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Authors: Kristin Watson, PharmD, BCCP; Brent N. Reed, PharmD, MS, BCCP; Zachary R. Noel, PharmD, BCCP; Stormi E. Gale, PharmD, BCCP; Sandeep Devabhakthuni, PharmD, BCCP
Teams have become ubiquitous across the workforce, and health care is no exception. Interprofessional teams are considered the optimal approach to patient care given the diverse expertise needed to overcome the complexities of the modern health care landscape.1 Although many health care organizations are affiliated with academic institutions, the latter are more often characterized by silos than teams.2 However, as academic institutions face many of the same challenges as health care organizations (i.e., increasing complexity, escalating workload in the face of limited resources), teams are likely to become more critical in meeting organizational goals.
The role of teamwork in improving organizational performance has been well-established by several decades of research.3 One of the most commonly cited explanations for this finding is that shared mental models allow team members to coordinate their efforts and persevere even in the face of increasing workloads.4 Indeed, evidence suggests that the collective efficacy of a team is more predictive of future performance than the individual efficacy of its members.5
Another benefit of teamwork is that it can promote positive work-related outcomes while also buffering the detrimental effects of escalating workplace demands. The social support provided in a team environment has been linked to greater job satisfaction,6 and these effects may even compensate for deficiencies in organizational leadership.7 A shared sense of optimism among team members can also increase workplace engagement (considered by some experts to be the antithesis of burnout), even after controlling for job demands.8 Regardless of team structure or composition, a culture of teamwork appears to buffer the effects of burnout.9
Given the limited use of teams in institutes of higher education, the objective of this paper is to describe the creation of a clinical faculty team, including the fundamentals of team development and strategies for implementation, using the Applied Therapeutics, Research, and Instruction at the University of Maryland (ATRIUM) Cardiology Collaborative as a case study. Although a variety of frameworks exist for describing team structure and function, we will rely on those used by the National Academy of Medicine given their familiarity to many readers of the journal.
The ATRIUM Cardiology Collaborative
The mission statement and sample goals for the ATRIUM Cardiology Collaborative are provided in Figure 1. The mission and initial goals for the group were developed by the founding members and their department chair. The idea for the ATRIUM Cardiology Collaborative developed during an impromptu discussion with their three founding members and the department chair. The intent was to develop a formalized team to coordinate strategies, capitalize on individual strengths, and to promote the work of the cardiology faculty in strategic manner. The department chair has served as ATRIUM’s “coach” since inception in 2015. Administrative and operational support is provided by “assistant coaches”, who support ATRIUM initiatives and aid in creation and procurement of marketing materials and other administrative efforts. The founding members, still involved today, are cardiology practice faculty in the Pharmacy Practice and Science Department at the University of Maryland School of Pharmacy. Colleagues, friends, and family were asked to provide input on creating the team name. The department provides financial support for the Collaborative. Two additional cardiology practice faculty elected to join shortly after their employment at the school.
Characteristics and fundamentals for a successful team
Teams should possess certain characteristics in order to be successful. First, the team needs to be comprised of individual “players” who will be consistently committed. Each player needs to have interdependence and boundaries. Clear and achievable goals should be defined. Goals can be assigned, designed and/or reframed by the team. High-functioning teams include members with characteristics that enable the team to be effective.10 These personal characteristics include honesty, discipline, creativity, humility and curiosity.11 Additionally, a structure that provides support and resources is required. Finally, a team should have a coach who is easily accessible, able to provide guidance to navigate barriers, and promote thinking and innovation.10,12–14
The National Academy of Medicine has sought to provide guidance to optimize team-based health care through coordinated efforts between patients, providers, administrators, etc. 11 More recently, the Academy issued a series of recommendations to improve clinician well-being, several of which relate to redesigning work in ways that facilitate team-based care. Five fundamentals for high-performing teams have been identified.1,11 The Table lists these principles and the definition for each. Each fundamental will be discussed in detail along with examples on how they apply to the ATRIUM Cardiology Collaborative.
Table. Fundamentals for High-Performing Teams1,11,18
|Shared Goals||The team establishes shared goals that can be clearly articulated, understood, and supported by all members.||– Used SMART framework to develop achievable goals.
– Reviewed goals on an annual basis due to changes in interest, priorities, the return on investment, and/or innovative ideas.
|Clear Roles||Clear expectations for each team member’s functions, responsibilities, and accountabilities to optimize team efficiency and effectiveness.||– Assigned focus area leads with well-defined roles and responsibilities that aligned with individual strengths and interest areas.
– Assigned a director to ensure that each member is held accountable in completing their responsibilities.
