamwork, during which members are given their charge or the purpose of the team.

Storming stageThe second stage of teamwork, during which team members learn about one another. This stage is characterized by conflict and emotional issues that may inhibit a team’s progress.

Norming stageThe third stage of teamwork, during which team members agree upon working styles, conflict is reduced, and group cohesiveness emerges.

Performing stageThe fourth stage of teamwork, during which team members are engaged in the work and purpose of the team.

Adjourning stageThe final stage of teamwork, during which team members review outcomes and successes and individuals disengage from the team.

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who approached him to conclude he does not support them or the team’s goals. He might encourage the three team members to talk with Joseph and Vince and let the team solve the problem. However, Amelia tried that without success. So Ben opted to meet with Joseph and Vince separately, and they developed a plan of correction. He also met with the team as a whole, the first step in creating a cultural climate of support and encouragement—a characteristic of effective teams. Ben’s intervention was critical, as this conflict was on track to cause errors and poor patient care (Salas et al. 2015).

As the team resolved its storming experiences and regrouped, leadership style was also addressed. Leadership in teams may be authoritarian in style, laissez-faire, or democratic. Joseph and Vince had each been vying for authoritarian rule, but the resulting conflict suggested this leadership style might not be the best for this team. Laissez-faire, or hands-off, leadership might not have been the best approach either, as team members needed to bring in their expertise from their different disciplines and discuss patient care specifics.

At various times, different team members may need to take the lead in a conflict or process—what is known as democratic, or shared, leadership. This may be the best approach for the five team members in the case study, as they each come from approximately the same hierarchical level and can pool their expertise to help the patient “restore the body and empower the spirit.” Research also favors democratic leadership, as studies have indicated teams who share leadership tend to perform better than those with one authoritarian leader (Solansky 2008).

Going forward, Ben’s challenge is to figure out the best way to ensure Joseph and Vince fulfill their roles as team members. Fisher, Ury, and Patton (1991) offer advice on principled negotiation among people who are in conflict with one another. The first step is to define the problem and outline the options. Ben already accomplished this. Second, the authors recommend separating the people from the issues and encouraging each person to understand the other’s position. When Ben met with Joseph and Vince, he asked Joseph why he ignores Vince’s ideas. Joseph replied that Vince is very new to the profession and could learn more if he took time to listen. Vince then offered his opinion that Joseph had been there more than 30 years and was a “know-it-all.” As the supervisor, Ben directed Joseph and Vince to propose what they thought might work for both parties so the team would function better. Fisher, Ury, and Patton (1991) suggest that the more the conflicting parties are involved in the negotiation process, the more likely they are to support any initiative that addresses the problem. Ben’s involvement of Joseph and Vince in the process was more likely to result in a successful outcome. As they brainstormed possible solutions, they were focusing on the ultimate goal of any healthcare team: working together to help patients.

Fisher, Ury, and Patton (1991) also stress that each team member should allow other team members to express their emotions and should listen actively to improve communi-cation. Active listening is discussed in detail in chapter 7; its basic principles are that the receiver of the message should pay attention to the sender (i.e., the speaker) and focus on the contents of the message. The receiver may summarize the message to ensure it was delivered

AuthoritarianA leadership style in which power is concentrated in the leader.

Laissez-faireA “hands-off ” leadership approach.

DemocraticA leadership approach in which team members share governance.

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clearly and correctly. Last, the speaker and receiver should respect one another throughout the process. If one party is unwilling to engage in this principled negotiation process, the other parties should keep guiding the conversation back to the problem at hand. This helps keep the attention focused on solving the problem, which lets the team move on to the performing stage, the ultimate goal of Ben’s meeting with Joseph and Vince.

a wo r d aB o u t gr o u P t h I n k

While research indicates that cohesive team efforts benefit patients and staff, evidence also suggests that mistakes may occur precisely because a team is especially cohesive. Janus (1972, 1982) proposed the term groupthink to illustrate this phenomenon. Groups whose members are well informed and intelligent but who also define themselves and their work as morally superior, are isolated from outside ideas and practices, have a stressful work environment, possess illusions of invulnerability, and experience strong in-group cohesiveness may make decisions that are not in the best interests of patient care (Janus 1972, 1982).

