Organizational Leadership For Building Effective Health Care Teams

Stephen H. Taplin; Mary K. Foster; Stephen M. Shortell

doi:10.1370/afm.1506

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Author response: Multi-team Systems
Stephen Taplin

Published on: 31 July 2013
Leading Medical Multi-Teams Systems
John E Mathieu

Published on: 19 July 2013
Author response: Can't get there from here ....without more research
Stephen H Taplin

Published on: 01 July 2013
Author response: Building the evidence base
Stephen H Taplin

Published on: 01 July 2013
Borrow from the best to build successful teams
Brian Y. Laing

Published on: 28 June 2013
Toward a systems perspective of organizational leadership: It's lonely at the top, much less so in a team
George W. Saba

Published on: 24 June 2013

Published on: (31 July 2013)
Page navigation anchor for Author response: Multi-team Systems
Author response: Multi-team Systems
Stephen Taplin, Branch Chief
Other Contributors:
Dr. Mathieu's comments are intriguing and a good example of how we in medicine need to reach out to other disciplines for evidence and insights. His work in business and other settings has implications for how we conceptualize the problems in medical care. As he notes, the pressures to move quickly in a complex environment are not unique to our world. I welcome the insight.
Dr. Mathieu and his colleagues also po...
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Dr. Mathieu's comments are intriguing and a good example of how we in medicine need to reach out to other disciplines for evidence and insights. His work in business and other settings has implications for how we conceptualize the problems in medical care. As he notes, the pressures to move quickly in a complex environment are not unique to our world. I welcome the insight.
Dr. Mathieu and his colleagues also point out that context matters for the connections between teams in multi-team systems. That is what we have in medical care, and it is important to begin thinking of it that way. Within a practice there may be lab teams, nursing teams, physician teams, emergency response teams, and combinations of the above as suggested by Dr. Laing from his experience at the Los Angeles Dept. of Publich Health. We need more evidence to build on the experience that teams of administrators and practitioners is a more effective team than either operating independently and we need to understand how several such teams connect to serve the organization as a whole. Within an organization it is easy to see that these connections need to serve that organization as a whole; to contribute to that organization's goal.
It is more challenging to recognize the super-ordinate goal when two or more organizations need to contribute to an individual's care. Whose goal is being pursued by each organization is critical, and re- introducing the term patient-centered care is a reminder that organizations may have lost track of the goal to serve patients first. In a competative system where bottom line financial obligations need to be met, it is not surprising there is complexity and confusion. So it is also not surprising that getting multiple organizations to talk about their shared goals in care and their practitioners to realize that is what they are serving, may be a rare phenomena.
Dr. Mathieu and others suggest that context matters. Agreeing that organizations like a primary care practice and a radiology group have a common goal may be a nice place to start in creating the context for the connection between these organizations. It is that connection where teams meet. Accountable care organizations look like they may be intended to create the structure that motivates the discussion and the connection. We need to work with our colleagues outside of medicine to learn how to understand and optimize the connections.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (19 July 2013)
Page navigation anchor for Leading Medical Multi-Teams Systems
Leading Medical Multi-Teams Systems
John E Mathieu, Professor
Other Contributors:
Taplin, Foster and Shortell (2013) highlight critical features of how teams should be staffed, trained, led, and supported. They submit "we need to abandon the view of a generic team and move towards an understanding of how leaders create the appropriate environment for the range of team types needed to deliver good care" (p. 280). We couldn't agree more, and the organizational literature supports these points.[1,2] Continui...
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Taplin, Foster and Shortell (2013) highlight critical features of how teams should be staffed, trained, led, and supported. They submit "we need to abandon the view of a generic team and move towards an understanding of how leaders create the appropriate environment for the range of team types needed to deliver good care" (p. 280). We couldn't agree more, and the organizational literature supports these points.[1,2] Continuing along similar lines, we further advocate abandoning the view that transitions or handoffs between teams are all the same (or worse 'just happen'). Coordination between teams is a process that needs to be actively managed.
Saba astutely notes that teams do not work in isolation from one another, and it is important to adopt a larger systems perspective. Again, we agree whole heartedly - yet, we have also seen the glazed-eyes that Taplin refers to when systems perspectives are evoked. While we appreciate the unique pressures and demands that exist in health care, as organizational researchers, we have encountered similar demands when working with teams in nuclear power plants, army aviation units, numerous Fortune 100 companies, etc. Each instance has unique challenges, but the core factors are universal: teams need to accomplish their particular (local) goals while aligning their efforts with and supporting the larger system.
