Effective teams can be significant drivers of innovations that enable broader quality improvements and efficiency gains across organizations. But despite the wealth of research and managerial expertise describing characteristics of effective teams, people and organizations still struggle to deploy teams that achieve their potential, regardless of individual effort and good intentions. More puzzling is that teams following the same template of best practices can achieve different results. We studied new team formation to understand why some teams work and others struggle. Our research suggests that transitioning to effective teams depends on mutually reinforcing functional and cultural change processes. The way in which organizations combine these two key change processes is critical for success.
In our study of a dozen primary care clinics trying to establish multidisciplinary health care teams, we identified three prototypical approaches to establishing team-based care: pursuing functional change only, pursuing cultural change only, and pursuing both functional and cultural change processes.1 While functional and cultural change processes were individually important, they were most effective when mobilized in tandem. This taxonomy of approaches to change can inform how organizations go about forming teams and evaluating progress toward effective teamwork.
Making change is difficult in any organization — particularly in health care, a field in which many individuals belong to professions with strong preexisting roles and identities. The dynamics we observed in team formation, however, are not unique to health care, which is just one of many knowledge industries turning to teams to cope with the proliferation of new information, new technologies, and an increasingly pressurized need to marshal data.
Teamwork in Health Care
Deploying effective team-based care is now recognized as an essential component of three organizational priorities in health care: high-quality, patient-centered care; continuous quality improvement; and enhanced clinical work satisfaction.2 These objectives broadly align with the three recognized objectives of teams more generally: achieving the team’s shared goal, improving as a team, and growth of individual members.3
Traditionally, primary care clinics assign a medical assistant to a physician based on who is present on a given shift, with nursing and administrative staff involved as needed on an ad hoc basis. Team-based care delivery deliberately partners doctors with clinic staff — medical assistants as well as nurses and administrative assistants.
As part of a multiyear learning collaborative,4 the primary care clinics in our study reconfigured the way they worked to establish multidisciplinary teams. Through surveys, interviews, and site visits, we studied how these primary care clinics went about organizational change to identify the most effective approach to successfully forming teams. Every clinic received the same evidence-based training and technical assistance, yet their outcomes were highly variable: Some established high-performing teams, while others did not.5 Success for clinics hinged on their ability to implement cultural and functional change processes in their transition to effective team-based care.
Approaches to Team Formation and Change Processes
We identified three prototypical approaches clinics took to establishing team-based care. Some groups pursued functional change only, with a focus on continuous improvement skills. Others pursued cultural change only, focusing on shifting team members’ roles and relationships. The most effective groups blended the two, pursuing both functional and cultural change processes simultaneously.
Functional Change
Functional change processes concerned practical, operational aspects of teaming. Clinic staff were trained on continuous improvement skills, such as PDSA (plan-do-study-act) cycles, a method for testing process improvement ideas in real-world settings, similar to Lean and Six Sigma. PDSA cycles facilitate a common language and process for continuous improvement efforts.
Some clinics strategically integrated continuous improvement, specifically PDSAs, into everyday work, encouraging staff to identify process improvement opportunities and test new approaches as a team. In routine team meetings, they allocated time to discussing new PDSA ideas and progress on current PDSAs. In these clinics, staff who attended learning collaborative workshops relayed continuous improvement training to colleagues not in attendance. In teaching everyone new skills, successful teams ensured that all members, not just those in high-status roles, were given the tools to participate in — or even to lead — continuous improvement efforts. In contrast, some clinics took a laissez-faire approach to PDSA implementation; interested parties were welcome to do PDSAs, but continuous improvement was not integrated into teams’ workflow or core duties.
Cultural Change
Implementing new continuous improvement practices required changing old ideas about personnel roles, reexamining who had authority to take initiative and lead innovation, and how “lower status” team members’ contributions were invited and valued by traditionally “higher status” colleagues, such as physicians. As one medical assistant explained, this meant opportunities to give their input and say, “We can’t do it that way. Because of insurance purposes, it has to be done this way,” and to feel that physicians “respect the fact that we know what we’re doing, even if sometimes they don’t like it.”
