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4 MANAGING TEAMS Leading and Developing Work Teams That Are Efficient, Focused, and Flexible

Starting Point

Go to www.wiley.com/college/Lombardi to assess your knowledge of the basics of team management. Determine where you need to concentrate your effort.

What You’ll Learn in This Chapter ▲ Characteristics of strong teams ▲ Five principles of team orientation ▲ Five phases of team development and three key ways that teams develop ▲ Methods of enhancing individual team members and overall team orientation ▲ Pros and cons of team decision making

After Studying This Chapter, You’ll Be Able To ▲ Implement the attributes of strong teams ▲ Practice ways to develop individual team players ▲ Practice methods of enhancing teams to higher levels of performance ▲ Demonstrate how managers effectively lead teams ▲ Apply techniques for successful group decision making

Goals and Outcomes ▲ Master the terminology of team management and team development and recognize

tools and techniques associated with strong team management ▲ Understand the importance of strong, high-functioning teams ▲ Compare successful and unsuccessful teams ▲ Use tools and techniques to establish and promote positive team orientation,

development, and enhancement ▲ Discuss the results, implications, and limitations of specific plans ▲ Collaborate with, encourage, and develop work team members ▲ Apply appropriate developing, enhancing, and leading techniques to real-life work-

team situations ▲ Evaluate overall performance and effectiveness of teams

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4.1.1 TEAM EFFECTIVENESS 91

INTRODUCTION Teams are one of the most popular ways to organize today’s health care opera- tion. Effective teams are motivated, respected, progressive, achievement-oriented, and supportive. Managers can help establish a strong team orientation by clearly defining job roles, creating shared goals, setting up open communication sys- tems, and celebrating team diversity and differences. Because most teams go through multiple stages of development, managers need to lay good groundwork in the areas of expected behaviors, task responsibilities, and communication pro- cedures. Leaders who both encourage a team orientation and develop individual members often produce the strongest teams. Teams can be effective decision- making structures, benefiting the entire organization.

4.1 Setting Up High-Functioning Teams

A team is a small group of people with complementary skills, who work together to achieve a shared purpose and hold themselves mutually accountable for its accomplishment. Teamwork is the process of people working together to accom- plish these goals.

The organizational designs and cultures of today’s health care organizations require teams, as well as a comprehensive commitment to empowerment and employee involvement. The ability of managers to develop their teams and lead through teamwork requires a special understanding of how teams operate and the commitment to use that understanding to help them achieve high levels of task performance and membership satisfaction.

4.1.1 Team Effectiveness

Teams transform resource inputs people and ideas into product outputs a fin- ished good or service, or a special report or action recommendation.1

On the output side, task performance—good, old-fashioned “getting the job done”—is a concrete result that adds value to the organization. See Figure 4-1.

Also on the output side, you can see that member satisfaction is essential. Unless team members are satisfied with their accomplishments and with their experiences working together, the team is unlikely to retain long-term perfor- mance viability.

An effective team is one that achieves and maintains high levels of both task performance and member satisfaction and retains its viability for future action. As shown in Figure 4-1, a team’s ability to be effective depends on the strength of its internal operations and on the quality of its inputs.

▲ Group process: The way the members of any team actually work together as they transform inputs into outputs. This includes how well

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92 MANAGING TEAMS

team members communicate with one another, make decisions, and handle conflicts.

When the group process breaks down and the internal dynamics fail in any way, team effectiveness can suffer.

In addition to good group processes, the following are also essential to team effectiveness:

▲ The team must have any necessary resource inputs to deal best with the task at hand. Among critical input factors, the organizational setting, in particular, can affect how team members relate to one another and apply their skills.

▲ The team must have support in terms of information, material resources, technology, spatial arrangements, organization structures, and rewards.

▲ The nature of the task also affects how well a team can focus its efforts and how intense the group process needs to be.

▲ Clearly defined tasks make focusing work efforts easier. Complex tasks require more information exchange and intense interactions.

Figure 4-1

A model of work team effectiveness.

Organizational setting • Resources • Technology • Structures • Rewards • Information

Nature of task • Clarity • Complexity

Team size • Number of members • Even-odd number

Membership characteristics • Abilities • Values • Personalities

Inputs

Group process Team effectiveness

Throughputs

Feedback

Outputs

The way members interact and work together to transform inputs into outputs

Accomplishment of desired outcomes • Task performance • Member satisfaction • Team viability

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4.1.1 TEAM EFFECTIVENESS 93

Additionally, several compositional factors affect team effectiveness:

▲ Team size affects how members work together, handle disagreements, and reach agreements. The number and complexity of interactions can make teams larger than six or seven members difficult to manage. When voting is required, teams with odd numbers of members are often pre- ferred so as to prevent “ties.”

▲ Membership characteristics are also important, particularly the blend of competencies, skills, and personalities. While a mix of skills, values, and personalities broadens the resources of a team, it also adds complexity to members’ interpersonal relationships.2

▲ Team diversity is the different values, personalities, experiences, demo- graphics, and cultures among the membership. This can present signifi- cant group process challenges. The more homogeneous the team—the more similar the members are to one another—the easier it is to manage relationships. As team diversity decreases, so, too, does the complexity of interpersonal relationships among members. The more heterogeneous the team—the more diversity among members—the greater the variety of available ideas, perspectives, and experiences that can add value to prob- lem-solving and task performance.

In teamwork, as with organizations at large, the diversity lesson is very clear. Much can be gained when the team (and the entire organization) value and man-

F O R E X A M P L E

Integrated Care Management at University of Minnesota Health System The Integrated Care Management program at the University of Minnesota Health System utilizes a team-oriented approach for patient care that com- bines the processes and talents of the institution’s Surgical Intensive Care Unit and its Patient Care Services. In Integrated Care Management, clinical profes- sionals and case managers collaborate on surgery cases, using processes and tools they’ve developed together. Although the two groups share tools for patient assessment, transition, and discharge, the arrangement allows multi- ple opportunities for decision making, assigns clear responsibility for various decisions, and permits discussion of alternative treatments. Following imple- mentation of the Integrated Care Management program, the unit achieved pos- itive results, including shorter hospital stays, fewer medication errors, and a cost savings of nearly $10 million.

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94 MANAGING TEAMS

age diversity. The process challenge is to maximize the advantages of team diver- sity while minimizing its potential disadvantages.

