Transcript
Speaker: Welcome to Critical Matters, a sound critical care podcast covering a broad range of topics related to the practice of intensive care medicine.
Speaker: Sound Critical Care provides comprehensive critical care programs to hospitals across the country.
Speaker: To learn more about our programs and career opportunities, visit www.soundphysicians.com.
Speaker: And now your host, Dr. Sergio Zanotti.
Speaker: Teams are an essential component of the practice of critical care medicine.
Speaker: We deliver care in the ICU as a team.
Speaker: We respond to medical emergencies as a team.
Speaker: And we work on teams to improve all aspects of the care we provide.
Speaker: Value for our patients is created at the bedside by a team of providers with a common purpose.
Speaker: We have all been part of good teams and we have all been part of bad teams.
Speaker: Today's episode of the podcast will focus on how to make a team better.
Speaker: Healthcare is an infinite game, and the purpose is to continue to play and improve the care we provide to our patients through improvements in ourselves and in our teams.
Speaker: In today's podcast, I will share a presentation I gave as part of our recent Sound Critical Care Leadership Week.
Speaker: But before we dive into the topic, I would like to make a request to our listeners.
Speaker: If you find the podcast useful, please share it with colleagues and take the time to write a review at whatever site you get your podcast from.
Speaker: Both of these will help us spread the message and increase our reach within the critical care community.
Speaker: Thank you very much for all the work you do at the bedside and thank you for listening to Critical Matters.
Speaker: And now, please join me for Above Average, How to Make Teams Better.
Speaker: Welcome all to our
Speaker: clinical webinar on teams.
Speaker: So the title of our presentation is Above Average, How to Make Teams Better.
Speaker: This is part of our Sound Critical Care Leadership Week.
Speaker: And I want to thank everybody for joining us and taking time out of your afternoon to talk a little bit about teams.
Speaker: So we'll go ahead and get started.
Speaker: And first, with a big thank you to all our teams, both at the bedside and our business teams, supporting our teams at the bedside.
Speaker: with all you've done over the last several months, taking care for our patients, creating value at the bedside, and really showing the best versions of yourselves during these very difficult times with COVID-19.
Speaker: So we're all in this together, and I think that our teams are a critical point of this, and we felt it would be worthwhile exploring a little bit more topics related to team building, to what make teams great, and to why we care so much about teams.
Speaker: What I'll try to cover throughout this hour is start with a little bit of an introduction on the team conundrum and some of the dichotomies between how we grow up as individuals yet are expected to function and excel in teams.
Speaker: We'll look at what we can learn from great teams and what makes a team great.
Speaker: Try to understand a little bit about the science behind great teams and team building.
Speaker: And finally,
Speaker: we'll talk about some of the things or the most important thing that we can do actually as leaders.
Speaker: And when I refer to leaders, I think that I refer to every single one of you on this call.
Speaker: We can all lead from the seat that we have, no matter our title.
Speaker: And especially in the clinical arena, we are all leaders at the bedside.
Speaker: So try to figure out how we can move that needle and really make our teams break average and go above average.
Speaker: We'll start in the coast of Indonesia.
Speaker: with Dr. Smith circa 1930.
Speaker: Dr. Smith was a biologist and anthropologist who was exploring Southeast Asia in the 1930s.
Speaker: And he came upon an amazing event.
Speaker: He was going down a river late at night and all of a sudden it felt like the whole forest and all the mangrove trees just basically lit up with lightning.
Speaker: To his own amazement, a couple of seconds later, lightning
Speaker: hit again, struck for a second time, and then a third time, and then a fourth time.
Speaker: And eventually he realized that it wasn't lightning, but it was literally millions of fireflies that were lighting on at the same time in synchrony throughout the forest.
Speaker: He came back and wrote about his encounter, published a paper where he talked about this synchronous fire flying lighting.
Speaker: And he really was mothed and made fun by his
Speaker: scientific colleagues who argued that first a firefly uses his light to find the mate.
Speaker: So why would they do it together when that would actually be, go against their self-interest?
Speaker: And furthermore, they said, how are thousands or millions of fireflies going to figure out how to do it at the same time?
Speaker: So that was something that a lot of people disregarded and it was forgotten for some time, but eventually more people observed similar behaviors and not too long ago,
Speaker: in a very interesting paper published in Science.
Speaker: The theory or what he observed was actually proven with a very interesting algorithm.
Speaker: And what they found is that if a firefly lights up their light by themselves, their chances of finding a responsive mate are around 15 to 18%.
Speaker: However, if there's a cluster
Speaker: of light at the same time, those chances go up to almost 80%.
Speaker: And what they found is that the fireflies don't need to see all the other fireflies in order to be synchronous within milliseconds.
Speaker: All they need to do really is to see fireflies on both sides of themselves.
Speaker: And if every firefly is connected to another firefly, you can really have this phenomenon that was described with millions of fireflies lighting up in synchrony
Speaker: recognizing that nature is telling us that when they work together, they are more likely to succeed as individuals than when they work by themselves.
Speaker: So a really interesting phenomenon that starts in nature and really talks to the big potential of people or organisms working together to achieve better results for them as individuals.
Speaker: There is a paradox, however, in how we raise our children for the first 20,
Speaker: something years, I mean, maybe even 32 years, if you go to fellowship of your life, you are really recognized and praised for your individual achievements, for your grades, for your successes, for what medical school you get in, the residency.
Speaker: Yet when you move into the real world, what's demanded is that you're a part of a team and that you actually can contribute and work in a team.
Speaker: So that dichotomy, I think is something that we don't really think about in education.
Speaker: And we're really not as deliberate in training individuals for excelling in teams.
Speaker: We see this very much in medicine, and I think a great example would be CT surgery.
