There is 6 articles, I need a summary for each one 1 page duple spaced for each artical 2 open questions each article (any question fit for this article)

BEST PRACTICE

Speeding Up Team Learning

The most successful teams adapt quickly to new ways of

working. Now, a study of 16 cardiac surgery teams offers

intriguing insights on how to make that happen.

CARDIAC SURGERY is One of medi-cine's modem miracles. In an oper- ating room no larger than many house- hold kitchens, a patient is rendered functionally dead-the heart no longer beating, the lungs no longer breath- ing-while a surgical team repairs or replaces damaged arteries or valves, A week later, the patient walks out of the hospital.

The miracle is a testament to medical technology-but also to incredible team- work. A cardiac surgical team includes an array of specialists who need to work in close cooperation for the operation to succeed. A single error, miscommunica- tion, or slow response can have disas- trous consequences. In other words, sur- gical teams are not all that different from the cross-functional teams that in recent years have become crucial to business success.

We studied how surgical teams at 16 major medical centers implemented a difficult new procedure for performing

by Amy Edmondson, Richard Bohmer,

and Gary Pisano

cardiac surgery. What we found sheds light on one of the key determinants of team performance: a team's ability to adapt to a new way of working. In cor- porate settings, teams frequently have to leam new technologies or processes that are designed to improve perfor- mance. Often, however, things get worse - sometimes for a long time - be- fore they get better. Team members may find it hard to break out of deeply in- grained routines. Or they may struggle to adjust to new roles and communica- tion requirements.

When a product development team adopts computer-aided design tools, for example, designers, test engineers, pro- cess engineers, and even marketers have to learn the technology. But they also have to create and become comfortable with entirely new relationships, working

collaboratively instead of making con- tributions individually and then hand- ing pieces of the project off to the next person.

Most teams become proficient at new tasks or processes over time. But time is a luxury few teams-or companies- have. If you move too slowly, you may find that competitors are reaping the benefits of a new technology while you're still in the leaming stages or that an even newer technology has super- seded the one you're finally integrating into your work. The challenge of team management these days is not simply to execute existing processes efficiently. It's to implement new processes-as quickly as possible.

Whether in a hospital or an office park, getting a team up to speed isn't easy. As a surgeon on one of the teams

OCTOBER 2001 125

BEST PRACTICE • Speeding Up Team Learning

we studied wryly put it, the new surgical procedure represented "a transfer of pain-from the patient to the surgeon." But if that came as no surprise, we were surprised at some of the things that helped, or didn't help, certain teams learn faster than others. An overriding lesson was that the most successful teams had leaders who actively man- aged their teams' learning efforts. That finding is likely to pose a challenge in many areas of business where, as In med- icine, team leaders are chosen more for their technical expertise than for their management skills.

Teamwork in Operation A conventional cardiac operation, which typically lasts two to four hours, unites four professions and a battery of spe- cialized equipment in a carefully chore- ographed routine. The surgeon and the surgeon's assistant are supported by a scrub nurse, a cardiac anesthesiologist, and a perfusionist-a technician who runs the bypass machine that takes over the functions of the heart and lungs. A team in a typical cardiac surgery de- partment performs hundreds of open- heart operations a year. Consequently, the well-defined sequence of individual tasks that constitute an operation be- comes so routine that team members often don't need words to signal the start of a new stage in the procedure; a mere look is enough.

Open-heart surgery has saved count- less lives, but its invasiveness-the sur- geon must cut open the patient's chest and split the breastbone - has meant a painful and lengthy recovery. Recently, however, a new technology has enabled surgical teams to perform "minimally invasive cardiac surgery" in which the surgeon works through a relatively small incision between the ribs. The pro- cedure, introduced in hospitals in the

Amy Edmondson, Richard Bohmer, and

Gary Pisano are faculty members at Har-

vard Business School in Boston. Edmond-

son is an associate professor; Bohmer, a

physician, is an assistant professor; and

Pisano is the Harry E. Figgiejr., Professor

of Business Administration.

late 1990s, held out the promise of a much shorter and more pleasant recov- ery for thousands of patients - and a po- tential competitive advantage for the hospitals that adopted it. (For a descrip- tion of the procedure, see the sidebar "A New Way to Mend a Broken Heart.")

