Improving On-the-Fly Teamwork in Health Care - Harvard Business Review

Calls for teamwork in health care are as persistent as they are hard to heed. Over the past decade, a growing number of observers, ourselves included, have called attention to the need for providers to coordinate better across specialties, shifts, departments, and even organizations (for example between primary care and urgent care facilities) to produce safe, affordable, high-quality care. Cross-boundary teamwork is particularly important when caring for patients who have chronic conditions and multiple additional diseases, increasing the need for collaboration among diverse providers. This type of teamwork is also critical in making the customized, time-sensitive care decisions required in busy emergency departments staffed around the clock by over-stretched clinicians. Prior research in health care and other industries makes clear the importance of team stability for team performance in general, yet stable teams are not always possible with chaotic 24/7 operations and heterogeneous work schedules.

Told to form and act as teams, most clinicians will agree with the spirit of the request but will struggle to make it happen given well-documented challenges of communicating across shifts, expertise areas, or hierarchical levels. For years, the basic model for managing coordination in health care delivery has relied on what organizational scholars called role-based coordination.  The premise is that professional training imbues “role occupants” (say, an emergency physician, or a scrub nurse) with the expertise needed to execute a part of a larger production or service operation. The model assumes that role responsibilities and boundaries are clear, and that crucial interdependencies between roles are sufficiently scripted to unfold appropriately.

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Unfortunately, role-based coordination theory faces important limitations in practice. First, although roles specify who is responsible for which tasks, role occupants often focus narrowly on their own responsibilities, neglecting the larger shared goal; this risk increases when their interdependent partners are difficult to identify or when accountability around the larger goal is ambiguous. Second, people in different roles are trained to think and communicate about, and value, different dimensions of performance, which further complicates coordination. Thus, even though roles are meant to clarify who is supposed to do what, they rarely guarantee the kind of teamwork across role boundaries in which people actively communicate about progress, exchange ideas, and help each other.

We have studied these challenges for years – separately (here and here) and together – and we suggest that health care providers focus on implementing effective teaming, rather than traditional bounded teams, to improve care coordination. What is needed is fast-paced communication and coordination on the fly, among constantly shifting partners in care who don’t have the luxury of forming stable, well-bounded teams.

There are structural and managerial ways to support this kind of teaming. In a study of teaming in a busy urban hospital’s emergency department, we found that implementing minimal role-based structures – which we call team scaffolds – helped people in different clinical roles collaborate effectively despite working together only temporarily. In that ED, coordination was given a boost – and made more like real team behavior – with the help of scaffolds that clarified fluid boundaries, provided an explicit shared goal, and ensured the availability of roles (skills) to accomplish that goal.

Prior to the redesign, the hospital used ad-hoc groupings in the emergency department; any available nurse would triage a patient, then return the patient’s chart for any available resident, who would then leave the chart for any available attending. The nurses did not know which doctor was working on which patient, and vice versa, which led to inefficiencies and a lack of perceived accountability to one another. Schisms between professional groups also hampered communication.

The redesign divided the ED into four pods, each of which had the necessary equipment to treat any type of patient. One attending physician, one or two residents, and three nurses were assigned randomly to a pod at the start of each of their shifts. Patients were doled out consecutively to the four pods, with the staff of each pod having ultimate responsibility for a queue of patients. Because of the staggered and differing shifts, the entire team composition could change over in as little as five hours.

Although the scaffolds lacked stable membership, they triggered significant changes in teaming networks and behaviors and improved operational performance. The doctors and nurses were co-located, making it easy to know who was on the team. They were collectively responsible for getting the patients through the ED. And their teaming improved: They held each other accountable, actively updated and helped each other, and explicitly prioritized their shared efforts.

Despite this noteworthy success, we’ve found that team scaffolds can underperform if they’re poorly managed. Thoughtful leadership is needed to implement them well – explaining the goals, engaging people in helping work out the details, and framing the entire endeavor as a learning journey. If scaffolds are simply imposed on people to make them “work as a team” without engaging them as equal partners in improving how work is done, the new structures are unlikely to enhance performance.

For team scaffolds to work, leaders from different role groups – say medical and nursing directors – must collaborate with each other and with the staff to design, pilot, and manage the new structures. To get started, leaders should elicit and use feedback from the staff about the new design. They must invest in training people in the new system, for example operating a pilot scaffold in parallel with the existing processes for a few weeks, allowing people to practice working as a team in the new structure. Using this iterative approach, by listening and learning together, real teamwork can take hold.