Feature

Teams as Tools for Changing the Culture of Academic Medicine

By R. Kevin Grigsby, D.S.W., kgrigsby@psu.edu, and Diane Magrane, M.D., dmagrane@aamc.org

The organizational leaders, professionals, and staff of our academic health centers face complex challenges. The necessity to confront these challenges calls to mind Albert Einstein's observation that "We cannot solve our problems by using the same kind of thinking we used when we created them." The "wisdom of teams" offers the necessary brainpower and talent to provide an alternative approach to traditional individual efforts for organizations to operate successfully in this new world of complexity (Katzenbach & Smith, 1993). In fact, teams may be one of the most powerful tools we can use to improve the organizational performance of academic health centers.

How do teams differ from other groups and committees?

The implementation of teams requires that individuals learn new skills of group work and that our culture changes from one of independence to that of interdependence. Working as a team member is different from working alone or from working as a committee or work group member. Team members, in contrast to committee members:

• represent diverse experiences, perspectives, and skills, yet work to serve a common purpose.
• share accountability for collective work products. Each member contributes to the creation of the product, but the final product is owned by the team.
• change leadership depending on the task at hand—as such, leadership "moves" from member to member.
• establish ground rules for working together and work to understand and appreciate the skills and perspectives (as well as various roles) played by team members.
• value interactions that incorporate conflict into team decision-making.

Grigsby makes important distinctions between formal committees and teams in his January 2008 article in Academic Physician and Scientist, Committee, Task Force, Team: What's the Difference? Why does it Matter? (PDF, 4 pages) These differences are compared in the chart below.

Comparing Characteristics of Committees, Work Groups, and Teams

The Role of Teams in Cultural Change

In his November 2007 AAMC presidential address, Culture and the Courage to Change, Darrell Kirch, M.D., argued that organizational culture is every bit as important as organizational strategy for academic medical centers. Kirch called for a redirection of our culture to one that is focused upon "collaboration, shared accountability, and team performance."

Transformation from traditional autonomy and hierarchy to collaboration and shared accountability is not an easy process. In his classic work, "Leading Change," John Kotter outlines eight essential change steps, beginning with a guiding team and culminating with reinforcement of a new culture. Readers may enjoy reading about these steps in Kotter's parable version of change in "Our Iceberg is Melting", (Kotter, 2006) or on his Web site Changing and Succeeding Under Any Conditions. Kotter describes the importance of a team of credible leaders who guide the change. In many cases, the teams themselves contribute to organizational change.

Team Approaches That Are Changing the Culture of Academic Medicine

Teams are changing the basic assumptions of how we provide the highest quality health care related to patient safety, effective education, organizational improvement, and how we translate the important discoveries of bench research into effective therapies for creating healthy communities. Katzenbach and Smith, authors of The Discipline of Teams (1993), describe three types of teams:

1. those that recommend things and hand them off to implementers by a predetermined completion date,
2. those that make or do things such as product development that operate within support systems and work to meet critical delivery points rather than specific deadlines,
3. those that run things in situations in which individual contributions to a joint work product produces better results than the sum of individual contributions.

Each of these types of teams may be called into play to address the challenges of our medical schools and teaching hospitals. Many serve more than one of these functions within our organizations. Specific examples of new team approaches found in academic medicine and health follow.

Team Learning—Team-Based Learning Collaborative

The practice of students learning in teams reinforces practices of shared accountability and can improve efficiency of the classroom. The Team-Based Learning Collaborative instructional strategies allow a single instructor to teach by conducting multiple small groups simultaneously in the same classroom. In this method of learning, students open their classroom learning activities by sharing responses to tests and then identifying the particular learning needs of the team.

Professional Development—AAMC TeamWorks! Program

The AAMC TeamWorks! Program guides health professions faculty and staff through approaches to improve the effectiveness of team dynamics and task management by addressing institutional objectives. TeamWorks! scholars and faculty coaches provide consultation and support for adapting team behaviors into their institutional work. As leaders and students of effective team practices, they learn about teams as they perform within teams.

Organizational Decision Making—The Pennsylvania State University Medical Center Unified Campus Teams

The Pennsylvania State University Medical Center Unified Campus Teams were organized to unify the clinical and the academic-research enterprises, breaking down barriers between academic departments, reducing traditional barriers between employees and management, promoting faculty and staff participation in decision-making, and solving complex problems often deemed as "intractable" in the past.

Team Science National Institutes of Health Clinical and Translational Science Awards Initiative

The National Institutes of Health (NIH) Clinical and Translational Science Awards demand inter-institutional collaboration and innovative partnerships between researchers and clinicians. In addition, NIH policy now allows more than one Principal Investigator (PI) to be recognized on individual research awards. This presents a new and important opportunity for investigators seeking support for projects or activities that clearly require a "team science" approach and do not fit the single-PI model.

