Team CultureStrengthen Team Cohesion and Engagement

Learning Objectives

1. Explain the importance of team culture

2. Describe strategies to improve team culture

3. List resources and tools that can be used to assess the current state of culture in your practice

4. Identify ways to engage your patients to help you build a stronger culture for your practice

Anyone who has ever tried to change anything where medical care is delivered may notice that sometimes the change sticks, and sometimes it doesn't. The change is a stunning success in one hallway, while in the next hallway, nothing happens. Why is that? Did we use the wrong strategy? Employ the wrong people? Not provide enough training? Team culture is an important place to look for answers.

What is team culture in a practice?

Quiz Ref IDThink of your culture as a set of underlying rules and beliefs that determine how your team interacts with patients and each other. Culture is the way an organization “does business.” New team members may gradually absorb the practice's culture without being taught or even noticing, but that process is not ideal. Having defined expectations and ways to achieve them can make all those in the medical practice feel part of the team.

1. Diagnose the Current State of Your Team Culture

2. Discuss the Results and Brainstorm Possible Improvements

3. Create a Team Compact

4. Quiz Ref IDCreate Opportunities for Team Communication Throughout the Day

5. Meet Regularly

6. Strengthen the Team by Focusing on Individual Development

7. Get to Know Your Team Members

8. Teach Leaders to Be Mentors, Not Managers

9. Create an Environment That Supports Continual Learning

10. Engage Patients

Similar to how we diagnose a patient before we treat, it is a good idea to diagnose your culture before you start intervening. Surveys are a great tool to gauge the health of your team culture. Examples of team culture surveys include PeaceHealth's TEAM Development Measure Survey¹ and the Agency for Healthcare Research and Quality's (AHRQ's) Medical Office Survey on Patient Safety.²Quiz Ref IDIt is important to emphasize that team culture surveys are anonymous, and the results will be used to improve the practice. These surveys should never be used to blame or punish any individual or group.

Once the surveys are complete, share the results with your entire practice. Posting the findings in a common area so team members can review the results and think about opportunities for improvement in their own time, before convening as a group, is an excellent way to show transparency and for leadership to demonstrate a desire to engage all team members in practice improvement.

“Culture is what we say, what we do, and what we value.”

—Gurpreet Dhaliwal, MD, Internal Medicine, University of California, San Francisco

Now that you have a better understanding of your current team culture and where there's room to improve, it is time to take a closer look at what you've discovered. Brainstorming potential improvements for the practice can be as simple as asking people what results they think the group should work on and what they can do to improve in those areas. You may hold informal brainstorming sessions during work hours, hold special listening sessions, or simply add as an agenda item to a regularly scheduled team meeting.

Follow the Basic Rules of Brainstorming

• Every idea matters. Don't criticize the ideas of others. Don't discuss the viability of the ideas while brainstorming.

• Combine and build on the ideas of others.

• Quantity matters more than quality. You can pare down the list of ideas later.

• If you cannot entertain ideas due to limited resources, note this limitation by putting those ideas in a “parking lot” that can be addressed at a later time when resources allow.

Choose the Brainstorming Approach That Suits Your Practice

• Use the freewheeling approach where group members call out their ideas spontaneously while a scribe records the ideas as members suggest them.

• Use round-robin where each member gets a turn to share an idea. Participants may pass on any round, and the session continues until all members have contributed at least once.

• Use an individual or silent approach where each participant writes ideas on sticky notes and passes them to the facilitator.

• Try a combination. If your practice finds that multiple approaches could work, use a combination. Give everyone one to 2 minutes to brainstorm silently, followed by the approaches that best fit your practice.

Categorize the Suggestions to Help Create Focus

• Begin to organize the ideas into categories if you have time during the brainstorming session. If you don't have time, the facilitator can organize the ideas later.

• Eliminate or “table” ideas that are not currently realistic for your practice, such as an idea that requires hiring a new employee or one that requires the electronic health record (EHR) to function in a way that is not possible.

• Let people know why some suggestions were eliminated, so it does not appear that you are neglecting particular ideas.

Invite the Group to Choose One or Two Ideas to Pilot

• Consider “multi-voting.” For example, give everyone 5 pennies. Label cups with the ideas that they're voting on. Team members can use their pennies to vote for the ideas that they support. They have the option to place all 5 pennies in one cup to support one idea, place one penny for each cup if they support all 5 ideas, or any combination in-between. The cup with the most pennies wins. The advantage of this process is that it can be anonymous.

• Create an impact–effort matrix (Figure 1). The matrix will help your practice determine where ideas fall on a scale of high to low effort regarding implementation and impact. Participants can rate each idea on the impact they think it will have and the effort it will take to implement. You can also do this as a group with sticky notes, a whiteboard, and a coordinate grid. The y-axis can be labeled “impact,” while the x-axis is labeled “effort.” Ask the group to place their sticky notes on the matrix based on the impact and effort they believe each idea will have.