Speaker: I mean, we all recognize the amount of education, of training that CT surgeons require, but we also recognize especially that there's a common belief that the abilities of the surgeon
Speaker: really determine the outcome of the patient.
Speaker: And historically, a lot of the training and surgery has been around owning that responsibility and really putting all the emphasis of the technique and the captain of the ship on the surgeon themselves.
Speaker: This has been studied not too long ago in a very interesting paper by Robert Huckman and Gary Pisano from Harvard Business School, where they actually took two large groups of surgeons.
Speaker: Traditionally,
Speaker: Not only we believe that the surgeon's ability determines the outcomes of the surgery or the most important determinant of outcomes in those patients, but we also always attached to that thought would say that large volumes of surgeries in terms of experience are what also determine or important factors in a surgeon's ability and a surgeon's impact on patient outcomes.
Speaker: So what they did in this study has a very interesting, I mean, firm specificity of individual performance, evidence from cardiac surgery, is they took two groups of surgeons.
Speaker: They were all high-performing surgeons with high volume of cases, yet one group only operated at one institution, and the other one were what they called splitters, where they operated at different institutions.
Speaker: And what they found was that the number of cases that a surgeon does per year or has
Speaker: done only impacts outcomes at one site.
Speaker: So you can't take your 10,000 aortic replacement cases to a new site and immediately make that experience work and impact the outcomes.
Speaker: And what it really is telling us that the team that you work with is really what matters or has a greater incidence on the outcome.
Speaker: And that's the combined experience of that team that ultimately really correlates with patients' outcomes.
Speaker: So the first thing that we learn is that the team has a much greater weight and impact on the outcomes of patients than the individual.
Speaker: There is also a common conception in the cognitive psychology related to our ability to measure general intelligence in individuals, and that's IQ and other tests.
Speaker: And we know that in general, a higher IQ is associated with a greater ability to solve
Speaker: different types of problems.
Speaker: It doesn't determine everything, but there is a general intelligence that can be measured in individuals.
Speaker: A group of investigators that included investigators from Carnegie Mellon, University of Pittsburgh, from MIT, and other institutions actually conducted a very interesting study and they had a hypothesis that groups like individuals have a measurable characteristic levels of intelligence
Speaker: which can be used to predict groups performance on a variety of tasks.
Speaker: So for example, how they solve a video game, how they design an architectural challenge, how they solve a puzzle, and many other types of cognitive group exercises.
Speaker: And they call this the C factor.
Speaker: And after multiple studies, they eventually found that the C factor is what correlates the most
Speaker: with the ability of a given team, whether it be three or eight or more people, to solve certain challenges and to perform a variety of tasks.
Speaker: And what they found is that the impact or the ability of this C factor to predict the ability of a team to perform is significantly more robust than the individual average intelligence of the members or
Speaker: than the maximum intelligence of a member within that group.
Speaker: And the C factor was correlated with two very interesting points.
Speaker: One was the average social sensitivity of the group members, which is basically the ability a person has to read your mood.
Speaker: And that is tested by basically looking at photographs of different people and different animals and just looking at photographs of their eyes and trying to interpret are they feeling or are they thinking.
Speaker: It's very interesting that on average, females have a much better average social sensitivity.
Speaker: So also, paired to that, a larger number of females in the group also helps in terms of predicting a higher collective intelligence.
Speaker: And the second factor was the equality and distribution of conversational turn taking.
Speaker: So do the members of that team
Speaker: take the same amount of time interacting with each other and everybody has the same amount of time to speak.
Speaker: And that's going to be an important theme that we're going to see recur as we go through this journey of looking at different teams.
Speaker: So the second thing that we learned is that the team's intelligence is really much more than the individual, the sum of the individual intelligence.
Speaker: So most people believe that if you want a great team, you find a three, you find the three brightest people.
Speaker: that you can find and that makes a great team.
Speaker: And over and over again, what we're finding is that that is not true and that the team's collective intelligence can be measured and it's independent of the intelligence of the members or the maximum intelligence within that membership.
Speaker: So we'll try to understand a little bit more of how that is shaped.
Speaker: This is a very important study on global engagement that was done by the ADP.
Speaker: It was published a couple of years ago.
Speaker: And it really included over 20,000 employees worldwide, 19 countries, 13 industries, including healthcare.
Speaker: They looked at organizations that were over 150 people, 82% of the employees or the colleagues in that organization worked in a team, and 72% worked in more than one team.
Speaker: So teamwork or being part of a team is really the
Speaker: predominant way of working in most businesses and in most lines of work today.
Speaker: Even in small organizations with less than 20 people, 68% of people worked in a team and half of them, almost half of them worked in more than one team.
Speaker: So clearly the presence of teams is ubiquitous and it's something that we have in all our organizations.
Speaker: We obviously have multiple teams within the hospital, multiple teams within sound physicians.
Speaker: What they found is that those that are in a team are twice as likely, almost three times likely to be fully engaged.
Speaker: So those who were on a team and fully engaged were 17%.
Speaker: And those who are not on a team or work by themselves are half the time, half as engaged.
Speaker: And as we all know, in today's workforce, engagement, apathy, and burnout, whole spectrum,
Speaker: is really important in terms of not only improved patient outcomes for us in healthcare, but also improved performance for an organization no matter what they do.
Speaker: So clearly being part of a team seems to help engagement.
Speaker: More importantly, those who actually trusted their team leader and felt that they could work and trusted their team leaders
Speaker: we're 12 times more likely to be fully engaged.
Speaker: And that seems to be one of the most important factors.
Speaker: And it also speaks to the idea that people don't leave companies, organizations, they leave teams.
Speaker: So as we build a strong organization, the better we can do with our teams, the more likely is that not only our colleagues will be fully engaged, but that we will continue to grow and perform at a high level.
