Staff and Executive-Level Teams Are Fundamentally Different A motivational poster frequently found in managers’ offices displays a team of rowers to illustrate the concept of people working t ogether; a popular offering from the Art of Rowingcompany is titled Teamwork: Together We Achieve More. When most people on a team are doing similar jobs, the rowing metaphor is very apt. However, executive-level teams aredifferent: Executive teams are more like baseball teams. Sure, they are all wearing one uniform and following one game plan, but sometimes they work alone (as in the case of a batter),sometimes they work in pairs (pitcher throws to catcher, or shortstop and first basem an collaborate in a double play) and only seldom do they all get in on the action.. . . Don’texpect a team at that level to feel the sam e way your department level team does. You’re not all in the same boat. So figure out the game plan, play your position, and keepy our head up to spot your chances to support your teammates. (Davey, 2012, p. 1) Randy Faris/CORBIS An executive team is similar to a company softball team. When one thinks of the ideal executive-level team, a better metaphor might be a company softball team— which can include both men and women of varying ages and ethnicities. However, company softball teamsare seldom good at play ing softball; many are formed to encourage camaraderie among the players andsupporters, thereby strengthening working relati onships and organizational commitment. Organizationsneed and value talented individuals who can work collaboratively with ot hers; being a “team player” is animportant attribute for success in almost every type of job. Since much of the clinical and administ rativework in health organizations is done in groups or teams, it is important for health care professionals tounderstand the work ings of, participate in, and lead teams. Critical Thinking and Discussion Questions 1. What have you learned from participating in a department or management team? 2. How important is team camaraderie among executives in health care organizations? 4.1 Introduction to Organizational Behavior—Macro Chapter 3 focused on the individual behavior in organizations. This chapter focuses on group behavior and discusses how orga nizations achieve their goals by coalescing the skillsand efforts of individuals into groups and networks. Organizational behavi or researchers and practitioners study behaviors within and between groups, both formal and informal.Formal groups are off icially designated to fulfill certain functions and accomplish specific tasks. Within the category of formal groups are command groups and task groups. Command groups are the building blocks of the organization’s structure. They are specified in the or ganization chart and include the executives, managers, supervisors, and thepeople who report to them. Task forces, also calle d task groups, are temporary groups charged with solving a problem or responding to an opportunity. Stakeholders are grou psand organizations that have a vested interest in the organization. Informal groups are naturally formed groups of people w ho work together or who are drawn together on thebasis of friendship or shared interests. Although they are not officially sanc tioned or recognized by the organization, they strongly influence its workings (Ivancevich & Matteson,2002). Successful health care management requires skill in managing individuals, groups, and stakeholders. 4.2 Group Dynamics Cartwright and Zander (1968) define group dynamics as “a field of inquiry dedicated to achieving knowledge about the nature of groups, the laws of their development, and theirinterrelations with individuals, other groups, and larger institutions” (p. 12 0). They note that this subunit of organizational behavior became an identifiable field in the UnitedStates in the late 1930s and has four distinguishing characteristics: 1. An emphasis on theoretically significant empirical research, based on effective experimental design, careful observation, reliab le measurement techniques, and statisticalanalysis of data performed according to accepted social science research methods. 2. Interest in the dynamics of group life and observed relationships, in order to discover general principles concerning what cond itions produce what effects and howcertain properties and processes depend on others. 3. Interdisciplinary relevance, incorporating and contributing ideas from and to sociology, psychology, anthropology, political sci ence, and other social sciences. 4. Potential applicability of findings to professional and business practice, in order to provide a sounder scientific basis for practi tioners in a variety of group settings andorganizations. While groups and teams are terms often used interchangeably in the literature, there are some important distinctions between them. Groups consist of two or more individualswho interact with each other and share a common purpose or affiliation. A tea m is a type of group; all teams are groups, but not all groups are teams. In business a team is a groupwhose members work tog ether on a specific project or are responsible for a specific organizational function. While there may be a designated team leade r, teams collectivelyassume responsibility, set goals, develop plans, and divide the work. “In order to be a team: (1) individuals’ actions must be interdependent and coordinated, (2) each membermust have a specified role, and (3) members must share co mmon task goals or objectives” (Ivanitskaya, Glazer, & Erofeev, 2009, p. 109). Group dynamics, as the name implies, deals with changes that occur when people interact. The following section highlights thr ee important theoretical contributions to the studyof group dynamics in the workplace. The first, roles, places the individual in context among peers, superiors, and subordinates and also defines his or her function in theorganization. The sections on gro up process and intergroup behavior deal with group development and group behavior toward other organizational groups. Roles A key construct of psychology is the role an individual plays in a given situation, which serves a specific purpose and involves a set of shared expectations. For example, nursesare the primary caregivers of patients in a hospital. In business others in the o rganization and the profession establish expectations for a given role. For a nursing supervisor,these others would include dire ct reports, the boss, fellow supervisors, patients and their families, and the nursing educational, professional, and licensing org anizations. Benne and Sheats (1948) developed functional role theory based on behavioral patterns they observed among individuals in many different smallgroup interactions. Someindividuals performed task roles, which involved completing a job and accomplishing an objective. O thers performed maintenance roles, which were social in nature, focusingon process and relationships. Still others performe d individual roles to