Leadership

Cultivating Great Teams: What Health Care Can Learn from Google

Article · February 21, 2017

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:

  1. 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?
  2. 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?
  3. Structure & clarity: Are roles, responsibilities, and individual accountability on the team clear?
  4. 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?
  5. 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 post originally appeared in NEJM Catalyst on October 19, 2016.

Call for submissions:

Now inviting expert articles, longform articles, and case studies for peer review

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

More From Leadership

From the Commonwealth to Obamacare: Reflections on 10+ Years of Expanding Health Insurance Coverage

The former Executive Director of the Commonwealth Health Insurance Connector — a model for the Affordable Care Act and other state marketplaces — reflects on what worked, what didn’t, and what could be done differently in both Massachusetts and at the federal level.

Time Spent Engaging Directly with 16 Camden RESET Participants or Coordinating Care on Their Behalf

“Putting All the Pieces Back”: Lessons from a Health Care–Led Jail Reentry Pilot

The Camden Coalition’s jail-based reentry program illuminated the necessity and challenges of engaging people with complex health and social needs and helping to transform the systems that serve them.

Sands01_pullquote clinical research partnership for learning health care

Real-World Advice for Generating Real-World Evidence

If envisioned and implemented properly, a partnership between clinical delivery systems and clinical research programs can get us closer to the goal of achieving learning within the care continuum and discovering evidence that is available when it is needed.

The Largest Share of Organizations Do Not Have a Formal Strategy for Clinician Engagement

Leadership Survey: Why Clinicians Are Not Engaged, and What Leaders Must Do About It

Clinician engagement is vital for improving clinical quality and patient satisfaction, as well as the job satisfaction of clinicians themselves. Yet nearly half of health care organizations are not very effective or not at all effective at clinician engagement.

Rowe01_pullquote - clinician well-being - fighting clinician burnout and creating culture of wellness takes all stakeholders

Defending the Term “Burnout”: A Useful Tool in the Quest to Ease Clinician Suffering

Health care leaders must take a preemptive approach to clinician well-being that is supported by all stakeholders and prioritized on an equal footing with essential clinical and financial measures.

Screenshot from the NewYork Quality Care Chronic Condition Dashboard

Success in a Hospital-Integrated Accountable Care Organization

How NewYork Quality Care achieved shared savings — by strengthening collaboration, enhancing care management with telehealth, and transparently sharing performance data.

Miller03_pullquote social determinants whole-person

How a State Advances Whole-Person Health Care

Pennsylvania addresses social determinants of health by bringing together managed care and social services organizations to expand access to vital resources.

Abigail Geisinger Scholars Program for Medical Students -Ryu02_pullquote

Why a Teaching Hospital Offers an Employment-Based Tuition Waiver Program

Geisinger Commonwealth School of Medicine subsidizes medical students’ education in exchange for their willingness to practice at Geisinger Health System.

Michael Dowling and Charles Kenney headshots

Rebooting Health Care: An Optimistic Outlook

The U.S. health care system may seem broken, but it’s on its way to greatness, according to the authors of Health Care Reboot. They discuss their optimism for U.S. health care reform, particularly on the social determinants of health, payment, consumerism, and technology.

Action Steps for Risk-Share Contracts for Medical Devices

Challenges and Best Practices for Health Systems to Consider When Implementing Risk-Share Contracts for Medical Devices

When done right, value-based contracting for medical devices can ameliorate shrinking margins at health systems, leading to a virtuous circle.

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

Topics

Leading Transformation

284 Articles

From the Commonwealth to Obamacare: Reflections…

The former Executive Director of the Commonwealth Health Insurance Connector — a model for the…

Physician Burnout

52 Articles

Survey Snapshot: How Do You Know…

The NEJM Catalyst Insights Council discusses strategies for clinical engagement.

From the Commonwealth to Obamacare: Reflections…

The former Executive Director of the Commonwealth Health Insurance Connector — a model for the…

Insights Council

Have a voice. Join other health care leaders effecting change, shaping tomorrow.

Apply Now