These dual concerns of optimizing both team and system effectiveness, motivated us and colleagues to promote the notion of multi-team systems (MTSs).[3] MTSs describe networks (systems) of teams that work closely together to achieve some higher-level collective goals (e.g., patient- aligned care teams, patient-centered medical home, multi-level cancer continuum). Following the example of the primary care and radiology teams which provide healthcare to women via mammogram screening, the authors identified numerous transitions (handoffs) during which coordination between the teams is required for effective system performance (i.e., comprehensive follow-up of accurate mammogram results with patient). Although teamwork training, incentives, etc. that target both teams will be essential, we also suggest that leadership needs to focus on these interfaces and coordination between teams (e.g., handover protocol). [4] Teams differences are important, but so too are the differences in linkages among teams which can take different forms such a sequential, reciprocal, or intensive interdependencies, all with different frequencies and rhythms. Leading these complex interfaces is different than leading individual teams and has important implications for managing the broader MTS to leverage and coordinate diverse expertise to maximize quality of patient care.[4]
[1] Burke, C.S., Stagl, K.C., Klein, C., Goodwin, G.F., Salas, E., & Halpin, S.M. (2006). What type of leadership behaviors are functional in teams? A meta-analysis. The Leadership Quarterly, 17, 288- 307.
[2] Morgeson, F.P., DeRue, D.S., & Karam, E.P. (2010). Leadership in teams: A functional approach to understanding leadership structures and processes. Journal of Management, 36, 5-39.
[3] Mathieu, J. E., Marks, M. A. & Zaccaro, S. J. (2001). Multi- team systems. Anderson, N., Ones, D., Sinangil, H. K. & Viswesvaran, C. (Eds.)., International Handbook of Work and Organizational Psychology. pp. 289-313.
[4] DeChurch, L. & Mathieu, J. E. (2009). Thinking in Terms of Multi-team Systems. In E. Salas, G. F. Goodwin, & C. S. Burke (Editors), Team Effectiveness in Complex Organizations: Cross- disciplinary Perspectives and Approaches. SIOP Frontiers Book Series, Lawrence Erlbaum and Associates. PP: 267-292.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (1 July 2013)
Page navigation anchor for Author response: Can't get there from here ....without more research
Author response: Can't get there from here ....without more research
Stephen H Taplin, Physician/Scientist
I almost agree with Dr. Saba's perspective that leaders need to take on a system's perspective that encourages interactive and facilitative leadership. He nicely summarizes several ideas for effective leadership that I suspect would be very helpful.
But I must also confess that I've witnessed eyes glaze over as believers in "systems thinking" talk the talk. There is a fair amount of jargon surrounding systems...
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I almost agree with Dr. Saba's perspective that leaders need to take on a system's perspective that encourages interactive and facilitative leadership. He nicely summarizes several ideas for effective leadership that I suspect would be very helpful.
But I must also confess that I've witnessed eyes glaze over as believers in "systems thinking" talk the talk. There is a fair amount of jargon surrounding systems thinking. Furthermore it is so much easier to conceptualize a linear set of events that will lead to improvement. It is also much simpler and faster to tell someone what to do than it is to have a discussion and decide together what is needed. In the pace and pressure of practice it is not surprising that top down leadership has survived.
So the challenge is getting there from here; of adopting a systems perspective while in a pressure cooker of care delivery. I would submit that the Patient Centered Medical Home is a systems-oriented solution that benefits from a systems perspective. Yet we know that adopting a Patient Centered Medical Home model is neither easy nor universally successful.1 Furthermore it may actually worsen patient's perceptions of care.1
Therefore the evidence that a systems perspective is more effective than the current top-down or bottom-up approaches must be strong and our ability to communicate what a systems perspective involves must improve. Glazed eyes in leadership are not going to lead to the change we need. Despite the appeal of "systems perspective" we need to develop the evidence base for what it is, demonstrate its effect, and show how to get there from here.
1. Crabtree BF, Nutting PA, Miller WL, Stange KC, Stewart EE, Jaen CR. Summary of the National Demonstration Project and Recommendations for the Patient-Centered Medical Home
Competing interests: ?? I work in a research institution.
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Competing Interests: None declared.
Published on: (1 July 2013)
Page navigation anchor for Author response: Building the evidence base
Author response: Building the evidence base
Stephen H Taplin, Physician/Scientist
Dr. Laing reports interesting experience with Bodenheimer's practice coaching program. Dr. Bodenheimer's record of cumulative work on coaching is encouraging but still is based in single diseases. Paying attention to almost anything in medical care will result in improvements. But the challenge is Family Physicians have to care for the health and disease of many people with many diseases. The randomized trial of coachin...
