Improving Healthcare Team Performance: The 7 Requirements for Excellence in Patient Care

By Leslie Bendaly and Nicole Bendaly

Practical, proven techniques for improving team performance in the health care world

Teams and collaboration have become an expectation in most healthcare facilities and environments. It is accepted that high performance, patient focused teams are critical to quality patient care. However, there is often a wide gap between traditional practices and the new behaviours and practices required for teamwork and collaboration. Improving Health Care Team Performance goes beyond theory to provide the knowledge, tools, and techniques required to develop a single team, or to develop an organization wide team based culture, from which exceptional patient care emerges.

Most uniquely it emphasizes that effective teamwork goes far beyond team dynamics and provides detailed description of additional requirements, such as shared learning and change compatibility, and how to fulfill them.

A practical handbook for healthcare leaders striving to ensure a superior patient experience and high quality of care, Improving Healthcare Team Performance not only provides specifics on how to develop high functioning teams, whether multidisciplinary, interdisciplinary, or departmental but also offers those dealing with the common healthcare leadership challenges of low morale, poor communication, interpersonal conflict, and lack of knowledge sharing the tools to take immediate action to improve performance. Providing a proven approach to addressing and preventing everyday issues impacting patient care, Improving Health Care Team Performance contains everything needed to identify areas of greatest need within a team or department, take targeted action to address key gaps, and measure progress towards positive change.

• Presents a clear depiction of what constitutes collaboration and a high-performing patient focused team. This includes the skills and practices required to improve team performance and ultimately the quality of patient care, how to develop new attitudes and behaviours within the team, as well as the leadership requirements for success in a patient focused, team based culture.
• Provides a set of development tools accessible online to help the reader quickly and easily apply the knowledge gleaned.
• Offers targeted solutions including tips/recommendations, a step-by-step approach for affecting necessary change at every level of the organization, and skills and team development activities.

Designed for leaders working in any healthcare environment, Improving Health Care Team Performance is a practical approach to improving team performance and the quality of patient care.

• Language: English
• Publisher: Wiley
• Release date: Sep 21, 2012
• ISBN: 9781118209677

Leslie Bendaly

Leslie Bendaly and Nicole Bendaly are inspirational consultants and coaches who have authored over a dozen books between them. Through their consulting firm, K&Co, they empower teams, leaders and individuals to tap their very best by providing the knowledge and tools to do so. Ask them what they find most rewarding in their work and they will tell you that it is seeing the people they support surprise themselves by what they can achieve.

Book preview

Acknowledgements

We would like to express our sincere thanks to all who have contributed to this book. We have been fortunate to have met and worked with countless healthcare professionals who have inspired us with their commitment, candour, and desire to help others, and we are grateful to them for sharing their stories so that others can learn from them.

Thank you to Dr. Ken Milne for his passion and dedication to improving patient safety performance and for so generously giving his time and energy to writing our foreword.

We much appreciate Hugh MacLeod, Dr. Ivy Oandasan, Janet Davidson, Dr. Joshua Tepper, Stephanie Leblanc, David Pole, Sandra Ramelli, Michelle DiEmanuele, Patricia Lefebvre and Anne Harvey, who took the time to share their wisdom and experience in transforming healthcare culture so that collaboration and exceptional quality care become firmly woven into its fabric.

The Oncology Program at the Niagara Health System, the New Patient Referral Team at the Juravinski Cancer Centre, Hamilton Health Sciences, and the Toronto Central Community Care Access Centre each participated in the development of this book through focus groups and the sharing of best practices and experiences. What an important contribution they made to our project.

Many individuals contributed to making this a better book. Joanne McNicol provided great feedback on parts of the manuscript, Don Loney, our editor, made valuable suggestions, effectively restrained any verbosity, and polished our prose, and Pauline Ricablanca and her production team did a terrific job of both hunting down our errors and omissions and making the book attractive.

And finally, thank you to Jason and Elie who supported us by sharing the load at home while we focused on the research and writing of this book.

Foreword

This book is very timely. Twenty-first century healthcare—with its vastly expanded knowledge base and technologies to manage increasingly complex clinical presentations—has resulted in unprecedented patient expectations. This, coupled with the need to deliver high-quality patient-centred care in a cost-effective manner, cannot be shouldered by one healthcare provider at a time. We have, for some time now, reached the point where the quality of care that patients and families receive depends not only on the knowledge and skills of the individual care providers, but also on the ability of the entire healthcare team to communicate and work well together in order to coordinate the care that the patient/family needs.