Healthcare teams in the performing stage are generally cohesive, and of course all healthcare team members are extremely busy and work under time constraints. Healthcare professionals often spend less time outside the healthcare arena because of the profession’s demands and, as a result, they may become isolated and form an even more cohesive group with other team members. In addition, healthcare is a stressful occupation, and team mem-bers may be pressured to contain costs. Combined, these factors may lead to groupthink and cause a good team to make poor decisions.

Heinemann, Farrell, and Schmitt (1994) applied Janus’s groupthink theory to the geriatric healthcare environment. They presented the case of an older couple in which the husband was paralyzed from the neck down and the wife had served as his primary caretaker for more than 18 months. Not surprisingly, the wife became exhausted from the physical toll of caring for her husband, and she regularly let the provider team members know she was overwhelmed. The team members did not hear her concerns; rather, they were strictly focused on the needs of their patient, her husband. Two members of the man’s healthcare team were extremely domineering; the rest were busy, under stress, and focused on containing costs.

Communication among team members was left to the two most vocal; other member input was nil. One option for the husband was nursing home care, but some team members exhibiting a morally superior stance looked down on this care, an opinion they felt was justified by the husband’s preference not to go to a nursing home. Again, they ignored the wife’s communications regarding the toll the care was taking on her mental and physical well-being.

However, after a year and a half of providing care at home, the wife knew she could not continue to deliver the care her husband needed. When she again expressed concern regarding her abilities, the team members did not listen to her, and options such as respite

GroupthinkConformity to group values and ethics that can lead to negative outcomes.

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care or nursing home care were never suggested as viable options. The result was that the wife threatened to abandon her caregiving role completely. Thus, while the team members felt the wife’s caring for the husband was best for the patient, their inability to listen to her and examine other options resulted in the team’s failure. The wife’s leaving would certainly not have been in the patient’s best interest.

Healthcare delivery team members need to be conscious of the potential for group-think. They should avoid assuming a morally superior stance, because other healthcare options may fit a patient’s needs well. They should also avoid isolation from other healthcare practices and protocols. A commitment to sponsor outside speakers may help a healthcare organization decrease the isolation factor. To provide an effective treatment plan, team members should commit to listening to others who care for a patient, such as a spouse, and to the patient’s desires. Determined to follow the patient’s wishes and fortified by their disdain for nursing home care, the team members in this example almost caused a disaster because the groupthink had created an environment in which the primary caregiver was ignored. The result was that the wife thought she had no other option than to abandon her supportive, caregiving role for her husband.

To avoid future groupthink, this team needs to reform to discourage disdain for one type of caregiving over another and to adopt a willingness to hear from current caregivers. Furthermore, this team was dominated by two members; it is important to allow each team member’s input. Open communication, respect for team member participation, and regu-larly scheduled evaluation of team behavior and performance will help prevent groupthink.

Be S t Pr a c t I c e S f o r te a m fo r m at I o n

Healthcare managers who rely on team output need professional staff members who under-stand why the team was formed; allow for respectful, open communication among team members; share leadership; deal with conflict effectively; and evaluate team performance on a regular basis (Couzins and Beagrie 2004; Hellriegel and Slocum 2003; Weaver, Dy, and Rosen 2014). Healthcare managers may help by clearly defining the team goals. The team then should adhere to the following best practices:

1. Determine the best way to attain goals (what protocol may help the patient improve).

2. Agree on team norms (how team members will collaborate and communicate with one another).

3. Advocate shared leadership for interprofessional teams.

4. Assign specific team member functions (e.g., one member may schedule meetings, another may make certain that documentation for the patient is complete).

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5. Hold regularly scheduled meetings.

6. Handle conflict with team members directly, but seek assistance from the supervisor if internal mechanisms do not work.

7. Evaluate team performance on a regular basis, addressing the team’s strengths and weaknesses. Healthcare managers provide a positive environment, intervene as necessary to help solve problems, and evaluate team performance. As a result, the team members are supported so they may work to “restore the body and empower the spirit.”

