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We shall not cease from exploration
And the end of all our exploring
Will be to arrive where we started
And know the place for the first time.

—T.S. Eliot, Little Gidding, 1942

We all know teams. We work in teams. We use teams in community and leisure-time activities. We play or watch team sports. And yet there is a great deal of useful information about teamwork that is unknown to many people in health care. The aim of this book is to make that information more widely known and used. It is a book of exploration and explanation, which, hopefully, will enable the reader to be more effective as a team participant, team leader, and team manager.

Health care today requires teams. The rise of multiple healthcare professions, each with its own specialties, has brought a rich array of knowledge and skills to the tasks of preventing illness and caring for the sick, but it has also created risks. Health care has enormous power to heal, and yet it is complex and often uncoordinated, or simply fragmented. By using teams, we can decrease the risks of fragmentation and achieve effective delivery of care. But, of course, for team-based care to be successful, it must employ effective teamwork.

Understanding Teamwork in Health Care is a book about how to work proficiently in and with teams. Our emphasis is on interprofessional teams, but the concepts discussed apply also to teams composed of people from any single profession. The book aims to offset in some measure a deficiency in the education of almost all healthcare professionals in the United States, namely, the lack of training about working in teams composed of people from various professions. There are currently some indications that interprofessional education will in time become part of the education of nurses, physicians, and other healthcare professionals. Eventually, there may be no deficiency to address. However, at this point, nearly all professionals working in health care are obliged to puzzle out interprofessional teamwork on their own. This book is intended to help healthcare professionals in this effort.

We, the authors, each have over 30 years of experience in health care—one of us as a general internist and healthcare leader (GM) and one of us as a researcher and teacher (JWB). During this time, we have both had an enduring interest in teams and, more generally, in the interactions among patients, their families, people providing health care, and people leading and managing healthcare organizations. But we do not need to rely solely on our experience. Sociologists, organizational psychologists, management scientists, healthcare professionals, health services researchers, and other scholars have produced a great deal of knowledge about teams over the past 75 years, including knowledge of teams in health care. Unfortunately, most of this body of knowledge has not yet been put to use to improve the delivery of health care. In this book we strive to make some of this knowledge available for concrete use in improving health care through better teamwork.

THE AUDIENCE

This book is intended for people who are clinicians or managers of health care. In other words, we hope, first, that it will be useful to nurses, nurse practitioners, physicians, pharmacists, healthcare social workers, dentists, physician assistants, physical therapists, psychologists, and all others whom we call clinicians because they provide care directly to patients. We hope, second, that it will be useful to clerical staff, healthcare administrators, public health officials, and senior leaders in health care. We also hope that students in the health professions will find the book useful.

We have written about healthcare teams in the United States. However, the precepts and principles discussed are applicable in any country. Indeed, the literature cited originates not only from the United States but also from the United Kingdom, Canada, Finland, Australia, and elsewhere. We hope that the book will be helpful to healthcare professionals in these countries and others.

THE GOAL AND PLAN OF THE BOOK

The goal of Understanding Teamwork in Health Care is to advance the understanding and functioning of teams as they are used in health care, including both clinical teams and management teams.

Section I, Healthcare Teams and Team Members (Chapters 1-5), introduces the concept of a work team, explains different types of healthcare teams, describes the backgrounds of the professionals who comprise healthcare teams, and elucidates the distinctive roles of patients and administrators in teams. Section II, Working in Healthcare Teams (Chapters 6-12), explains how effective teams function and sets forth the competencies that individual team members and team leaders need to have to function effectively in teams. Decision making, creativity, and conflict management in teams are examined in detail. The final chapter in this section (Chapter 12) explains the role and competencies of the team sponsor, the person to whom the team is accountable and through whom the team interacts with the larger organization in which it functions. Since sponsors are usually the designers of teams, principles of team design are explained in this chapter. Section III, Evaluating and Improving Healthcare Teams (Chapters 13-17), first explains how to assess team members and whole teams. It then explores 4 areas of action for improvement: training, team building, improving processes in teams, and troubleshooting of specific problems commonly encountered in teams. Section IV, Advancing Teamwork in Health Care (Chapters 18-19) addresses the role of senior leadership in advancing teamwork and looks to the future. Chapter 18 depicts the responsibilities of senior leaders in supporting teams and explains the senior leader competencies and the organizational culture needed to support teams. Finally, the conclusion (Chapter 19) speculates on the future of teams in health care and delineates near-term strategies for healthcare organizations and educational institutions to improve team-based care in the United States.