4.1.2 Identifying Characteristics of Strong Teams

As a health care manager, establishing a team orientation is important in order to build a progressive work environment.

As a new health care manager, you are most likely inheriting a ready-made team. Your department may have been working together under the leadership of your predecessor. (Even if you are forming a brand-new team, the following guidelines can help establish the standards you wish to incorporate into your team-building and team-orientation efforts.) The following are key qualities con- sistent in all winning teams:

▲ A motivated team attains its stated mission successfully and effectively. Motivation can come from a variety of sources, the first of which should be the department manager. Motivation can be positive, emphasizing encouragement and progressive action, or negative, emphasizing less- than-satisfactory consequences due to failure to meet team objectives. Motivation also must come from the work group itself. Individuals must inspire one another to greater performance and support the efforts of all team members. Also, each team member must be self-motivated. See section 10.1 for more information on motivation.

▲ A credible and respected team is known for getting the job done. The team earns credibility and commands the respect of patients and other departments. Strong teams have a wide base of technical knowledge and can readily provide whatever level of assistance is needed. Such teams are self-perpetuating, as they attract and retain other strong members.

▲ A progressive team grows continuously and develops expertise in an ongoing effort to enhance quality. Teams become progressive by valuing individual contribution, constantly attaining new technical knowledge, and experimenting with and implementing new methods of practices. Conversely, a regressive team loses ground and fails to participate posi- tively in organizational activities, and its members are labeled as losers throughout the organization.

▲ An inspired team is fueled by their will to win. Individual members are success driven, and their leaders reinforce the importance of succeeding. This combination is the basis for inspiration. So that teams remain inspired, clear goals must be established, outcomes must be defined, and methods of attaining success should be delineated by the leader with the participation of all members.

▲ A talented and seasoned team has the skills and abilities needed to achieve a desired end, even if surprises pop up along the way. Talent

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4.2.1 CLEARLY DEFINED ROLES 95

encompasses technical knowledge, performance ability relative to current health care mandates, and awareness of business objectives within the context of those mandates.

▲ An achievement-oriented team wants success on an individual, group, and organizational level. In making their contribution, team members must be challenged to become the best they can be. As a manager, you must foster educational development, training opportunities, open com- munication, and goal attainment for each staff member.

▲ A spirited team is supportive, positive, results-oriented, and winning. These adjectives relate not only to the perceptions others have of the team, but also to something perhaps more important: the team’s percep- tion of itself. Losing teams are characterized as whiners, dysfunctional, or negative.

• Identify and define team, teamwork, resource input, and product output.

• Cite the three compositional factors of any team.

• List the main characteristics of a strong team.

S E L F - C H E C K

4.2 Establishing a Team Orientation

As first-time manager, you might generate a sense of team orientation by defin- ing the policies—either implicitly or explicitly through staff meetings—that define how the team gets work done. Or perhaps you can establish a team ori- entation by having your staff brainstorm lists of principles by which they should be guided.

The following five basic principles of team orientation provide a foundation to assist you in formulating a policy of team action.

4.2.1 Clearly Defined Roles

Team members should know their role on the team, and the team itself should have a defined role throughout or within the organization. Role definition is essential so that individuals can identify with their work role and with the over- all mission of their work group.

Some departments, by virtue of preexisting job descriptions or work group objectives, already have clearly established roles for every team member. If the

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96 MANAGING TEAMS

team you’re leading or managing doesn’t have clearly defined roles—or if you want to adjust or redefine the roles within your team—take time to review pri- mary work roles with each staff member; compile, refine, or update a job descrip- tion for each individual; and enlist assistance from your human resources depart- ment to establish clearer job descriptions.

In addition to defining the roles of individuals, establish an objective for the entire work group that specifies its relevance to the health care organization’s big picture. Compile a departmental mission statement (see section 6.4.7 for more on mission statements). Invite input from your staff and team members by ask- ing, What is it that we contribute to our overall health care organization? What would happen to the hospital if our department was not here?

4.2.2 Strong Interest in Shared Objectives and Goals

A winning team is goal-oriented. Accordingly, upon establishing (or reinforcing) team goals, ensure that all team members are committed to achieving these goals. If they are not, you may want to discuss why, either individually or in a group setting.

Individuals may not be committed to department goals for a number of rea- sons. For example, a worker may not understand the goals, may be misplaced in his or her work role, or may simply be apathetic.

Hopefully your entire team can be motivated by the goals and objectives. If not, check performance documentation (see section 5.4). You may find that individuals who are not committed to the goals may not be contributing according to the orga- nization’s performance standards. If this is the case, consider placing them elsewhere in the organization or perhaps even terminating their position.

F O R E X A M P L E

Three Common Team Personalities Even if a team doesn’t have defined job descriptions or roles for each mem- ber, health care consultant Donald N. Lombardi contends that most teams have one or more of the three common team personalities. Star players are typically outspoken, have been on the team a long time, and have credibility with other team members. Lombardi recommends that managers seek out the allegiance of star players from day one. Steady players usually make up the majority of the team, producing average to above-average results. Managers should deal with steady players individually to learn their perceptions on how to increase group performance and enhance their contribution to the group. Underachievers are generally disinterested in their work and have no innate drive to improve on their activities. Managers should document their work during performance evaluations, and, if necessary, recommend termination.

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4.2.5 A VARIETY OF TALENTS, A DIVERSITY OF PERSPECTIVES 97

4.2.3 Open Communication System

Maintaining open communications with all team members is essential. The eas- iest way to go about this is to hold regular staff meetings (biweekly or monthly) in which you discuss department objectives, recent events, and organizational information. A roundtable discussion in which all team members describe their current activities and other essential information can be helpful. (Section 4.3.4 explores different types of formal communication systems.)

Also, consider less-formal methods of communication to encourage cooper- ation and communication among all team members. Take time to discuss work dynamics with each member as frequently as possible—for example, by engag- ing in a one-on-one “coffee conference” once a week or simply by walking around the department and asking each person how his or her day is going.

4.2.4 Resilience

Great teams are not defeated by adversity—they bounce back. No team is per- fect, but you must remember that no team operates under perfect conditions every day. As a result, adverse situations arise that can have negative and demo- tivating effects. When these situations occur, call a staff meeting to ask these questions:

▲ What went wrong? ▲ How could it have been avoided? ▲ What have we learned from this? ▲ What will we do next time given the same circumstances?