Although the scene and players re- main the same, the new technology sig- nificantly alters the nature of the surgi-

cal team's work. Obviously, individual team members need to leam new tasks. The surgeon, with the heart no longer laid out in full view, has to operate with- out the visual and tactile cues that typ- ically guide this painstaking work. The anesthesiologist has to use ultrasound imaging equipment, never before a part of cardiac operations. But the mastery of new tasks isn't the only challenge. In the

The challenge of team

management these

days is to implement

new processes - as

quickly as possible.

126 HARVARD BUSINESS REVIEW

Speeding Up Team Learning • BEST PRACTICE

A New Way to Mend a Broken Heart

The cardiac surgery technology we studied is a modification of conventional cardiac surgery, but it requires the surgical team to take a radi- cai new approach to working together.

The standard cardiac operation has three major phases: opening the chest, stopping the heart, and piacing the patient on a heart-lung bypass machine; repairing or replacing dam- aged coronary arteries or valves; and weaning the patient from bypass and closing the chest wound. The minimally invasive technology, adopted by more than lOO hospitals beginning in the late 1990S, provides an alternative way to gain access to the heart. Instead of cutting through the breastbone, the surgeon uses spe- cial equipment to work on the heart through an incision between the ribs.

The small size of the incision changes open- heart surgery in several ways. For one thing, the surgeon has to operate in a severely re- stricted space. For another, the tubes that con- nect the patient to the bypass machine must be threaded through an artery and vein in the groin instead of being inserted directly into the heart through the incision. And a tiny catheter with a deflated balloon must be threaded into the aorta, the body's main artery, and the bal- loon inflated to act as an internal clamp. In conventional cardiac surgery, the aorta is

blocked off with external clamps inserted into the open chest

The placement of the internal clamp is an example of the greater coordination among team members required by the new procedure. Using ultrasound, the anesthesiologist works carefully with the surgeon to monitor the path of the balloon as it is inserted, because the surgeon can't see or feel the catheter. Correct placement is crucial, and the tolerances on bal- loon location are extremely low. Once the balloon clamp is in position, team members, including the nurse and the perfusionist, must monitor it to be sure it stays in place.

"The pressures have to be monitored on the balloon constantly,"said one nurse we interviewed.'The communication with perfu- sion is critical. When I read the training man- ual, I couldn't believe it. It was so different from standard cases."

Perhaps it isn't surprising that adoption of the procedure-by all of the teams-took longer than expected. The company that developed the technology estimated that it would take surgical teams about eight operations before they were able to perform the new procedure in the same amount of time as conventional surgery. But for even the fastest-learning teams in our study, the number was closer to 40.

new procedure, a number of familiar tasks occur in a different sequence, re- quiring a team to unleam the old rou- tine before learning the new one.

More subtly, the new technology re- quires greater interdependence and communication among team members. For example, much of the information about the patient's heart that the sur- geon traditionally gleaned through sight and touch is now delivered via digital readouts and ultrasound images dis- played on monitors out of his or her field of vision. Thus the surgeon must rely on team members for essential information, disrupting not only the team's routine but also the surgeon's role as order giver in the operating room's tightly structured hierarchy.

Isolating the "Fast Factors"

The 16 teams we studied were among those that adopted this demanding new procedure. Given its complexity, they exercised great care in carrying it out, checking and double-checking every step. As a result, the rate of deaths and serious complications was no higher than for conventional procedures. But the teams were taking too long. At every hospital we studied, operations using the new technology initially took two to three times longer than conventional open-heart procedures.

Time is important in cardiac surgery. Long operations put patients at risk and strain operating teams, both mentally and physically. And with operating-

rtx>m time costly and profit margins for cardiac surgery relatively high, cash- strapped hospitals want to maximize the number of operations cardiac teams perform daily. •

As teams at the various hospitals struggled with the new procedure, they did get faster. This underscored one of the key tenets of leaming, that the more you do something, the better you get at it. But a striking fact emerged from our research: The pace of improvement dif- fered dramatically from team to team. Our goal was to find out what allowed certain teams to extract disproportion- ate amounts of learning from each in- crement of experience and thereby leam more quickly than their counterparts at other hospitals.