Our practical, larger purpose is to assist people working in health care to improve the performance of the teams they work in, lead, or manage so that the interests of patients are better served.

VIGNETTES

Writers about organizational behavior often use abstract concepts and terms. While abstract concepts and theory have their places in advancing knowledge of how people behave in organizations, they have limited utility for those who wish to use the knowledge in their day-to-day work providing and managing health care. To make the knowledge useful, a writer needs to render the concepts concrete and actionable. To this end, we make liberal use of vignettes throughout the book. Most of these vignettes are stories of clinical practitioners at work. Some of them are stories about managers or about clinicians and managers working together. We hope that these vignettes will make the material clearer and more immediately useful to clinicians and managers seeking to apply the book's ideas in their own settings.

The vignettes are based on our own experiences, the experiences of colleagues, or reports in the public media, healthcare literature, or management literature. Almost all of the vignettes are fictionalized to focus on the pertinent details and to assure privacy. In a few stories, the events are reported as they occurred, but the names and locales have been changed.

VOCABULARY

Much of the subject matter of this book is referred to as interprofessional teamwork or interdisciplinary teamwork. We see these 2 phrases as essentially synonymous and do not wish to mark any important distinction by using the phrases as labels for different ideas. We have chosen to use the phrase interprofessional teamwork for 2 reasons. First, for some readers, the phrase interdisciplinary teamwork suggests teamwork among people in different disciplines of medicine—pediatrics, internal medicine, surgery, and so on—or in different academic disciplines—physiology, anatomy, biochemistry, and so on. We are discussing teamwork across a broader range, that is, among individuals in wholly different professions—nursing, medicine, pharmacy, and others. Second, the phrase interprofessional teamwork appears to have become the favored phrase among people writing about this topic in recent years.

OUR VIEWPOINT

We come to the topic of healthcare teamwork with a viewpoint on the current state of affairs and what should be done to improve it. The reader will notice that our opinions have shaped various portions of the book. To eliminate any doubt about our position, we articulate our views here.

Teamwork Needs to Be Improved

A great deal of health care in now delivered by teams. In order to make care safer, more effective, less expensive, and more responsive to patients' values and choices, healthcare teams need to perform much better than they often do. Failures of communication, collaboration, and team management too often degrade patients' experience of care, their health outcomes, and the safety of their care while increasing costs. We can and must improve teamwork as part of our overall efforts to improve health care.

Healthcare Professionals Need to Understand Each Other's Professions

Some shortfalls in teamwork arise because healthcare professionals are not adequately familiar with their colleagues' professions. Too often the knowledge bases, skills, and values of people in other healthcare professions are not well known by physicians, nurses, social workers, and others. Sometimes they are barely known at all. In order for team members to make full use of each other's knowledge and skills, they must know what the other team members can contribute. Moreover, some team dysfunction results from differences in professional values, and these difficulties cannot be overcome unless team members understand the differences.

Patients Are in Charge If They Choose to Be

Patients have the right to make the decisions about their care if they choose to do so. In other words, if a patient wants to decide what his or her healthcare team does in providing care for him or her, then that patient should be permitted to make these decisions. Patients may also delegate decision making to their physicians or to other care providers—or to family members or to other people whom they trust to speak for them. Alternatively, they may be partners with their physicians and other care providers if they choose to be partners. But if they prefer to have the final word without partnering, they are entitled to have the final word. Of course, there are exceptions for patients who are incapacitated because of injury or illness, who have certain kinds of mental illness, or who are making decisions that will cause harm to them and are based on plainly false beliefs. However, these cases are unusual and do not undo the general rule that patients are in charge if they want to be.