By following this sequence, you give everyone an opportunity to learn from their mistakes, avoid reactive (as opposed to proactive) behavior in tough situations, and become more effective in their everyday work activities.

As manager, take the lead in this discussion by admitting any mistake you may have made and acknowledging whatever may have caused a problem that was outside your department’s power to remedy. This process provides a basis on which to generate progressive discussion, which can help turn negative situ- ations into positive future action.

4.2.5 A Variety of Talents, a Diversity of Perspectives

The individual team members in any health care team have various types and levels of experience and different viewpoints and opinions on work activity. Wise health care managers celebrate this diversity by being open and perceptive to a variety of ideas and encouraging staff to share their ideas and perspectives.

Many new managers, in particular, make the mistake of trying to force individuals into one perspective or one common viewpoint. Unfortunately,

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98 MANAGING TEAMS

eliminating diversity sabotages creativity and cuts off individual initiative before it has a chance to blossom.

Ask your team members for their opinions, encourage them to share their opinions in meetings and other group communication forums, and reward cre- ative behavior by giving individuals the opportunity to pursue ideas that might enhance effectiveness and efficiency within the department, thus contributing to the entire organization.

• Explain the importance of clearly defined work roles and shared objectives within teams.

• Identify common tools and methods for open communication.

• List the four questions for dealing with adverse or negative situations.

• Discuss the positive aspects of having teams with diverse back- grounds, skills, and perspectives.

S E L F - C H E C K

4.3 Developing Teams

Great work teams rarely just happen. Generally, a manager or team leader, who understands the stages of team development, helps build a strong team by estab- lishing norms (see section 4.3.2), task and maintenance needs (4.3.3), and com- munication networks (4.3.4).

4.3.1 Team Development Process

Research on small groups suggests that there are five distinct phases in the life cycle of any team: forming, storming, norming, performing, and adjourning.3

Health care managers need to be aware of these phases, identify where their teams are in the development process, and assist their teams in moving on to the next phase, when appropriate.

▲ The forming stage involves the initial entry of individual members into a team.

This is a stage of initial task orientation and interpersonal testing. As individu- als come together for the first time or two, they ask a number of questions: “What can or does the team offer me?” “What am I asked to contribute?” “Can my needs be met while I serve the task needs of the team?”

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4.3.1 TEAM DEVELOPMENT PROCESS 99

In the forming stage, people begin to identify with other members and with the team itself. Team members are concerned about getting acquainted, establishing interpersonal relationships, discovering what is considered acceptable behavior, and learning how others perceive the team’s task. This may also be a time when some members rely on or become temporarily dependent on another member who appears powerful or especially knowledgeable. Such things as prior experience with team members in other contexts and individual impressions of organization philoso- phies, goals, and policies may also affect member relationships in new work teams.

Difficulties in the forming stage tend to be greater in more culturally and demographically diverse teams.

▲ In the storming stage of team development, tension often emerges between members over tasks and interpersonal concerns.

This is a period of high emotionality. Team members may experience periods of outright hostility and infighting. Coalitions or cliques may form around person- alities or interests. Subteams form around areas of agreement and disagreement involving group tasks or the manner of operations. Conflict may develop as indi- viduals compete to impose their preferences on others and to become influen- tial in the group’s status structure.

Important changes occur in the storming stage as task agendas become clar- ified and members begin to understand one another’s interpersonal styles. Here attention begins to shift toward obstacles that may stand in the way of task accomplishment.

Efforts are made to find ways to meet team goals while also satisfying individ- ual needs. Failure in the storming stage can be a lasting liability, whereas success in the storming stage can set a strong foundation for later team effectiveness.

▲ In the norming stage, members of the team begin to become coordinated as a working unit and tend to operate with shared rules of conduct.

Cooperation is an important theme for teams in the norming stage. The team feels a sense of leadership, with each member starting to play useful roles. Most interpersonal hostilities give way to a precarious balancing of forces as norming builds initial integration. Harmony is emphasized, but minority viewpoints may be discouraged.

In the norming stage, members are likely to develop initial feelings of closeness, a clearer division of labor, and a stronger sense of shared expectations. These devel- opments help protect the team from disintegration. At this stage, holding the team together may become even more important than successful task accomplishment.

▲ In the performing stage, team members are able to deal in creative ways with both complex tasks and interpersonal conflicts. The team operates with a clear and stable structure, and members are motivated by team goals.

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Teams in the performing stage are more mature, organized, and well function- ing. The primary challenges of teams in the performing stage is to continue refining the operations and relationships essential to working together as an integrated unit. Such teams need to remain coordinated with the larger organi- zation and adapt successfully to changing conditions over time.

▲ The adjourning stage is the final stage of team development, and is one in which team members prepare to disband.

It is especially common for temporary groups that operate in the form of com- mittees, task forces, and projects to have an adjourning stage. Ideally, the team disbands with a sense that important goals have been accomplished. Members are acknowledged for their contributions and the group’s overall success.

The adjourning stage may be an emotional time. For members who have worked together intensely for a period of time, breaking up the close relationships may be painful. The ideal is for a team to disband with members feeling they want to work with one another again in the future, should the need or opportunity arise.

4.3.2 Establishing Norms and Cohesiveness

A norm is a behavior expected of team members.4 It is a rule or standard that guides their behavior. When violated, a norm may be enforced with reprimands and other sanctions. In the extreme, violation of a norm can result in a member being expelled from a team or socially ostracized by other members. Groups and teams typically operate under a host of norms—some clearly communicated, others unspoken but powerfully understood.

▲ The performance norm defines the level of work effort and performance that team members are expected to contribute.

This important norm can have positive or negative implications for team per- formance and organizational productivity. In general, work groups and teams with positive performance norms are more successful in accomplishing task objectives than are teams with negative performance norms.

Other important norms relate to such things as helpfulness, participation, timeliness, and innovation. Because a team’s norms are largely determined by the collective will of its members, a manager or designated leader may not be able to simply dictate which norms are acceptable. Instead, managers must help, sup- port, and encourage team members to develop positive norms. To help build positive norms, team leaders and managers should

▲ act as a role model; ▲ reinforce the desired behaviors with rewards; ▲ control results by performance reviews and regular feedback;

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4.3.2 ESTABLISHING NORMS AND COHESIVENESS 101

Figure 4-2

Productivity and the relationship between team cohesiveness and performance norms.