OCTOBER 2001 127

BEST PRACTICE • Speeding Up Team Learning

A Tale of Two Hospitals

The leader of the team implementing the minimally Invasive surgical procedure at Chelsea Hospital was a renowned cardiac surgeon who had significant experi- ence with the new technology. Despite that apparent advantage, his team learned the new procedure more slowly than the teams at many other hospitals, including Mountain Medical Center, where the team leader was a relativelyjunior surgeon with an interest in trying new techniques, Why?

The New Technology as a Plug-in Component Chelsea Hospital (the names of the hospitals are pseudo- nyms) is an urban academic medical center that at the timeofourstudy had just hired a newchief of cardiac surgery. He seemed an ideal choice to lead the depart-

Procedure time

in hours 5 -

10

Number of procedures

Mastering the new technology proved unexpectedly difficult for al! team members. After almost 50 cases at Chelsea, the surgeon said: "It doesn't seem to be getting that much better. We're a little slicker, but not as slick as I would like to be."As at other sites, team members at Chelsea reported being amazed by the extent to which the procedure imposed a need for a new style and level of communication. But they were less confident than team members at other hospitals that they would be able to put these into practice.

The New Technology as a Team Innovation Project Mountain Medical Center is a respected community hos- pital serving a small city and the surrounding rural area. Although the cardiac surgery department didn't have a

history of undertaking major research or cardiac surgical innovation, it had recently hired a young surgeon who took an interest in the new procedure. More than any of the team leaders at other hospitals, this surgeon recog- nized that implementing the technology would require the team to adopt a very dif- ferent style. "The ability of the surgeon to allow himself to become a partner, not a

Mountain Medical Ceriter

Chelsea Hospital

Average of all hospitals in the study

Procedure times have been adjusted for the type of operation and the severity of the patient's illness. The curves are trend lines that reflect the average improvement ir\ procedure times.

ment's adoption of the new technology, as he had used the new procedure in numerous operations at another hospital (one that was not in our sample). Administrators at Chelsea supported the surgeon's request to invest in the new technology and agreed to send a team to the supplier company's formal training program.

The surgeon, however, played no role in selecting the team,which was assembled according to seniority. He also didn't participate in the team's dry run prior to the first case. He later explained that he didn't see the tech- nique as particularly challenging, having experimented for years with placing a balloon in the aorta. Conse- quently, he explained,"it was not a matter of training my- self It was a matter of training the team." Such training, though, wouldn't require a change in his style of commu- nicating with the team, he said: "Once I get the team set up, I never look up [from the operating field], It's they who have to make sure that everything is flowing."

dictator, is critical," he said. "For example, you really do have to change what you're doing [during an operation]

based on a suggestion from someone else on the team. This is a complete restructuring of the [operating room] and how it works,"

Team members, who were picked by the surgeon based on their experience working together, responded enthusi- astically to his approach. One noted that the "hierarchy [has]changed,"creating a "free and open environment with input from everybody." Said another: "I'm so excited about [the new procedure]. It has been a model, notjust for this hospital but for cardiac surgery. It is about what a groupof people can do," He explained that the team got better because "the surgeon said,'Hey, you guys have got to make this thing work.'That's a great motivator."

In the end, despite the team leader's modest reputa- tion and the hospital's limited experience in implement- ing new cardiac procedures. Mountain Medical was one ofthe two hospitals in our study that learned the new technology most quickly.

128 HARVARD BUSINESS REVIEW

Speeding Up Team Learning • BEST PRACTICE

The adoption of the new technology provided an ideal laboratory for rigor- ously studying how teams learn and why some learn faster than others. We collected detailed data on 660 patients who underwent minimally invasive car- diac surgery at the 16 medical centers, beginning with each team's first such operation. We also interviewed in per- son all staff members who were in- volved in adopting the technology. Then we used standard statistical methods to analyze how quickly procedure times fell with accumulated experience, ad- justing for variables that might influ- ence operating time, such as the type of operation and the patient's condition. Using these and other data, we also as- sessed the technology implementation effort at each hospital.