At the beginning of this chapter we met Ben, who had to address a conflict between two team members in his department. We quickly surmised that the problem was larger than just two employees disagreeing. Rather, a culture of mutual respect was missing, as team members made clear through their frustration with the dysfunctional team and the lack of collaboration and cooperation among them. Throughout this chapter, we put forth that Ben’s solution to the problem rested with his intervention on two levels—the team level, to confront both Joseph and Vince, and the department level, to confront the need for a culture of team excellence. Ben could learn from our example of MedMan, where a strong culture helps lead to better team performance. Ben’s success—as well as yours when you manage teams—will depend on master-ing an understanding of team formation and assessment, which are essential for quality patient care and employee satisfaction.

As discussed earlier, Jim Trounson (2018a) founded MedMan Medical Management in 1977 with the strategy that placing quality on-site healthcare managers in physician-controlled practices would create clinics that work well. His philosophy was that clinics are best managed by a team, not an individual, and that if a high-functioning team managed a physician practice, the physicians could devote their time to their patients and improve patients’ quality of care. The business model worked like this: The physician-led clinic hired MedMan to place a healthcare manager on the clinic site. Through a team approach, MedMan managers, based in Idaho and the five surrounding states, served as experts and resources for each other, providing continual support on- and off-site for its clients.

To create and reinforce a culture based on respect, integrity, loyalty, and sharing, Troun-son established a “taken-for-granted assumption” of the MedMan approach to teamwork. Newly hired MedMan managers undergo a two-day orientation in Boise that introduces the MedMan culture and reviews best clinic practices. To maintain the positive teamwork environment,

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numerous communication channels have been established so knowledge is shared among practice managers, to the benefit of all the clinics. The MedMan managers team up with each other in person twice annually at retreats, and at other times of the year during regular virtual meetings. These virtual conferences include the “think tanks” (held three times per day), the 30-minute weekly meetings, the monthly colloquia that last 60 minutes, and the quarterly town hall meeting, led by Trounson.

Along with the face-to-face and virtual encounters, all managers have a mentor with whom they talk once a week. In addition, they regularly e-mail each other questions such as the following:

While we are familiar with dogs as service animals, what do we do about a support parrot, if anything?

We have a patient who is a jail inmate, and his wife is authorized to receive health information about him. However, the jail does not want us to give out information about appointment dates outside the jail. Can we release the personal health information, but not include the next appointment date with the wife?

Along with the managers and Trounson to provide responses, MedMan can forward e-mails to their attorney on retainer or the board of directors, which is made up of physicians and clinic and hospital executives. MedMan also deploys a monthly newsletter and publishes an ongoing corporate blog. All communications, whether in person, virtual, or in writing, are centered on the same theme of providing excellent administrators to client practices to facilitate better patient care. Overall, MedMan’s activities reinforce a culture of teamwork, which helps improve physician and patient lives, helps the clinics perform better, and increases access so patients receive quality healthcare.

A recent blog post illustrates the MedMan culture (Trounson 2018b):

We’ve gone overboard inconveniencing ourselves and our patients. “If this in an emergency, hang up and dial 911” is my favorite example of an

assault on patients. There are clinics with locked doors needing secret codes to get the patients from the reception to exam areas. I hate sliding glass windows at reception desks allegedly for HIPAA privacy.

When trying to find actual requirements for these kinds of restraints I’m being referred anecdotally to some “recommendation” by an attorney, insurance company or advisor. Unlike consultants who achieve full employment scaring physicians into hyper-compliance, MedMan stays around to manage clinics and, while complying with regulations, rationally balances safety with practicality.

The price is too high in terms of productivity and quality of our and our patients’ lives for mindless acceptance of all safety considerations. In a one-physician practice,

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patients listening to the 911 admonition takes them a combined thirty hours per year. Was that a consideration, and who made this decision to annoy them anyway?

I prefer a world in which the masses have fewer restrictions and delays, and we deal bravely with the occasional exceptions and offenders.

mI n I ca S e St u d y Qu e S t I o n S

1. Explain how the virtual meetings allow for team development at MedMan. 2. Explain how the blog post, “We’re Becoming Too Safe,” illustrates the MedMan culture.3. MedMan was founded in 1977 and remains a successful business to date. Why do you

think MedMan enjoys such success with its clients? Refer to the MedMan Medical Management website, www.medman.com, as you consider your answer.

