Teamwork as an underlying determinant of excellence and innovation

There is a growing literature on the characteristics that underlie excellence and innovation in the delivery of health care. Of key significance appears to be the development and support of an interdisciplinary team, empowered to better collaborate with external partners, so that together they can deliver coordinated, family-centred care, develop new knowledge, and facilitate innovative approaches to education. ^{Reference Taylor, Clay-Williams, Hogden, Braithwaite and Groene2} It is widely acknowledged that team-based care improves outcomes for our patients and increases professional satisfaction and provides crucial peer support. “With a strong culture of collaboration, teams become powerful drivers of innovation and quality improvement. When teamwork is absent, clinicians may complete their tasks, but they lack the commitment needed to truly innovate”. ^{Reference James3} Nonetheless, the increasing appreciation of the importance of teamwork is matched by increasing recognition of the difficulties of making teamwork actually happen. In the now classic book ^{Reference Lencioni4} “The Five Dysfunctions Of A Team” Lencioni wrote that “if you could get all the people in an organization rowing in the same direction, you could dominate any industry, in any market against any competition at any time”. He continues that “whenever I repeat that adage to a group of leaders, they immediately nod their heads, in a desperate sort of way. They seem to grasp the truth of it while simultaneously surrendering to the impossibility of actually making it happen”. In modern paediatric and congenital cardiac care, we cannot surrender to the impossibility of making teamwork happen, for the sake of our people, our patients, and their families.

Organisational culture as an underlying determinant of teamwork

What then are the foundational characteristics that underlie excellence and innovation in the healthcare team? Of key significance appears to be the development of a strong organisational culture. ^{Reference Taylor, Clay-Williams, Hogden, Braithwaite and Groene2,Reference Alsaqqa5} This organisational culture will be developed by the team leaders and its members and will be supported by complementary structures and processes. We can define organisational culture as the shared beliefs, values, and assumptions that are held within the organisation. These shared beliefs values and assumptions will be evident in the behaviour of individuals and amplified by the behaviour of leaders. In other words, it is these beliefs, values, and assumptions that drive behaviour, which in turn determines results. Simply put, if we wish to improve our results, if we wish to innovate, we need to explore and define our beliefs, negotiate and model our behaviours, and focus on and measure our results.

It must be emphasised that this is not about “being nice”; it is about being purposeful. Indeed, it is been suggested that when leaders are too invested in everyone getting along and where being nice is prioritised at the expense of honest critique, performance may be compromised. ^{Reference Scott6} There are some who believe that the qualities necessary to contribute to a positive organisational culture are somehow intrinsic (being a “touchy-feely person”). But it is increasingly recognised that the ability to contribute meaningfully to an innovative team is not necessarily about intrinsic pre-existing attributes of the individual. Just as with cardiac catheterisation and echocardiography, many of the skills necessary for teamwork can, with purposeful attention, be learned. Then there are some “serious scientists” who have no time for the “soft sciences”. To those, it must be emphasised that there is an increasing body of well-designed studies, all pointing in the same direction, that organisational culture makes an important impact on our ability to innovate in healthcare. ^{Reference Armit7,Reference Trzeciak and Anthony8}

Cultural values underlying excellence and innovation in healthcare

Trust. One essential cultural value that we need to enhance if we are to innovate is trust. According to Stephen Covey, trust is the one thing that changes Everything and “the first job of a leader… is to inspire trust. It’s to… create an environment in which high trust interactions inspire creativity and possibility”. ^{Reference Covey and Merrill9} In the “Five Dysfunctions of a Team” Lencioni places the absence of trust as a root cause for poor results within the team setting. The absence of trust leads to fear of above-board conflict. Without above-board conflict, people will not be committed. If people are not committed, they won’t be accountable and in turn they will not feel responsible for and will not pay attention to results. In this context, Lencioni makes a distinction between “familiarity-based trust” and “vulnerability-based trust”. It is the latter that appears necessary for improvement. The team leader must go first in demonstrating this vulnerability. He or she must create a safe environment for open discussion and must constantly reinforce and model the team’s commitment to trust above-board conflict, commitment, and accountability.

Service. A second important value that is necessary for innovation is a spirit of service. Our healthcare systems can no longer be ivory towers but rather must be obsessed by service. The old paradigm for healthcare is that the academic centre is the gold standard for clinical care, it typically has more highly educated and skilled clinicians and delivers more advanced care. But what is valued now by our patients and their families is more personable, convenient, efficient, compassionate communicative care.