Low productivity Strong commitments to

harmful norms

Low to moderate productivity

Weak commitments to harmful norms

High productivity Strong commitments to

supportive norms

Moderate productivity Weak commitments to

supportive norms

Team cohesiveness

High

Low

Negative Positive

Performance norms

▲ train and orient new members to adopt desired behaviors; ▲ recruit and select new members who exhibit the desired behaviors; ▲ hold regular meetings to discuss progress and ways of improving; ▲ use team decision-making methods to reach agreement.5

Cohesiveness is the degree to which members are attracted to and moti- vated to remain part of a team. This determines the degree of conformity to norms. People in a highly cohesive team value their membership and strive to maintain positive relationships with other team members. They experience sat- isfaction from identifying and working with the team.

Look at Figure 4-2. When the performance norm of a team is positive and cohesion is high, a best-case scenario results. Competent team members work hard and reinforce one another’s task accomplishments while experiencing satis- faction with the team.

But when the performance norm is negative in a highly cohesive team, con- formity to the negative norm results in a worst-case scenario—low productivity and restricted work efforts. Between these two extremes are mixed situations of moderate to low productivity.

Managers and team leaders should build and maintain teams with both pos- itive performance norms and high cohesiveness. To help develop positive cohe- sion, managers should

▲ induce agreement on team goals; ▲ increase membership homogeneity;

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▲ increase interactions among members; ▲ decrease team size; ▲ introduce competition with other teams; ▲ reward team rather than individual results.

4.3.3 Taking Care of Task and Maintenance Needs

Two types of activities are essential if team members are to work well together over time.6

▲ Task activities contribute directly to the team’s performance purpose. ▲ Maintenance activities support the emotional life of the team as an

ongoing social system.

All team members share responsibility for both activities. In this sense, any member can help lead a team by taking actions that satisfy its task and maintenance needs. This concept of distributed leadership in teams is explained further in Figure 4-3.

Leading through task activities involves such behavior as initiating agendas, sharing information, and summarizing. Leading through maintenance activities involves such things as gatekeeping, encouraging others, and reducing tensions.

Both task and maintenance activities stand in distinct contrast to the dys- functional activities also described in the figure. Self-serving activities such as with- drawing and horsing around detract from, rather than enhance, team effectiveness.

4.3.4 Instituting Communication Networks

Figure 4-4 shows three interaction patterns and communication net- works that teams commonly use.7 As expected, the best teams use com-

F O R E X A M P L E

Performance Norms from NRC For more than 20 years, the for-profit research service National Research Corporation (www.nationalresearch.com) has utilized performance norms to evaluate more than 800 health plans and more than 1,300 hospitals across the United States to create its annually published Healthcare Market Guide. In fact, NCR was the first national reviewing organization to utilize perfor- mance norms as a way to measure and compare performance by health care providers. Based on its experience in performance measurement research, NRC served as technical advisor to the National Committee for Quality Assurance (www.ncqa.org) during the development of the HEDIS 3.0 Mem- ber Satisfaction Survey and to the Joint Commission on Accreditation of Healthcare Organizations (www.jcaho.org).

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4.3.4 INSTITUTING COMMUNICATION NETWORKS 103

munication networks in the right ways, at the right times, and for the right tasks.

▲ In a centralized communication network, sometimes called a wheel or chain structure, activities are coordinated and results pooled by a central point of control. Most communication flows back and forth between individual members and “the hub,” or center point. Centralized networks tend to work best on simple tasks that require little creativity, informa- tion processing, and problem-solving.

▲ In a decentralized communication network, sometimes called the all- channel or star structure, all members communicate directly with one another. The decentralized networks work best for more complex tasks because these networks are able to support more intense interactions and information sharing.

▲ In a restricted communication network, subgroups within a team expe- rience issue-specific disagreements, such as a temporary debate over the best means to achieve a goal, and the result is a breach in communica- tion. Communication between the subgroups is often limited and biased, with the result that problems can easily occur. When various factions become polarized, the subgroups often engage in contests and even antagonistic relations.

Figure 4-3

• Being aggressive • Blocking • Self-confessing • Seeking sympathy

Team leaders avoid disruptive activities

• Competing • Withdrawal • Horsing around • Seeking recognition

Team leaders provide maintenance activities

• Gatekeeping • Encouraging

• Following • Harmonizing • Reducing tension

Distributed leadership roles in teams

Team leaders provide task activities

• Initiating • Information sharing • Summarizing

• Elaborating • Opinion giving

Distributed leadership helps a team meet its task and maintenance needs.

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Figure 4-4

Interaction patterns and communication networks in teams.

Pattern Diagram Characteristics

Restricted communication network

Counteracting Group

Interacting Group

Decentralized communication network

Coacting Group

Centralized communication network

Slow task accomplishment

High interdependency around a common task

Best at complex tasks

Independent individual efforts on behalf of common task

Best at simple tasks

Subgroups in disagreement with one another

• Define norm, performance norm, cohesiveness, task activity, maintenance activity, and distributed leadership.

• Identify and define the five stages of team development.

• Compare the characteristics of centralized, decentralized, and restricted communication networks.

• Describe how positive and negative norms can affect teams.

• Compare and contrast task activities and maintenance activities.

S E L F - C H E C K

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4.4.1 BUILDING—AND REBUILDING—TEAMS 105

4.4 Enhancing Teams

Most health care managers first work within an established team—or at least an established team structure. The decisions of your management predecessor(s) have a significant impact on the team you work with, but you always have the oppor- tunity to evaluate and refine the group you’re responsible for and lead them toward your personal vision of a healthy, functional, dynamic, high-performing team.

4.4.1 Building—and Rebuilding—Teams

Even the most mature work team is likely to experience problems over time. When such difficulties arise, team-building activities, often led by the team leader or manager, can help.

Team building is a sequence of planned activities used to gather and ana- lyze information on how a team functions. Managers then strive to implement constructive changes to increase the team’s operating effectiveness.8 Most systematic approaches to team building follow the steps described in Figure 4-5. The cycle begins with the awareness that a problem may exist or may develop within the team. Team members then work together, gathering and analyzing data, so the problem is finally understood.