help the group accomplish its goals. Whetten and Cameron (2011) noted that two types of roles, taskfacil itating and relationship building, were both important contributors to group performance. Most people, whether group memb ers or leaders, tend to emphasize one role overthe other. While at certain times one role may predominate, effective groups ne ed to strike a balance between task-facilitating and relationshipbuilding roles. Tushman (1977)described individuals whose roles primarily involve interactions and communications with ext ernal stakeholders as holding boundary-spanning roles, such as compliance orgovernmentrelations officers in a health organization. Another type of role common in large-scale or hightech health organizations is that of horizon scanning, which involvesidentifying new and evolving interventions or technologic al advances, as well as analyzing their potential impact on the health care industry generally and the organizationspecifically ( Sun & Schoelles, 2013). Whetten and Cameron (2011) categorized a number of unproductive behaviors that inhibit group wor k as blocking roles, and emphasizedthe importance of managerial proficiency in developing, participating in, and leading grou ps. Theory in Action: Management Behavior and Group Roles Here are common behaviors of each role type, with examples of statements to illustrate group leader behaviors or, in the case of blockers, to deal with them effectively(Whetten & Cameron, 2011). Task-Facilitating Roles • • • • • • • • • Giving directions: “Let’s start by brainstorming ideas.” Seeking information: “What do the licensing regulations specify?” Giving information: “Here are the regulatory specifications.” Elaborating: “To add to Joe’s comments. . .” Urging: “We need to win this bid to make our revenue target next year.” Monitoring: “Who will be lead staff with accountability for each task we’ve identified?” Analyzing process: “Some members seem to have checked out on this project.” Reality checking: “Can we really meet this deadline?” Enforcing: “We’re getting off track; let’s focus on what we have to decide today.” • Summarizing: “Here is what I understand are our next steps, and who is lead staff for each.” Relationship-Building Roles • • • • • • • • Supporting: “Your root-cause analysis was spot-on!” Harmonizing: “Let’s just agree to disagree about this; we don’t need to agree on every point to move ahead.” Relieving tension: “I haven’t had this much fun since my last root canal!” Confronting: “Maria, this is your department’s domain, so you need to assign staff to complete this part of the job.” Energizing: “I can’t believe how much we’ve accomplished so far!” Developing: “Jerry, I know this is a new area for your department but Ruben will help you; he’s done a lot of similar projects.” Building consensus: “Let’s list the things we have agreed to so far.” Empathizing: “I know it’s stressful to have such a lot to do in such a short time.” Blocker Roles • • • • • • • • • • • • Dominating: “Remember, this is a group project; we need everyone’s ideas.” Overanalyzing: (a) General: “We need to avoid analysis paralysis”; (b) Specific: “Hilary, will you please summarize your concer ns in no more than 1 page for thenext meeting?” Stalling: “Folks, we need to make a decision on this today.” Disengaging: “Charlie and Lisa, you haven’t said anything and I know you have opinions about this.” Overgeneralizing: “Is the issue that Oscar raised as much of a problem for other people?” Faultfinding: “Let’s keep an open mind as everyone presents their ideas.” Premature decision making: “Are we jumping to a solution here?” Presenting opinions as facts: “Do you have any data or facts to support that statement?” Rejecting: Include instructions prior to the meeting: “Please type out on separate sheets of paper your idea(s) for resolving iss ues 2 through 5 and bring them tothe meeting.” Pulling rank: “We need to hear more from the people who will be doing the work.” Resisting: “Let’s concentrate on how we can move forward on this project.” Deflecting: “We’re getting off track here, let’s focus on the main points.” Group Process and Phases Educational and research psychologist Bruce Tuckman became well known following the publication of a short article in 1965 in which he proposed a fourstage linear process ofgroup development: Forming, storming, norming, and performing. Hare, Borgatta, and Bales (1965) arg ued that since group members will seek a balance between accomplishingthe task and building relationships with fellow group members, it becomes a repetitive cyclical process as the group moves from storming, norming, and performing, as illustratedi n Figure 4.1 (Smith, 2005). Understanding dynamics of the group developmental process is particularly important for health p rofessionals participating in or leading themultidisciplinary teams so common in health organizations. Figure 4.1: Group development phases Early group dynamics researchers developed a fourphase developmental model that included the phases offorming, storming, norming, and performing. Source: Smith, M. K. (2005). Bruce W. Tuckman— forming, storming, norming and performing in groups. The Encyclopaedia of InformalEducation. Retrieved August 15, 2013, from infed website: http://infed.or g/mobi/bruce-w-tuckman-forming-storming-norming-and-performing-in-groups 1. In the forming stage, groups organize themselves and test each other to establish boundaries for both task and relationship be haviors. It is also during this stage thatleadership and dependency roles are established. 2. The storming stage involves some conflict or polarization as members compete for leadership or to control the group’s directi on, which disrupts task requirements. 3. In the norming stage, members develop feelings of identification and cohesiveness with the group as they put aside their pers onal agendas, adopt new roles, and committo new behaviors as group members. 4. In the performing stage, the interpersonal structure becomes the vehicle for accomplishing the task activities as members rec ognize the importance of group goals,develop pride in identity, and direct their energies as a group to accomplishing the task. Figure 4.2: Tuckman, Jensen, and Coppola’s groupdevelopment phases Groups develop over time in a series of stages that include preparing towork together and bringing their work to a close. In 1977 Tuckman and Jensen added a fifth stage, adjourning, since not all groups are ongoing. Thisstage can be a stressful pro cess because it involves loss and the termination of roles (Smith, 2005).Coppola (2008) argues that an additional preparation s tage is important, especially in hospitals andother large, complex organizations. The informing stage begins with an initial (wr itten or verbal)notification of or invitation to membership when a new team is officially designated or when new teammember s join an existing structural (command) team where members rotate in and out. During thisstage the member(s) form opinions