Speaker: An important distinction, I think, to make that has been made many years ago by Katzenbach and his collaborators is that not all groups at work are teams.
Speaker: There are plenty of working groups which are different than a true team.
Speaker: And I think some of the differences that are important recognizing are that in a working group, there's a strong, clearly focused leader.
Speaker: In the team, a lot of times there is a leader, but there are shared leadership roles.
Speaker: The working group is really based on individual accountability.
Speaker: In the team, it's both individual, but there's also a mutual accountability, and that's a key determinant of a team where the team is accountable for a given outcome or a given project, and that's shared among all the team members.
Speaker: The purpose of a working group is usually within the broader organizational mission, and the purpose of a team can be very specific.
Speaker: And that is also, I think, an important distinction
Speaker: Another distinction goes to the work product.
Speaker: Work groups are usually individual work products that then are conglomerated versus the team only has one work product and it's a collective work product that ultimately determines their performance.
Speaker: Working groups are usually run through meetings.
Speaker: They're very efficient.
Speaker: They have agendas.
Speaker: They're very organized.
Speaker: Teams are really based on open-ended discussion and actively problem solving
Speaker: which makes sometimes their meetings look a lot more disorganized, but they're actually working at the time that they're meeting versus working groups where they meet and then people go and work individually.
Speaker: And that ultimately really talks about how they measure each other or their performance, and it's by the influence of others or the influence on others in the working group.
Speaker: And for the team, it's directly on the output of the team's work product.
Speaker: So as you see, the team discusses, decides,
Speaker: and does real work together, and the working group discusses, decides, and delegates.
Speaker: So not every time we're with another group of people at work, we're in a team, but at healthcare, and especially at the bedside, we do have multiple teams, and we need to understand how to make those teams stronger.
Speaker: Before we move on, the whole point of the talk was not only understand
Speaker: how teams function and how teams can be stronger, but how do we make teams beat average?
Speaker: How do we make teams above average?
Speaker: So I wanted to take a little bit of time to just talk about the problem with average.
Speaker: Nobody wants to be average.
Speaker: Most people don't think they are average, yet most people are average and most teams are average.
Speaker: And the problem with average is that average measures the past and it's very constraining.
Speaker: Average does not measure potential.
Speaker: It does not inspire.
Speaker: And it really looks backwards as opposed to looking forward, which as we'll see in healthcare, which is an infinite game, is much more important.
Speaker: Now, why do we have so many teams and so many people that are average at work?
Speaker: It's because we are afraid to take risks.
Speaker: We're afraid to fail and we are afraid to go beyond our comfort zone to break average.
Speaker: And that is the problem with average.
Speaker: And that's what we're going to talk about today in terms of from a team perspective, how can we be above average and help our teams move in that direction?
Speaker: So the next part of our conversation, we'll look at what makes a team great.
Speaker: It's a great question that might give us some insights to ultimately lead to an answer of what can we do as individuals, members of the team to make our team better?
Speaker: What can we do as leaders to make our teams stronger?
Speaker: I'd like to start with, many of you may have heard of this or read about this, but Peter Skillman is a design engineer and he devised an exercise that was meant to evaluate how teams perform and interact.
Speaker: And that's called the Marshmallow Challenge, very simple.
Speaker: You got 15 minutes, you get 20 sticks of spaghetti, got teams of three, got one marshmallow, a meter of tape and a meter of string.
Speaker: And in that time, the question is, which team can build the highest
Speaker: freestanding structure with the spaghettis and these tools and on the top put the marshmallow.
Speaker: So this is a challenge or an exercise has been conducted around the world at MIT, business schools in Stanford, University of Tokyo, big companies and Peter Skillman and other people have accumulated data.
Speaker: And what you can see here is that the worst performing teams are usually the MBA students.
Speaker: Sorry to my business colleagues on the call.
Speaker: Second, the lawyers, the CEOs were a little bit better, but there was one group that consistently beat every single group, no matter how you looked.
Speaker: And it's very interesting here, what you see is that this is a finite game and the goal is to build the highest freestanding structure.
Speaker: And what you can see is that the average height in inches was significantly higher for Group X. So let's see what Group X can teach us about teams.
Speaker: So Group X was basically kindergarten graduates.
Speaker: And it's very fascinating that this has been done multiple times and with similar results on average.
Speaker: And what we learned is that ultimately, probably what differentiates the kindergarten from the MBA students is the lack of ego.
Speaker: It's the ability that they have to communicate.
Speaker: So they communicate in a very brisk, to the point way versus the MBA students when observed are usually
Speaker: trying to figure out if what they say is right, if what they say makes them look smart, who's the leader, who's the alpha person, what's my role.
Speaker: And the kindergartens just get into the purpose of building the structure as tall as they can.
Speaker: So they communicate in a much more efficient way, and that leads to a higher performance.
Speaker: The second thing that was learned from this interesting experience is that the kindergartens learn very quickly to fail.
Speaker: So they try things and as they fail, they try again and they fail again and they try again.
Speaker: One of the things that happened often with the groups that didn't do very well is they didn't realize that the marshmallow is really heavy for the spaghetti.
Speaker: So if you put it at the end, it's very possible that your structure will collapse and they would, at the end of the 15 minutes,
Speaker: actually have a structure that collapsed and had nothing to show for their effort.
Speaker: Versus they tried it very early and basically through multiple reiterations got a higher freestanding structure.
Speaker: So clearly here, if you had to bet, you would not have bet on the kindergarten students, but they outperformed the other teams because of how they communicated and how they approached their task.
Speaker: This is one experience that I think is a fun story to share.
Speaker: A good anecdote has been reproduced, but people have gone deeper in trying to understand the science of team dynamics.