Figure 4-5

Collaboration and involvement in the team-building process.

Step 4:

Action planning

Step 6:

Evaluation

Step 1:

Problem awareness

Step 2:

Data gathering

Step 3:

Data analysis and

diagnosis

Step 5:

Action implementation

Team member active

collaboration and

involvement

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Action plans are made by members and collectively implemented. Results are evaluated in similar fashion by team members working together. Any difficulties or new problems that are discovered serve to recycle the team-building process.

The ultimate goal of team building is to create more and better teamwork among group members. This is accomplished as members work together to con- duct careful and collaborative assessments of the team’s inputs, processes, and results. It is also accomplished as they collectively decide to take action to resolve and/or prevent problems that interfere with team effectiveness.

4.4.2 Encouraging Strong Team Players

Strong health care team members possess eight critical characteristics. As a man- ager or team leader, you should identify these characteristics (and the work-related behaviors associated with them), as well as encourage your team members to fur- ther develop.

▲ Drive: Each team member must have a certain amount of drive to attain individual and group goals. He does not need to be jump-started every morning or at the beginning of each shift. The drive toward performing strongly, learning and growing every day, being a motivator for others purely by example, expending energy and applying on-the-job initiative all characterize a stellar team player.

▲ Confidence: All team members should feel self-assured about their tech- nical abilities, as well as their resilience to perform under changing and critical circumstances. A strong player usually radiates confidence about departmental goals and everyday work activities. Patients and fellow workers pick up on this attitude and therefore feel comforted by this individual’s presence. They have the conviction that the job will get done and that when the going gets tough—an everyday occurrence in health care—the job will still get done.

▲ Discipline: Good workers are disciplined. They steadily make exact determi- nations and seek all facts necessary to making a decision. They get the job done correctly the first time and do not cause little problems that can add up to big problems. Good team members know intrinsically what has to be done and how to do it; that is, they set their own objectives and determine a course of action for achieving those objectives with excellence. Their sense of discipline is self-perpetuating throughout the entire department.

▲ Desire: A hunger to get better all the time is a constant motivator for team players. An individual with desire wants to help others and has a strong need to learn and grow on the job. Team members who possess desire do not need to be “hand-fed” with the promise of educational opportunities, promotions, or raises; rather, they seek out learning opportunities every day and are perpetually fueled by this desire to become better at their

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jobs and stronger in their daily contributions to the organization, team, and patient’s health.

▲ Dedication: Strong team members emanate dedication to a common goal for all health care workers—to provide stellar health care to all patients. They are equally dedicated to all team goals, departmental objectives, and one another in providing help, guidance, and technical assistance.

▲ Acumen: Every health care employee has a certain amount of technical acumen and expertise that they bring to the job. Whether that expertise lies in conducting a good lab assay, filling a prescription correctly, or cleaning a patient’s room quickly and efficiently, strong team members bring their unique, essential ability to the workplace every day.

▲ Loyalty: Team loyalty is critical in any workplace, especially in the health care industry. Each team member’s first loyalty, of course, is to the health care institution and its mission of providing care to its patient community. The second loyalty is to the department manager or team leader and is demonstrated by following set objectives, providing feed- back, and accomplishing team goals. The third loyalty is to the work group, to act as a positive participant who contributes to group goals. Fourth, the team members maintain a dedication to escalating their indi- vidual strong performance and progressive development on the job.

▲ Development: Each team member should desire to grow and develop on the job. This development expands beyond the parameters of basic tech- nical growth: Strong health care team members seek to learn more about the health care industry and understand the changing dimensions of the business. They know how to interpret the impact of change in the social environment and their communities, and they understand how these changes may affect their particular duties and the institution’s mission.

An often-overlooked aspect of team member development is interpersonal skills. A strong team member seeks to learn more about others’ personalities and professional preferences, relative to job performance. Developing interpersonal skills contributes significantly to an ever-expanding knowledge base from which an employee can grow, prosper, and continuously improve the quantity and qual- ity of their work contribution.

4.4.3 Maintaining and Reinforcing a Strong Team Orientation

Just as establishing a team orientation is not an exact science, keeping a work group committed to and engaged with a team orientation for many months— and perhaps years—is a day-to-day challenge that health care managers face.

Numerous strategies are available to help health care managers constantly reinforce a team concept within their department. Many hospitals or health care organizations have ongoing training programs to help managers continually

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refine how they motivate their teams and improve efficiency. The following are some of the most useful strategies:

▲ Point team members back to established, common objectives. All team members need to know the objectives and mission of the depart- ment as well as the organization. Remember that management involves asking the right questions. Question your staff about their perceptions as to the main objectives of the department and the common goals toward which individuals should be striving as members of the team.

▲ Recognize individual talents and ask for suggestions on how each individual’s talent can be applied to the team. Be a manager who asks team members for individual, unique suggestions and recommendations. The best source for learning how to create synergism between individual talent and group contribution is the individual department member.

▲ Maintain two-way feedback. In addition to providing feedback to your staff on ways they can become better team members, ask team members their opinions on your management style within the team and on the way that the team is progressing toward stated goals.

▲ Identify changing dynamics or factors affecting your department as proactively as possible. While good teams have the ability to handle change, aware managers make the process of responding to change less painful. Again, elicit ideas from your staff about what is changing relative to their jobs and, more important, how they can best prepare to handle that change successfully.

▲ Be unafraid to reassign. A team’s ability to bounce back from adversity is a hallmark of success. As a health care manager, you may have to reas- sign individuals occasionally to help team members who require extra assistance. Rely on veterans and stronger players to provide assistance. Reassigning not only helps a team achieve objectives, but it can increase team allegiance and individual motivation.

▲ Provide opportunities to grow, learn, and develop. Present as many in- service exercises as possible, and use the expertise within your department to present new ideas to the group. One strategy in this area is to have show-and-tell sessions in which team members explain to each other new principles, strategies, and methods of accomplishing technology-based ends.

▲ Establish new goals. Hold meetings at least once a quarter (or even monthly) to set new goals for the department for continuous improve- ment. Review past goals and accomplishments, seek explanations for why goals were either achieved or not achieved, and seek input from the group concerning their perceptions as to the achievement of these goals. Make this a group process to ensure credibility as well as maximum input and opportunities for shared knowledge.

