Irwin M. Rubin.

Making health teams work: and educational program online

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Irwin Rubin, Ronald Fry, Mark Plovnlck **

October, 1974 WP 710-74 REVISED

MAR 3 1975






•M 2 74'



Irwin Rubin, Ronald Fry, Mark Plovnick **

October, 1974 WP 710-74 REVISED

Part of the research reported in this paper was supported by a grant from
the Robert Wood Johnson Foundation.

The authors are co-directors of the M.I.T. Sloan School Educational
Programs in Health Management Project.


in7n r>n JAN

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Health care teams are being used to deliver care in many
settings. Research on over forty such teams reveals that many are
seen as not functioning as well as potentially possible. Because
teams provide the most sensible answer to care delivery in many
health care settings, there is a need to increase the operating
efficiency of these teams.

One possible way to improve team productivity is through
structured educational programs. One such program, developed by
the authors, is designed to help teams clarify and/or establish
their (a) goals/objectives, (b) roles/responsibilities, and (c)
working procedures (e.g., decision-making). Field tests with this
program in twelve team settings have led to reports of improved
team coordination, higher morale and cohesivencss, better follow-up
and management of patient care, better utilization of health work-
ers' resources, an increased sense of effectiveness on tlic team,
and a perceived improvement in patient care.


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Many health care systems are experimenting with a new model for
the delivery of health care. Groups of health workers are pulled to-
gether and asked to coordinate and integrate their efforts to meet pa-
tient needs — to function as a "team" rather than as solo practitioners.
As could be expected, experience with this new model has been mixed.

Research and experience in over forty settings where teams are being
used has led to the conclusion, shared by many administrators and team
members, that most of the teams are operating at levels well below that
which is potentially i)ossible. The majority of team members and adnilii-
istrators in these settings report that teams are functioning, only
"fairly well." Few report that teams are functioning "well" or "very
well." Critics of the team approach will point to these data as "proof"
that the team approach cannot work, that it is ineffective and inefficient,

This conclusion is incorrect.

Certain health care goals require a team approach. For example,
goals such as comprehensive, family-centered health care (a commonly
stated goal in community settings) require the coordinated efforts of
several interdisciplinary health workers. Seldom is any provider, even
with the best intentions, capable of achieving such a )',oa] for any large
number of patients. The interdependence of these health workers, be it
through referrals or joint, hands-on care, makes them a team by defini-
tion whether or not they formally call themselves a team.

The relevant focus then is not upon whether to have health

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teams or not, but rather upon what needs to be done to improve the
effectiveness and efficiency of health teams (or any group on inter-
dependent health workers) given that they are necessary.

The remainder of this article will address this question by
discussing an approach to team functioning and describing the main
elements and field test results of a specific educational program
which has been developed to improve team functioning.


What is a Te am?

If a task or job to be done requires the interdependent efforts
of two or more people, then a tc£im situation exists. Interdependent
means that the individuals involved must work together and coordinate
their activities with each other — the job cannot be done by one
person alone.

Many health care problems fit this definition of a team situation.
Different individuals, with different knowledge, skills, attitudes,
backgrounds, training, etc., must function interdependently to get
the task done. There is a dilemma, however, in that the individual
differences which are essential to effectively accomplish the task
also represent potential obstacles to efficient teamwork. Inter-
dependence creates its own problems.

Problems Caused by Interdependence - The Symptoms of Poor Teamwork ^

The symptoms of poor teamwork are easily discernable and are
reflected in the following kinds of concerns held by team members

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and administrators in team settings:

- there is often an unnecessary duplication of effort;

- some things just don't get done, they seem to "fall
in the cracks";

- we seem to be pulling in different directions;

- I'm always having to check to see if things get
done, decisions are not followed up as well as they
could be;

- some people seem less than enthusiastic, like they
are just going through the motions — there is a lot
of grumbling behind the scenes;

- our meetings could certainly be better;

- communication is sloppy, messages and dates are
lost or forgotten — some just don't get filled in
about what is happening;

- you really have to be careful about what you say
around here — never stick your neck out;

- the job is getting done, but only because I'm busting
my back — I'm not sure I can keep it up.

These concerns are not, as is often assumed, the result of
"personality quirks." Rather, their existence is an indication
that a team has not successfully dealt with the problems inherent in
trying to accomplish a task requiring interdependence. The problems
caused by interdependence fall into four general areas:

1. "What are we supposed to be doing?" - problems

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caused by different goals (short and long range)
and priorities;

2. "Wlio is doing what?" - the issues of role
responsibilities and problems caused by different
specialists working in an integrated way;

3. "How do we accomplish our work?" - problems caused
by the need to develop effective and efficient
mechanisms for group decision-making, problem-
solving, communication, etc.;

4. "How does it feel to work around here?" - inter-
personal issues which arise when people function
interdependently, such as trust, need for support, etc.