Leslie Bendaly and Nicole Bendaly have leveraged their extensive experience and expertise in building effective high-performing functional teams in a variety of organizational structures and applied this to the healthcare environment. They have done this with clarity, mapping out the elements of high-performing teams and showing how each of these elements is independent and yet collectively linked. It is really like an anatomy dissection illustrating the linkage of all the individual parts.

The other important aspect of their book is devoted to providing the strategies, or, as some would call it, a play book, on the how to achieve high performance in healthcare teams. This, in my opinion, has been lacking in healthcare development. Much has been written about what defines a high-performing team and how to measure performance, but little attention has been paid on how to achieve this important construct in healthcare. The solutions the book offers are wide-ranging in scope, from team development processes, balancing behavioural tasks, and process tasks, to the importance of facilitating and nurturing the growth of teams.

The authors also emphasize the importance of leadership in successfully improving healthcare team performance. From my own personal observations and experience, this is fundamental to sustained success of high-performing teams and the impact this has on the provision of safer healthcare. As they so ably demonstrate, leadership in healthcare organizations, as in any other work environment, sets the values and shapes the attitudes that drive the behaviours that in turn drive the performance. Positive behaviours result in high-performing teams, which positively impact patient-care outcomes and cost efficiencies. With negative behaviours the opposite occurs.

Effective leadership walks the talk; leaders behave with integrity and are credible. The credibility is achieved because effective leaders consistently do what they say they are going to do. Great leaders display energy and they energize those around them. As well, great leaders are passionate about mentoring growth.

Leslie and Nicole have captured all of these important attributes of leadership and demonstrated how they are pivotal in building and sustaining high-performing teams. Their work also highlights that it is not just the C suite or senior administration team that is responsible for leadership in healthcare—it is, rather, a responsibility that must be shared by many throughout our healthcare structures. In truth, we can all lead from where we are. Leadership is about influence. Leadership is about leading change. If we were all to integrate the behaviours and attitudes that are the component parts of the seven elements required for excellence in healthcare team performance as described in this book, then our progress in providing quality, safe, and cost-effective healthcare would be dramatically expedited.

The book has been written with real narratives from patients and healthcare providers, making it human, relevant, and causing us all to reflect on why we must never give up on trying to improve team performance in healthcare. The use of quotes from notable leaders from many walks of life reinforce the need for all of us to carry and project a positive attitude every day in all aspects of our work. Reading this book will provide direction and guidance for anyone in healthcare, from the front-line workers to senior administration and boards, on how they can raise their participation bar in their own team performance or be more effective in providing leadership for team performance. In doing so, all patients and their families will benefit.

Ken Milne

MD, FRCSC, FSOGC, FACOG

Introduction

This is a book written with purpose and hope. Much has been researched and published about teamwork and collaboration as the essential ingredients in the nurturing of committed, focused, and empowered staff who together provide exceptional patient care. It is theory headed in the right direction. Our purpose in writing this book is to go beyond theory and to provide the knowledge and tools with which one can develop truly collaborative and high-performance healthcare teams, rather than groups that simply carry the team name, and to do so with greater ease. Many healthcare leaders have made huge strides in their development of patient-focused teams. Our hope is that the knowledge we share will encourage, perhaps even inspire, leaders and their organizations to embrace teamwork with even greater commitment and vigour.

During our 25 years of working with leaders and their teams, we have found that the importance put on teamwork in healthcare has waxed and waned, sometimes due to the introduction of different approaches to quality care and sometimes due to budgetary constraints.

The intense and consistent focus that has been put on teamwork and interprofessional collaboration in healthcare over the last few years is an encouraging sign that the enormous benefits that are reaped by taking a deliberate and committed approach to developing a team-based culture have been recognized by those dedicated to the profession.