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4.4.4 ACCEPTING THE CHALLENGE OF TEAM LEADERSHIP 109

4.4.4 Accepting the Challenge of Team Leadership

Harnessing the full potential of teams in today’s health care organizations involves special leadership challenges. High-performing teams generally share common characteristics, including a clear goal, a task-driven and results-oriented struc- ture, competent and committed members who work hard, a collaborative cli- mate, high standards of excellence, external support and recognition, and strong and principled leadership.9

This last characteristic, the need for strong and principled leadership, may be the key to them all. Outstanding teams are built with the efforts of strong and principled leadership. The best team leaders

▲ establish a clear vision of the future. This vision serves as a goal that inspires hard work and the quest for performance excellence. It creates a sense of shared purpose;

▲ help to create change. They are dissatisfied with the status quo, influ- ence team members toward similar dissatisfaction, and infuse the team with the motivation to change in order to become better;

▲ unleash talent. They make sure the team is staffed with members who have the right skills and abilities. And they make sure these people are highly motivated to use their talents to achieve the group’s performance objectives.

F O R E X A M P L E

The Delphi Technique The Delphi technique, refined and promoted by consultant and meeting facilitator Bruce Withrow (www.facilitators.com), puts team members in charge of the group’s future goals and direction. The Delphi technique assumes that team members are experts on their workplace functions and as such can provide better forecasts than upper management or outside con- sulting gurus. The technique focuses on three phases. During the first phase, a leader asks the team to individually forecast a specific goal for the team (for example, how the team will improve the results of customer feedback surveys by 10% in the next year). The manager then compiles and sum- marizes the forecasts. In phase two, team members individually evaluate the summarized list of forecasts, critique forecasts, and each prepares a revised forecast. In the third and final phase, the team meets face-to-face and dis- cusses only revised forecasts. Through discussion and voting, the team develops a unified revised forecast, which it can present to management and use as a planning and goal-setting tool for the next year.

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Clearly, you don’t get a high-performing team by just bringing a group of peo- ple together and giving them a shared name or title. Leaders of high-performance teams create supportive climates in which team members know what to expect from the leader and each other, and know what the leader expects from them. The best team leaders empower team members. By personal example, they demonstrate the importance of setting aside self-interests to support the team’s goals. And they use team building on a relatively continuous basis, viewing it as an ongoing leadership responsibility.

• Identify and define team building and interpersonal skills.

• Cite the eight characteristics of strong individuals within a team.

• Discuss strategies for further enhancing and developing high- functioning teams.

• Describe essential traits for leading a team.

S E L F - C H E C K

4.5 Making Decisions in Teams

Decision making is one of the most important group processes, and decisions in teams can be made in several different ways. Edgar Schein, a respected scholar and consultant, notes that teams make decisions by at least six meth- ods: lack of response, authority rule, minority rule, majority rule, consensus, and unanimity.10

▲ In decision by lack of response, one idea after another is suggested without any discussion taking place. When the team finally accepts an idea, all others have been bypassed and discarded by simple lack of response rather than by critical evaluation.

▲ In decision by authority rule, the leader, manager, committee head, or some other authority figure makes a decision for the team. This can be done with or without discussion and is very time efficient. Whether the decision is a good one or a bad one, however, depends on whether the authority figure has the necessary information and on how well other team members accept this approach.

▲ In decision by minority rule, two or three people are able to dominate or “railroad” the team into making a mutually agreeable decision. This is often done by providing a suggestion and then forcing quick agreement

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by challenging the team with such statements as “Does anyone object? Let’s go ahead, then.”

▲ In decision by majority rule, formal voting may take place, or members may be polled to find the majority viewpoint. Majority rule is perhaps the most common way teams make decisions, especially when early signs of disagreement arise. Although this method parallels the democratic political system, it is often used without awareness of its potential prob- lems. The very process of voting can create coalitions; that is, some peo- ple will be “winners” and others will be “losers” when the final vote is tallied. Those in the minority—the “losers”—may feel left out or discarded without having had a fair say. They may be unenthusiastic about implementing the decision of the “majority,” and lingering resent- ments may impair team effectiveness in the future.

▲ In decision by consensus, discussion leads to one alternative being favored by most members and the other members agreeing to support it. When a consensus is reached, even those who may have opposed the chosen course of action know that they have been heard and have had an opportunity to influence the decision outcome. Consensus, therefore, does not require unanimity. But it does require that team members be able to argue, engage in reasonable conflict, and yet still get along with and respect one another.11 And it requires that there be the opportunity for any dissenting members to feel they have been able to speak—and that they have been listened to.

▲ In decision by unanimity, all team members agree on the course of action to be taken. While decision by unanimity may sound like the ideal state of affairs and method for decision making in teams, it is also extremely difficult to attain in actual practice. One of the reasons that teams sometimes turn to authority decisions, majority voting, or even minority decisions, in fact, is the difficulty of managing the team process to achieve consensus or unanimity.

The best teams don’t limit themselves to just one decision-making method. Instead, they change methods to best fit the problems at hand. An important team leadership skill for managers is helping a team choose the most appropri- ate decision method—one that provides for a timely and quality decision to which the members are highly committed.12

4.5.1 Assets and Liabilities of Team Decisions

In order to manage teams effectively, team leaders must understand both the potential assets and potential liabilities of team-based decisions.13

Team decisions are highly desirable whenever time and other circumstances permit. They bring greater amounts of information, knowledge, and expertise to

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bear on problems. They expand the number of action alternatives that are exam- ined, and they help to avoid tunnel vision and consideration of only limited options. Team decisions increase the understanding and acceptance of outcomes by members. And, importantly, they increase the commitments of members to work hard to implement final plans.

The potential disadvantages of team decision making trace largely to possi- ble difficulties in group process. In a team decision, there may be social pres- sure to conform. Individual members may feel intimidated or compelled to go along with the apparent wishes of others. There may be minority domination, where some members feel forced or “railroaded” to accept a decision advocated by one vocal individual or small coalition. Also, the time required to make team decisions can sometimes be a disadvantage. As more people are involved in the dialogue and discussion, decision making takes longer. This added time may be costly, even prohibitively so, in some circumstances.