A. Problems with Goals

Meeting patients' health care needs is, in and of itself, a
very frustrating task. Success is very hard to measure. In the absence
of specific, short-range measurable goals, team members may never get
the sense of having accomplished anything. In addition, without an
agreed-upon mission or set of objectives, individual team members are
very likely to go off in a variety of different directions, each doing
"his own thing." Conflicts then develop around how time should be spent,
by whom, around which kinds of tasks, etc. These get interpreted as
"personality clashes" when, in fact, they stem from different and un-
shared priorities of "what's important — what are our goals?" Even
in instances where the organization or administration has stated
specific goals, wasted time and energy can result if individuals do not
take the time to clarity their interpretations and ownership of these

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B. Problem of Roles

No standardized job descriptions exist for team doctors,
team nurses, team social workers, etc. Individuals who fill these
roles on teams have been trained to be individual specialists, not
team members. On most health teams, therefore, full utilization
of the team's human resources is stymied because people relate to
each other solely as role categories. Indeed, it is unlikely, given
the complexities of the task, that completely exhaustive job descrip-
tions will ever be feasible for team care.

C. Problems with Work Structures and Procedures

There is no single right way to organize a team. How a
particular group makes decisions; how it conducts its meetings; how
it decides who is to initiate, consult, or support various activi-
ties all depends upon the particular task and particular individual
roles in a given situation. A team must therefore spend some time
in meetings talking and deciding upon how to coordinate itself.
This time and energy spent in meetings is often wasted because
health workers are seldom trained to work in groups or to manage
collective problem-solving or decision-making sessions. As a result,
meetings are often characterized by unclear decisions, mixed commit-
ments to follow-up, low energy to volunteer or participate in future
team meetings, etc.

D. Problems with Interpersonal Relationships

Most "personality clashes" are actually the result of
problems stemming from one of the above three areas. Sometimes,

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however, after having dealt with the above issues, interpersonal
tension and conflicts are still apparent. This can happen because
the frustrating nature of the task (delivery of care) creates strong
needs in many for peer support, positive feedback on one's competence,
etc. Thus, behaviors that lead to or detract from trust, self-
confidence, support, pleasant working relationships, etc. are issues
to be worked on by the team as a whole.

Sometimes, interpersonal problems may be indicative that someone
actually is mismatched with the job. It could very well be that one
is not suited for a job or a team, but this alternative should only
be considered after the other three categories of problems have been
addressed (for the same reasons that surgery is used as a last resort).

Team Development

The needs to (a) set (or clarify mandated) goals and priorities;
(b) analyze (or clarify) and allocate role responsibilities; (c)
examine the team's work processes; and (d) examine the relationships
among people; all stem from having to work interdependently. These
needs will never disappear, nor can most teams learn how to effectively
deal with these issues solely through their work experience or through
guidelines and protocol from others outside the team. The knowledge
and skills needed to manage the inherent problems caused by inter-
dependence, on a day-to-day basis, can and must be learned through an
explicit educational process called team development.

Team development consists of activities aimed at helping the
team to minimize the time and energy lost mismanaging the problems

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stenuning from its members' interdependence, and maximize the energy
the team devotes to accomplishing its task. Team development is
like a planned maintenance activity to prevent major problems from
occurring. The rationale for team development is that by invest-
ing time to explicitly focus on the problems of coordination among
team members, the team will avoid greater time and energy losses
resulting from ineffective coordination.

The following sections describe the major elements of one
program in team development designed specifically for health care


Overall Objectives

The Health Team Development (HTD) program has two overriding
objectives: (1) to help a team solve specific task-related problems
(e.g. goal setting, role allocation, etc.) and therefore begin to
function more effectively right away; and (2) to provide the team
with a set of skills and concepts which they can apply in the future
as similar problems develop. While this dual goal has some costs
(e.g. primarily the amount of time investment required which will be
discussed in a later section) , it is important that both goals be
maintained if teams are to derive any long-run benefit from the
effort. The team is helped to "get into better shape" and to be
able to "stay in shape."

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Developmental Learning Model

This program is not like a traditional lecture or classroom
training period. Rather, the activities in this program are real
in the sense that they focus on helping the team to solve their
own problems which result from the nature of their job. The under-
lying model or approach is called the "action-research" approach to
team development. ^ (See Figure One.)