Accountability. Closely related to the value of service is accountability. ^{Reference Persaud10} Edmondson defines accountability as “the degree to which people are expected to adhere to high standards and pursue challenging goals”. ^{Reference Edmondson and Edgar11} To this end, accountability is a crucial driver of innovation with individuals and teams recognising that they are responsible for generating new ideas and seeing them through to execution, against a background of transparency. Leaders must equally be accountable to the team by providing the necessary resources and removing bureaucratic hurdles. It is accountability that will ultimately transform the idea of innovation from a vague aspiration into a disciplined core competency, ensuring that the team not only generates new ideas but also brings them to execution with excellence.

Behaviours arising from organisational values

Psychological Safety. A high-trust environment, built on vulnerability and openness, facilitates psychological safety. In an organisational context, psychological safety might be considered both an organisational value or belief and a set of observable behaviours. Psychological safety can be defined as “the belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns or mistakes and that the team is safe for interpersonal risk taking”. ^{Reference Edmondson12} It will be observed in the specific behaviours of leaders as they acknowledge their own fallibility, frame the work as a learning problem, and invite participation. It will be observed in the behaviour of individuals as they speak up with concerns, report errors, and admit mistakes within fear of retribution. It will be manifested by the behaviour of teams as they create regular opportunities to interact, with everyone being provided space to speak and to respond to feedback. ^{Reference Edmondson12} According to Edmondson, it is the combination of psychological safety and performance accountability that lays the groundwork for learning and innovation as people collaborate and learn from their own and each other’s mistakes. Team members are not afraid to express concerns while feeling an internal sense of ownership and desire to contribute.

Above-board Conflict. An important behavioural outcome of trust is the ability to partake in above-board conflict. In the New York Times Bestselling book “Radical Candor”, ^{Reference Scott6} Kim Scott provides a model within which conflict within a team can be examined. Radical candour, which is an important tool for performance improvement, is achieved when leaders cultivate strong interpersonal relationships while providing an environment to share ideas and challenge directly. Trust is essential to this free sharing of ideas, and trust will be engendered by appreciation that team members care for each other personally. Where team members can interact with radical candour, and criticism comes from a place of caring, people will trust the intentions of others and use that criticism for improvement, even when words sting a little.

Creating Joy. It is important that the spirit of service is not only extended to the external clients being served by the healthcare team but is equally applied internally to the service of debatably the most important and often most underrecognised clients of the healthcare team and that is the team members themselves. Team leaders must create an environment in which healthcare can become joyous. Again, this is not just aboutbeing nice”, it is about being purposeful. As Bisognano wrote “The gifts of hope, confidence and safety that health care should offer patients and families can only come from a workforce that feels hopeful, confident and safe… Joy in work is an essential resource for the enterprise of healing”. ^{Reference Perlo, Balik, Swensen, Kabcenell, Landsman and Feeley13} To this end, there is accumulating evidence that joy at work not only improves staff engagement and satisfaction, as well as reduces turnover, but also that it impacts on patient experience, quality of care, and patient safety. An important behaviour arising from the positive organisational values therefore will be to develop structured frameworks, which will support joy within the healthcare team.

It all begins with leadership

As has been highlighted up to now, leadership is key to the development of a positive organisational culture. As has been said “if you don’t create a culture, a culture will create itself”. Leaders must take the first steps to enunciate the values and beliefs and model the resulting behaviours of vulnerability, fallibility, and radical candour, while creating a psychologically safe environment. All of these require that we take a fresh look at the characteristics that we may seek of our future leaders. As McChrystal taught us, our future leaders need to be less “Commander”, akin to a chess grandmaster, moving pieces around the board of conflict, to being more akin to a gardener “enabling rather than directing, tending to relationships, someone who creates and maintains an ecosystem within which the organisation operates, thrives and innovates”. ^{Reference McChrystal14} This combination of humility and fierce resolve is the essence of what Collins termed a “Level 5” leader. These leaders display a compelling modesty and act with quiet, calm determination. But they equally demonstrate clarity in enabling the transition from good to great with an unwavering resolve to do whatever must be done to produce the best long-term results and will settle with nothing less ^{Reference Collins15} . Today’s leaders must foster, mentor, and make way for these leaders of the future.