4.5.2 Avoiding Groupthink

Among the risks of team decision making is a phenomenon called groupthink, the tendency for highly cohesive groups to lose their critical evaluative capabil- ities.14 Members of very cohesive teams may publicly agree with actual or suggested courses of action while privately having serious doubts about them. Strong feelings of team loyalty can make it hard for members to criticize and evaluate one another’s ideas and suggestions. Desires to hold the team together and avoid disagreements may result in poor decisions.

Symptoms that groupthink may be occurring include15

▲ having illusions of invulnerability: Members assume the team is too good for criticism or beyond attack;

▲ rationalizing unpleasant and disconfirming data: Members refuse to accept contradictory data or consider alternatives thoroughly;

▲ believing in inherent group morality: Members act as though the group is inherently right and above reproach;

▲ stereotyping competitors as weak, evil, and stupid: Members refuse to look realistically at other groups;

▲ pressuring others to conform to group wishes: Members refuse to tol- erate anyone who suggests the team may be wrong;

▲ self-censorship by members: Members refuse to communicate personal concerns to the whole team;

▲ having illusions of unanimity: Members accept consensus prematurely, without testing its completeness;

▲ mind guarding: Members protect the team from hearing disturbing ideas or outside viewpoints.

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4.5.2 AVOIDING GROUPTHINK 113

Team leaders and managers can help identify and minimize the effects of groupthink by keeping the following tips in mind:

▲ Assign the role of critical evaluator to each team member; encourage a sharing of viewpoints.

▲ Don’t, as a leader, seem partial to one course of action; do absent your- self from meetings at times to allow free discussion.

▲ Create subteams to work on the same problems and then share their proposed solutions.

▲ Have team members discuss issues with outsiders and report back on their reactions.

▲ Invite outside experts to observe team activities and react to team processes and decisions.

F O R E X A M P L E

Good Group Decision Making at FutureThink What will the delivery of care look like in the year 2013? Rather than blindly follow a vision handed down by upper management, members of the Ohio Hospital Association (OHA) and the Ohio Organization of Nurse Executives (OONE) decided to collaborate and establish as an independent advisory team known as FutureThink. Over the course of 12 strategic brainstorm- ing sessions, the team evaluated best practices of team-based organiza- tional structures throughout Ohio (as well as technological innovations and preventive care measures) and through consensus building developed an integrated model for delivering health care to Ohioans now—and well into the future. You can review FutureThink’s proposed solution at www. futurethink.org.

• Identify and define groupthink and its associated symptoms.

• Describe the six types of decision-making processes for groups.

• Discuss pros and cons of making group decisions.

• List strategies for avoiding negative aspects of group decision making.

S E L F - C H E C K

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114 MANAGING TEAMS

SUMMARY Working with and developing teams is a major daily responsibility for most of today’s health care managers. Knowing the characteristics of successful teams helps managers identify weaknesses, improve interactions, and further develop their own work teams. Clearly defined job roles, goals, and communication pro- cedures—along with mutual respect—are all critical components for effective teams. Although teams naturally change over time, established expectations, responsibilities, and procedures provide long-term structure and benefit. Strong team leaders must develop both individual members as well as the overall team orientation. Making decisions as a team is a challenging but effective way to enhance the overall effectiveness of a health care organization.

KEY TERMS Adjourning stage The final stage of team development, and is one

in which team members prepare to disband.

Cohesiveness The degree to which members are motivated to remain part of a team.

Distributed leadership A team in which all members share responsibil- ity for both task and maintenance activities.

Forming stage The first stage of team development; involves the initial entry of individual members into a team.

Group process The way the members of a team actually work together.

Groupthink The tendency for highly cohesive groups to lose their critical evaluative capabilities.

Heterogeneous team A team comprised of a more diverse array of members.

Homogeneous team A team comprised of same or similar kinds of members.

Interpersonal skills Ability to learn more about others’ personalities and professional preferences, relative to job per- formance.

Maintenance activities Work activities that support the emotional life of the team as an ongoing social system.

Norm A behavior expected of team members.

Norming stage The third stage of team development; mem- bers begin to become coordinated as a work-

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KEY TERMS 115

ing unit and tend to operate with shared rules of conduct.

Performance norm Any behavior expectation that defines the level of work that team members are expected to contribute.

Performing stage The fourth stage of team development; the team operates with a clear and stable structure, and members are motivated by team goals.

Product outputs The finished good or service that a team produces.

Resource inputs The people and ideas that teams use to create outputs.

Role definition Helps individuals identify with their work role and with the overall mission of their work group.

Storming stage The second stage of team development; tension often emerges between members over tasks and interpersonal concerns.

Task activities Work activities that contribute directly to the team’s performance purpose.

Task performance The act of getting a job done.

Team A small group of people with complementary skills who work together to achieve a shared purpose and hold themselves mutually account- able for its accomplishment.

Team building A sequence of planned activities used to gather and analyze information on how a team functions.

Team diversity The different values, personalities, experiences, demographics, and cultures among the mem- bers of a team.

Teamwork The process of people working together to ac- complish goals.

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116 MANAGING TEAMS

ASSESS YOUR UNDERSTANDING Go to www.wiley.com/college/Lombardi to evaluate your knowledge of the basics of team management. Measure your learning by comparing pretest and post-test results.

Summary Questions

1. Teams transform resource inputs into product outputs. Which of the follow- ing is not an example of a product output from a health care organization? (a) A medicated heart catheter (b) A bill detailing health insurance claims (c) A malignant mole (d) An office visit

2. A group process is the way teams actually work together as they transform inputs into outputs. Patient charges are an example of a group process. True or false?

3. Strong teams are usually progressive, which means the team members can join or leave the team with considerable freedom and frequency. True or false?

4. If a team member is not committed to a team objective or goal, a rea- sonable initial managerial response might be to discuss the objective and expectation with the worker in a one-on-one setting. True or false?

5. All of the following methods are forms of open communication, except (a) sticky notes with constructive feedback placed on a team member’s

work station. (b) a biweekly team meeting. (c) a 10-minute status roundup at the start of a shift. (d) a work-related chat by a team member by the coffee machine.

6. Which of the following is an appropriate question to ask after a team experiences adversity? (a) How could the negative situation have been avoided? (b) What have we learned from this situation? (c) What went wrong? (d) All of the above

7. During the norming stage of team development, tensions often emerge between members over tasks and interpersonal concerns. True or false?