Continuous improvement also entails a potentially stressful state of constant change. Clinics successful in cultural change came to understand the effort of continuous improvement as progress, and teams felt like they were in it together. One physician from a practice committed to cultural change reflected, “Failure is how you learn. There isn’t good and bad; there’s ‘So, what can we learn from it?’ That’s a change for sure, both culturally and personally.” In clinics that struggled with cultural change, on the other hand, setbacks were perceived as failures, and personnel were often defensive or skeptical about the value of improvement data.
Combining Cultural and Functional Change
While functional and cultural change processes were individually important, they were most effective when mobilized in tandem. The recursive, mutually reinforcing relationship between functional and cultural change processes was key to the effectiveness (or not) of team-based care. Cultural changes created an environment conducive to functional changes, and functional changes furnished practical support systems for cultural changes.
Indeed, high performers on the team dynamics survey exhibited the strongest qualitative evidence of effective team-based care. These sites made functional change around continuous improvement skills — for example, training all staff in how to do a PDSA — while promoting a cultural openness to experimentation, which engendered a virtuous cycle. In contrast, clinics without functional changes struggled to sustain cultural changes and required a constant reinvestment of activation energy from clinic staff. In clinics without cultural changes, functional changes were imposed on an interpersonal context unable to support them.
Change Processes and Implications for Data Use
Clinics’ approaches to using data for continuous improvement vividly illustrated the mutually reinforcing relationship between functional and cultural change. An important cultural adaptation to support collecting and responding to new data was a shift to viewing data as a tool for empowerment rather than as a mechanism for uncovering failures and allocating blame.
For high-performing clinics, information sharing provided an opportunity to strengthen both technical skills and interpersonal relationships. Data became a tool that enabled individuals and teams to make sense of their work and practice environment, visualizing successes and pinpointing barriers. One nurse at a high-performing clinic explained, “We have become data fanatics.”
Lower-performing clinics, in contrast, failed to establish an information-sharing feedback loop. In contexts where functional change processes were neglected, clinics often found that patchy data collection was a stumbling block in their aspirations for change. Without consistent feedback, projects could end up in a perpetual cycle of starting and restarting. A social worker at a site that emphasized only cultural, not functional, change described an ineffective pattern of bursts and lulls of activity: “We have these projects and a lot of energy goes into them, and then they get dropped.”
More perniciously, when cultural change processes were overlooked, clinics that focused solely on functional change were more likely to view the introduction of data with suspicion, perceiving it as unwelcome oversight rather than helpful feedback and responding with defensive challenges to its validity. A program manager at a struggling clinic described her experience of sharing improvement data: “Providers will say, ‘Where did this data come from? How do I know this is the right data?’” Clinics that instead balanced cultural and functional change were better able to tolerate uncertainty and the risk of failure when they felt they had the functional tools and cultural support to work through challenges.
Optimize Your Team-Building
Simultaneously initiating both functional and cultural change may seem daunting, but our research suggests that committing to both pays off. For leaders hoping to build teams and assess their development, consider the following practical guidance.
Track progress. Our taxonomy of change types offers a quick diagnostic framework for assessing a team’s progress and potential pitfalls. Teams tackling both functional and cultural change may be on a strong trajectory even if progress seems slow. Similarly, for teams that have good energy but struggle to maintain momentum, examine whether they are putting in place the functional changes to support their cultural change efforts. Teams that organize and go through the motions without becoming interdependent or building new interpersonal relationships may need to deepen their focus on cultural change to support their functional changes.
Beware false positives. Too often, standardized assessment tools focus on formal, structural features easily codifiable in an organizational chart. But a team that looks good on paper is not enough. Relying strictly on this type of assessment risks false positives about whether or not teamwork is truly present; moreover, such assessments are potentially unreliable indicators of the underlying sources of disappointing team performance.
Give it time. Change patterns in successful primary care clinics started slowly before building momentum. Evaluating team formation after the first year or two of an intervention may be too early to detect success or failure. A full three years in, even the most advanced clinics reported feeling like they were still early in their transformation.
A single focus emphasizing either cultural or functional change leads to low-performing teams with limited capacity for continuous improvement. Groups prioritizing both change processes formed the most effective teams, as simultaneous functional and cultural change spurred a mutually reinforcing, virtuous cycle. Devoting greater attention to how your teams combine cultural and functional change processes can support organizational transformation — and help deliver on the promise of high-performing teams.
Establishing High-Performing Teams: Lessons From Health Care
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