Speaker: And the MIT Human Dynamics Group at the MIT Media Lab led by Alex Pentland have been studying this for a long time.
Speaker: And they basically created these sociometric badges, which are the badges you can see on the figure.
Speaker: They're like ID cards.
Speaker: There are seven or eight iterations of this.
Speaker: They can capture 100 data points per minute.
Speaker: They usually can capture, they don't capture content, but they can capture who you're communicating with, how are you positioned towards that person, where are you within the organization geographically.
Speaker: They can measure tone, other gestures.
Speaker: They can measure multiple points of data.
Speaker: So really an enormous amount of data is
Speaker: And he's deployed these sociometric badges and over 21 organizations in one study for seven years of data.
Speaker: He measured communication patterns of thousands of people up to six weeks at a time and really found that there's a lot of interesting insights that you can take from the sociometric badges.
Speaker: But what he found is that once again, when you match the patterns of data to performance,
Speaker: It's the form of communication that matters over the content.
Speaker: He had no idea how people were, what people were saying, but the form of communication is very important.
Speaker: And you can immediately create visual maps with this technology that can predict to the point and very effectively, which is a high performing team and which is going to be a lower performing team.
Speaker: And here you have two very simple examples.
Speaker: A low performing team on the left, a high performing team on the right.
Speaker: And the difference goes back to the study I presented earlier on collective intelligence of teams and also speaks to what we saw with the kindergartens.
Speaker: So the high performing teams, everybody's communicating with everybody else.
Speaker: Everybody has a similar voice time in terms of giving their opinions and talking about that.
Speaker: So that seems to be a recurrent theme that we're now seeing in terms of communication being key for high-performing teams and outweighing other factors that we traditionally have thought to be more important.
Speaker: There are key elements of team communication that he has studied, and I think there's a couple that are worth mentioning.
Speaker: So there's energy.
Speaker: which is how team members contribute to a team as a whole.
Speaker: And you can see in that example that the circle in the middle in gray would be the ideal team energy and it should be equally distributed among the team members.
Speaker: And then you see the different nodes, who talks with who more often, and the amount of energy that each person contributed.
Speaker: And the key here is to have balance where everybody's talking with everybody else and not just with the leader or just with one or two of the team members.
Speaker: There's also,
Speaker: engagement in terms of how team members communicate with one another.
Speaker: And again, what we're looking for there is balance.
Speaker: And finally, there's exploration, which was also able to measure, which is how teams communicate with one another.
Speaker: So if you are part of a team in the ICU, if you go and talk with the people in the ED, with the team in the ED, and bring information back to your team in the ICU, or if you are a sound critical care program, let's say in the East Coast,
Speaker: and you connect with people on our virtual meetings or our meetings in persons with a team in the West Coast, you might learn information that if you bring back and share with your team, will enhance your team.
Speaker: So especially for teams that require creative work, exploration is very important.
Speaker: But again, this whole idea of how we interact among team members and communicating emerges and has been shown in multiple studies by this group led by Alex Pentland
Speaker: to be a key determinant, the most important determinant of performance.
Speaker: Everything else together equates to the percent of incidents that this has in their ability to predict which team is a high performer and which team is a low performer.
Speaker: They can even do the social metrics during different negotiations and they can predict which team is going to have a better negotiation deal at the end just based on the patterns of communication and how people behave within the team.
Speaker: I think this is very important, and this is something that he has shown over and over again, is that not all forms of communication are equal.
Speaker: And especially in the time of COVID-19 and how we're communicating these days, something worth understanding because we can improve how we communicate just by using the right form.
Speaker: So the best form of communication without any question is face-to-face.
Speaker: Second best is either video calls or phone calls, but we have to have a caveat here in terms of Zoom calls or even phone calls, conference calls, that if the number of people on the call starts going up, the quality of that form of communication starts degrading for the team.
Speaker: So calls with a lot of people or video calls with a lot of people are not as effective.
Speaker: A one-on-one video call is almost as effective as a one-on-one face-to-face, but that is what we should be seeking and creating as much opportunities as possible within the teams that really matter for us.
Speaker: I mean, remember that not every group of people we work with is a team, but for our teams, that's what we should try to build.
Speaker: Email is worse and email is, I think, pervasive.
Speaker: It really has hindered most teams and most organizations.
Speaker: There's a whole...
Speaker: a wave now of behavioral economists, people who study tech talking about how unproductive email really makes us and how much time we waste doing email.
Speaker: And we believe we're working, but we're just really, I mean, sending people emails that really do not have consequential impact on our outcomes.
Speaker: And finally, the worst form is probably text messaging.
Speaker: And that includes groups like WhatsApp,
Speaker: where really, I mean, the biggest failure is the illusion or the illusion, sorry, that communication has occurred and for multiple reasons is really the worst way to communicate and build team effort.
Speaker: So just something to keep in mind, and that's not only how we interact with each other, but what medium or what forms are we using can also have an impact on that.
Speaker: There are some defining characteristics of these great successful teams according
Speaker: to Pentland and everyone on the team talks and listens roughly in equal measures.
Speaker: That's something that we saw in other studies.
Speaker: It's something that was observed with the kindergarten teams.
Speaker: And I think it's something to keep in mind if you are in a team and there's somebody who does not contribute, we should actually try to seek out that person and get their opinion and have them contribute.
Speaker: Members face one another in their conversations and gestures are energetic.
Speaker: So people feel very safe to really express what they're feeling and that's very important.
Speaker: Members connect directly with one another, not just with the team leader.
Speaker: And that is very important when we have, I mean, teams at the clinical level that everybody is interacting with everybody else, not just with whom they perceive is the clinical leader or the team leader.
Speaker: Another very important aspect of defining interactive security successful teams is that members carry on back channel or side conversations within the team.
