Chapter 6: Understanding and Improving Team Effectiveness in Quality Improvement
Outline
Introduction
Teams in health care
High performance teams and quality improvement
Understanding and improving the performance of quality improvement teams
Resources and Support
Team Processes
Conclusions
Introduction
Teams are the building blocks of health care organizations used for virtually every activity carried out in health care organizations, including clinical, management-focused and CQI activities
They are the primary vehicle through which CQI problems are analyzed, solutions are generated and change is evaluated
Understanding And Improving The Performance Of Quality Improvement Teams
A microsystem is one of several subsystems of a larger system that is integral to system performance (Nelson et al. 2002)
A health system is composed of many subsystems, including the clinical microsystems
These front-line systems or teams are charged with meeting the needs of the patient population
These microsystems provide the directs services that result in positive patient outcomes, provider and patient safety, system efficiency, and patient satisfaction
Understanding And Improving The Performance Of Quality Improvement Teams
Teams are:
People working together towards specific goals
using multiple interconnected processes
producing performance outcomes, and
having access to information about the team’s performance
Teams must:
adapt to changing circumstances,
ensure the satisfaction of team members, and
maintain and improve their performance over time.
Teams In Health Care
To diagnose, treat, and follow up with a patient requires information from multiple sources, and, very often, the involvement of multiple individuals
Patient-centered multispecialty teams are increasingly important
Healthcare has moved away from organizational structures based on functional areas of technical expertise (e.g. nursing, surgery) and to functionally integrated organizational structures with clinical care teams based on patient needs (e.g. women’s services, cancer care services)
Teams In Health Care
Teams and supporting organizational structures do not spontaneously form, and are not always easily managed
The functional nature of most health care works against the formation and maintenance of teams
Reward systems are typically designed around individual rather than team focus
Where teams do exist, performance is, more often than not, suboptimal
If the key elements necessary for teams to perform to their maximum potential are not addressed, teams can easily exhibit poor communication, member dissatisfaction, patient dissatisfaction, disjointed care provision, and inefficient and ineffective operations nested in a cumbersome bureaucracy (Hackman 2002).
High Performance Teams And Quality Improvement
Teams are critical to success in quality improvement because:
Individuals on the ground in teams understand the nuances and manifestations of problems in a way which may not be visible to senior management
Individuals involved in a dysfunctional process are usually those who are most knowledgeable about the process and its context
Individuals at the front lines often have the most feasible suggestions for improvement
Addressing quality problems requires the support of all individuals in the organization, not simply those at a senior level
High-functioning teams empower people by providing opportunities for meaningful participation in problem identification and problem solving.
Understanding and Improving the Performance of Quality Improvement Teams
The task
Team Characteristics
Team Composition and Size
Team Relationships and Status
Psychological Safety
Team Norms
Stage of Team Development
The Task
A team’s primary task will affect many other aspects of team management, such as team size, and team composition, and the manner in which decisions are made
Teams must have a shared understanding of their goals
Teams involved in CQI must be clear about their authority to implement change
Team Characteristics, Composition and Size
The optimal team size depends upon the nature of the team, its goals, and tasks
Teams must be sufficiently large to have the requisite expertise and have adequate diversity and expertise to inform all aspects of the team’s tasks and goals
Teams should not be so large that they are cumbersome, difficult to manage, have trouble reaching consensus or following an appropriate timeline
A team size of 7 is a general rule of thumb (derived from experience rather than scientific evidence)
Team Relationships and Status
CQI is based on the philosophy of participation of all team members
Team members bring with them their roles and status from regular organizational life, as well as existing interpersonal relationships and conflicts
Preformed relationships (such as those between physicians and nurses) and associated status systems influence the effectiveness of a team
Status differences can stifle participation
Individuals from a lower status group are less likely to contribute than those of higher status
For CQI teams, such status differences are dysfunctional and need to be addressed by a leader with adequate authority to do so
Psychological Safety
Team psychological safety is: shared belief that the team is safe for interpersonal risk taking(Edmonson 1999)
CQI requires individuals to be forthcoming and honest about quality problems
This requires a belief by each individual team member that they can speak without fear of intimidation, condescension, or castigation
Team members need to feel psychologically safe if they are to feel secure and capable of changing (Schein & Bennis 1965)
Team Norms
A norm is a standard of behavior that is shared by team members
Norms have a strong impact on individuals in organizations and teams
Norms set expectations and establish standards of behavior and performance
Behavioral norms consist of the rules that govern the work of individuals
Team Norms
They can designate factors such as how people are expected to participate on a team, attendance at meetings, the type of language and dress that are acceptable, and the use of formal procedures
It is important to note that norms may differ in each team and that they can be dysfunctional as well as functional
Performance norms govern the amount and quality of work expected of team members
Stage of Team Development
Forming
Norming
Storming
Performing
Mourning
Adjourning
d
Resources and Support
Organizational Culture
Material and Nonmaterial Support and Recognition
Rewards
Organizational Culture
Organizational culture is the fabric of values, beliefs, assumptions, myths, norms, goals, and visions that are widely shared in the organization (French 1998)
Cultures are very difficult to change
Teams develop their own culture (or organizational subculture), including rituals, languages, particular modes of communication, and unique systems of rewards and sanctions
Organizational Culture
Effective teams are characterized by strong cultures, including interdisciplinary respect, open communication, and a collective spirit
Teams can have an appropriate culture but be enmeshed within an organization with a contrary culture; organizational cultures can be highly supportive, unsupportive, or destructive to the work of teams (Kiassi et al. (2004)
Material and Nonmaterial Support and Recognition
Effective teams require material resources including financial resources, intellectual resources, information, people with the necessary knowledge, skills and abilities, equipment, communication systems, and moral support and credibility
A team’s access to material and nonmaterial support reflects the moral support and encouragement given a team by the larger organization and senior management
Nonmaterial support includes providing team members with appropriate autonomy, feedback, a sense of meaningfulness, and a belief that their work is having a broad impact (Hackman and Oldham 1980).