– Attended quarterly meetings and annual retreats to review progress and assess team efficiency and effectiveness.
|Mutual Trust||Team members trust one another enough to admit a mistake, ask a question, offer new data, or try a new skill without fear of embarrassment or punishment.||– Allowed focus area leads autonomy in setting expectations and deadlines for their assigned activities.
– Established culture where individuals can request assistance or additional time without any judgment if obstacles occur.
|Effective Communication||The team prioritizes and continuously refines its communication skills and established consistent channels for bidirectional communication.||– Used storage platforms to provide ready access to the most current information.
– Provided Progress updates using Microsoft Office® Excel
– Tracked research progress in Microsoft Team®
|Measurable Processes and Outcomes||Reliable and ongoing assessment of team structure, function, and performance that is provided as actionable feedback to all team members to improve performance||– Assessed progress and challenges at quarterly meetings
– Recognized and celebrated individual team member’s major accomplishments (e.g., promotion, baby shower, publication)
ATRIUM, Applied Therapeutics, Research, and Instruction at the University of Maryland; S.M.A.R.T., Specific, Measurable, Attainable, Realistic, Time-bound
Principle 1: Shared Goals
To facilitate goal commitment, each team member plays an integral role in both creating and refining goals. These goals should be clear and agreed upon by all members of the team. 1,11 Setting goals serves as a motivator and enables a team or individual to focus their attention.15 Commitment to well-defined goals has been shown to drive performance even when faced with challenging objectives.16,17 The Specific, Measurable, Attainable (or assignable), Realistic, Time-bound, or S.M.A.R.T., framework draws upon several decades of goal-setting research and can serve as an effective tool when developing goals (Figure 2).18,19 Goals should be specific, attainable, and explicit in order to prevent ambiguity and enable more precise performance.17 Furthermore, setting achievable goals can promote a sense of accomplishment, and the ability to prove oneself.17,20 Each goal should include a quantifier to measure progress and identify goal attainment. Available resources should be considered to ensure goals can be realistically completed. Unrealistic goals should be avoided because they may set an individual or team up for failure.18 Finally, including a realistic time-frame for goal achievement should be carefully considered and clearly stated. Hasty turnaround times that limit performance have been shown to reduce the likelihood of success. 18,20,21
On an annual basis, ATRIUM members review team goals. The group discusses if any changes or revisions are warranted. Modifications are made only if unanimously agreed upon. Each goal is written according to the S.M.A.R.T. framework and discussed with the department chair before implementation. Goals may evolve over time due to changes in interest, priorities, opportunities, or resources. These may also change as a result of a perceived limited return on investment. For example, routine creation of YouTube™ videos was previously a goal for ATRIUM; however, the group determined that the benefits of these were outweighed by the intensive effort to produce them and thus is no longer a team goal. The time previously spent on this activity has been channeled elsewhere (e.g., social media, infographic design, American Heart Association® Basic Life Support instruction).
Principle 2: Clear Roles
The second fundamental principle of a highly functioning team is delineating clear roles and responsibilities for each member.1 Failure to do this may lead to unequal distribution of workload (whether perceived or actual). Role conflict and role ambiguity has been shown to cause personal job dissatisfaction, workplace tension, decreased productivity, and turnover.22–25 It is recommended to align roles and responsibilities with each individual’s strengths and interest areas. However, individuals should also allow for flexibility in certain situations. Finally, accountability for individual responsibilities is key in maintaining a high-functioning team. 1,11
For several years, there was no team “captain” for the ATRIUM Cardiology Collaborative, and each member rotated oversight of various initiatives. Occasionally, members supervised events or projects that were not aligned with their interest areas and/or strengths. Given the importance of clear roles and the impact it has on team performance, the ATRIUM Cardiology Collaborative developed an annual, one-day retreat to review roles and responsibilities. Over the years, this retreat has been used to create roles based on individuals’ strengths and interests; these include a director and three “leads”. Each role includes a defined set of responsibilities (Appendix). For example, the Social Media lead for ATRIUM is responsible for overseeing all social media outlets, including Twitter® and blogs. A clearly defined list of tasks related to social media was also created (e.g., creating a social media schedule, providing quarterly updates on performance and analytics). An equally important part of the annual retreat is critically appraising each person’s role to ensure equitable workload distribution and realigning with team members’ interests.