Speaker: So people are constantly exchanging ideas
Speaker: talking about things related to the team and how they can make the team work better.
Speaker: And finally, the concept of exploration where members periodically break, go exploring outside the team and bring back information that can be useful for the team.
Speaker: So these are some of the defining characteristics that the MIT Media Lab has found after literally thousands of data points and people study with these sociometric badges, which I think is a very,
Speaker: cool application of technology and understanding human dynamics and team dynamics.
Speaker: So let's go from marshmallows to cardiac surgery again.
Speaker: I think cardiac surgery, obviously because of a high stakes game and team performance, now that we understand that it's the team that makes a difference is a very fertile ground for studying teams in medicine.
Speaker: It's also very finite in terms of the procedures and there's a lot of numbers to follow.
Speaker: So Amy Edmondson from Harvard,
Speaker: business school is perhaps the leader in the concept that we're going to evaluate now that she created of psychological safety.
Speaker: And she really started studying teams in healthcare.
Speaker: And before we dive into the cardiac surgery team, what she found was that the safest teams in hospitals are those that have the highest number of reported adverse events.
Speaker: And initially that was counterintuitive, but then what she figured out is that those are the teams
Speaker: that feel psychologically safe to report problems because they really have a growth mentality.
Speaker: And that's where the concept of psychological safety starts.
Speaker: But let's look at DCT surgery teams.
Speaker: Very interesting study.
Speaker: 16 high-performing cardiac surgery teams.
Speaker: They were learning a new technique of minimally invasive cardiac surgery.
Speaker: So this is a new technique that has been developed.
Speaker: None of these teams have used this technique for surgery and they were learning it.
Speaker: And this was a study
Speaker: on the success for implementing this new technology for minimally invasive cardiac surgery.
Speaker: So this is just, these are not real names, but these are real teams.
Speaker: And what you can see here is the different hospital teams, the annual number of cardiac bypass operations that they did as a team.
Speaker: And as I said before, the number of operations matters as long as it's the same place, the same team that is doing them.
Speaker: This is the type of hospital, academic versus community.
Speaker: and this is different geographical regions.
Speaker: And then they had the status of the adoptive surgeon.
Speaker: Was it the department head, the junior surgeon, the senior surgeon?
Speaker: And really what they found is that none of these individual region, type of hospital, size in terms of numbers of cardiac surgeries done before, or the seniority or level of the adopting surgeon determined who had the best
Speaker: Implementation Success Index.
Speaker: And these actually are ranked by success index.
Speaker: And you can see that there was a way they calculated that.
Speaker: But what you can see if you look at all the ones that are high, which are the 26 and above in terms of the Implementation Index, you have a variety of large number, small number.
Speaker: You have a variety of academic and community hospitals.
Speaker: You have different regions of the country.
Speaker: And you have both, you have department heads, junior surgeons, and senior surgeons.
Speaker: So really interesting that the top three are very different hospitals and that ultimately none of these items that most people would give a lot of weight to in terms of predicting who could adopt a new technology quicker really are important factors in the ability to successfully adopt a new technology in the OR.
Speaker: And what she found is that the most important were coordination between the clinical areas and actually psychological safety.
Speaker: And psychological safety is the concept that she has really been pushing since the early 2000s as a key aspect of a team's performance.
Speaker: And we'll see a little bit more about that.
Speaker: But the idea was that once you create a team stability, the leader and his actions plus the team create that psychological safety.
Speaker: And that really creates the right environment for collective learning, for the process of learning something new through failure,
Speaker: and through risk taking that ultimately results in the implementation outcomes that make a difference.
Speaker: So clearly to learn new things in healthcare, which is always evolving, psychological safety seems to be the key.
Speaker: It's important to recognize that psychological safety can be a little bit complex and can be compromised by perceptions of hierarchy within the team.
Speaker: And this is much more pronounced in the OR.
Speaker: It's something that people have tried to change.
Speaker: But we know that the lack of psychological safety is a tremendous factor associated with unsafe care for patients and with major medical errors.
Speaker: The typical example is in an OR when the senior surgeon is about to amputate the wrong leg.
Speaker: These are real cases that have happened and nobody feels comfortable telling them that they're about to do something that's wrong.
Speaker: And that's a lack of psychological safety.
Speaker: So when Edmundson and her team looked at multiple clinicians within hospitals, they found that there seems to be a decrease in the perceived psychological safety or the mean psychological safety among different groups in the ICU team.
Speaker: So physicians, nurses, and respiratory therapists.
Speaker: And I think as clinicians who work with all these entities, it's important for us to remember that our job as leaders is
Speaker: And our job as clinicians is to make sure that everybody in the team feels psychological safe and can contribute their opinions and can take risks and learn together.
Speaker: The last study that I want to go over before we go to the last section in our presentation is a study that Google conducted a couple of years ago called Project Aristotle.
Speaker: And this was really Google's attempt to use big data to
Speaker: figure out the perfect team.
Speaker: Google had a tremendous motivation and incentive to really optimize their teams because ultimately that is what drives their performance.
Speaker: And obviously being a company that is on the cutting edge of technology, they attract a tremendous amount of talent.
Speaker: They have probably some of the brightest minds coming to them for work.
Speaker: And they really invested a lot of energy, a lot of resources in identifying the perfect team.
Speaker: What they found after studying over 180 teams and really capturing millions of data points was that the individual characteristics of the members of a team did not show any patterns that could predict high-performing teams.
Speaker: It didn't matter
Speaker: how many people came from top schools.
Speaker: It didn't matter if there was a combination of different personalities.
Speaker: It didn't matter if the leaders came from certain aspects, if they had certain traits.
Speaker: It didn't matter if people had a diversity of backgrounds.
Speaker: So really all the things that they tied to the individuals in this big data analysis with millions of data points, it panned out to not be predictive
Speaker: of what a team's performance would be.