about both the mission of the team and its other members. Figure4.2 displays the team development phases as a sixstage process that includes informing and adjourning. Often, one of a new manager’s first assignments is to lead a newly formed or existing group.Understanding the developmental group processes will assist managers in maximizing output; it willalso prepare them to lead more complex interdisciplinary gr oups as their careers progress, such as ahospital committee required by the Joint Commission or staffing a board of directors c ommittee. Ledlowand Coppola (2014) suggest strategies for health managers to employ at each of the six stages of groupdevel opment, as summarized in Table 4.1. Table 4.1: Group developmental stages and management strategies Stage Strategy Additional considerations Infor • ming Officially notify each member of appointment to the• group Formally present group goals, measurable objectiv• es in abounded time frame • Communicate in person with group members • Allow a reasonable time period (15 to 30 days) between noti fication and firstrequired meeting Known desire of members to be or not be in the group Skill set, track record in prior groups Personality dynamics between group members Formi• ng 1. 2. 3. Hold a “kick-off meeting to: • Outline group roles Clarify goals and objectives Establish time line with milestones and deliverable s Challenge of allowing time for group development process w ithin timeconstraints for task completion Storm• ing • Encourage constructive professional discourse Resist temptation to intervene prematurely Push to develop a new collective idea that reflects input from all groupmembers • • • Stage Strategy Additional considerations Normi• ng Recognize that group has developed a unique persp• ective of thetask to be accomplished Work with nonnorming members to encourage the m to supportgroup norms Better to remove or replace obstinately noncooperative me mbers Perfor• ming • Thank group members Recognize individual contributions • Know contributions of each member and use this knowledge for staffdevelopment to build on strengths Adjou• rning • 1. 2. Document the process and save the output • Recap lessons learned Best practices • Opportunities for improvement Disseminate knowledge gained to other segments o f theorganization Acknowledge that people will miss some aspects of the grou p’s work andtime with each other Use learnings to build knowledgemanagement and organizational-learningsystems • • Source: Ledlow, G. R., & Coppola, M. N. (2014). Leadership for health care professionals: Theory, skills, and applications (2nd ed.). Burlington, MA: Jones & Bartlett. Intergroup Behavior Industrial psychologists Blake, Shepard, and Mouton (1964) found in their studies of group dynamics that members of a group who strongly identify with the group will feelobligated to conform to its norms and positions and to uphold their group’s positi ons against other groups. Acting in ways contrary to their own group position would beregarded as disloyal to the group, wher eas holding fast to it would be considered highly effective behavior as a member or leader. Each group within an organization has its owngoals, yet these groups are interdependent with each other. When organizations encourage groups to compete with each other and reward them on a relative basis with groupincentive plans, the groups perceive defeat of the other groups as n ecessary to achieve their objectives, and a power struggle ensues. The researchers proposed three sets ofassumptions about in tergroup disagreement and identified mechanisms of intergroup conflict resolution for each. 1. If intergroup disagreement is considered inevitable and permanent, the operating assumption is that it must be resolved in fav or of one or the other group, either by apower struggle or by a third party arbiter—or left to resolve itself. 2. If intergroup disagreement is not considered inevitable but agreement is not possible, conflict can be resolved by reducing the interdependence between groups andallowing or encouraging the groups to act more independently from each other. 3. If achieving agreement and maintaining interdependence are both considered possible and necessary to organizational functio ning, conflict may be resolved by groupactions to (a) maintain surface harmony, (b) bargain or compromise, or (c) make a gen uine effort to address fundamental points of difference between groups (Blake etal., 1964). Alderfer (1987) notes the importance of intergroup relationships to explain group behaviors in larger organizations. He distin guished between identity groups and organizationalgroups, which are comparable to informal and formal groups. Identity gr oup members share some common characteristic (e.g., age, ethnicity, gender) and have sharedexperiences (e.g., alumni, profes sional degree), and as a result they have similar perspectives on life and work. Members are assigned to organizational group s based on theorganization’s division of labor and authority structure. Identity group and organizational group membership is frequently related. For example, a majority of executives in healthorganizations are older white males who often share prior w ork or educational experiences and similar hobbies such as golf; clinicians who trained in the same institution oftenwork toget her in other organizations during their careers. Intergroup theory proposes that both organization and identity groups affect members’ intergroup relations and thusshape beliefs and behaviors. Teams Teams are widespread in health organizations because the clinical and administrative staff need to work together closely to m eet the needs of their patients, customers, ormembers. There are teams based on discipline (such as those composed exclusive ly of physicians or nurses) or hierarchical position (such as the governing body/board ofdirectors, executive team/chief team, directors/unit leaders council, etc.). Multidisciplinary teams are used extensively for quality-improvement initiatives. Permanent and Temporary Teams Interdisciplinary teams are organized to perform a particular function involving the work of several operational units; if the fu nctions are ongoing, the teams are designated as committees. Committees have permanent standing, elected or appointed me mbership, and provisions for alternate representatives. In some committees members have timelimited terms of office. In other committees membership is automatically assigned to the position; for example, the qualityimprovement committee of a hospital typicallyincludes the chief of the medical staff and the director of nursing or their delega ted physician or nurse representatives. Staffing committees is a key health administration role andhelps support clinicians or s enior executives. Theory in Action: Typical Health Organization and Hospital/Health-System Board Committees Some typical health organization committees with ongoing responsibilities and a brief description of their function are: • • • • • • • • • Utilization Review—patient-care management case reviews, medical-management process analysis Clinical Documentation Review—monitoring of documentation adequacy Risk Management—liability exposure and overall safety assessment Infection Control—physical facility and patient-care process monitoring to prevent and deal with infection Patient Safety—adverse event case analysis, care-process improvement to prevent adverse events Quality Improvement—proactive patient-care and business-process improvement Professional Development—individual and group skill enhancement and training Credentials—clinical credential assessment, verification and monitoring Patient/Health Plan Member Grievance Review—complaint assessment and adjudication At the governing body level, hospital and healthsystem boards commonly do much of their work through committees. A 2013 survey by the American HospitalAssociation’s Ce nter for Healthcare Governance found that over half had committees for finance (83%), quality (75%), executive (68%), gover nance and nominating(61%), and audit and compliance (51%) (Gamble, 2013). Task forces are temporary teams organized as needed to solve a particular problem or complete a specific project. These team s are time limited, have specific and strategicobjectives, and disband when the problem is resolved or the project is finished. Of ten there is a work product such as an accreditation selfstudy or a revised policy and proceduremanual. Examples of health organization task force functions and work products inclu de: • • • • • • • • Accreditation or licensing application or renewal Policies and procedures—development or update Event planning: Holiday party, charitable activity, organizational anniversary celebration Space planning (for a move or facility renovation) Technology transitions—planning and implementation (e.g., electronic medical records) Customer service initiatives involving significant business-process changes Feasibility studies for new business ventures or programs Pursuing an award such as the Baldrige prize for quality, magnet hospital designation, or five-star Medicare health plan rating Cross-Functional Teams Many organizations create customer teams in response to increased market competition and customer demands for better ser vice coordination. Managed health care systemshave resulted in the creation of everlarger economic bargaining units among both payer and care delivery organizations as evidenced by health plan mergers and acquisitionsand hospital system affiliations. These large customers (mega health plans and multihospital systems) expect not only lower prices but also knowledge of their business and rapidresponsiveness to their needs; they often demand a single poi nt of contact for inquiries and service. In such an environment, a coordinated approach to business developmentand customer relations is essential and typically involves people from marketing, finance, information systems, and operations on the team. The crossfunctional team memberspossess the competencies needed to achieve an optimal outcome, such as winning a new contract or i mproving customer satisfaction and regulatory or accrediting agencyratings. Theory in Action: Ten Tips for What Not to Do as a Team Manager Parker (1994) offers a David Letterman–style “Top 10 List” of practices to avoid when managing cross-functional teams. 1. Don’t listen to any new idea or recognition from a team. It’s probably not a good idea since it’s new and comes from a team. 2. Don’t give teams any additional resources to help solve problems in their area. Teams are supposed to save money and make d o with less. Besides, they willprobably just waste more time and money. 3. Treat all problems as signs of failure and all failures as a reason to disband teams and downgrade team members. Teams are s upposed to make things better, notcause you more problems. 4. Create a system that requires lots of reviews and signatures to get approvals for all changes, purchases and new procedures. Y ou cannot be too careful thesedays. 5. Get the security department involved to make it difficult for teams to get information about the business. Don’t let those team members near any computers. Youdon’t want them finding out how the business is run. 6. Assign a manager to keep an eye on teams in your area. Tell the teams that he or she is there to help facilitate (teams like that word)— but what you really wantthese managers to do is control the direction of the teams and report back to you on any deviations fr om your plan. 7. When you reorganize or change policies and procedures, do not involve team members in the decision or give them any advan ce warning. This will just slowthings down and make it difficult to implement the changes. 8. Cut out all training of team members. Problem solving is just common sense anyway, and besides, all that training really accom plishes is to make a fewconsultants really rich. 9. Express your criticisms freely and withhold your praise and recognition. Teams need to know where they have screwed up so that they can change. If you giveout praise, people will expect a raise or reward, and you don’t want that. 10. Above all, remember you know best. That’s why they pay you the big bucks. Never forget that (pp. 210–211). Source: From Parker, G.M., Cross-functional teams: Working with allies, enemies & other strangers. Copyright (c) 1994 John Wiley and Sons Inc. Reprinted by permission. Virtual Teams Blend Images/John Fedele/Getty Images A virtual team meeting via video chat saves time andmoney. Advances in electronic communication technology have encouraged the formation of virtual teams in manyorganizations and s ome entirely virtual organizations as well. As the use of virtual work teams grew, bothorganizations and workers realized that virtualization had both benefits and drawbacks. At InternationalBusiness Machines (IBM), an early adopter, more than 45% of its 400,000+ employees and independentcontractors work remotely; however, employees joke that the company’s initials stan d for “I’m by myself” (Johns& Gratton, 2013). Marissa Mayer made headlines when she was named CEO of Yahoo! in July 2012 at age 37,when she was 6 months pregnant with her first child; she sparked a firestorm of controversy 7 months later byelimin ating the company’s longstanding telecommuting programs. Mayer argued that employees needed to bephysically present to create a unified organizati on. Yahoo!’s share price increased by more than 70% in Mayer’sfirst year in office, although the company’s revenue rose at a m uch slower rate than its competitors in the digitaladvertising industry (Efrati & Silverman, 2013). As in other businesses, a growing number of administrative professionals in health organizations aretelecommuting. Managers in these organizations recognize that new work models bring new challenges, and it isnot easy to achieve a balance between t he independence and freedom of virtualization and the camaraderie andopportunities for collaboration in a traditional office s etting. Finding or creating new ways to provide a sense ofcommunity can mitigate worker isolation, avoid alienation, and foste r team collaboration (Johns & Gratton,2013). 