➤ Teams have an important role in providing quality patient care. The Joint Commission has mandated interdisciplinary input and included teamwork as one of its corporate values because of the relationship between effective teamwork and patient outcomes.

➤ Organizational culture affects teamwork climate, which in turn affects patient care.

➤ Healthcare professionals who experience effective teamwork report better job satisfaction.

➤ Groupthink may yield negative outcomes, for the team members as well as for the patients. Too much conformity to group values and ethics may lead team members to fail to consider alternative ideas.

➤ Effective teamwork results from a culture that supports open communication among team members that is respectful yet can deal with conflict effectively.

1. Think of a team you have been a part of (e.g., a sports team or musical group). With reference to Hellriegel and Slocum (2003) and the Academic Health Center Task Force on Interdisciplinary Health Team Development (1996) assessment plan, evaluate your team. Was it successful, according to the assessment criteria? Why or why not?

2. When is an authoritarian leadership style more effective for teams? A democratic style of leadership? A laissez-faire style? Which do you think is more appropriate for teams dedicated to healthcare delivery? Why?

3. The mini case, “MedMan and Its Cultural Climate,” quoted from two e-mailed questions. Conduct your own research. How would you respond to these e-mails? Interview local

P o I n t S t o r e m e m B e r

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clinic or hospital administrators. How would they respond to the queries? What insight do their answers give into their corporate culture?

1. Explain why effective teams are important for better outcomes. Give an example to illustrate.

2. This chapter’s discussion of groupthink presented a case in which the healthcare team did not pay attention to the wife’s concerns. Why do you think they did not listen to her?

The physicians of Beachside Medical Group had spent more than five years combining seven local practices into a single, multispecialty group practice. The goal of this merger was to bring the best, most respected practices together to create efficiencies in clinic management. It also gave the doctors a more powerful bargaining position in negotiations with insurance compa-nies on policies and payment structures. The group had also introduced a radiology center, which would not have been possible if the practices had remained separate. Beachside Medical Group was now made up of 20 physicians, five physician assistants, ten nurses, three radiology technologists, one clinic manager, and six general staff and office assistants.

The governing board of Beachside Medical Group made decisions about third-party contract negotiations, resource allocations, and strategy for the group’s future. The six board members were all physicians. They noted that the board’s makeup was skewed toward a physi-cian perspective, but they were satisfied that they would represent all interests and take their commitment to the group seriously. After all, they were the ones who were in charge and had volunteered to serve on the board.

The board met on a monthly basis for the first year to deal with all of the new clinic’s business activities. Sometimes they asked Leslie Duncan, the clinic manager, to attend; some-times they did not include Leslie. They made resolutions and passed them without input from the other physicians in the practice or from the clinic staff. After all, they knew best. They were the doctors who had volunteered. The result was that the board often met without notifying other clinic physicians and staff. Closed-door meetings became the norm.

Some of the new rules being passed frustrated Leslie. “The board is creating a series of problems for the staff. They are creating a mess, and I do not know how much longer I can continue to clean up after them.” The previous month, the board had mandated a change in work schedules for the office staff, converting eight-hour days into ten-hour shifts without consulting

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Leslie or the staff members affected by the change. This change in working hours meant that those staff members with children needed to change their childcare arrangements to accom-modate the board’s rules, and all staff members needed to change their day-to-day routines.

Two office assistants quit out of frustration, and Leslie was left to find qualified assis-tants to fill the positions quickly. She had just succeeded when the board issued two new mandates. The first was that all promised annual pay raises for staff would be postponed until the following quarter because profits had been lower than expected. The second was that all office personnel except for the physicians would punch a time clock so their hours could be documented. The staff members who had not quit after the schedule changes had stayed primarily because they were proud of their contributions to the multispecialty practice. Leslie questioned the decision not to follow through on a promised pay raise because of lower-than-expected profits while at the same time incurring an expense to add a monitoring system (the time clock). Leslie asked the board if she could talk about the new policy with them, and they agreed to meet with her today.

ex e r c I S e 8.1 Qu e S t I o n S

1. What do you think Leslie should say to the board members when she meets with them?2. With reference to the concept of groupthink, how do you think the board made the

decisions Leslie is questioning?3. What will the repercussions be if the board members go unchecked? What do you think

will happen to staff–physician relations?