Because teams doing conventional cardiac surgery follow widely accepted protocols and use standardized tech- nology, the teams adopting the new pro- cedure started with a common set of practices and norms. They also received

the same three-day training program in the new technology. This consistency among teams in both their traditional work practices and their preparation for the new task helped us zero in on the "fast factors" that allowed some teams to adopt the technology relatively quickly.

Rethinking Conventionai Wisdom We were surprised by some of the fac- tors that turned out not to matter in how quickly teams learned. For instance, variations among the teams in educa- tional background and surgical experi- ence didn't necessarily have any impact on the steepness of the learning curve. (For a comparison of teams at two med- ical centers, see the sidebar "A Tale of T\vo Hospitals.")

We also turned up evidence that coun- tered several cherished notions about the ways organizations-and, by im- plication, teams-adopt new technolo- gies and processes. For one thing, high-

level management support for the min- imally invasive technology wasn't deci- sive in hospitals' success in implement- ing it. At some hospitals, implementation was unsuccessful despite strong vocal and financial support from senior offi- cials. At others, teams enjoyed tremen- dous success despite support that was ambivalent at best. For example, one surgeon initially had difficulty convinc- ing hospital administrators that the new procedure should be tried there; they saw it as a time-consuming dis- traction that might benefit surgeons but would further tax the overworked hospital staff. Even so, the surgeon's team became one of the more success- ful in our study.

The status of the surgeon who led the team also didn't seem to make a differ- ence. Conventional wisdom holds that a team charged with implementing a new technology or process needs a leader who has clout within the organization - someone who can "make things hap- pen" in support of the team's efforts.

BEST PRACTICE • Speeding Up Team Learning

But we saw situations in which depart- ment heads and world-renowned car- diac surgeons coirtdn't get their teams to adapt to the new operating routine. At other sites, relatively junior surgeons championed the new technology and, with little support from more senior colleagues, brought their teams quickly along the learning curve.

Finally, the debriefs, project audits, and after-action reports so often cited as key to learning weren't pivotal to the success or failure of the teams we studied. In fact, few surgical teams had time for regular, formal reviews of their work. At one hospital, sucb reviews were normally conducted at midnight over take-out Chinese food. Some research- oriented academic medical centers did aggregate performance data and ana- lyze the data retrospectively, but teams at these hospitals didn't necessarily im- prove at faster rates. Instead, as we will discuss, the successful teams engaged in real-time learning-analyzing and draw- ing lessons from the process while it was under way.

Creating a Learning Team We found that success in learning came down to the way teams were put to- gether and how they drew on their ex- periences - in other words, on tbe teams' design and management. Teams tbat leamed the new procedure most quickly shared three essential characteristics. Tbey were designed for learning; their leaders framed the challenge in such a way that team members were bighly motivated to learn; and the leaders' be- havior created an environment of psy- chological safety that fostered commu- nication and innovation.

Designing a Team for Learning. Team leaders often have considerable discretion in determining, tbrougb choice of members, the group's mix of skills and areas of expertise. The teams in our study had no such leeway-car- diac surgery requires a surgeon, an anes- thesiologist, a perfusionist, and a scrub nurse. But tbe leaders who capitalized on the opportunity to choose particu- lar individuals from tbose specialties reaped significant benefits.

At one extreme, the leaders-the sur- geons-took little initiative in cboosing team members. At one hospital,the staff members chosen for training in the pro- cedure were, essentially, those wbo hap- pened to be available the weekend of tbe training session.

In a few teams, however, selection was much more collaborative, and tbe choices were carefully weighed. An anestbesiology department bead, for instance, might get significant input from the cardiac surgeon before choos- ing an anesthesiologist. Selection was based not only on competence but also on sucb factors as the individual's abil- ity to work with others, willingjiess to deal witb new and ambiguous situa- tions, and confidence in offering sug- gestions to team members witb higber status.

Another critical aspect of team design was the degree to which substitutions were permitted. In conventional sur- gery, all members of the surgical de- partment are assumed to be equally capable of doing tbe work of their particular discipline, and team mem- bers within a discipline are readily sub- stituted for one anotber. It's logical to assume that training additional team members would allow for more cases to be performed using the new procedure, but we found that such flexibility bas a cost. Reductions in average procedure time (adjusted for patient complexity) were faster at hospitals that kept tbe original teams intact.