Quiz Ref IDA team compact is a written document that details how team members should treat each other. Everyone in your practice should contribute to the team compact. The process of creating the compact can be more important than the final product, as team members will be more invested and motivated to adhere to the compact if they are involved in its creation. The process of drafting a compact strengthens team culture by focusing the team on the values at the core of the practice's culture. Annually updating the compact gives your team an opportunity to make appropriate changes and involve new team members in making cultural decisions. Some organizations refer to it as a “code of conduct” and is required to be agreed to by all new hires and annually by all those employed by the medical practice.

The team compact should include a list of observable behaviors. Some examples include, “I will treat my colleagues with respect” or “I will arrive on time and evenly share my work with my teammates.” Listing specific behaviors lets the team reinforce positive behaviors that help shape a productive work environment.

The 5 STARR service model tenets can also be used as the basis for a compact or on their own to detail how team members should behave towards each other. “STARR” stands for Service, Teamwork, Attitude, Reflection, and Renewal.

Co-location, morning huddles, warm handoffs, end-of-day debriefs, and weekly team meetings can strengthen relationships and help to build a positive team culture.

Teams that have frequent face-to-face exchanges perform better than those that don't. One study found that an increase in face-to-face communications in a practice or organization reduced the number of emergency room (ER) and urgent care visits among their patients and decreased the global costs of care by nearly $600 per patient per year.⁵

Regular team meetings that take place weekly or every other week make a huge difference in your practice culture. Making team meetings a regular occurrence can improve relationships and productivity while further emphasizing the importance of teamwork.

Meetings should be scheduled based on team members' availability, though it may be necessary to adjust patient scheduling so that everyone can be present. Distribute an agenda covering key discussion items in advance. Assign one team member to lead the meeting, one to act as a timekeeper to keep the meeting focused, and one to act as a recorder to take notes on the discussion. The meeting should be used to build relationships, discuss important updates, and solve problems. Make a point to start and end on schedule, showing respect for everyone's time. For more information, see the AMA STEPS Forward™ toolkit, Team Meetings.

People thrive in work environments where they can continue to learn and grow. Create opportunities for the team to take on new responsibilities. Encouraging team members to take courses, get a degree, and take on new roles and responsibilities sends a powerful message about a practice's values. In one clinic, the manager and medical director meet annually with every team member. During this review, they discuss goals for advancement for the upcoming year and for the next 3 years. Discussing these goals helps team members establish a plan to attain their goals. Individuals who know that their team is invested in them will be more engaged in their interactions and work, leading to better performance.

“Culture is the sum total of shared habits and expectations. Culture has tremendous inertia. That's why it's culture. It works because it lasts.”

—Bill Thomas, MD, Excerpt from the book Being Mortal by Atul Gawande, MD⁷

It may seem obvious, but getting to know your team members is a simple way to strengthen team culture. Simple methods to learn more about your colleagues and improve team spirit include:

• Celebrate birthdays, work anniversaries, a new team member joining, promotions, and retirements.

• Celebrate your local sports teams, including letting people break the dress code and wear shirts with their favorite team's logos.

• Celebrate holidays.

• Host potlucks or institute a monthly rotation where specific team members, such as the nurses or doctors, cook for the rest of the practice.

• Foster new relationships across multiple groups in your building (eg, primary care and specialty practices) by finding opportunities to connect all groups to get to know each other.

• Eat lunch together. Studies show that something as simple as rearranging the lunchroom to have one large communal table improves how well a team functions. This arrangement encourages people to sit next to someone they may not know.

“Walk a mile in my shoes” is another exercise used to get to know team members and their roles. At an initial team meeting, break everyone into groups based on their roles (ie, front desk personnel, medical assistants, nurses, doctors). If a team member has a specialized role (eg, you only have one nurse care coordinator), that person should do this initial exercise alone, allowing every team member to orient themselves with respect to their own role and those of their colleagues. Use a structured brainstorming technique (see examples in STEP 2) to answer a few of the questions listed below:

1. What is your role?

2. What training did you receive to do your role?

3. What is not part of your role?

4. What do you do during a typical day?

5. What do you like about your job?

6. What don't you like about your job?

7. What can others on the team do to help you do your job better?

8. Is there anything else you think other people would find useful or interesting about your role?

Have a team member in each group record the ideas generated during the exercise and eliminate duplicate responses. You may discover that some team members enjoy aspects of their role that others in the same position do not like.

Each group should then take 5 to 10 minutes at a subsequent meeting and present their answers to the entire team. Encourage everyone on the team to participate, even if it means each team member presents one answer to a question of their choice. Leave time for questions from other team members.

Leadership plays a significant role in setting the tone for the culture of the practice. Successful team cultures promote leadership that emphasizes teaching and mentoring over traditional management structures. Physicians and advance practice providers (APPs) use leadership and coaching daily through communicating with and teaching patients, so strive to use those skills in your interactions with your teams as well.

There are others who lead on your team (eg, other practitioners, nurses, administrators) who should be recognized and fostered in their leadership roles.