Principle 3: Mutual Trust
Honesty is a critical element of building and maintaining trust between team members. Trust impacts job performance, citizen behavior in the workplace, and job satisfaction, among other outcomes.26–28 Clear protocols should be developed to guide action if concerns with or breaches in trust occur. The benefits of developing trust can extend into other professional and personal interactions. Other values – discipline, humility, creativity, and curiosity – further enable the development and sustainability of strong relationships. Recognizing and respecting team culture is also fundamental. As such, activities that allow the opportunity for team members to learn more about one another is important.1,11 Finally, celebrating the successes of both individuals and the team can forge relationships and may thwart burnout.1,11,29
Fortunately, the founding members of ATRIUM had already established a level of trust prior to forming the Collaborative. Conducting periodic SWOT (strengths, weakness, opportunities and threats) analyses has promoted self-discovery and enabled members to freely voice their opinions.30 This practice has enhanced trust between all members. Other successful strategies to maintain trust include empowering area leads to develop plans for their respective activities. Strong relationships bolster confidence in assigned activities and the ability to effectively communicate (to be described further below) should modifications in tasks and/or deadlines be required. The group also seeks input from the department chair and/or administrators when hurdles arise. The group has found that allowing each person to be him/herself is instrumental in maintaining trust. No judgment is passed on other’s personalities, priorities, etc. Instead, unique qualities and strengths are embraced. Relationships are further cultivated through celebratory gatherings and public recognition on social media to highlight team members’ achievements.
Principle 4: Effective Communication
Developing successful communication strategies may depend on both individual preferences and available technologies. The National Academy of Medicine states that “effective communication should be considered an attribute and guiding principle of the team.”11 High-performing teams have implicit coordination; teammates anticipate and share information before it is needed rather than waiting to communicate when asked to do so (explicit coordination). Implicit coordination also relies on dynamic adjustment, team members amending, and mutually adopting new behaviors. 30,30–32 Implicit coordination is the habitual process that the team utilizes to coordinate efforts.33 Effective communication also includes a defined documentation process, and it is imperative that the team environment encourages open-lines of communication between members.34 Additionally, communication methods need to be standardized, taking personal preferences into consideration when possible.1,11 Altogether, these features serve as the essential building blocks of a shared mental model between team members.
ATRIUM Cardiology Collaborative has created a standardized process for communicating and sharing information. For example, files are stored on a shared online platform using clearly defined folders and standardized file names. Use of file storage platforms (e.g., Dropbox™, Google Drive™, Microsoft® SharePoint®) may facilitate timely access to current information. Folders should be clearly labeled and structured to prevent ambiguity. A consistent naming convention for shared files (e.g., minutes labeled as 20XX_Month_Day_Team_Minutes) in addition to other customary procedures have been developed. ATRIUM’s research projects are updated on a quarterly basis using a standardized process on Microsoft Teams®. Furthermore, each team lead is responsible for providing a quarterly update so all members can see each other’s progress. Because many of the activities coordinated by the leads involve all members, progress on these are discussed at each team meeting. Other effective communication practices include clearly stating deadlines and routinely meeting on a quarterly basis.
Principle 5: Measurable Process and Outcomes
The National Academy of Medicine recommends developing a process that allows for rigorous, continuous, and deliberate measurement of team goals.1 Outcome measures are designed to evaluate what a team sets out to achieve.35 Setting goals utilizing the “S.M.A.R.T.” framework provides a framework for evaluating progress. A timeline for reporting goal progress should be established early on. Frequent review of goal progress allows for identification of potential barriers. Action steps should be created when substantial progress does not occur and/or if there are concerns regarding the ability to fulfill the goal in the established timeframe. Individual satisfaction with the team and their responsibilities should also be assessed on a regular basis.1,11,29
Completing SWOT analyses is one mechanism that ATRIUM uses to identify barriers and how to overcome them. All members meet in-person on a quarterly basis to discuss goal progress. Team leads propose any necessary changes to stay on track with their respective goal(s). Other members provide input on strategies to assist with goal fulfillment, if needed. A detailed outcome report is prepared, shared, and discussed with the team coach twice a year. Members maintain an open line of communication so that challenges or time-sensitive issues can be shared outside of quarterly meetings, too.
In part 2 of this blog, we discuss tips for creating your own team as well as common challenges that arise within teams and how to overcome them.
Kristin Watson, PharmD, BCCP
Brent N. Reed, PharmD, BCCP, FAHA
Dr. Reed is an associate professor in the Department of Pharmacy Practice and Science at the University of Maryland School of Pharmacy, and practices as a clinical pharmacy specialist in advanced heart failure at the University of Maryland Medical Center in Baltimore, MD. Follow him on his website or on Twitter @brentnreed.
Zachary R. Noel, PharmD, BCCP
Stormi Gale, PharmD, BCCP
Sandeep Devabhakthuni, PharmD, BCCP
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