No one questions that the technical challenges of using robotics in cardiothoracic surgery make it a team sport. An experienced team that makes excellent decisions in the OR is necessary for the program to enjoy sustainable success but it is not sufficient.  An array of decisions made outside the OR – broadly categorized by the term “politics” – also have a major influence on the program.  In contrast to the importance of teamwork, the role of politics in successful innovation in healthcare is seldom discussed and seems to be underappreciated.  The purpose of this blog is to discuss how coaching and team meetings are the key to manage these political interactions and maintain a successful program.

The life cycle of any team starts on the day of its formation and ends when its mission is either accomplished or no longer needed by the organization.  Teams go through predictable and discrete phases, as described in a classic model proposed by Tuckman.  Understanding these transitions is a key to coaching.  Even well-designed interventions don’t help a team that isn’t ready. At the beginning, it is inevitable that team members have high uncertainty and anxiety about the new (and often unclear) project.  This is that phase that members politely follow their leader and pose few objections as they search for personal security within the new order. The appropriate coaching during a state of high anxiety is motivation.  Teaching more complex concepts needs to wait until the team accrues enough hands on experience to have made important mistakes.  Only at that point – often characterized by the midpoint of the proposed timetable – will team members more fully engage in discussions about how to do things better.  The phenomenon that teams become open to strategic ideas for improvement at the halfway point of their project is surprisingly reproducible.   Most sports teams avoid making major changes to events that unfold during the course of the game’s first half and defer their most important adjustments to halftime.

Even the most disciplined teams don’t agree lockstep with their coach.  A team that isn’t afraid of conflict is often the one most committed to finding the best answer.  OR teams always have “early adopters” that buy in to the initial plan of robotic heart surgery at the outset.  A single meeting triggers their enthusiasm.  There are also skeptics.  Careful listening and responsiveness to their feedback is the most effective way to motivate team buy in.  Ongoing (e.g. weekly) team meetings or debriefings are useful to unearth the dissenters and any hidden agendas.  In the words of one of my senior scrub techs, “we’ve gossiped about each case for years, so we might as well discuss things with you so that the whole team can benefit.”

The default position for most OR teams is to remain quiet and avoid contradicting the surgeon.  This is the consequence of a long history of abusive heart surgeons.  Newton’s first law – a team at rest (i.e. quite about concerns) remains at rest – prevails out of the fear of punishment for saying something critical and the belief that their ideas won’t prompt lasting change.  With this in mind, I start each of my debriefings by restating our ground rules: “conflict is a sign of a team that cares so argue like your right but listen like your wrong”, “what we say in here stays in here”, and “think about the defenseless patient as you consider whether to speak up about a safety concern”.  Well-established ground rules set the stage for everyone to put aside politics and collaborate towards common goals, but they are not sufficient for getting universal participation.  It is also a helpful tactic for leaders to admit their own faults first if they want others to join it.  Whatever approach is used, it is the job of the team leader (surgeon) to develop the insight, experience and skill to make participation happen.  Since the critics are the last ones to speak up, it is not enough to get some people to participate – it has to be everyone.

Getting some input is easy, but getting all to speak up requires changing the culture of the team.  A surprisingly helpful approach to this is to tap into thehuman desire to explain the causes of things. Surgeons should recognize nascent efforts in the team to speak up.  This small act gives credibility to the idea that everyone’s thoughts matter. As this behavior is further reinforced, a new set of underlying values emerges among the team.  The group starts thinking of themselves as “that kind” of team that likes to speak up and continuously improve.  A new course of action is far more likely to “grow legs” when attributed to internal factors (“I succeeded because I tried hard”) than external factors (“We failed because of the boss’ bad idea”). Debriefings, training exercises and team building programs each amplify members’ commitment to the goals of the team by making a member’s support public and socially visible.

The instinct of many surgeons is to change their team’s behavior through persuasive or coercive arguments.  This immediately provokes rebuttals, resistance and push back from skeptics.  In contrast, getting team members to see themselves differently is more gradual and not perceived as an effort to persuade, so it often evades these psychological defenses.  The most expedient alternative of all – forcing change on the team by fiat – is the most unlikely to gain wholehearted support. One of the most consistent (and underappreciated) findings of social science research is that carrot-and-stick incentives– a mandate from the boss, bonus pay, or political favors – or any other “extrinsic motivator” almost never influence behavior in the long-term.