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8. Rather than dictate performance norms to a team, managers should do all the following except (a) hold regular team meetings to discuss progress and ways of improving. (b) give individual team members quarterly minireports on whether

they’re meeting norms. (c) act as a role model. (d) recruit and select new team members who exhibit desired behaviors.

9. The strongest team combines positive performance norms with low cohe- siveness. True or false?

10. The ultimate goal of team building is to (a) establish close interpersonal connections between team members. (b) encourage open dialogue between leaders and team members. (c) introduce new tools and technique for working together. (d) create more and better teamwork among group members.

11. Technical acumen is job expertise that relies on scientific understanding and the ability to use technology effectively in the workplace. True or false?

12. The best team leaders (a) establish a clear vision of the future. (b) help to create change. (c) unleash others’ talents. (d) All of the above

13. Upper management reviews three possible staffing plans and selects the plan your team will follow for the next year. What sort of decision mak- ing is happening here? (a) Decision by minority rule (b) Decision by priority rule (c) Decision by authority rule (d) None of the above

14. When a team protects itself from information, outside viewpoints, or disturbing ideas, the team is engaging in mind guarding. True or false?

15. Managers can avoid the effects of groupthink on their teams by assuming the role of critical evaluator and carefully weighing each member’s view- point. True or false?

Review Questions

1. What are the three main compositional factors that affect team effectiveness? 2. Strong teams are typically achievement-oriented. Define achievement-oriented. 3. Contrast homogeneous and heterogeneous teams.

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4. Why is role definition important to the overall health of a team? 5. What are Lombardi’s three most common team personalities? 6. What are some common forms of open communication between manager

and team members? 7. During what development stage does a team deal in creative, effective

ways with complex tasks and interpersonal conflicts, guided by stable team structure and clear team goals?

8. Distributed leadership allows all team members to share responsibility for both task and maintenance activities. What are some examples of task and maintenance activities?

9. Which type of communication network features subgroups with limited communication opportunities?

10. Loyalty is a characteristic of a strong team player. What are the four key loyalties?

11. Team goals should be established by the group rather than the leader or manger. Why?

12. A team leader who is dissatisfied with the status quo and motivates his or her team to change in order to become better is exemplifying which characteristic of a strong leader?

13. A team that requires all members to agree on the course of action taken is using which kind of decision-making process?

14. Decision-making as a group can be effective when the process is utilized at the right time. When are team decisions most effective?

15. What are signs that your team may not be thinking clearly about problems—and possibly engaging in groupthink?

Applying This Chapter

1. The team of nurses you manage is consistently not meeting its team goals because of a lack of motivation. As the manager, you can motivate team members positively and negatively to achieve goals. What might be an example of a positive and negative motivation?

2. Your team gathers for two short status meetings every week. During meetings, team members present their problems and questions and other team members offer suggestions. As team leader, you sometimes offer rec- ommendations as well, but you generally let the team come to its own solutions. What team-based strengths is your team exhibiting?

3. As team leader, you set the team rule that all patient charts must be up-to-date and submitted to you by noon each workday. Members who don’t comply receive a note in their ongoing performance log. What sort of norm are you setting?

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4. You manage a treatment team at a daytime hospitalization program for adults with severe mental illnesses. Your treatment team, which includes a consulting psychiatrist, a nurse, a social worker, a physical therapist, and several aides, works directly with 20 patients, facilitating socialization activities for clients. Which of the three most common types of communi- cation networks—centralized, decentralized, or restricted—would be most appropriate in this situation?

5. During last week’s team meeting, several team members complained openly about having to complete a new, highly detailed form to request the services of a social worker. The unhappy workers claimed that “paperwork is a waste of time and not in their job descriptions.” Which of the strategies for maintaining and reinforcing a strong team orientation might be useful in dealing with these team members?

6. You would like all nurses on your staff, regardless of their professional degree, to do four to six hours of preoperation counseling each week. Most RNs on the team feel that they’re too busy to spend time in preop- eration counseling. What sort of group decision-making process could you initiate to achieve your goal?

7. During weekly staff meetings for the communication and education department at a large teaching hospital, all staff members recommend potential stories for the hospital’s monthly newsletter. One staffer recom- mended devoting an entire issue of the newsletter to diabetes-related programs at the hospital; another staff member countered that the newsletter should focus on something “exciting and controversial like stem-cell research.” Although a diabetes-focus was more appropriate for the newsletter’s intended audience (urban, largely African American, and elderly), the staffer in favor of stem-cell research persuaded the director of communications that the next newsletter had to cover stem-cell research. On their joint recommendation, the diabetes-focused newsletter was shelved for a later date. What decision-making process is at work here?

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YOU TRY IT

Your Dream Team? Ideally, successful teams exhibit each of the seven qual- ities listed in section 4.1.2. However, in the real world, each team has different strengths and weaknesses. Also, as a manager, you have limited time to encourage and develop the seven qualities. As the manager of a communications team that produces a monthly newslet- ter to patients and family members served by a national conglomeration of nursing care facilities, which three of the seven qualities would you most want to encourage and develop within your team member?

Catching a Star Player The patient-care team you lead at a nursing care facility includes Shirley, a physical therapist with more than 20 years PT experience and nearly 12 years working at your facility. Everyone has considerable respect for Shirley, but she can sometimes be very outspoken in team meetings, convincing other team members to agree with her point of view or complaint. What approach can you take to maximize Shirley’s contributions to the team?

Forming Activities for a New Team You’re the leader of a newly established cross-fun- ctional team that combines social workers, case man- agers, custom-service representatives, occupational therapists, and physical therapists at a large, suburban hospital. In the past, each functional group has been very isolating, developing its own culture and proce- dures. Your new cross-functional team has the goal of sharing information and resources more quickly and ef- ficiently, providing improved care for patients. What are some “forming activities” that would be appropriate for your new team?

Team Building as Problem-Solving Your team of social workers and case managers has seen a significant increase in cases of pediatric AIDS over the last 5 years, despite extensive public educa- tion about preventing the disease. Following the six- step process depicted in Figure 4-5, how might your team utilize a formalized team-building process to col- laborate effectively and possibly solve the problem?

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