I’ve gained invaluable experience in my role as a chief of cardiac surgery over the last 10 years. One of the most important (and painful) lessons I’ve learned is that consistently good patient outcomes requires a great team and this doesn’t happen merely by putting a group of people together in an OR. Exceptional results requires a high performance team…the type that can land a plane safety on the Hudson River without losing a single passenger. The members of Sully’s crew trusted each other to not only do their jobs well, but to perform at highest levels even when the chips were down. Unfortunately, the reality of healthcare is usually far different. Without an active and highly skilled effort to manage the development of this type of team, the default is always dysfunction. High performance never happens by accident.
Of all the behaviors that characterize dysfunctional teams, the most basic finding is that team members fail to speak up about problems in a way that would improve patient safety. This is critical because it inevitably promotes three other behaviors that steer their patients farther away from safety. The first consequence from failure to speak up is that the team does not commit wholeheartedly to patient safety. Bringing forward a problem creates an obligation to propose a solution. Not fixing ongoing problems creates a mindset of normalized deviance; bad care “is just the way things are done around here”. In my experience, this type of defeatist attitude is the rule in healthcare.
The second problem triggered by keeping quiet at meetings is that it allows team members to avoid accountability. The discomfort of being held accountable to team goals can be resolved by one self evident fact: one is not held accountable for concerns left unspoken. It is easy to avoid having “skin in the game” by just lacking assertiveness at team meetings. Amy Edmondson argues that members on dysfunctional teams engage in a kind of tacit calculus before speaking up. They assess the interpersonal risk associated with making their views known against the potential for the humiliation or punishment derived from being held accountable. This type of calculus is an understandable part of human nature but regrettable when it causes the team to stray from putting their patients first.
Poor assertiveness, commitment and accountability lead teams to their final dysfunction: lack of alignment. Just because team members are not assertive at meetings does not mean they don’t have strong opinions about things that are going on wrong. It is easier and more comfortable to “leak” those concerns to a variety of other venues, often in the form of anonymous complaints, rather than to debate these issues face to face at a team meeting with those that might not agree. Such complaints serve an important role in clinical governance and patient safety and should not be discouraged. However, this route has far less chance of fixing the underlying problem, at least in the short term. The complaint signifies a lack of commitment to the team’s goals that spreads to others, depletes morale and saps the sense of teamwork and common mission to achieve a singular purpose. The power of having a forum to air complaints at regular team meeting is that it elucidates the true intent of these leaks (hint, it is not patient safety or team effectiveness). If you deny this reality, your boat will not go in the right direction because your crew is paddling in opposite directions.
The sine qua non of a team out of alignment are personality conflicts. Discussions of a personal nature create conflict that distracts from critical safety issues and increase the risk of bad outcomes. Conflict still happens among those on high performance teams but it is rarely personal. Instead it is about who should do what and when and other factors that are an important part of developing an excellent plan. At the end of the day, great teams agree to resolve those conflicts and align themselves with the final decision of the team. Jeff Bezos at Amazon calls it the willingness to “disagree and commit”. In stark contrast, dysfunctional teams silently disagree and sabotage.
The result of team dysfunction is poor communication and teamwork failure, which is an important and well known cause of bad outcomes in cardiac surgery. These failures are common and likely lead to most preventable postop complications. When we think about these failures, what often comes to mind are the big obvious disasters. Team members that fail to communicate with each other during critical moments in the case, resulting in a catastrophic death from air embolism or thrombosis of the bypass machine. The wrong valve was replaced or a needle was left in the chest despite repeated warnings from a flustered circulating nurse.
The problems with teamwork that are more common and have a larger impact aren’t so overt and obvious. It is more common to find team members that do their jobs reliably but fail to be accountable to the subtle safety defects that are difficult for outsiders to notice. For instance, not having the right equipment for the job and accepting “no” from people that don’t understand the implications on patient safety from that answer. Not persisting in getting help from the IT department on issues that are important for safe cardiac surgery because they are purportedly engaged in other (less critical but more politically important) projects. A team that doesn’t maintain situational awareness during critical moments in the case because it hasn’t seemed to matter in other cases that this issue wasn’t noticed or emphasized. The best way to prevent all these issues from happening is by recruiting members that are fully committed to team goals, which is often best illustrated by the willingness to fight these small battles. As Jim Collins said, “who before what”. It is more important who is on the team that what it is you want to accomplish. A team needs those willing to put patients first.
Most surgeons feel they would have done enough to provide a regular venue (like a weekly team meeting) for team members to speak up and maintain an open door policy. They might feel that if the team chooses not to use this opportunity, it is not the surgeon’s fault. You can bring a horse to water but you can’t make it drink. However, I disagree that the surgeon’s obligations stop at this point. A cardiac surgeon has a fiduciary responsibility to patients to do everything possible to keep them safe. If I truly believe that my team has ideas that would improve care, then I cannot rest until I have created an environment where members are psychologically safe to speak up. I am far from an expert on this topic but I have found a few things over the years that have worked:
- Call on people to provide their opinion at team meetings. One good way to get the team’s opinion is to call on them. Edmondson’s tacit calculus of personal risk changes when you are required to provide an answer as opposed to voluntarily speaking up.
- Train the team on SBAR. There are excellent, well established tools like SBAR (Situation, Background, Assessment, Recommendation) that help the team communicate more effectively. I like to emphasize the “R”. Most members of the health care team are uncomfortable providing a recommendation to the surgeon about how they should respond to an important communication. This makes the message less clear and needs to change if teamwork is going to be optimized.
- Improve the team’s assertiveness by pointing out mitigated speech. The teamwork of other hazardous activities (e.g. crews in airplanes, nuclear power plants, paramilitary) has been improved by creating clear strategies for how teams should communicate. One important issue is to avoid what is called mitigated speech, which is a softening in the strength of the message due to a sense of respect for hierarchy. Such communications should be pointed out in the team debrief and more assertive alternatives encouraged.
Finally, one of the most effective and underappreciated ways to create psychological safety is to be clear about proper team behavior. Without these norms being established, team members that want to speak up are always uncertain about when they might be sanctioned. Most important: the perverse strategy of silent disagreement and sabotage cannot be tolerated. The world of marketing has taught us that there are always a small cohort of people – called late laggards – that are against something new and only buy in when there is no other choice. These are not people that will help overcome the safety challenges that face a new team. The task of creating change and maximizing the safety of cardiac surgery is hard enough. No team should be required to put up with those that become engaged in active sabotage and prevents a culture that is able to learn from mistakes and improve patient safety.
Hospital administration and other entities responsible for oversight of cardiac surgical programs help advance patient safety goals by accepting that saboteurs are bad. At first this might be difficult to accept. After all, anonymous complaints provide juicy gossip about a high profile program and occasionally may provide some insight into its problems. However, a complaint that has not been vetted by the team is unlikely to be based on more than a kernel of truth. That’s not to say it has no value, but it ranks lower than most other evidence about the program. More importantly, these complaints represent an end-run around the team meetings, dampening its effectiveness and making it harder to learn from mistakes. Hospitals are known to be particularly poor environments for learning from mistakes. All stakeholders – including administrators and regulators – help create this learning environment. In the end, getting serious about safety hazards is likely to require getting rid of those that silently disagree and sabotage.