Speaker: What they did find is that psychological safety, team members feel safe to take risks and be vulnerable in front of each other, was by far the most important factor in determining what the team would do with performance.
Speaker: And they also found that there are other important aspects that are probably tied to psychological safety in many ways, like dependability,
Speaker: The team members get things done on time and meet Google's high bar for excellence.
Speaker: Structure and clarity.
Speaker: Team members have clear roles, plans, and goals.
Speaker: Meaning work is personally important to team members and team members think that their work matters and creates change, which is impact.
Speaker: So a lot of people look at this study and say, it's an amazing study.
Speaker: It really contributes tremendously to our understanding of teams.
Speaker: Other people who are more cynical might say, well, it just told us what we already knew.
Speaker: But the reality is that
Speaker: And it's always good when our intuitions or the things that we believe are demonstrated with science and the way most people behave in their teams, even if they knew that psychological safety was the most important thing, they clearly don't behave like that is really what matters because the majority of teams that are in the workplace do not have psychological safety.
Speaker: So we'll talk a little bit more about this as we move forward.
Speaker: The last part of our talk is about how do we make our teams better?
Speaker: How do we break average?
Speaker: How do we keep pushing our teams and propelling them forward to keep excelling and performing at a high level?
Speaker: I think that before we go into what I think is the most important thing we can do, which you already can imagine what it is, but I'll give you some more concrete things to think about.
Speaker: We can probably explore a little bit of game theory and the whole concept of finite games versus infinite games.
Speaker: Finite games have known players, fixed rules, accrued upon objectives.
Speaker: Example is baseball.
Speaker: You have nine innings and at the end, whoever has more runs is the team that wins.
Speaker: And you play to beat those around, players play to beat those around them.
Speaker: And joy comes from comparing yourself to others, right?
Speaker: That's where the whole point of a winning team comes from.
Speaker: Now, there might be some projects within healthcare or some projects within our arena that are
Speaker: a finite game and that we're just trying to deliver.
Speaker: But the reality is that day to day and year after year, healthcare and caring for patients in the ICU or beyond is an infinite game.
Speaker: And it's, we have known and unknown players.
Speaker: The rules keep changing.
Speaker: We know that very well.
Speaker: And the objective is to keep the game going, to keep playing the game as long as we can.
Speaker: And the example given here is business, but I think it's in our case, it's healthcare.
Speaker: And here, the players are playing to be better today than they were yesterday.
Speaker: So our goal really is to continue to improve our performance and the performance of our team.
Speaker: Finally, joy does not come from winning because we will win and we will lose and we continue to play the game.
Speaker: It comes from advancement.
Speaker: And how can we move the needle in our performance, but how also that advancement has an impact on the life of the people we care for.
Speaker: So we really live in an infinite game situation.
Speaker: And I think that our goal as a team is to continue to improve compared to what we are today to be better tomorrow.
Speaker: So how do you improve a team?
Speaker: I already gave you the answer.
Speaker: The most single and most important thing you can do is increase psychological safety.
Speaker: And a very important concept, I think, for everybody on this call is that there might be a assigned leader based on their title, but
Speaker: We can lead from any position on the team.
Speaker: And as members of a team, we have an obligation, I think, to make our contribution and try to push psychological safety forward.
Speaker: So psychological safety is a shared belief that the team is safe for interpersonal risk taking.
Speaker: It's the only way that we can break average.
Speaker: If we always do the same thing, we're going to be average.
Speaker: We have to take risk in terms of saying our opinions,
Speaker: trying new things and trying to move the needle forward.
Speaker: Most teams have some component of psychological danger.
Speaker: People are fear, there's fear of admitting mistakes.
Speaker: There's a lot of blame going around.
Speaker: We're less likely to share our different views.
Speaker: And people think of nobody ever got fired for being silent or I think rather be safe in sorrow.
Speaker: And there's this common knowledge effect where we assume
Speaker: that everything that we think is obvious is obvious for everybody else.
Speaker: That is a recipe for disaster sometimes, but more commonly it's a recipe for average, which as we said is not what we want.
Speaker: What about those teams that strive and create psychological safety?
Speaker: There is tremendous comfort within the team members in admitting their mistakes.
Speaker: And that starts with the leader.
Speaker: They learn from failure.
Speaker: There's no such thing as we failed, either we achieve something or we learn something.
Speaker: Everyone openly shares their ideas, and it ultimately leads to better innovation and decision making.
Speaker: And in our line of work, we need innovation for these changing times.
Speaker: COVID was a great example.
Speaker: And we need to make very difficult decisions, sometimes with incomplete information.
Speaker: So clearly, any team that we participate in, the higher the psychological safety, the higher the performance of that team will be.
Speaker: There are four quadrants to consider, and then we'll talk about what are the things that we can do to create a psychological safety.
Speaker: So there's a learning safety, there's challenging safety, collaborating safety, and inclusion safety.
Speaker: Learning safety basically is, do I feel comfortable saying, I don't know something, and am I somebody who has a fixed mindset or a growth mindset where we actually learn from our mistakes or are willing to expand our horizons and do things differently?
Speaker: The answer, that's the way we do things here because that's the way we did it before, is not really a learning safety type of answer.
Speaker: The idea is to feel very comfortable in taking some risk to doing things different, to learning together and moving forward.
Speaker: Challenging safety, I think the example I gave in the OR is a perfect one.
Speaker: If you are in a team and somebody's about to do something that could be dangerous, you should feel comfortable
Speaker: pointing that out, recognizing that either you're right and you make a big difference, but if you're wrong, nothing happens.
Speaker: That's what the team does.
Speaker: They challenge each other when they think that it's going to make a difference for the outcome.