FIGURE ONE: The Action Research Model

Data Collection



Feedback Analysis



Action Planning

The HTD program helps the team to collect information from
themselves (diagnosis) about a particular obstacle to team effective-
ness (e.g. clarity of goals). The team asks itself "Where are we on
this issue?" These data are then summarized and shared (feedback
and analysis). At this stage, the team answers, for itself, the
question: "Are we where we need to be?" Discrepancies between
where they are and where they need to be become the stimulus for
new action plans. These action plans are then implemented and re-
evaluated (new data collection) at some later point.

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Self-Instructional Approach-'

The program is designed so that it can be run by the team it-
self, with no outside consultants, trainers, observers, etc. The
authors' early experiences with health care teams were as tradition-
al outside consultants working directly and personally with teams
in team development activities. The success of those experiences^
plus the belief that (a) more health teams existed than could be
handled by the available number of consultants, and (b) many health
teams did not have the resources to hire outsiders, led to the
creation of this instrumented program.

Content and Flow of the Program

The program consists of two phases (a more detailed description
of the program content can be found in the Appendix) :

1. Phase One : Core Work - this phase consists of seven,
three-hour sessions or modules and makes up the basic team develop-
ment package. These modules focus on the most essential elements
of team effectiveness (i.e. goals, roles, procedures). Each module
has some individual preparation (usually 15-30 minutes) and specific
action outcomes to be achieved by the team. In this phase, the team
is strongly encouraged to follow the sequence in which the modules
are presented and not skip any modules.

2. Phase Two : Optional Resource Modules - this phase
consists of six optional, special interest resource modules, each
il I rcit i-it .u spc»-iti\- problem areas which a developed team may en-
coiiuter (e.g. briui;iiig now members on board). These resource modules
can be used as either individual reading guides or guides for a team

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session to work on a particular issue. After completing Phase One,
the team is free to choose whichever (if any) of these they want to
work on at any time.

The Investment

The core program requires a team to work together for seven, three-
hour sessions preferably once per week over a seven-week period. For
many, the initial reaction is: "It's too much. Can't it be done

The paradox can perhaps best be understood by comparison to a foot-
ball team. A football team spends 40 hours per week practicing and
learning teamwork for the two hours on Sunday when they must deliver.
Teams in other settings — like a health team — seldom spend two
hours per year practicing.

Given the realities in most health settings, however, freeing up
the time required is a major obstacle. Administrators in settings using
teams must, therefore, be prepared to provide short run support to
permit a team to get in shape. In no setting in which the program has
been used has this been an easy task. However, as is discussed below,
preliminary results from initial test sites strongly suggest that the
returns warrant the investment.

The ijrogram incluiie.s a set of Guidellno^; to Adini ni sL r.i tors
designed to lielp administrators (a) get the organization re.idy to
support the team development program, and (b) introduce the actual
program to a team (or teams); and Guidelines to Users.

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Some Specific Effects: Managing Problems Stemming from


Evaluation data was gathered in various ways: (a) periodic
questionnaires from team members; (b) xerox copies of session out-
puts, e.g. goal statements, role relationships; (c) audio tape record-
ings of teams discussing their own progress; and (d) group interviews
conducted with administrators and teams after completion of the program.
Once a team began the program, we did not personally intervene into or
influence the program in any way until the team finished the program.

To date, the program has been completed by twelve teams. The
settings include: several community centers delivering comprehensive
care; the ward shifts in a mental health setting; several university-
based clinics with both teaching and ambulatory primary care responsi-
bilities. Half are located in the New England area, the remainder are
spread geographically.

The problems caused by interdependence, as discussed earlier,
fall Into four general areas. Preliminary evaluation data from
initial test sites are organized into these four general areas.

A. "What are we Supposed to be Doing?" - Problems of Goals
As a result of the program, the teams produced written
statements of their general goals and rank-ordered lists of more
specific performance objectives to attain these goals. For most
teams, this was the first time such a task had been undertaken and
riMiipl ri i-il. M.inv discussions occurred around subtle differences in
semantics (e.g. quality "comprehensive" health care versus quality

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"medical" care) , with the realization that there were differences with-
in a given team that had never been dealt with before. Two general
effects of this process were: (1) it created a sense of direction and
forward movement for the first time; and (2) the sessions, in and of
themselves, gave the teams a sense of having set goals and accomplished
an output for the first time. The analogy of a "shot in the arm" giving
additional energy to team members to devote to delivering care was
reported several times.