Grace Hunter, the vice president for strategic management, listened to Oli Bordeux, the CEO. They were discussing a new strategic initiative to eliminate patient errors. In the past five years, the 336-bed hospital where they worked had reported nine adverse patient errors that had resulted in death or a permanent vegetative state. Grace knew these statistics did not compare favorably with numbers for other hospitals in their area. Virginia Hope, 50 miles away and licensed for 1,400 beds, had reported four incidents and no deaths in the past five years. Swan Valley Medical Center, 80 miles away and licensed for 450 beds, had reported five incidents and three deaths over the same time period.

Oli said to Grace, “I need you to form a team to deal with this. And Grace, I need this team to find us some answers. Put together a team that can underscore the need for every staff member to step up. We need to identify potential problems before they become errors that affect our patients and their families.”

e x e r c I S e 8 . 2 n e w t e a m f o r m at I o n a n d t h e r e d u c t I o n o f P at I e n t e r r o r S

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Grace promised Oli she would do what he had asked. As she left Oli’s office, she said to herself, “I just need to get the right people to commit to making a difference, and then to get them to make the difference. Not an easy task.”

ex e r c I S e 8.2 Qu e S t I o n S

1. What advice would you offer Grace regarding who should be on this team? What advice would you offer regarding the team’s forming phase?

2. How should the team evaluate its own performance?3. How should Grace evaluate the team’s performance?

Academic Health Center Task Force on Interdisciplinary Health Team Development. 1996. Developing Health Care Teams. Published September 1. https://conservancy.umn.edu/handle/11299/103777.

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Amos, M., J. Hu, and C. Herrick. 2005. “The Impact of Team Building on Communication and Job Satisfaction of Nursing Staff.” Journal for Nurses in Staff Development 21 (1): 10–16.

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Barczak, N. 1996. “How to Lead Effective Teams.” Critical Care Nursing Quarterly 19 (1): 73–82.

Borrill, C., M. West, D. Shapiro, and A. Rees. 2000. “Team Working and Effectiveness in Health Care.” British Journal of Health Care Management 6 (8): 364–71.

Caplan, G., A. Williams, B. Daly, and K. Abraham. 2004. “A Randomized Controlled Trial of Compre-hensive Geriatric Assessment and Multidisciplinary Intervention After Discharge of Elderly from the Emergency Department—The DEED II Study.” Journal of the American Geriatric Society 52 (9): 1417–23.

Cohen, H., J. Feussner, M. Weinberger, M. Carnes, R. Hamdy, F. Hsieh, C. Phibbs, D. Courtney, K. Lyles, C. May, C. McMurtry, L. Pennypacker, D. Smith, N. Ainslie, T. Hornick, K. Brodkin, and P. Lavori. 2002. “A Controlled Trial of Inpatient and Outpatient Geriatric Evaluation and Management.” New England Journal of Medicine 346 (12): 905–12.

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Couzins, M., and S. Beagrie. 2004. “How To . . . Build Effective Teams.” Personnel Today , February, 29–30.

Ettinger, W. 2001. “Six Sigma: Adapting GE’s Lessons to Healthcare.” Trustee 54 (8): 10–16.

Fisher, R., W. Ury, and B. Patton. 1991. Getting to Yes: Negotiating Agreement Without Giving In. New York: Penguin Books.

Harmon, S., S. Brallier, and G. Brown. 2002. “Organizational and Team Context.” In Team Performance in Health Care, edited by G. Heinemann and A. Zeiss, 57–70. New York: Kluwer Academic/Plenum Publishers.

Heinemann, G. D. 2002. “Teams in Health Care Settings: Assessment and Development.” Team Per-formance in Health Care, edited by G. D. Heinemann and A. M. Zeiss, 3–17. New York: Kluwer Academic/Plenum Publishers.

Heinemann, G. D., M. P. Farrell, and M. H. Schmitt. 1994. “Groupthink Theory and Research: Implica-tions for Decision Making in Geriatric Health Care Teams.” Educational Gerontology 20 (1): 71–85.