Speaker: Collaborating safety is basically the safety that I have in terms of exposing my vulnerabilities to the members of the team when we're collaborating and recognizing that even as a leader, I don't have maybe all the answers,
Speaker: but we're working together to figure out what the best answer is.
Speaker: And finally, inclusion safety is, are all the team members feeling valued, feeling part of that team?
Speaker: Is there a feeling of belonging?
Speaker: I am valued for who I am.
Speaker: I am valued for what I bring to the table and what I do in this team.
Speaker: And that is something that's very important.
Speaker: I think that especially with everything that's going on today,
Speaker: We talked a lot about at Sound on our efforts on diversity, inclusion and belonging.
Speaker: That is an aspect, a very important aspect of psychological safety and a high performing team without that does not exist.
Speaker: So there's three things that I want to focus on as we end this conversation.
Speaker: One is building safety.
Speaker: Number two is sharing vulnerability.
Speaker: And number three is establishing purpose.
Speaker: In terms of building safety, I think it's important to remember that we have to dial into these small, subtle moments and deliver targeted signals at key points during our interactions with others.
Speaker: Now, this is obviously something that I would expect leaders that are very aware and interested in improving our teams to be able to do.
Speaker: But even if you're not the leader de facto, you can actually improve the psychological safety of a team by doing these things and being part of this culture of building safety.
Speaker: So number one, over-communicate your listening.
Speaker: We don't listen enough to our patients.
Speaker: We don't listen enough to each other's.
Speaker: Most of our arguments outside of work are just trying to convince others of our point of view.
Speaker: Listening is trying to
Speaker: to figure out what somebody else is saying, how it changes the way you think, right?
Speaker: So really listening and not waiting our turn to give our opinion, but truly listening to what somebody is saying and trying to say, what needs to happen for me to believe that that's true or for me to change the way I think?
Speaker: That's true listening.
Speaker: And we should over-communicate and really be present, not on our phone when somebody is sharing something with us.
Speaker: Overdoing our thank yous.
Speaker: I think that one of the biggest problems we have
Speaker: Today is the lack of gratitude to ourselves and towards others.
Speaker: So being very deliberate, being very genuine and thanking people for the work they do and on a daily basis.
Speaker: I think contributions that are impactful, that are meaningful should be thanked.
Speaker: When somebody delivers bad news, we should thank the messenger.
Speaker: We are better off as a team knowing the bad news and somebody sharing that than it being either ignored or being unknown.
Speaker: Dealing with the bad apples, obviously, as we build a culture of safety within our team, of psychological safety, we have to make sure that people are aware of the impact their behavior has on others.
Speaker: And if their behavior is not a behavior that can be changed, I think that eventually those people should not be part of the team.
Speaker: And finally, I think, is making sure everybody has a voice.
Speaker: And we saw plenty of evidence, both in the human dynamics studies from MIT, but also in other experiments, that equal time
Speaker: in terms of talking and listening is a very important hallmark of super high functional and high performing teams.
Speaker: The second aspect of building psychological safety relates to vulnerability.
Speaker: And I think it's something that we don't do well enough, but it's also rooted in the concept that no matter who you are, you should be humble.
Speaker: There's always things to do wrong and there's always things you could do better.
Speaker: And understanding that group cooperation is created by small, but often repeated moments of vulnerability.
Speaker: And in order for this to work, you have to be vulnerable first and often.
Speaker: And I think that from a leadership perspective, the most important words you can say as a leader is, I am wrong.
Speaker: I messed up.
Speaker: Right.
Speaker: Recognizing when we do something wrong is key and being vulnerable and nobody's going to be perfect.
Speaker: And I think that that is the single most important thing I think leaders should do.
Speaker: And it's something that really starts creating an environment where people are okay, recognizing that there's some an opportunity they have to do something right, or maybe a decision they made was the wrong one.
Speaker: Along those lines of vulnerability, I think it comes with being vulnerable and humble and recognizing that we can do things better and that there's always room for improvement, but also
Speaker: making sure people understand what are their expectations.
Speaker: We over-communicate this over and over again.
Speaker: It's something that we don't do very well as a team or as leaders sometimes, but make sure that there are certain things that are expected from the team members and that people really know that.
Speaker: And finally, in terms of improving and learning, I think candor-generating practices, which is something that I'll share in a second, I think are very important, not only when things go wrong, but also when things go well.
Speaker: for things that are important, we should have these often and really get to a point where people can really have them with vulnerability on the table and just very openly in terms of what they really feel happened and sharing.
Speaker: So psychological safety, it does not drive performance without accountability.
Speaker: I think that's important.
Speaker: Now, what we said is that accountability in a team is really on the product of the team as one,
Speaker: There's an individual accountability for each member that's participating, but ultimately the team's accountable for the outcome that they produce as one team.
Speaker: And this is something that's very important because when you plot psychological safety over accountability, you can see that when both of them are low, what you have is apathy.
Speaker: And just one step out of apathy is active disengagement and burnout.
Speaker: When you have high psychological safety, so people feel very comfortable, but there's no accountability, you're in the comfort zone.
Speaker: and comfort zone basically lives in the world of average.
Speaker: And that's, as we said, is not something that we want.
Speaker: When you have low psychological safety and high accountability, you might have performance for some time, but you live in the anxiety zone.
Speaker: And that definitely leads to burnout.
Speaker: It is not a good place to be, especially in times like the ones that we're living.
Speaker: So ultimately, what we really are striving for is for our teams to have high psychological safety
Speaker: with high accountability, and that leads to learning zone.
Speaker: And that's how teams grow, and that's how teams break average.
Speaker: The other thing I mentioned was the candor practices that allow us to reflect on what we did.
Speaker: Without reflection, there's no improvement.