B. "Who is Doing What?" - Problems of Roles

In most cases, these sessions were reported to be the high
points of the program. Team members reported that the sessions on
role negotiation and role definition helped them to open better lines
of communication, confront problems collaboratively, and clear a lot
of confusion regarding who should be doing what. Specific outcomes
reported by team members included:

1. more willingness to make referrals now that
individual capabilities and responsibilities
are clear;

2. less feelings of isolation and more willingness
to take on more work as a result;

3. more appreciation for other's inputs in case
problems or organizational matters;

A. much more information being volunteered without

5. more in depth problem-solving with patients because

providers felt they could depend on others for

support, back-up.

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C. "How do We Accomplish Our Work?" - M anaging the Team's Work

Structure and Processes
One area of marked improvement in all cases was team meetings
and case conferences. Teams reported that as a result of the program
more people have taken responsibility for creating meeting agendas,
more shared leadership is occurring in meetings, and discussions have
become more pointed and closure is clearer. In general, more is getting
done in the same time as before. More cases are addressed, and there
are more follow-up discussions concerning previous decisions.

In the area of general team functioning, team members reported
that responsibilities are more widely shared, conflicts are confronted
more directly and resolved or managed, and people are making greater
efforts to support one another.

D. Impact on Patient Care

The ultimate objective in engaging in any form of team develop-
ment is, quite obviously, to improve a team's ability to deliver care.
At this point, rigorous empirical data about patient care is not avail-
able. However, there is substantial perceptual evidence — from both
team members and administrators — that better care is being delivered
as a direct result of the developmental program. Such perceptions were
evident in the following reported results:

1. there are greater conscious efforts to follow
through on tough cases because team members are
following up with each other;

2. there are more original and creative solutions to

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patient health problems because of greater know-
ledge and use of team members' resources;
3. better, more efficient care is being delivered
because team members check with each other more
about their objectives and responsibilities in
specific instances;
A. fewer patients are getting "lost" because team
members are coordinating more and being more
helpful to each other (which rubs off on patients
as well) .
It is Important to note how few of these perceptions deal with
people's feelings per se . To be sure, people seem to "feel" much more
positive and enthusiastic - not because they have been through some
strange therapy, but rather because now they are coordinating their
efforts more successfully, and as a result, see direct effects on
their ability to meet patient needs.
The Managerial Role

The management of a health setting using teams plays a critical
role in the total process of team development at two specific points —
getting started and dealing with the after effects.
A. Getting Started - Top Management Commitment

Getting the program to a team has invariably been a lengthy
and difficult process." Health administrators and managers are
under severe environmental constraints which represent major obstacles
to freeing up the time required for team development. Management's
response to these constraints confronts directly the issue of its

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commitment to team care. Some systems argue, for example, that
team development is important but teams should do it on their own
time — lunch hours, evenings, weekends, etc. The subtle (but power-
ful) message thereby communicated is that management is not committed
to finding ways to support a program that the team perceives as high
priority. The team is likely to lose some of its own commitment in
such a situation.

On the other hand, managerial efforts to do the work needed to
offer the programs (e.g. freeing up the time required), sets in
motion a positive, self-reinforcing motivational pattern. Team
members reported two types of comments in this regard:

1. the fact that the center would invest that kind
of time in them resulted in an increase in the
team's commitment to work on their development;

2. the fact that the administration gave them time
made them take themselves much more seriously
both as a team and as individuals.

B. Some After Effects : Rnnaging Developed Teams

The act of offering and implementing a team development
program represents an organizational , as well as a team, intervention.
A particular team is only a subsystem within a larger organizational
system. Newly developed teams are very likely to want to use their
new-found strength to improve the organization of which they are a

In effect, what happened in the test cases was that teams began
to question the rationale and usefulness of certain policies, decisions.

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procedures, etc. Once developed, the teams felt capable of handling
more responsibility and sought ways to be more autonomous and self-
sufficient (e.g. to be more responsible themselves for personnel
decisions such as hiring and firing). It is important to note,
however, that such action was not directed towards "taking over the
organization" or "doing the administration ourselves." The intent
in these instances was to make organizational goals and administrative
functions more effective and relevant to the team's specific setting,
patient population, mixture of disciplines, etc.

Several administrators, quite appropriately, have still reacted
to these phenomena with initial hesitancy and concern. They feel like
teams are "ganging up on them," and degrading the role of administration.
However, this tension has not necessarily led to negative results. In
several of the organizations where teams have completed the program,
the administration has initiated changes in organization structure and
policy to facilitate team and administrative functioning. In some


Online LibraryIrwin M. RubinMaking health teams work: and educational program → online text (page 1 of 2)