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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
0.5 Credit CME
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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

Introduction

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.

Watch how Brigham and Women's Created Team Culture

Physicians at Brigham and Women's Advanced Primary Care Associates share their experiences regarding team culture: why creating a cohesive environment is beneficial in the practice setting and for patient care and satisfaction

Ten STEPS to Cultivate Strong Team Culture in Your Practice

  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

STEP 1 Diagnose the Current State of Your Team Culture

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
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Q&A

  • Why focus on team culture in your practice?

    Your practice's culture may be more impactful than individual strategies and policies you adopt. In fact, it has been said that “culture eats strategy for lunch.”3 You can change your culture to be one that will flourish in the current rapidly changing health care environment. Furthermore, there is a feedback loop—if your practice's team culture is healthy, it will influence the success of your practice's operations.

  • What drives successful team culture in health care?

    The attributes that are found in medical practices with successful team cultures include:

    • Integrated teams

    • Continuous learning opportunities

    • Methods to engage patients in meaningful ways

    • Team members with strong communication and listening skills

STEP 2 Discuss the Results and Brainstorm Possible Improvements

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.

Figure 1. Impact–Effort Matrix
STEP 3 Create a Team Compact

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.

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Q&A

  • How do we get everyone to participate in creating the team compact?

    The following process should encourage broad participation:

    1. Set the stage using a “get to know each other” activity, for example with an icebreaker.4 You can also ask participants to share positive team experiences, such as winning a high school basketball championship or their first job as a teenager.

    2. Do small group brainstorming sessions. Focus on cultural questions like “What do you expect from the people you work with?” and “What are you willing to promise them?”

    3. Specify a facilitator and have them compile those ideas into a single document.

    4. Consider letting the group review other compacts for more ideas to add to the list.

    5. Combine similar ideas into single bullet points and organize them into categories like communication or helping others.

    6. Discuss the ideas with the group, limiting the length of the document using voting methods.

    7. Share the draft compact with the team to allow them the opportunity to make further contributions or revisions. Adjust the document based on the feedback received.

    8. Vote for the final version of the team compact. The goal is to reach a group consensus where each team member is satisfied with the final document.

    9. Post laminated, colorful copies of the new team compact in all the offices and team rooms.

    10. Refer to the team compact when conflict arises to remind everyone of their commitment to each other. As a team, discuss the compact prior to culture-building activities.

STEP 4 Create Opportunities for Team Communication Throughout the Day

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

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Q&A

  • Our doctors prefer private offices. How can we show them co-location could be good for our teams?

    Co-location means strategically seating team members near each other and allows teams to have multiple brief conversations during clinical sessions. It is easier for team members to communicate if they are near each other. Co-location helps foster more interactions. Communication builds camaraderie, trust, and reliance among team members.

    Co-location also creates efficient workflows, so the workday can end earlier. The nurse or medical assistant (MA) and physician can discuss messages verbally rather than having time-consuming conversations over email or batching communications for the end of the day. Creating opportunities for team members to naturally interact not only improves collegiality, but may also result in better patient outcomes and lower health care costs.6

  • What is a huddle?

    Huddles are informal, 5- to 10-minute meetings that often occur before the clinic day or session starts. In these brief meetings, the team might discuss staffing (eg, who is out today and who is filling in), the needs of particular patients on the schedule, the team's needs, and any schedule changes.

    Huddles get the team on the same page about the clinic workflow each day. Letting the non-physician members run the huddle helps break down some of the hierarchy that can damage team culture. This also helps shift the practice's culture from physician-centric to one that fosters teamwork and team-based patient care. Huddles not only change team culture, but they also make the day run more efficiently and improve patient care.

  • What is a warm handoff?

    A warm handoff happens when patient care transitions directly from one team member to another. For example, after rooming a patient, the physician enters the room and the nurse or medical assistant explains to the physician in front of the patient what he or she has learned about the patient during rooming. Another example is a physician introducing a patient to the behavioral health specialist and giving a brief synopsis of the patient's case. Warm handoffs make it clear to the patient that their doctor and other professionals involved in their care work together on the patient's behalf.

  • At the end of the day, we all pack up and head home. Is there a positive way to conclude the day?

    Some clinics have found that a quick debrief at the end of the day allows teams to reflect on the good work they have done together or to call attention to a process that should be added to their weekly team meeting schedule.

STEP 5 Meet Regularly

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.

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Q&A

  • What activities can we use in meetings to help build team culture?

    Here are 4 ideas to consider, as mentioned briefly above:

    • Icebreakers can provide a chance for team members to learn something new about each other. To bring energy to the meeting, try an activity that involves movement.

    • “Shout-outs” provide teams with the opportunity to publicly praise teammates who have done something great. Shout-outs encourage team members to emulate positive behaviors, recognize that their work is valued, and enhance team spirit. It is also an opportunity to thank each other for team initiatives.

    • Tell stories. Stories are how you figure out who you are as a group—an essential aspect of culture. Encourage your colleagues to share stories that exemplify teamwork or great patient care.

    • Find a piece of data and review it with your team. Some people respond to stories, some respond to data, and some team members will respond to both. Stories and data are complementary. Stories tell you who you are; data tells you how you are doing.

  • We are worried about losing revenue by spending time in a meeting that could be spent with patients. What should we do?

    Improving how your practice functions is worth every penny. You will make up the time devoted to the meeting by making your workflow more efficient, thus freeing up time to see patients. If time is a serious concern, you may need to meet before the clinic opens, at lunch, or at the end of the day—though that risks sending the message that team building and improving culture are not real work.