Effective leaders should:

• Facilitate, encourage, and participate in improvement efforts alongside patients and team members

• Communicate clearly to keep all team members on the same page and moving in the same direction

• Demonstrate humility and show interest in their team members—all members of the team have something to share or give, and there is always more to learn

• Teach, guide, and coach patiently and with clarity

• Build day-to-day processes loosely to give the team flexibility to do their work most effectively

• Protect and foster the processes that impact team culture

Leaders can teach the practice how to give positive and actionable feedback. Like any skill, giving feedback needs to be taught and practiced before it becomes a habit. You may find it helpful to receive training on providing useful feedback from someone outside your organization. Once you are trained, practice giving feedback for a few months until it becomes comfortable and routine.

Suggestions for giving feedback:

• Reinforce and encourage positive behavior.

• Give positive feedback in public so that other team members can learn by example. Shout-outs at team meetings are a good forum for giving positive feedback. Use caution with this approach, though, and make sure your shout-outs are spread around the group, rather than being focused on a few individuals. This approach can keep everyone encouraged and engaged.

• Give negative feedback constructively and in private. The goal of negative feedback is not to embarrass or shame the person receiving it, but to help them improve.

• Ensure feedback is specific to the action (eg, “you were observed using your phone during work time”) and not the person (“you are goofing off”).

• Provide timely feedback.

One challenge for many leaders is that they spend most of their time in rooms with patients or in front of computers by themselves. This limits their opportunities to coach the team they lead. Consider spending more time with your team and learning about their work. This can be done when a patient “no-shows,” before or after a session, or over lunch. Ask how things are going, how you can help, and use the feedback to find areas that can improve.

A robust team culture will enable a practice to remain nimble in today's ever-changing health care environment. Identify opportunities for improvement and promote continuous learning for both individual team members within the practice and the practice as a whole. This will help the team grow and evolve together, strengthening team culture. You can find tools to help your practice create an environment of learning and improvement in the AMA STEPS Forward™ Lean Health Care toolkit.

Quiz Ref IDPhysicians and other health care professionals are often too close to their work to experience health care as their patients do. Fortunately, when asked, most patients will share feedback with you. There are multiple ways to engage patients in an effort to redesign your operations and culture:

1. Focused surveys

   If you have specific questions about a process, policy, or pilot program, ask patients what they think. Create a 1- to 3-question survey and ask patients to complete it at checkout. Emailing a survey link is another cost-effective way to obtain patient feedback.

2. Patient/Family Advisory Council

   Do you frequently solicit patient input? Patient and family advisory councils can help strengthen relationships with your patients and communities.⁸ Select the right patients from your practice and form an advisory council. Some patients may be happy to volunteer their time to serve as a sounding board to help the practice develop its team culture. Advisory council meetings can occur at a frequency that works best for the practice, such as monthly or quarterly. Members are often treated to dinner during evening meetings or given a small gift card to show appreciation for their time. Patient volunteers should be able to:

   • See beyond their own personal experiences

   • Listen well

   • Respect the perspectives of others

   • Speak comfortably in a group

   • Help the practice attain its goals

Team culture is an indicator of the health of an organization. Use the strategies in this toolkit to build and strengthen your team and improve your culture.

Journal Articles and Other Publications

• Newbell B, Schafer D, Pfenninger JL, et al. 10 big ideas that could make your practice better. Fam Pract Manag. 2008;15(8):33-41. http://www.aafp.org/fpm/2008/0900/p33.html

• Woolley AW, Chabris CF, Pentland A, Hashmi N, Malone TW. Evidence for a collective intelligence factor in the performance of human groups. Science. 2010;330(6004):686-688. doi:10.1126/science.1193147

• Hochman M. Improvement happens: team-based primary care, an interview with Stuart Pollack. J Gen Intern Med. 2015 Apr; 30(4): 521–528. doi:10.1007/s11606-014-3119-z

• Toussaint J. A management, leadership, and board road map to transforming care for patients. Front Health Serv Manage. 2013;29(3):3-15. https://journals.lww.com/frontiersonline/Abstract/2013/01000/A_Management,_Leadership,_and_Board_Road_Map_to.2.aspx

• Woolley M, Malone TW, Chabris CF. Why some teams are smarter than others. The New York Times. January 16, 2015. Accessed February 16, 2021. https://www.nytimes.com/2015/01/18/opinion/sunday/why-some-teams-are-smarter-than-others.html

• Nutting PA, Crabtree BF, Miller WL, Stange KC, Stewart E, Jaén C. Transforming physician practices to patient-centered medical homes: lessons from the National Demonstration Project. Health Aff (Millwood). 2011;30(3):439-445. doi:10.1377/hlthaff.2010.0159

Videos and Webinars

• Chapman B. Truly human leadership: Bob chapman at TEDxScottAFB. TEDx Talks. June 20, 2012. Accessed February 16, 2021. https://www.youtube.com/watch?v=njn-lIEv1LU

Websites

• Surveys on Patient Safety Culture™ (SOPS®). SOPS medical office database. Agency for Healthcare Quality and Research. Last reviewed March 2020. Accessed March 4, 2021. https://www.ahrq.gov/sops/databases/medical-office/index.html