At one hospital where several addi- tional members of the nursing, anes- thesiology, and perfusion staff were trained in tbe new procedure sbortly after adoption, the makeup of the team changed with almost every operation. Again and again, teams bad to learn from scratch how to work together. After the tenth time, the surgeon de- manded a fixed team wbenever he per- formed tbe new prcKedure. Operations went more smoothly after that.

Framing the Challenge. When dis- cussing tbe new procedure with team members, the leaders of teams that suc- cessfully implemented the new tech- nology characterized adopting it as an

organizational challenge rather than a technical one. Tbey emphasized the im- portance of creating new ways of work- ing together over simply acquiring new individual skills. They made it clear that this reinvention of working relation- ships would require the contribution of every team member.

By all accounts, tbe difficulty of the new procedure makes cardiac surgery even more stressful than usual, at least initially. But many surgeons didn't ac- knowledge the higber level of stress or help their teams intemalize the ratio- nale for taking on tbis significant new challenge. Instead, tbey portrayed the technology as a plug-in component in an otherwise unchanged procedure. As one surgeon told us: "I don't see what's really new here. All the basic compo- nents of tbis technology bave been around for years." Tbis view led to frus- tration and resistance among team members. Another surgeon, who char- acterized the procedure as primarily a technical challenge for surgeons, was as- sisted by a nurse who, with grim humor, said sbe would rather slit ber wrists than do the new procedure one more time. Her attitude was shared by many we interviewed.

But that attitude wasn't universal. At si>me hospitals, staff members were ex- cited to be "part of something new" as one expressed it. A nurse reported that she felt honored to be a member of the team, in part because it was "exciting to see patients do so well." The leaders of teams with positive attitudes toward the cballenge explicitly acknowledged that the task was difficult and empha- sized the importance of eacb person's contribution. Tbe surgeon who talked of the transfer of pain from the patient to the surgical team belped his team by highlighting, witb light bumor,the frus- tration they all faced in this leaming cballenge.

Creating an Environment of Psy- chological Safety. Teams, even more tban individuals, learn througb trial and error. Because of the many interactions among members, it's very difficult for teams to perform tasks smoothly the first time, despite well-designed train-

130 HARVARD BUSINESS REVIEW

speeding Up Team Learning • BEST PRACTICE

ing programs and extensive individual preparation. The fastest-learning teams in our study tried different approacbes in an effort to shave time from the op- eration without endangering patients. Indeed, team members uniformly em- phasized the importance of experi- menting with new ways of doing things to improve team performance - even if some of the new ways turned out not to work.

As we have noted, this ieaming in ac- tion proved to be more effective than the after-action analysis so often touted as key to organizational leaming. Real- time learning occasionally yielded in- sights that might have been lost had a team member waited for a formal re- view session. During a procedure at one hospital, for instance, a nurse sponta- neously suggested solving a surgical problem with a long-discarded type of clamp affectionately known as the "iron intem."The use ofthe nearly forgotten medical device immediately became part of that team's permanent routine.

When individuals leam, the process of trial and error-propose something, try it, then accept or reject it-occurs in private. But on a team, people risk ap- pearing ignorant or incompetent when they suggest or try something new. This is particularly true in the case of tech- nology implementation, because new technologies often render many ofthe skills of current "experts" irrelevant. Neutralizing the fear of embarrassment is necessary in order to achieve the ro- bust back-and-forth communication among team members required for real- time leaming.

Teams whose members felt comfort- able making suggestions, trying things that might not work, pointing out po- tential problems, and admitting mis- takes were more successful in learning the new procedure. By contrast, when people felt uneasy acting this way, the leaming process was stifled.

Although the formal training for the new procedure emphasized the need for everyone on the team to speak up with

observations, concems, and questions while using the technology, such feed- back often didn't happen. One team member even reported being upbraided for pointing out what he believed to be a life-threatening situation. More typi- cal was the comment of one nurse: "If you observe st>mething that might be a problem, you are obligated to speak up, but you choose your time. 1 will work around the surgeon and go through his PA [physician's assistant] if there is a problem."