Research shows that nurses who believe that their team is well-functioning have higher levels of job satisfaction, are more likely to stay in their jobs, and demonstrate lower levels of stress and burnout.¹ Another important finding is that higher levels of teamwork have been linked to higher quality care, improved patient outcomes, and an enhanced patient experience.² In a study conducted by Donald C. Cole, et al., that investigated the understanding, collection, and use of Quality of Work Life (QWL) indicators in Canadian healthcare organizations, one of the participants articulated the importance of teamwork in maintaining a healthy work environment:

To provide [the] best patient care, staff need to take into consideration what patient needs are. What does it take to do that? There has to be teamwork. There have to be integrated teams. There have to be staff who feel valued. It's all centred around making life better for the patient. If you have a happier group of people, working in teams, you’ll have a better end product.³

While ideally the development of a team-based culture is an organizational priority, we more often see unit managers and directors taking it upon themselves to improve the effectiveness of their teams. Happily, there is forward movement, but there are still many organizations and leaders who have not made sufficient headway toward creating a team culture. These organizations may be struggling to achieve true teamwork due to any of the following unnecessary blocks that we see every day:

A misunderstanding of what teamwork is all about (it goes far beyond team dynamics)

Insufficient endorsement from the senior management of teamwork as a priority (as we will explore, however, this should not stop individual team leaders from taking their groups forward to reap the benefits of true teamwork)

Lack of team development knowledge and skills

A false belief, or perhaps hope, that a single intervention or team-building activity can turn a group into a team

Lack of commitment and follow-through

We strive through this book to provide the know-how to prevent or remove these blocks so that leaders gain the ability to develop and sustain true teamwork within their units and across the organization.

The 7 Elements of a High-Performance Healthcare Team

Our commitment to team-based culture in healthcare began in the mid-1980s, when Leslie was invited by the Ontario Hospital Association to deliver her intensive five-day program on teamwork to hospitals across the province. This sparked our passion for teamwork, which led us to conduct ongoing research into team effectiveness; to work with hundreds of teams in Canada, the United States, and other countries, both within and without the healthcare sector; to publish several books on the subject; and to develop our now-classic Team Fitness Test, a tool used by teams around the world to measure and improve team performance.

Early on it became evident that teams that were high performing had much more going for them than just good team dynamics. Although a healthy dynamic is essential, other ingredients also need to be present in order for teams to make a powerful contribution to their organization. As demands on healthcare organizations have changed and increased over the years, so have the areas in which teams must excel in order to provide the best patient care.

When the Society of Obstetricians and Gynaecologists of Canada (SOGC) and Salus Global Corporation (Salus) invited us to support their obstetrical patient safety program, MOREOB, by developing instruments to measure culture and communication, we had the opportunity to collect data from hundreds of healthcare workers in Canada and the United States through questionnaires, interviews, and focus groups. The result was data that not only shaped the instruments now being used by Salus to successfully improve patient safety in hospitals across North America, but also reconfirmed the essential nature of what a high-performance healthcare team looks like, including its specific behaviours and practices.

Seven elements are essential to team success and the delivery of exceptional patient care:

Healthy Climate

Cohesiveness

Open Communication

Change Compatibility

Team Members’ Contribution

Shared Leadership

Shared Learning

When a team performs consistently well within each of these elements, both the patient and the team win. When any one or more of these elements are weak, the team experiences challenges that either directly or indirectly impact the patient experience, the quality of patient care, as well as the wellbeing of the team's members. These elements and the tools to help leaders strengthen each make up the heart of this book.

More than healthy team dynamics goes into making an effective patient-focused team.

When Teamwork Is Lacking

When we are invited to support the development of a healthcare team, the request is usually triggered by the leader's recognition of some level of dysfunction within the team. The dysfunction most commonly relates to poor team dynamics—ineffective communication, stress-inducing interpersonal relations, and conflict. Although there are critical team requirements in addition to healthy team dynamics, when the dynamics create dysfunction, they become the team's singular pain point.

Although the need for team development is usually identified from internal indicators, the need is actually most urgently evident in the quality of patient care and the issues surrounding it. Is the number of harm events decreasing or increasing? How are mistakes, whether near misses or actual harm events, managed? Are they talked about and learned from in order to prevent them from happening again, or are they hidden due to fears of judgment and blame?

Equally important an indicator is the total patient experience. This may be an even stronger measure of the team's effectiveness, as it is something that is constantly, and too often unconsciously, being created by the team. From an organizational and management perspective, a healthcare organization's reputation for its commitment to quality is a key criterion for individuals choosing a healthcare service provider.⁴ And how does the patient define quality? Fred Lee, author of If Disney Ran Your Hospital, emphasizes that from the perspective of the patient, quality is not defined by the hospital's patient-safety record any more than airlines win the loyalty of their customers on the field of who has the best safety record. How they are treated as people and their total care experience are patients’ first considerations when defining quality.

From the perspective of the caregiver, who deliberately chose to belong to a caring profession, it is disillusioning and discouraging if their work environment is not conducive to creating a caring experience. From the patient's perspective, it is painful if the one place where they greatly need and expect to receive true care is incapable of offering it.