4.3 Group Performance and Effectiveness Teams are an integral element of health organizations’ administrative infrastructure. Effective teams are like flocks of geese: B oth have interdependent members who care for andsupport each other and are more efficient working together than alone. M embers rotate as leaders and help each other when one falters or is distressed. Benefits and Costs of Teams Considerable research has demonstrated the benefits of teams for both the organization and the individual: Enhanced commu nication, higher productivity and satisfaction, anddecreased turnover (Buchbinder & Thompson, 2012). Teams maximize the organization’s human resources, for in teams, each member learns to be more effective through the coach ing, help and leadership of all the othermembers. All members, not just the individuals, feel success and failures alike. Because failures are not blamed on individual members, they have the courage to takemore risks in a team setting and more ideas are f orthcoming. The greatest lesson learned by team members is: Teams consistently outperform individuals. And thesecond great est is: Individuals may be considered for career advancement as a result of broadening their knowledge of the organization an d acquiring teamwork skills.(Costa, 2009, p. 315) Katzenbach and Smith (1993), in their bestselling business book, The Wisdom of Teams, present the following findings to support their fundamental premise that teams a ndorganizational performance are inextricably connected. • • • • • “Real teams” are jointly responsible for specific results that the company performance ethic demands. They emerge and operat e best when management makes clear andstrong performance demands and holds them accountable for results. Highperforming teams are rare, mainly because few teams elicit the high degree of personal commitment that distinguishes membe rs of high-performing teams frompeople on other teams. Teams integrate, rather than replace, formal hierarchical structures and processes. Teams integrate performance and learning by defining performance goals and developing the skills needed to achieve them. Teams are increasingly the primary unit of performance for organizations, essential for the speed and quality that customers i n all types of industries expect. There are, however, significant costs of teamwork. The greatest cost is the staff time spent in meetings and the associated oppo rtunity costs (how that time might be better spent).Other costs include time spent in arranging, scheduling, and recording mee tings; travel or communication expenses for inperson or virtual meetings; and expenses for food,travel, and accommodations. There are also psychic costs associated with ha ving to work with other people, such as delayed decisions, loss of autonomy, and pressure tocompromise (Buchbinder & Thom pson, 2012). Health administrators therefore need to weigh the costs and benefits of forming teams under varying circumstances, since wh ether a team or individual approach is mostappropriate depends on the nature of the problem, the goal to be achieved, and the skill of the team leader (Maier, 1967). Generally, teams are most useful in situations requiringmultiple skills, a variety of persp ectives, broad experience, and a free flow of communication (Whetten & Cameron, 2011). Dysfunctional Teams Not all teams function successfully. Patrick Lencioni (2002) has identified five dysfunctions of teams that prevent them from p erforming effectively. Table 4.2 compares theprincipal characteristics of dysfunctional and well-functioning teams. Table 4.2: Functional and dysfunctional teams Att rib ute Dysfunctional teams Functional teams Tru st In the absence of trust, team members are unable to be genuinely op en with each otherabout their mistakes and weaknesses. Team members feel free to ask for or offer help . Co nfli ct Failure to establish a foundation of trust creates fear of conflict, so th at team memberscannot frankly and passionately debate ideas, and f ail to resolve the issues about which theydisagree. Productive conflict enables a team to produce t he best possiblesolution in the shortest amoun t of time, then move on to thenext important is sue. Co m mit me nt Lack of healthy conflict results in lack of commitment, since team me mbers have not openlyexpressed their opinions. The quest for certai nty about the correctness of a decision canparalyze a team and unde rmine members’ confidence in their ability to make any decisions. Seeking consensus is not necessary; reasonabl e people cansupport a decision they do not agr ee with as long as theyperceive that their opini ons have been heard and seriouslyconsidered. Acc ou nta bili ty Lacking commitment to a clear plan of action, team members avoid a ccountability andhesitate to confront their peers regarding counterp roductive actions and behaviors. Members of great teams demonstrate their res pect for eachother by holding them accountabl e for performing at a highlevel. Att rib ute Dysfunctional teams Functional teams Res ult s Failure to hold each other accountable leads to inattention to results when team membersput their individual needs or the needs of their work unit above the collective goals of theteam. Great teams want to achieve the goals they set and the resultsto which they commit. Source: Lencioni, P. (2002). The five dysfunctions of a team: A leadership fable. San Francisco: Jossey-Bass. Teamwork in health organizations is often very challenging, especially in large, complex organizations with members from diff erent professional groups. Forming and leading agreat team is hard work, but the results are worth the effort. Web Field Trip: Mind Tools Team Effectiveness Assessment Go to http://www.mindtools.com/pages/article/newTMM_84.htm. Answer the 15question assessment fora team in which you are a leader or participant. 1. Analyze your responses and identify your areas of strength and weakness. 