  • The doctors meet regularly. Does that count?

    To build a strong and effective culture you must involve team members from all levels in your practice. Individual members of the team may still need to meet separately (eg, physicians, nurses, medical assistants) but this would not be considered a team meeting.

STEP 6 Strengthen the Team by Focusing on Individual Development

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
STEP 7 Get to Know Your Team Members

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.

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Q&A

  • How can we build culture from the first day of employment?

    One organization begins to build culture during the job interview process by having a patient interview the prospective employee. Another includes shadowing as part of the orientation process. For example, a medical assistant spends time in the call center to observe how work there will impact their future work in the clinic.

STEP 8 Teach Leaders to Be Mentors, Not Managers

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.

STEP 9 Create an Environment That Supports Continual Learning

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.

STEP 10 Engage Patients

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

Conclusion

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.

Box Section Ref ID
Graphic Jump Location
AMA Pearls

AMA Pearls

Connect with colleagues

Intentionally sharing meaningful stories and experiences with co-workers makes for a richer work life and environment. Giving these stories a title, such as “the reason I came to work today,” can help team members overcome any reluctance to speak positively about the value of their work.2

Observe your team IQ

Research shows that teams have an IQ. A smart team is one that emphasizes the “equality in distribution of conversational turn-taking,” which essentially emphasizes the importance of all team members having a voice.3 To gain the full benefit of your practice's team IQ, use the tactics in this toolkit to synergistically combine every team member's knowledge and problem-solving abilities to create better results than each individual could achieve on their own.

Create your practice “tribe”

According to Dave Logan's book, Tribal Leadership, very few workplaces have the giant “uni-cultures” exhibited by companies such as Zappos and Nordstrom.9 In fact, his book argues that culture lives at the tribe level in groups of 25 to 100 people. Interestingly, this is the typical number of people found in our cell phone address books and the size of the average group of primates.9 Using this logic, this toolkit can help change culture at the practice level. Even as practices merge with other groups to form larger health care systems, individual practices can retain aspects of their own culture if they are aligned with the mission and vision of the larger organization.

Use Lean to build your culture

Lean has become a popular way to improve processes in the health care setting. Lean is successful because it involves everyone on the team and helps to change the relationship between team members and team leaders, which helps build a stronger culture. When done well, Lean builds continuous learning, integrated teams, and collective intelligence. See the AMA STEPS Forward™ toolkit on starting Lean Health Care in your practice.

Further Reading

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AMA STEPS Forward® presents actionable, practical toolkits and customizable resources that you can use to successfully implement meaningful and transformative change in your practice or organization. See How it Works

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

0.5 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;

0.5 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;

0.5 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program; and

0.5 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program;

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

Article Information

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this enduring material activity for a maximum of 0.50 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

If applicable, all relevant financial relationships have been mitigated.

Credit Renewal Dates: February 22, 2016, May 23, 2019, May 20, 2021

References
2.
Medical office survey on patient safety culture.  Surveys on Patient Safety Culture™ (SOPS®). Agency for Healthcare Research and Quality. Last reviewed October 2020. Accessed March 4, 2021. https://www.ahrq.gov/sops/surveys/medical-office/index.html
3.
Coffman  CW, Sorensen  K.  Culture Eats Strategy for Lunch: The Secret of Extraordinary Results Igniting the Passion Within. Liang Addison Press; 2013.
4.
Toastmasters International.  Icebreaker: level 1 project.  Accessed February 15, 2021. https://www.toastmasters.org/websiteApps/Pathways/IceBreaker/tm100101/resources/8101%20Ice%20Breaker.pdf
5.
Mundt  MP, Gilchrist  VJ, Fleming  MF, Zakletskaia  LI, Tuan  W, Beasley  JW, .  Effects of primary care team social networks on quality of care and costs for patients with cardiovascular disease.  Ann Fam Med. 2015;13(2):139–148. doi:10.1370/afm.1754Google ScholarCrossref
6.
Nelson  KM, Helfrich  C, Sun  H,  et al.  Implementation of the patient-centered medical home in the Veterans Health Administration: associations with patient satisfaction, quality of care, staff burnout, and hospital and emergency department use.  JAMA Intern Med. 2014;174(8):1350–1358. doi:10.1001/jamainternmed.2014.2488Google ScholarCrossref
7.
Gawande  A.  Being Mortal: Medicine and What Matters in the End. Metropolitan Books; 2014.
8.
Fondrick  M, Johnson  BH.  Creating patient and family advisory councils.  Institute for Patient- and Family-Centered Care. April 2019. Accessed February 16, 2021. http://www.ipfcc.org/resources/Advisory_Councils.pdf
9.
Logan  D, King  JP, Fischer-Wright  H.  Tribal Leadership: Leveraging Natural Groups to Build a Thriving Organization. Harper Business; 2011.

Disclaimer: AMA STEPS Forward® content is provided for informational purposes only, is believed to be current and accurate at the time of posting, and is not intended as, and should not be construed to be, legal, financial, medical, or consulting advice. Physicians and other users should seek competent legal, financial, medical, and consulting advice. AMA STEPS Forward® content provides information on commercial products, processes, and services for informational purposes only. The AMA does not endorse or recommend any commercial products, processes, or services and mention of the same in AMA STEPS Forward® content is not an endorsement or recommendation. The AMA hereby disclaims all express and implied warranties of any kind related to any third-party content or offering. The AMA expressly disclaims all liability for damages of any kind arising out of use, reference to, or reliance on AMA STEPS Forward® content.

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