But other teams clearly did foster a sense of psychological safety. How? Through the words and actions ofthe surgeons who acted as team leaders- not surprising, given the explicit hier- archy of the operating room. At one hospital, the surgeon told team mem- bers that they had been selected not only because of their skills but also be- cause of the input they could provide on the process. Another surgeon, accord- ing to one of his team members, re- peatedly told the team: "I need to hear

BEST PRACTICE • Speeding Up Team Learning

Becoming a Learning Leader

Creating an environment conducive to team learning isn't hard, but it does require a team ieadertoact quickiy. Social psychologists have shown that people watch their supervisors carefully for cues on how team members are expected to behave. These impressions form early in the life of a group or project. To set the right tone, team leaders must:

Be accessible. In order to make clear that others' opinions are welcomed and valued, the leader must be available, not aloof One nurse in our study commented about a successful team leader: "He's in his office, always just two seconds away. He can always take five minutes to explain something, and he never makes you feel stupid."

Ask for input An atmosphere of information sharing can be reinforced by an explicit request from the team leader for contributions from members. The surgeon on one successful team "told us to immediately let him know - let everyone know - if anything is out of place," said the team's perfusionist.

Serve as a "fallibility model." Team leaders can fur- ther foster a learning environment by admitting their mistakes to the team. One surgeon inourstudy explic- itly acknowledged hisshortcomings."He'll say/I screwed up. My judgment was bad in that case,"'a team mem- ber reported. That signaled to others on the team that errors and concerns could be discussed without fear of punishment.

from you because I'm likely to miss things."Tbe repetition itself vyas impor- tant. If tbey hear it only once, people tend not to hear - or believe - a message that contradicts old norms.

Leading to Learn While our research focused on the en- vironment of cardiac surgery, we believe our findings have implications that go well beyond the operating room. Orga- nizations in every industry encounter challenges similar to those faced by our surgical teams. Adopting new technok> gies or new business processes is highly disruptive, regardless of industry. Like the surgical teams in our study, business teams tbat use new tecbnology for the first time must deal with a learning curve. And the leaming that takes place is not just technical. It is also organiza-

tional, with teams confronting problems similar to those encountered by the sur- gical teams we studied: issues of status and deeply ingrained pattems of com- munication and behavior.

Implementing an enterprise resource planning system, for example, involves a lot of technical work in configuring databases, setting operational parame- ters, and ensuring that the software runs properly on a given hardware platform. The bard part for many companies, thougb, is not tbe technical side but the fact tbat ERP systems completely change the dynamics-the team rela- tionships and routines-of the organi- zation. As our study shows, it takes time for teams to leam bow decisions should be made and who should talk to whom and when. It takes even longer if people don't feel comfortable speaking up.

There's yet another parallel hetween business teams and surgical teams. Busi- ness teams are often led by people who have been chosen because of their tech- nical skills or expertise in a particular area: Outstanding engineers are selected to lead product development projects, IT experts lead systems implementa- tions, and so on. Tbese experts often find themselves in a position similar to that of tbe cardiac surgeons. If tbeir teams are to succeed, tbey must transform themselves from technicians into lead- ers who can manage teams in such a way that tbey become leaming units.

Thus the key finding of our study- that teams leam more quickly if they are explicitly managed for learning- imposes a significant new burden on many team leaders. Besides maintain- ing tecbnical expertise, they need to be- come adept at creating environments for leaming. (See the sidebar "Becoming a Leaming Leader.") This may require tbem-like surgeons who give up dicta- torial authority so that they can func- tion as partners on tbe operating teams- to shed some of the trappings of their traditional status.

The importance of a team leader's actions suggests tbat the executives responsible for choosing team leaders need to rethink their own approaches. For instance, if an executive views a team's challenge as purely tecbnical, he or she is more likely to appoint a leader based solely on technical competence. In the worst (and not unfamiliar) case, this can lead to disaster; we've all known superstar technocrats with no interper- sonal skills. Clearly, there is a danger in erring too far in the other direction. If team leaders are technically incom- petent, they're not only liable to make bad decisions but they alst> lack the cred- ibility needed to motivate a team. But senior managers need to look beyond tecbnical competence and identify team leaders who can motivate and manage teams of disparate specialists so that they are able to learn the skills and rou- tines needed to succeed. ^

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132 HARVARD BUSINESS REVTEW

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