Hellriegel, D., and J. Slocum. 2003. Organizational Behavior, 10th ed. Cincinnati, OH: Southwestern College Publishing.

Huang, D. T., G. Clermont, L. Kong, L. Weissfeld, J. Sexton, K. Rowan, and D. Angus. 2010. “Intensive Care Unit Safety Culture and Outcomes: A US Multicenter Study.” International Journal for Quality in Health Care 22 (3): 151–61.

Janus, I. 1982. Groupthink: Psychological Studies of Policy Decisions and Fiascoes, 2nd ed. Boston: Houghton Mifflin.

. 1972. Victims of Groupthink: A Psychological Study of Foreign-Policy Decisions and Fiascoes. Boston: Houghton Mifflin.

Joint Commission. 2009. “The Joint Commission Mission Statement.” Published August. www.joint commission.org/assets/1/18/Mission_Statement_8_09.pdf.

Korner, M., A. M. Wirtz, J. Bengel, and S. A. Goritz. 2015. “Relationship of Organizational Culture, Teamwork and Job Satisfaction in Interprofessional Teams.” BMC Health Services Research 15 (243): 1–12.

Lemieux-Charles, L., and W. McGuire. 2006. “What Do We Know About Health Care Team Effective-ness? A Review of the Literature.” Medical Care Research and Review 63 (3): 263–300.

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MedMan Medical Management. 2018. “Our Culture: We Do the Right Thing.” Accessed April 29. www .medman.com/culture.

Polacco, M., L. Shinkunas, E. Perencevitch, L. Kaldjian, and H. Reisinger. 2015. “See One, Do One, Teach One: Hand Hygiene Attitudes Among Medical Students, Interns, and Faculty.” American Journal of Infection Control 43 (2): 159–61.

Profit, J., P. Sharek, P. Kan, J. Rigdon, M. Desai, C. Nisbet, D. Tawfik, E. Thomas, H. Lee, and J. Sexton. 2017. “Teamwork in the NICU Setting and Its Association with Healthcare-Associated Infec-tions in Very Low Birth Weight Infants.” American Journal of Perinatology 34 (10): 1032–40.

Pronovost, P., S. Berenholtz, C. Goeschel, I. Thom, S. Watson, C. Holzmueller, J. Lyon, L. Lubomski, D. Thompson, D. Needham, R. Hyzy, R. Welsh, G. Roth, J. Bander, L. Morlock, and J. Sexton. 2008. “Improving Patient Safety in Intensive Care Units in Michigan.” Journal of Critical Care 23 (2): 207–21.

Pronovost, P., B. Weast, C. Holzmueller, B. Rosenstein, R. Kidwell, K. Haller, E. Feroli, J. Sexton, and H. Rubin. 2003. “Evaluation of the Culture of Safety: Survey of Clinicians and Managers in an Academic Medical Center.” Quality and Safety in Health Care 12 (6): 405–10.

Salas, E., M. Shuffler, A. Thayer, W. Bedwell, and E. Lazzara. 2015. “Understanding and Improving Teamwork in Organizations: A Scientifically Based Practical Guide.” Human Resource Man-agement 54 (4): 599–622.

Schein, E. 2010. Organizational Culture and Leadership, 4th ed. San Francisco: John Wiley & Sons.

Sexton, J. B., R. L. Helmreich, T. B. Neilands, K. Rowan, K. Vella, J. Boyden, P. R. Roberts, and E. J. Thomas. 2006. “The Safety Attitudes Questionnaire: Psychometric Properties, Benchmarking Data, and Emerging Research.” BMC Health Services Research 6: 44.

Smits, M., E. Keizer, P. Giesen, E. Deilkas, D. Hofoss, and G. Bondevik. 2017. “The Psychometric Prop-erties of the ‘Safety Attitudes Questionnaire’ in Out-of-Hours Primary Care Services in the Netherlands.” PLoS ONE 12 (2): e0172390.

Solansky, S. 2008. “Leadership Style and Team Processes in Self-Managed Teams.” Journal of Lead-ership and Organizational Studies 14 (4): 332–41.

Spath, P. 2018. Introduction to Healthcare Quality Management, 3rd ed. Chicago: Health Adminis-tration Press.

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