A story about an old man and boys playing baseball illustrates this point. A group of kids played baseball in a lot next to the man’s house every day.  It bothered the man so he asked them not to, but they ignored his complaints and continued.  One day, he went onto the field during a game and told the kids he actually really enjoyed watching them play and payed $5 for the entertainment.  The kids accepted and received payments every day for the next week.  Then, the man suddenly stopped paying.  When the boys’ demand for the money was not met, they decided to punish him by moving their game to another field.  In this case, the extrinsic motivation of money was able to “crowd out” their initial intrinsic motivation to have wanted to play on that particular field in the first place.  That’s the power of money.

Harsh judgment against those that speak up is another powerful motivator of team silence. Formal structures, like weekly debriefing sessions with clear ground rules, help mitigate this risk by establishing a safe and consistent venue for different views to be heard.  In lieu of debriefings or other meetings, the vast majority of cardiac surgeons instead use an informal approach, like telling those with concerns “my door is always open”.  The problem with informality is that the rules for decisions are not made explicit.  People confused about how decisions are made often turn their energies away from speaking up and towards infighting and personal power games.  Some leaders purposefully use the lack of structure as a smokescreen to mask their unquestioned dominance over all decisions and avoid accountability (see the influential essay “The Tyranny of Structurelessness”).

The speed of turning feedback into corrective action determines whether the project stays on track and the team engaged.  All the details of such a highly complex project cannot be managed efficiently without regularly scheduled meetings.  That point has been made in previous blogs and is too obvious to repeat.  The optimal strategy for organizing those meetings (e.g. six sigma, rapid cycle improvement, PDSA) is covered by other better informed authors elsewhere.  A more interesting and underappreciated role for team meetings is their invaluable role at navigating the political minefields.  Trying to innovate in cardiac surgery is one of the most political acts in all of healthcare.  My wisdom about the role of team meetings as a way to tame the politics was acquired after five key realizations:

The first realization is to beware of a “signal to noise” problem with criticism of robotic heart surgery.  Much of feedback is precious because it helps avoid the unforeseen safety risks that can happen with robotics (i.e. signal).  However, there are also skeptics that don’t accept any chance for a future for robotics in heart surgery.  Their views are not meant to be helpful (i.e. noise).  The layman looks at the dramatic impact of robotic and less invasive techniques in other surgical specialties and see its future in heart surgery as self-evident. Experts in robotics admit that further effort will be required for it to reach full potential, but see the progress to date as sufficient to justify optimism.  Yet the debate about robotics being viable continues to be kept alive. Often times, those with the most malice against robotics are from teams that have shown true mastery of traditional heart surgery.  Such vast experience and high status is used as a shield from having to consider any alternative that might be competitive, no matter how logical the idea might be.  The discounting of logical ideas this way is called “moral licensing”.  It happens in the subconscious – none are aware of using this strategy but we all do – which is what gives it power.  This same processexplains the finding that people who smoke or eat cheeseburgers also consume more vitamins and diet soda.  Vitamins and diet soda are used to balance the portfolio of risks and to illustrate a person’s interest in a healthy lifestyle, which provides them the “moral license” to discount the harmful effects smoking and cheeseburger

It helps to improve the signal to noise ratio by becoming clear about who are your enemies.  As the Godfather warned, you should keep these people closer than friends.  It is hard to levy unfair criticism on someone if you meet with them in person regularly. In the words of the Saturday night live character,Jack Handey: “before you criticize someone, you must walk a mile in their shoes.  That way you are a mile away and you have their shoes.”  When an enemy agrees to sit face to face at a team meeting, I often frame that as a generous favor to me.  Ben Franklin was the first to describe in his autobiography the power asking for small favors from enemies as a means of converting them into friends.  An enemy that grants the favor of regular meetings gets an uncomfortable feeling called cognitive dissonance.  Becoming a friend reduces this discomfort; friends don’t use moral licensing to reject us.  Salesmen have long recognized the “foot-in-the-door” effect of a small favor.  Compliance with a small request (accept a free sample; show up at meetings/training sessions) creates a new relationship, which promotes compliance with a subsequent big request (buy your product; fully support the change).

The second realization is leading a robotic heart surgery team is an undoable task for one person.  Rapid implementation of all appropriate suggestions in order to grow a successful program demands a scope of effort and a breath of necessary competencies that are just too broad.  The solution to this dilemma proposed by Peter Provonost and many other quality improvement experts is to pair an administrative leader with a physician leader.  This dyad partnership creates leadership synergy by bringing together “the best of both worlds” of skills and expertise.  Physician leaderssurveyed by the advisory board almost unanimously agreed that a dyad arrangement improves leadership performance and accountability.  Unfortunately, non-clinical leaders and hospital boards were in need of more convincing about its merits.  Productive team meetings provide the playing field to help the administrators see the value of this new approach.