2. How will you use what you learned from this assessment to become a more effective group leader? Groupthink Henry Burroughs/AP The Kennedy administration’s 1961 Bay of Pigs fiasco is aprominent example of groupthink. Yale University research psychologist Irving Janis (1971) developed this concept from research on the actions ofPresident Joh n F. Kennedy’s cabinet toward Cuba. After concluding that Cuban president Fidel Castro wasworking on behalf of the Soviet Un ion, in late 1961 Kennedy authorized a clandestine brigade of Cuban exiles toinvade the island. The Bay of Pigs fiasco, as it bec ame known, failed within days and was an embarrassing defeatfor the Kennedy administration. A few months later, the same t eam handled the Cuban missile crisis brilliantly.After aerial reconnaissance photographs revealed Soviet missiles under constr uction in Cuba, the administrationboldly confronted Soviet premier Nikita Khrushchev while avoiding armed conflict (U.S. Dep artment of State,n.d.). Janis (1971) reviewed hundreds of documents on the Bay of Pigs invasion attempt and other unsuccessfulgovernment and mili tary leadership team decisions and made a surprising discovery: Each group of highlevelleaders and officials displayed the same type of social conformity that psychologists had routinely observed instudies of g roups composed of students and the general population. Janis called this phenomenon groupthink,defined as remaining loyal to the group by sticking with the policies to which the group has already committed itself,even when these poli cies are working out badly and have unintended consequences that disturb theconscience of each member . . . when concurren ceseeking becomes so dominant in a cohesive ingroup that ittends to override realistic appraisal of alternative courses of action. (p. 157) Groupthink Signs and Signals Behavioral symptoms of groupthink typically arise during the norming stage of the group developmental process, but they can develop at any time. Signs and signals ofgroupthink include: 1. Illusion of invulnerability: Members feel their group or organization is too smart, powerful, or rich to be wrong or to experienc e defeat. 2. Rationalization: Members discount warnings and other signals that their thinking is incorrect. 3. Morality: Members’ belief in the inherent morality of their group and the rightness of their position leads them to ignore the et hical consequences of their decision. 4. Stereotypes: Members consider opponents too weak, stupid, or corrupt to deal effectively with whatever the ingroup decides to do and dismiss disconfirminginformation by discrediting its source. 5. Pressure: Group leaders and members apply direct pressure to any member who expresses doubts about the proposed course of action or who questions theassumptions on which it is based. 6. Self-censorship: Members suppress misgivings and doubts, deciding that they are not relevant and should be set aside. 7. Illusion of unanimity: Members assume that not speaking in opposition indicates agreement with the group’s position. 8. Mind guarding: Members protect the group leader and fellow members from adverse information that would disrupt the conse nsus, such as objections or questions from“outsiders”— even highly respected experts. A Closer Look: Consequences ofGroupthink The effectivenss of an organization can be underminedby groupthink or conformity. Groupthink at NASA, andits dramatic consequences a re explored in this video. Critical Thinking Question How can an organization's culture encouragegroupthink? The author’s experience during the 1980s in a nonprofit hospital system executive team meeting illustrates groupthink inhealt h care organizations. The corporate director of marketing and planning presented her plan for an integratedmarketing approa ch by the system’s member hospitals as a costeffective way to promote the hospitals in their respectivecommunities and compete with the erosion of market share and doct or defections to forprofit hospitals chains in theregion. The CEO of the flagship hospital stated, “I refuse to engage in any form of advertising; it’s n ot dignified, and it’sunethical for a nonprofit religious hospital to use its funds in this manner. Besides, everyone knows we pro vide the bestquality care and have the best physicians. They lure patients with false advertising and doctors with kickbacks. If weadopt their tactics, we stoop to their level.” The seniorlevel leadership team ignored the marketing director’s rejoinderthat advertising was just one small part of the overall plan and that the physician relations program did not and wouldnever involve payment for admissions. After some murmuring, discuss ion of the plan was tabled; it did not appear on theexecutive council agenda again until the flagship hospital CEO was on vacati on. Groupthink Remedies To counteract groupthink, Janis (1971) offers the following suggestions based on the successful actions taken by theTruman a dministration’s Marshall Plan team for post– World War II European economic recovery as well as the actions ofthe Kennedy cabinet in peacefully resolving the Cuban miss ile crisis: • • • • • • • Assign the role of critical evaluator to at least one team member, who will encourage the group to consider bothpros and cons of any proposed course of action. Leaders should refrain from expressing their opinions or expectations at the beginning of a group discussion. Set up subgroups of team members or outsiders to develop and debate independent proposals. Require each team member to seek input from members of their organizational units and report back to thegroup. Invite one or more outside experts to each meeting to hear and critique core members’ views. Assign at least one team member to play devil’s advocate whenever the agenda calls for an evaluation of policyalternatives. In contrast to the critical evaluator’s neutral stance, this member’s role is to make opposingarguments. Hold a “secondchance” meeting at least 1 day after the group reaches a preliminary consensus, where allmembers are encouraged to express their second thoughts about the decision. Taking these actions will help ensure that team decisions in health organizations are well formed, carefully considered,vigorou sly debated, and thoughtfully adopted. An illustration of groupthink often used in management classes is the Abilene Paradox (http://www.crmlearning.com/abil eneparadox), which recounts the story of a Texas family that made a long, hot, and unpleasant drive to Abilene for dinner. They al l would have preferred to stay home, but eachagreed because they felt the others wanted to go (Harvey, 1988). 4.4 Stakeholder Dynamics Health care organizational stakeholders and their relationships are especially complex and involve many players and forces. T hese individuals, groups, and organizations arelinked together by cooperative economic exchanges as well as legal and regulat ory relationships. Table 4.3 lists the major types of health organization stakeholders and brieflydescribes their primary charac teristics (White & Griffith, 2010). Table 4.3: Principal attributes of health organization stakeholders Stakehold er Principal attributes Owners Vary according to whether the organization is a not-for-profit or forprofit corporation, or a federal, state, or local government agency Customers, buyers, and payers Patients and families, differentiated by age, gender, clinical need, and language preference; employers, health insurance and other types of payersdifferentiated by company and type of coverage Suppliers a ndworkers Direct patientcare providers differentiated by professional credentials; many other types of employees; contract providers; suppliers of goods and services;and volunteers who support and supplement the efforts of workers in myriad ways Regulators andadvocat es Government agencies (federal, state, and