Many people have shared their patient experiences with us over the years. Some experiences are positive and illustrate the best of healthcare. Others ask the question, what happened to the care in healthcare?

We share the following recent story, written by a patient, because it is a vivid example of a patient experience in which teamwork, collaboration, or compassion for the patient was lacking. While it did not lead to a harm event, it is the kind of example that should be recognized as a critical call for the development of collaboration and teamwork.

6:26 p.m.

A first-time mother is dazed and is starting to feel the beginnings of fear settling in as her midwife works to free her child's neck from the umbilical cord. She anxiously awaits the sound of her son's cry as the midwife passes him off to the physician who works to help him take his first breaths. Finally, after what feels like hours, she hears a soft cry and is temporarily relieved, but then suddenly everyone rushes from the room with her son without so much as a glance in her direction or an explanation as to why. Her husband hurries after the medical staff to the neonatal intensive care unit (NICU), leaving the mother alone in the room. She is in shock but wills herself to have faith that her son will be fine. Her husband returns with pictures of their tiny baby boy in an incubator attached to an IV and numerous tubes, but with little information. The midwife enters the room just as the parents begin to talk about calling their family with the news of the arrival of their son. The midwife says flatly, I wouldn't be calling anyone just yet, and walks away. What does that mean, they wonder? Is it a more serious condition than they thought? Why isn't anyone giving them any information?

Finally, the midwife returns and informs them that their baby's breathing is laboured, likely due to having inhaled meconium during delivery, and his heart rate is low but that all signs are indicating that he will recover well. They are informed that their baby is now in the care of a physician, which physician the parents do not know, and that the mother will be able to go to the NICU once her epidural wears off.

12:45 a.m.

At long last, a nurse arrives to take the parents to the NICU. The mother holds her beautiful boy for the first time and is relieved to feel his warmth and to see that his heart rate had risen and is now maintaining a healthy rhythm. A nurse stops to look at her son's chart and the mother says, I’m so relieved he's okay. Will we be taking him home this morning?

The mother once again feels the beginnings of fear settling in when the nurse, barely looking up from her son's chart, says bluntly, No, your son won't be going home for a while. He has a boot heart.

I’m sorry, what did you say? ask the parents in unison.

The nurse responds in a flat, almost distracted tone: The X-ray shows his heart is shaped like a boot and he will have to see a neonatal cardiologist and most likely have several more tests.

The first-time parents, who by this point had been awake for over 36 hours, are stunned. Fighting away tears, the mother asks to see the doctor right away and is informed that it is a busy night so she probably won't see the doctor until the morning. The nurse turns and leaves the parents alone holding their sleeping baby with a heart shaped like a boot.

9:30 a.m.

Almost nine excruciating hours later, with still no sleep, the parents see a doctor. The doctor tells them that their son will need more tests, an echocardiogram, and more X-rays that will be sent to the neonatal cardiologist for review. Until they receive the test results, they will not know how serious the condition is or whether it is simply a shadow on the X-ray. The parents push for more information: What is a boot heart? How serious is it? What can be done? How common is a shadow on an X-ray? Can't they just take another X-ray right away to double check? They are simply told that there is a range of possibilities and they won't know any details until more tests are done. The physician assures them the tests will be done as soon as possible.

The parents spend the day with their baby in the NICU. No tests are conducted and no physician comes by to check on their son. The nurses are pleasant, encouraging the mother to begin pumping so that she can at least provide her son with important colostrums; however, every time the parents ask to speak with a doctor, they are informed the doctor is busy and will be with them soon. Each time they ask when the tests will be conducted they are given the same answer: It must be busy up there. I’m sure someone will come down soon to get him.

10:00 p.m.

After a long, anxious day with still no information, the mother goes back to the NICU frustrated and in demand of answers. She spots a woman dressed in pants and a blouse with a stethoscope around her neck. Assuming she is a doctor, the mother asks her if she can look at her son's chart and give her some information about his condition. The physician obliges, and the mother explains that she has been waiting for her son to have tests but she hasn't received an update on his condition. The physician looks at her son's chart and explains that early that morning they received a response from the neonatal cardiologist indicating that it was in fact a shadow on the X-ray and that the child is fine. The physician looks surprised that nobody has informed the mother of the news, and that she and the baby are in fact still in the hospital at all. The physician instructs a nurse to move the baby into the mother's room right away and to discharge them