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Dr. Laing reports interesting experience with Bodenheimer's practice coaching program. Dr. Bodenheimer's record of cumulative work on coaching is encouraging but still is based in single diseases. Paying attention to almost anything in medical care will result in improvements. But the challenge is Family Physicians have to care for the health and disease of many people with many diseases. The randomized trial of coaching the complex patient that he is launching is exactly the kind of evidence base that is needed...and is still being built.1
1. Willard-Grace R, DeVore D, Chen EH, Hessler D, Bodenheimer T, Thom DH: The effectiveness of medical assistant health coaching for low-income patients with uncontrolled diabetes, hypertension, and hyperlipidemia: protocol for a randomized controlled trial and baseline characteristics of the study population. BMC Fam Pract. 2013 Feb 23;14:27. doi: 10.1186/1471-2296-14-27.
Competing interests: I am employed by a research institution.
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Competing Interests: None declared.
Published on: (28 June 2013)
Page navigation anchor for Borrow from the best to build successful teams
Borrow from the best to build successful teams
Brian Y. Laing, Family Physician
Taplin and co-authors eloquently summarize the relevant research and outline important action items for cultivating successful teams (1). In addition to understanding research on teams, it may behoove leadership to do a "deep-dive" into specific examples of high-performing healthcare teams. This could take the form of site-visits and collaboration between organizations with similar characteristics and challenges.
...
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Taplin and co-authors eloquently summarize the relevant research and outline important action items for cultivating successful teams (1). In addition to understanding research on teams, it may behoove leadership to do a "deep-dive" into specific examples of high-performing healthcare teams. This could take the form of site-visits and collaboration between organizations with similar characteristics and challenges.
Willard and Bodenheimer provide an exemplary report on essential lessons learned from site visits of high-performing primary care practices (2). The authors conclude that each of the seven clinics possess effective teams. They delineate several common elements among these teams, including shared vision and goals, established teamlets (e.g. clinician and medical assistant), standing orders, and use of clear, actionable data. Bodenheimer and colleagues are now applying these elements in a well- received practice coaching program for the San Francisco Department of Public Health's primary care clinics.
In the Los Angeles County Department of Health Services, we are beginning to adopt Kaiser Permanente's highly successful Unit-Based Team (UBT) model. UBTs are defined as a "natural work group of physicians, managers, and frontline staff who work collaboratively to solve problems, improve performance and enhance quality for measurable results"(3). In each clinic or unit, UBTs are led jointly by one representative from management and one from labor. These co-leads are tasked with engaging their team of frontline staff in quality and performance improvement. This joint labor-management leadership and employee engagement appear to be critical. In an assessment of 15 units in Kaiser's Northwest Region, researchers found greater improvement in immunization rates, breast cancer screening, lipid screening, and asthma monitoring among teams with higher levels of self-reported "labor-management activities and employee engagement"(4). As we begin to adapt this labor-management team model to the needs of LA county, we are already witnessing improvements in cycle time and no-show rates.
Health organization leaders need not re-invent the wheel of teams. Leadership can collaborate with colleagues and practice coaches from neighboring institutions to learn from existing, high-functioning teams. The lessons learned can be invaluable and should be implemented and adapted by organizations seeking effective teams.
1. Taplin, S. H., Foster, M. K. & Shortell, S. M. Organizational Leadership For Building Effective Health Care Teams. Ann Fam Med 11, 279- 281 (2013).
2. Willard-Grace, R. & Bodenheimer, T. The Building Blocks of High-Performing Primary Care (2012). Available at http://www.chcf.org/publications/2012/04/building-blocks-primary-care
3. Cohen, P. M., Ptaskiewicz, M. & Mipos, D. The Case for Unit- Based Teams: A Model for Front-line Engagement and Performance Improvement. Perm J 14, 70-75 (2010).
4. Kochan, T. A., Eaton, A., McKersie, R. B. & Adler, P. S. Healing Together: The Labor-Management Partnership at Kaiser Permanente. p.206-9. Ithaca, NY: ILR Press (2009).
Competing interests: None declared
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Competing Interests: None declared.
Published on: (24 June 2013)
Page navigation anchor for Toward a systems perspective of organizational leadership: It's lonely at the top, much less so in a team
Toward a systems perspective of organizational leadership: It's lonely at the top, much less so in a team
George W. Saba, Psychologist
Taplin, Foster and Shortell1 focus our attention on the pivotal role that organizational leaders will play in the successful transition to team -based care: fostering environments in which teams can either thrive or flounder. Noting that teams come in all varieties, the authors identify the complexity that leaders face as they tackle thorny issues such as the allocation of time, space, resources and reimbursement.
...