local); accrediting bodies; trade and professional associations; lobby ing groups; unions; consumer associations;community groups; competitors; and other organizations influenci ng health organization transactions and operations Source: White, K. R., & Griffith, J. R. (2010). The well-managed healthcare organization (7th ed.). Chicago: Health Administration Press. Health organization stakeholders include individuals and groups within and external to the organization. Employees, including managers and executives, are internalstakeholders. There are also interface stakeholders, which function both externally and internally; for health care organizations these groups would include the medical staff,the governing body, and stockholder s in the case of forprofit organizations. External stakeholders for health care organizations include patients, community organizations,insurers, vendors, competitors, employers, labor unions, and regulatory and accrediting bodies (Ledlow & Coppola, 2014). Sometimes s takeholders are individuals; more oftenthey are groups. Figure 4.3 illustrates a generic model of stakeholderorganizational relationships. Figure 4.3: Stakeholder-organizational relationships An understanding of stakeholder-organizational relationships is essentialto stakeholder management. Stakeholder Management Health organization leaders must thoroughly understand the function and role of stakeholders todetermine which are relevant to their organizations and then assess which are potential partners orallies and which are potential threats. Stakeholders have their own interests and agendas, which mayalign or conflict with that of the health organization, and they all make demands o n the organization tosome degree. Balancing the demands of multiple stakeholders pursuing different interests and seekingto i nfluence the organization to act in ways that further their agendas is a major challenge for healthorganization leaders— especially when conflicting responsibilities to patients, governing bodies,professional staff, employees, and community pose et hical dilemmas (Levey & Hill, 1986). Achieving thisbalance is part of the larger challenge of delivering highquality care while simultaneously increasingaccess to health care services and reducing costs; to achieve one objective often in volves a trade-off inanother area. Thus, health organization leaders are hardpressed to satisfy their various stakeholdergroups in terms of what these stakeholders most value in terms of access, cost, and quality (Coppola,Erckenbrack, & Ledlow, 2009). Stakeholder analysis is a widely used method in health organizations to understand how differentstakeholders influence the o rganizational decisionmaking process. As part of the strategic planningprocess, it is especially useful in generating knowledge of relevant individuals , groups, and organizationsin order to understand their interests, agendas, interrelationships, resources, and vulnerabilities(Br ugha & Varvasovszky, 2000). When stakeholder representatives are willing to forthrightly state thepositions of their organizat ions and share these with other relevant stakeholders, organizational leaderscan engage in a more transparent and productive relationship with stakeholders. Unfortunately, thissituation rarely occurs, so it is often necessary to conduct interviews, focus groups, or surveys to discernstakeholders’ true intentions or to accurately predict their actions. Interface stakeholders present the biggest challenge in stakeholder management, since they interactwith the organization acro ss boundaries. With the increase in integrated delivery systems and neworganizational structures, the number and types of th ese stakeholders are increasing. Managers need to identify the key stakeholders and understand their interests and agendasin order to develop and sustain successful relationships with them (Dansky & Gamm, 2004). Physician Relations Physicians are key interface stakeholders who can interact across organizational boundaries to manage a variety of internal an d external stakeholders. In addition to practicingmedicine, physicians may serve on hospital, medical group, and health plan co mmittees; on medical school faculties; on governmental planning or advisory committees or reviewboards; as consultants to p harmaceutical, medical device, and other health care organizations; and as expert witnesses in legal actions. In these various r oles they can be valuablesources of organizational business intelligence. Physicians also represent the organization to the exte rnal environment and thereby contribute positively or negatively to theorganization’s reputation and image, particularly with respect to clinical outcomes and qualityperformance indicators reported to and reviewed by insurers and regulatory andaccrediting agencies. Most importantly, physi cians represent their organizations to patients; as patient care managers, they are the principal source of both the medical care andthe information about the care that patients receive. Since stakeholder relationships directly impact an organization’s financial performance, an important function for health orga nization executives is to help physicians, as interfacestakeholders, develop and maintain strong positive connections with thei r mutual key stakeholders of patients, insurers, and regulatory and accrediting agencies. To do thisinvolves assessing specific physician behaviors about patient communications, adherence to insurance clinical and administrative protocols, and complia nce with regulatory andaccrediting agency data collection and reporting requirements (Malvey, Fottler & Slovensky, 2002). Theory in Action: Training Physicians as Group Leaders An example of how health organizations might help physicians with patient communications is to offer them training in group facilitation and education skills. Grouppatient visits are an emerging trend in a growing number of medical practices today and have been proposed as one way to deal with anticipated increases in demand formedical care by newly insured patients under the ACA. The percentage of practices offering group visits grew from 6% to 13% between 2005 and 2010 and includes some of the nati on’s leading medical groups such as theCleveland Clinic and Harvard Vanguard Medical Associates (Park, 2013). Cleveland Clin ic nurses note that shared medical appointments have improved patient access,outcomes, and patient satisfaction. For chronic conditions, patient education is repetitive and timeconsuming yet necessary; group visits are a much more efficient wayto provide this education. They allow providers to devote more time to patients and encourage patients to learn from each other how to manage their conditions.Additionally, the group visit model allows nurse practitioners to serve as primary care providers by leading patients in group discussions and evaluati ng their currenthealth status (Bartley & Haney, 2010). Physicians who move into management positions will benefit by acquiri