The third realization is that all new teams go through a phase known as “storming”.  This is a process familiar to any school teacher.  Kids start their first few days of a new class well-behaved and attentive but soon thereafter begin to misbehave.  The wise teacher knows that the students are just testing their boundaries and accept the teacher’s role to control the class.  The OR team misbehaves in an analogous way.  In the beginning, its hard to complain about robotics until the reality of change starts to sink in.  At that point, emotions flare up about changing the comfortable routines of a sternotomy that worked for years.  Interpersonal conflicts arise from having to take on new roles.  “Concerns” are raised about the robotics program that contradict objective metrics of how things are actually going.  Legitimate patient safety problems get lost in the trees.

The storming phase determines the fate of the project.  Multiple narratives about the about the safety/success/viability program circulate among stakeholders and actively compete on equal footing for truth and legitimacy.  Any conclusion that is unfavorable, even if it is clearly erroneous, will be magnified as it spreads outside those in the OR with direct knowledge. Competent, well-timed coaching and dispassionate debriefings are critical at this point to cultivate the team’s perceptions to be objective and less vulnerable to emotional black and white thinking that interprets any setback as a failure.  Abraham Lincoln recognized the power of managing the team narrative when he said to his cabinet: “We can complain because rose bushes have thorns, or rejoice because thorn bushes have roses.”  The default pathway is to view major change as threatening and painful.  Lincoln understood the imperative to reframe the feelings caused by change as compelling and exciting.  Teams with the latter view become a tight knit crew with a clear vision and members that take responsibility for that vision.  Aviation research has shown that flight crews that have been together long enough to work through their storming phase, even when fatigued, perform significantly better than do rested crews whose members have not worked together.  Standard training exercises are no substitute for a team that had to show the persistence and tenacity to get through its first round of challenging clinical cases.

A fourth realization is that a successful change effort is bounded by the culture of its organization.  The pursuit of a high impact innovation in a weak organization that is unclear on its objectives is doomed from the start.  The phrase “cultural fit” may just be used as code for the discrimination of any idea going against entrenched interests, but it is still very relevant to the success of robotic heart surgery.  The core values of a hospital tend to be blindly accepted as dogma.  Creating change in a culture that is not open to it is analogous to growing rose bushes in a desert.  Heroic effort makes it possible to produce a few beautiful results for a time but, sooner or later, the desert reclaims the rose.  After a decade of failure, robotic heart surgery has resembled the fable of Sisyphus, the greek man penalized by the gods to a life of repeated failure at a meaningless task.  The conservative “gods” in charge of our cardiac surgery societies long ago declared robotics as having no meaningful benefit for heart surgery.  This doomed the few robotic enthusiasts rolling the rock uphill to clash against a culture that constantly pushes it back down.

This leads us to the final, and most important, realization: the leader of this project should come prepared for a rough ride.  An entrenched status quo has many options available to stop competitors.  A common option is to stigmatize robotic surgery (and surgeon) as unsafe.  Developing a failsafe structure for excellent communication among the robotic team provides a strong rebuttal against this allegation.  The wise leader constantly searches for other areas that the team is vulnerable to criticism.  For instance, a focused, stable group of nurses and anesthesiologists is a universal requirement to implement robotic surgery.  However, the demand for a dedicated team can eventually cause problems from surgeons in other fields that also want their own dedicated team.  There is a point at which the robotic project gains enough momentum that it is safe to shift to a more inclusive staffing model.  This is just one example often brought up at team meetings.  The point is to surrender these small battles if it helps win the war that happens within the broader organization.  The amount of flexibility required is best reflected by a quote by Winston Churchill:  “Success is going from failure to failure without losing enthusiasm.

Well organized meetings become effective when they provide great coaching and efficient when they employ the physician-administrator dyad model.  This creates an environment where signals (i.e. appropriate critiques meant to improve the team) are easily separated from noise (i.e. unhelpful criticisms meant to bring the team down).  When all team members enthusiastically speak up, it unearths those that dissent.  This last point perhaps has the most political importance of all.  Albert Einstein said that leading any type of effort to change is problematic (in this case, to the safety of patients and career of surgeons) not because of those that directly oppose us, but because of those who look on and do nothing. Effective and efficient meetings don’t let that happen.