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Taplin, Foster and Shortell1 focus our attention on the pivotal role that organizational leaders will play in the successful transition to team -based care: fostering environments in which teams can either thrive or flounder. Noting that teams come in all varieties, the authors identify the complexity that leaders face as they tackle thorny issues such as the allocation of time, space, resources and reimbursement.
To better equip organizational leaders in the challenging task of cultivating effective teams, I propose the systems perspective as a guiding framework. Historically, healthcare organizations have been generally conceptualized in reductionistic ways (as units whose sum equal their parts), and leaders functioned as authorities who directed in the "control and command" style. In the 1980's, empowerment models of leadership emerged and encouraged leaders to transfer control to those doing the work.2 Both models reflect the dualism of the reductionistic perspective, in which control remains in the hands of one or the other. In its white paper on leadership, the Joint Commission states that "[i]f we want a healthcare organization to succeed, it must be appreciated as a system, the components of which work together to create success."3 A systems perspective envisions the organizational leader as inextricably linked with the healthcare system they lead. To effectively work from this perspective, a leader could consider the following:
* As physicians move from being the lone physician to becoming a participant leader of a collaborative team (a shift from "I" to "We"), organizational leaders will need to make a similar shift4. The reductionistic model of leadership often results in leaders growing apart from those on the front-lines. This disconnection can increase a leader's sense of isolation and feeling overly responsible for the organization's success and failure. The lone leader model can lead to burnout at work and stress at home. Understanding one's interconnectedness to the subsystem offers a model of participant leadership that can help protect against such detachment.
* A systems perspective, with its focus on interaction and relationship, delineates many of the essential questions that leaders and teams must address: How do we want to create effective boundaries among subsystems; define roles; craft rules that govern critical patterns of interaction (such as decision-making, conflict-resolution, and responsibilities); facilitate clear communication; create a context of trust; focus on strengths and resources; and support a balance of autonomy and dependence; and deal with uncertainty?4
* Many healthcare organizations have looked outside the field for guidance about team-based solutions (e.g., airplane industry, Toyota, Disney). In addition to the lessons these organizations have learned about structuring successful teams, they offer ideas for effective leadership. Systems oriented healthcare leaders can easily adopt many of their recommendations:
o Ensure connectedness and identify positive and problematic patterns of interaction by directly observing, on a frequent basis, the day-to-day operations;5,6
o Provide clear direction along with message of wanting to collaborate with the team to solve problems; it's not just the leader or the other members who decide;5
o Don't sacrifice people for products. Relationships matter. Leaders of teams emphasize respect, provide a caring supportive work environment, and model integrity, compassion and perseverance 5,6,7
* Systems thinkers are alert to process. The process of leadership of teams should be the focus of continuous quality improvement. Organizational leaders will need to develop a safe context for the evaluation of the interactional effectiveness of their team leadership. They need to adopt a mindful awareness of themselves plus the team. Patients and their families, as part of the team, can serve as a valuable resource in the improvement of the quality of organizational leadership.
As Taplin and colleagues brilliantly articulate, we must work with organizational leaders (who may well be ourselves) to ensure the development of effective teams. A systemic perspective can provide a roadmap for leaders so that they will not find themselves isolated at the top but located in the teams they serve and lead.
References
1. Taplin SH, Foster MK, Shortell SM. Organizational leadership for building healthcare teams. Ann Fam Med. 2013:11.279-281.
2. Womak JP, Shook J. Lean management and the role of lean leadership. Lean Enterprise Institute. Available at: http://www.lean.org/images/october_webinar_project_slides.PDF. Accessed 21 June 2013.
3. Schyve PM, Governance Institute. Leadership in healthcare organizations: a guide to Joint Commission leadership standards. Winter 2009. Available at: http://www.jointcommission.org/assets/1/18/WP_leadership_standards.pdf. Accessed 22 June 2013.
4. Saba GW, Villela TJ, Chen E, Hammer H, Bodenheimer T. The myth of the lone physician: toward a collaborative alternative. Ann Fam Med. 2012;10:169-173.
5. Doss R, Orr C. Lean leadership in healthcare. Solutions that perform.com. 2008. Available at: http://gpstrategies.rwd.com/uploadedfiles/industries/healthcare/healthcare%20white%20paper.pdf. Accessed 22 June 2013.
6. Cockerell L. Creating magic: 10 common sense leadership strategies from a lifetime at Disney. New York: Doubleday Business, 2008.
7. Letourneau, R. Successful leadership requires integrity, compassion: interview with C. Sullenberger. Healthcare Finance News. 25 June 2012. Available at: http://www.healthcarefinancenews.com/news/successful-leadership-requires- integrity-and-compassion. Accessed 22 June 2013.
Competing interests: None declared
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Competing Interests: None declared.