Physicians may enter training drawn to the autonomy of medicine, but effective health care delivery — particularly in the era of accountable care organizations and patient-centered medical homes — will likely be driven by effective teams, not individuals working solo.
But what is the secret to creating an effective team? Over two years, Google conducted 200+ interviews and a series of analyses of over 250 attributes to understand what drives team performance. What emerges is not the who, but the how: the attributes of the team members matter less than how the members interact, structure their work, and view their contributions.
For health care, this may mean that individual clinicians’ technical excellence is necessary, but insufficient to improve team-driven patient outcomes.
How Teams Excel
We’ve learned that there are five key dynamics that set successful teams apart from other teams at Google:
- Psychological safety: Can team members take risks by sharing ideas and suggestions without feeling insecure or embarrassed? Do team members feel supported, or do they feel as if other team members try to undermine them deliberately?
- Dependability: Can each team member count on the others to perform their job tasks effectively? When team members ask one another for something to be done, will it be? Can they depend on fellow teammates when they need help?
- Structure & clarity: Are roles, responsibilities, and individual accountability on the team clear?
- Meaning of work: Is the team working toward a goal that is personally important for each member? Does work give team members a sense of personal and professional fulfillment?
- Impact of work: Does the team fundamentally believe that the work they’re doing matters? Do they feel their work matters for a higher-order goal?
It may surprise people to learn that psychological safety is the most important of these five dynamics by far. In fact, it’s the underpinning of the other four.
At Google, we have found that psychological safety leads to better team results. For example, among sales teams, those with high psychological safety exceeded their targets by, on average, 17%. In contrast, those with low psychological safety missed their targets by, on average, 19%. While these outcomes were demonstrated in a sales organization, we believe they are likely to apply more broadly; psychological safety drives effectiveness because it inspires a learning culture, which is beneficial to any organization.
To encourage psychological safety within teams, we created a tool at Google called the gTeams exercise: a 10-minute pulse-check on the five dynamics, which generates a report summarizing how the team is doing. This report is used to start a live in-person conversation to discuss the results among the team, and suggestions and resources are provided to help teams improve. In the first year of adopting gTeams, more than 3,000 Google employees across 300 teams used this tool. Of those teams, the ones that adopted a new group norm — like kicking off every team meeting by sharing a risk taken in the previous week — improved 6% on psychological safety ratings and 10% on structure and clarity ratings. Teams told us that having a framework around team effectiveness and a forcing function to talk about these dynamics had been missing previously and was by far the most impactful part of the experience.
How Health Care Organizations Can Improve Teamwork
We suggest six steps to improve team performance and psychological safety, outlined below. These are adapted from our research and experience at Google as well as the evidence base.
1. Ask: “Are we really a team?”
- Real teams are relatively small — from 3 to 15 people. Teams larger than this often work better in smaller sub-teams.
- Teams have mutual accountability and interdependence. Teams share common goals as well as the rewards and responsibilities for achieving those goals.
- If these aspects don’t describe your team, then you might actually have a working group or a collection of individuals who report to the same manager, or you might have an organization — a team of teams. It’s important to not force team-building if you’re not actually dealing with a team.
2. Watch actual team meetings.
Reviewing recordings of meetings can overcome inattentional blindness. Take a look at the AHRQ CUSP toolkit video, and then consider making a video of an actual team meeting. Some questions to ask yourself while watching:
- When it comes to psychological safety, what are people doing well?
- What could they be doing better?
- What would you have done if you were in this meeting?
3. Look for warning signs that your team needs to improve psychological safety.
- Fear of asking for or delivering constructive feedback
- Hesitance around expressing divergent ideas and asking “silly” questions
- Presence of few strong voices that marginalize other people or perspectives
- Gossiping (often when the person is not in the room) or the existence of cliques within the team
4. Ask team members and leaders their perceptions of psychological safety.
Gather perspectives in a safe, anonymous fashion:
- Do all team members feel comfortable brainstorming in front of each other?
- Do all team members feel they can discuss mistakes and learn from them, or will they feel shunned?
- Do team members feel as if others try to undermine them deliberately?
- How is conflict currently managed? How might it be better managed?
5. Act to increase psychological safety in your team.
- Identify a team member who is not in the “in crowd” and invite them to lunch or a drink.
- In your next disagreement, reflect to the other person with “what I heard you say . . .” before responding with your point.
- Find one opportunity to praise another team member’s contribution in front of others.
6. Transform the meeting paradigm for your teams.
- Consider the use of huddles, or daily clinical team meetings. In a study of six VA primary care practices, team members who huddled reported higher psychological safety — even among respondents who did not find huddling to be very helpful.
- Empower morbidity & mortality (M&M) conference participants to comment, without fear of reprisal, on the psychological safety of the teams involved.
By its nature, medicine is meaningful, with high impact at the outset of practitioners’ careers. However, in addition to real-world revenue pressure, physicians may also be penalized by a culture of poor psychological safety. Uncivil behavior impacts performance by disrupting working memory, reducing creativity, hampering attention to complex tasks, lessening motivation, and more. For example, in one survey among doctors and nurses, nearly three out of four identified uncivil, disruptive behaviors that led to medical errors, and more than a quarter reported that these behaviors contributed to the deaths of patients.
Furthermore, physicians tacitly assume that their voices are valued more than those of nurses, and do not perceive the same level of interpersonal risk associated with self-expression experienced by non-physicians. A study of cross-disciplinary NICU teams demonstrated that leadership inclusiveness predicts psychological safety, and in turn psychological safety mediates the relationship between leader inclusiveness and team engagement in quality improvement work. Thus, it is up to leaders to set the tone for psychological safety.
This blog post originally appeared in NEJM Catalyst on October 19, 2016.