Rewards
Rewards are distributed as recognition and commendation for the team’s work
In CQI, team rewards usually consist of the intrinsic satisfaction of achieving results, positive feelings created by a successful team effort
Individual rewards may be provided to team members through performance appraisal and incentive pay programs
Team Processes
Team Leadership
Communication Networks and Interaction Patterns
Decision Making
Member and Team Learning
Team Leadership
Leadership in teams is defined as the ability of individuals to influence other members toward the achievement of the team’s goals
An individual with no formal authority may emerge as a leader and influence member behavior
Various leadership models may operate in different teams, depending upon the team’s purpose
Leadership may be:
focused on one individual or
shared or
rotated among team members and
formal or
informal
Team Leadership
Leadership in relation to CQI must reflect the fact that Quality Improvement is by definition ambiguous and largely a problem-solving process
Team members are brought onto a quality improvement team because no single person has the expertise to solve a particular problem
They participate in CQI teams because they have expertise and are able to participate actively in identifying problems, analyzing causation, developing interventions, evaluating the impact of change
Communication Networks and Interaction Patterns
For CQI processes to work, communication must be effective not only within the team, but also between the team and the larger external environment, including other teams
Communication networks come in several varieties, and each situation demands a different type of communication structure:
A centralized communication structure where information passes from the team leader to other team members, or from team leader down in hierarchical manner, may be appropriate with simple tasks (note no upward communication is possible)
Communication Networks and Interaction Patterns
The network hub structure has an individual placed as the center of the communication node, and information from team members must pass through this hub in order to reach other team members
An all-channel communication structure is dense; communication lines are open and encouraged between all members of the team.
This is useful for complex situations where the work of each team member is interdependent with their colleagues.
Formal lines of authority are blurred or meaningless here
Leaders can assume boundary-spanning roles between their team and the larger organization, or other organizations, ensuring that relationships with critical outside groups are workable
Decision Making
Decision making is a task of all teams
Teams may reach decisions by consensus, voting, or team members may simply advise the team leader, leaving the final decision to the leader
There is no single best way for a team to make decisions, but rather is dependent upon the circumstances and goals of the team
However, the decisional authority of the team and that of team members needs to be specific and clear
Care needs to be taken that cohesion in a team does not develop into conformity and “group think”, where members lose their independence as free thinkers, and fear expressing views opposed to what they consider to be the team consensus
Member and Team Learning
A learning organization is one that proactively creates, acquires, and transfers knowledge and that changes its behavior on the basis of new knowledge and insights (Garvin 1993, Senge 1994)
Teams enhance their ability to learn and apply new knowledge through the use of a number of facilitating factors, including:
scanning the environment for new information;
identifying performance gaps within the team;
adopting an “experimental mindset,” such that team members are open to new approaches;
having leadership supportive of change
Member and Team Learning
Effective teams:
continuously look for new information to improve their performance
are open to new ideas and seek them out
include people on teams with new expertise and alternative perspectives
ensure that team members are engaged in continuous training and learning
use new information and ensure that new knowledge is transferred to the team
Member and Team Learning (continued)
use knowledge to change the team’s behavior in pursuit of higher levels of achievement
Effective CQI teams review their own performance, satisfaction of members, and seek to develop strategies and new team management techniques that will enhance their performance
Conclusions
Cohesive teams and effective teamwork are essential in healthcare in general and CQI processes in particular
Steps in team development and team processes include: the development of balanced team relationships; equal status to ensure participation of all team members; and open communication and feedback, ensuring efficient team performance through empowerment and high levels of motivation
Critical to the success of any team includes the role of team leaders and the importance of developing a team’s culture
Ongoing team learning is one of the most important aspects of teamwork in continuous quality improvement; providing the means for sharing knowledge and improving performance of a team as well as the larger organization in which the team exists.
Conclusions