Patient Safety—Department of Defense TeamSTEPPS™ Program

When the 1999 Institute of Medicine report, To Err is Human: Building a Safer Health System, suggested medical errors account for 98,000 deaths every year a team approach was proposed. The Department of Defense / Agency for Healthcare Research and Quality (AHRQ) TeamSTEPPS™ program was adapted from successful models of crew resource management in the aviation industry and is being implemented to assist with large-scale systemic change to improve patient safety. Medical Centers are noting particular improvements in areas of critical care such as emergency centers and rapid response teams.

In each of these team approaches, tasks are delegated, opportunities and risks are communicated, conflict is adapted into creative decision-making, and rewards are recognized collectively, usually as outcomes. Early adopters of these new team practices found the process challenging and offer some valuable lessons about how to support the work of teams within academic medical organizations.

Lessons Learned About the Challenges of Evolving into a Team Based Culture

These lessons are garnered from literature (Ancona & Bresman, 2007), professional development, and experiences of the authors. They are quite consistent across sources and disciplines.

• Team skills are learned

Team management of the tasks of agenda-building, effective meeting management, consideration of differences in perspectives and conceptual conflict, and consensus approaches to outcomes often requires development of both individual skill and insight and team learning. Not everyone will be eager to make the shift from "me" to "we". In fact, some persons may see the development of interdependence as a threat to their success. However, experiences in team training and organizational development from the programs listed in the previous section suggest that the learning of team skills simultaneously can contribute to leadership development of individuals and improved outcomes of their organizations.

• It takes time—and attention—to become an effective team member and a productive team

Launching the team is a critical first step in the process. Because teams are deliberate in selecting members and in attending to "team process", getting started with the work of the team may be slow. Investing in process on "the front end" is wise, as issues that are not resolved in the early part of the process may arise and interrupt progress later. Remember that most sports teams engage in intensive training and focused practice sessions before games. Likewise, most continue to practice during the time between games. In organizations, teams are often less effective because they do not have the luxury of extensive training and practice. In effect, every team meeting is "a game". As such, becoming a high-performing, productive team requires attention to "team process" as the team engages in meeting its charges.

• Teams need to be supported at the highest levels of leadership

Support for teams is much more than "cheerleading" by other members of the organization. It requires providing critical feedback to team members as well as providing necessary resources. This is especially critical in organizations where the use of teams is unfamiliar. Unless teams are supported and their work is endorsed by top leadership, teams may never have a successful launch. Even if the launch is successful, the lack of supportive leadership may doom the success of teams.

• Teams need structure

Teams need to be clear about what they need to do, when, and how to do it. A structure for meeting process, scheduling of dates, times, and places of meetings, and clearly defining deadlines and deliverables allows teams to know what to expect and to remain focused on accomplishment.

• Teams need to be clear about expected "collective work products"

Finally, the collective work products, also known as deliverables, should be defined from the outset of the initiative. Having a blueprint that allows the team members to know and understand the features of the final work product cuts down on loss of focus and allows the team to "stay out of the weeds" as they proceed towards meeting goals.

Conclusions

To keep up with the rapid pace of change, increasing complexity, and growth of mission in light of restricted resources in academic medicine, we need to use the best tools we can find. Teams focus on effective collaborative processes and shared performance goals. As such they can be effective organizational development tools. However, their effectiveness requires that organizational leaders in academic medicine:

• select the right type of team for the task.
• invite diverse members who can develop skill in the management of tasks and the interpersonal dynamics of interdependent work.
• provide support for both the learning and group work process.

The ultimate goal for academic medicine is to provide the highest possible quality education, clinical care, and research outcomes. The culture that results from the successful implementation of teams is characterized by shared accountability, interdependence, and effective collaboration. The process is more responsive, creative, and efficient—and that benefits everyone involved in our health care systems.

References

1. Katzenbach JR, Smith DK. "The wisdom of teams." Boston: Harvard Business School Press, 1999.

2. Kotter JP. "Our iceberg is melting." New York: St. Martin's Press, 2006.

3. Katzenbach JR, Smith DK. "The discipline of teams." Harvard Business Review, 1993;71:111-20.

4. Institute of Medicine. "To Err is Human: Building a Safer Health System." Washington: National Academies Press, 1999.

5. Kirch DG, Grigsby RK, Zolko WW, Moskowitz J, Hefner DS, Souba WW, Carubia J, Baron SD. "Reinventing the Academic Health Center." Academic Medicine 80(11):980-989, 2005.

6. Ancona D, Bresman H. "X-teams: How to build teams that lead, innovate, and succeed." Boston: Harvard Business School Press, 2007.

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