Speaker: So this is a tool that the SEALs use for every operation, every mission that they have.
Speaker: It's after assignment reviews of the AARs.
Speaker: Those of you who are fans of Jack O'Wilkins will probably hear him talk about him or read about this in one of his books.
Speaker: But basically is at the end of every mission or at the end of every operation is just answer a couple of questions very, very genuinely and with total candor and vulnerability.
Speaker: What were our intended results?
Speaker: What were our actual results?
Speaker: So is there a gap there?
Speaker: What caused our results?
Speaker: And then the two questions that I think that we should be asking ourselves on a regular basis is,
Speaker: What will we do the same next time?
Speaker: So what worked and we should repeat or keep enhancing and what will we do differently?
Speaker: Now, these are five simple questions, but for them to be truly effective and driving performance, you need a team that psychologically feels safe and that can really share their vulnerabilities and share their opinions openly and with candor.
Speaker: And the last part is establishing purpose.
Speaker: And on Friday when I talk about joy, finding joy in our work, I think purpose will come up again center as a centerpiece of that discussion.
Speaker: But I think it goes to the idea that people don't buy what you do, they buy why you do it.
Speaker: And in terms of creating teams, it's not what we do, it's why we do it.
Speaker: So naming and ranking our priorities.
Speaker: I always say that we should do fewer things for deep effect.
Speaker: as opposed to a lot of things with side effects.
Speaker: So really being very deliberate on what are our priorities, what's our purpose.
Speaker: And then I think once we establish that with our teams is being very, very clear about these priorities and it's repetition, repetition, repetition, and making sure that the whole team understands what's the purpose and what we're trying to do.
Speaker: So by building safety, sharing vulnerability and establishing purpose,
Speaker: With those simple tools that I shared, I think that where you're the leader of a team or a team member, you can move the needle on psychological safety.
Speaker: Ultimately, what you want to have is safety to learn, safety to challenge each other, safety to work together and collaborate, and safety where everybody feels they're a part of the team and a valued part of that team.
Speaker: And if you can move the needle in that respect, I can guarantee you that what the science shows and what experience shows is that the performance of your team
Speaker: will move accordingly and you will move above average and break average.
Speaker: So we talked a little bit about the whole conundrum of teams in terms that we really value individual development, individual accomplishments, and given over, overvalue the contribution of individual intelligence to team performance.
Speaker: Yet the world today is not looking for individuals.
Speaker: It's looking for teams that can really excel, especially in healthcare.
Speaker: What makes a team great?
Speaker: it's the ability to communicate and that ability to communicate is based on psychological safety.
Speaker: So there's clearly skills that teams need to learn and things that they can do, but a team that has psychological safety can learn, can improve and can really make a difference.
Speaker: So in terms of moving the needle and breaking average, moving our teams forward, it's recognizing what are the things that we do that can create technological safety and also remembering
Speaker: that it's very hard to build psychological safety, but it's exceedingly easy to destroy it.
Speaker: So a lot of times our behaviors might have the unintended consequence of alienating team members that ultimately deteriorate the dynamics of that team and will have a tremendous impact on the performance.
Speaker: So we have to be very aware of this and constantly being deliberate and moving things forward to create that psychological safety.
Speaker: So I'll stop there and
Speaker: If there's any questions in the chat box, we'll try to go to those.
Speaker: And thank you very much for your time.
Speaker: So there's a question here in the critical care arena where turnover is constant, challenge, especially with nursing workforce, how do you maintain team efficiency and cohesiveness?
Speaker: So that is a great question.
Speaker: And there's a concept that has emerged over the last couple of years, not of team, but of teaming.
Speaker: And the recognition that especially in healthcare, you might not work with the same team.
Speaker: There might be pieces of that team that keep changing, but the bottom line is it goes back to the same thing.
Speaker: The way you maintain cohesiveness and efficiency is by creating psychological safety where people feel that they can take risks, they can try things, they can share their opinions, they can challenge each other.
Speaker: The other thing I would say to that question
Speaker: is this goes to burnout and to what I'll talk about on Friday, the importance of creating a remembering purpose as the driving motive of what we do.
Speaker: And when people forget their purpose in healthcare, and when they think of their job as a team in terms of tasks and not in terms of the people for whom they're working or making a difference,
Speaker: that becomes very difficult.
Speaker: But when people get back to purpose, I think you can improve cohesiveness and efficiency.
Speaker: Now, is this a solution for everything?
Speaker: Probably not.
Speaker: There's still a lot of headwinds and challenges that teams face, but these are the things that have been proven to make a difference.
Speaker: In the AR template for the question, what caused our results?
Speaker: How do you avoid the answer being one of blame, like blaming another department, for example?
Speaker: Well, I think that the way you avoid that is when it comes out,
Speaker: is to really move the team above the line.
Speaker: So there's two ways of leading or two ways of thinking of anything in life, what they call a conscious leadership.
Speaker: You can be below the line where it's about who is right and it's about assigning blame, or you can move above the line in which question is what is right and it's about learning, how can we move the ball forward?
Speaker: So I think that when blame comes up, I think it's very easy to get that included.
Speaker: I think that we should acknowledge
Speaker: what people feel.
Speaker: But again, we should refocus the team to move above the line and ask them, well, what can we do to move the needle forward?
Speaker: What can we do to change things?
Speaker: Because most people attribute things that go well to things that are internal, characteristics of themselves, and things that go bad to external factors.
Speaker: And I think that what we need to recognize is that both bad and good things are ultimately determined by what we control and not by external factors.
Speaker: But that's a great question.
Speaker: Thank you for listening to Critical Matters, a sound critical care podcast.
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Speaker: Sound Critical Care is transforming the way critical care is provided in hospitals across the country.
Speaker: To learn more, visit www.soundphysicians.com.