Healthcare Administrators Should Become Team Members

When clinicians think about team-based health care, they ordinarily regard the members of the team to be the clinicians plus the patient and, sometimes, key clerical staff in the units where they work. They do not think of administrators as team members. Health care would be improved if administrators were brought into the team. Administrators have pertinent knowledge and skills that many clinicians do not have: skills in designing and improving workflow processes, project management skills, facility in managing people, and organizational political skills useful in mobilizing resources. To become members of the team, administrators will need to stop standing at a distance. They will need to understand the training, activities, and values of other healthcare professionals.

Teams Should Become Less Hierarchical

Large differences in authority and status between team members interfere with communication and inhibit participation by the junior members, leading to lost information, lost insights, and diminished contributions from the junior members. Flattening the hierarchy in commercial airline cockpits has made aviation safer. During the past 25 years, airlines have used intensive training to flatten hierarchies and make other improvements in teamwork. As a result, they have achieved dramatic improvements in accident rates. In order to improve health care, we need to make hierarchies in healthcare teams less steep.

Roles of Physicians Are Changing and Should Change

For over a century, physicians have been presumed to be the leaders of most healthcare teams to which they have belonged. They have been presumed to be the final authorities on any questions that might arise. Having this authority makes sense when answering questions that require knowledge that only physicians have. However, it does not make sense to use the medical knowledge of physicians as a rationale for generalizing their authority to cover all healthcare and organizational questions. Health care already has teams that include physicians and are led by practitioners in other professions. In many teams, a professional who is not a physician will be better suited than any physician on the team to maintain the team's focus, develop the team's capacity over time, and coach team members. Considerations of suitability for leadership should determine whether a particular person is the team leader, not whether the person is a member of a particular profession.

Future Healthcare Organizations Will Be Able to Support Teams

Many of the activities discussed in this book can be pursued only by organizations large enough to have the economy of scale necessary to provide adequate funding and other resources. These activities include team training, coaching, and systematic improvement of performance. We believe that the current aggregation of medical practices and hospitals into larger units will continue to the point that solo practitioners, small clinical groups, and independent, small hospitals will be uncommon, in both urban and rural areas. Even those small practices and hospitals that persist will find it necessary to form associations to achieve economies of scale, permitting them to support teamwork better than they can now. Thus we believe that institutional support for teamwork will be increasingly available in the future.

ACKNOWLEDGEMENTS

We wish to thank Kendall Richardson and Isaiah Zirkle for background research on the health professions, Preethi Nakappan for research on team building and initial development of selected graphics, and Thaddeus Murray for contributions to editing of vignettes. Discussions with Susan Anderson, Paul Batalden, Mark Gildea, Nancy Jaeckels, Linda Lindeke, Shailey Prasad, Omer Sanan, Curt Wyman, Thomas Wyman, Ken White, and Andrew Zinkel on healthcare teamwork provided insight and inspiration. Ken White was a major contributor to the material in Chapter 5. The McGraw-Hill team of James Shanahan, Christina Thomas, and Laura Libretti was supportive and accommodating. Thomas Bodenheimer helped us greatly through his early enthusiasm and support for the project. Our spouses, Nina Mosser and Jean Wyman, sustained us with insights, patience, love, and grace throughout the long process of researching and writing this book.

Any errors or misinterpretations are, of course, our responsibility. We welcome comments and suggestions for improvement from readers.

CONCLUSION

This is a book about a facet of health care that has been neglected until recently, namely, teamwork among individuals in different healthcare professions. Better interprofessional teamwork promises to improve patient care, outcomes of care, and costs. Better teamwork also promises to make working in health care more collegial and gratifying for healthcare professionals and for those who support them. It is time to take up the challenge of improving our teams.

Gordon Mosser
James W. Begun
Minneapolis, Minnesota
April 2013

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