ng skills in group leadership. Strong positive relationships with physicians are essential to health organizations in almost every sector of the industry. Press ures to do more with fewer resources make it moredifficult to maintain the trust and respect that are essential building blocks of positive relationships. As a result, relationships with physicians are becoming more adversarial thancollaborative. This situa tion often negatively impacts workplace morale and patient care and increases the risk of litigation and its associated costs (Ya mada, 2009). Under conditions of steadily increasing economic pressures to deliver highquality care at affordable costs, physicians and administrators today must (a) document inincreasingly precise and standardiz ed ways how they are meeting quality standards and (b) break down and justify their service charges to increasingly demandi ng andsophisticated purchasers of care. These pressures drive efforts for health organization alignments with physician group s. However, achieving successful alignment is difficult foradministrators and physicians alike, since their training and professio nal orientation predispose them to different ways of working. Physicians and nurses operate from a clinicalframework, advoca ting at the individual level for patients and families, while managers are trained to look at populationlevel health status and organizationwide issues. Healthadministration education emphasizes working collaboratively with employees and colleagues, while clinica l care education focuses on development of individual skills andcompetencies (Buchbinder & Shanks, 2012). Research on hosp italmedical staff collaborations and the effectiveness of interdisciplinary teams shows that conflicts betweenphysicians and hospit al staff (including nurses) are often due to physicians’ refusal to embrace teamwork (Weber, 2004). The ACA has strong financial incentives designed to encourage closer physicianorganization alignment through formation of clinically and administratively integrated deliverysystems called accountable car e organizations (ACOs), as discussed in Chapter 2. Integration offers physicians opportunities to access greater financial resour ces and focus onpracticing medicine while remaining independent members of their medical group or independent practice association. To succeed, integrated arrangements requirestructures and processes for administrators and physicians to jointl y set goals, develop strategies, make decisions, and resolve conflicts. Studies of successful physicianintegration efforts found that trust was considered the critical success factor in establishing the cooperative relationship neces sary to make these processes work, and identifiedthese indicators of trust-based relationships (Zuckerman et al., 1998): • • • • frequent, open, and candid communication, both formal and informal; willingness to share and explain relevant clinical, financial, and performance data; demonstrated management competence—responsiveness, following through on actions, and delivering on promises; and placement of physicians in management and governance positions. There are varying degrees of physician alignment, ranging from loosely structured contractual agreements to those in which t he physicians become salaried employees of eitherthe hospital/health system or a separate integrated services– delivery organization. Hospitals and health systems were eager to acquire and manage physician practices duringthe 1990s, b ut many of these acquisitions turned out to be expensive mistakes: Hospitals did not know how to manage medical practices, a nd many physicians were lesshardworking and productive as employees than they had been as independent practitioners. Tod ay hospitals recognize the need to carefully evaluate physician practices beforeacquiring them and to employ experienced med ical group administrators to manage them (Aston, 2013). Professional services agreements in which the physician remainsem ployed by the practice allow physicians to more closely align with a health system without becoming an employee. Various pra ctice services agreement models enablehospitals and health systems to realize financial benefits without incurring the legal ob ligations and financial risks of an employer (Reiboldt & Greeter, 2013). 4.5 Organizational Misbehavior and Dysfunction Organizations, like individuals, can behave in ways that are counterproductive, selfdefeating, and even pathological. Researchers have found that organizational dysfunctionreflects problems with the leadership of the organization and, to a lesser extent, with managers at lower levels. This chapter concludes by discussing the diagnosis, p rognosis, andtreatment of organizational dysfunction. Theory in Action: Crime Does Not Pay Some cases of organizational misbehavior are so flagrant that they make front page headlines, such as the saga of Richard Scru shy. Trained as a respiratory therapist,Scrushy quickly rose to top management and in his early 30s founded the HealthSouth C orporation to deliver a wide range of outpatient rehabilitation services. Thecompany soon went public and rapidly expanded i nto sports medicine and workers’ compensation, despite repeated lawsuits and settlements with Medicare and privateinsurer s claiming fraudulent billing practices. Scrushy enjoyed and flaunted the company’s success, earning millions of dollars and tra veling and living in high style. Hewas widely admired as a brilliant businessman—until he was indicted for securities fraud. Although all five of the HealthSouth chief financial officers who worked for him were found guilty and sentenced to prison ter ms, Scrushy was acquitted. However, a fewmonths later Scrushy was convicted on unrelated charges and spent about 5 years i n prison. Once revered as a Wall Street wonder, today Scrushy is a poster boy forgreed who was profiled in a 2009 episode of t he CNBC series American Greed. Diagnosing Organizational Misbehavior and Dysfunction Seldom is organizational misbehavior by health organization executives so clearly pathological. More often organizational dysf unction reflects egotism and groupthink, whenhighly intelligent people display poor judgment. It can also result when leaders are unable to • • • • clearly articulate the organization’s vision, values, goals, and culture; engage and motivate employees; develop meaningful reward systems; and effect needed changes (Graber, 2009). Manfred Kets de Vries (2003) of the international INSEAD business school faculty developed a typology of five types of neurot ic organizations based on the typical andrepetitive behavior patterns of their leaders and managers and the effects of these b ehaviors on the organization’s employees. Each style has its strengths and weaknesses, asdisplayed in Table 4.4. Table 4.4: Neurotic organization leadership style summary Sty le Description Illustrativeex ample Strengths Weaknesses Dr am atic Driven by the need to impress and gain atte ntion. Leaders arehighly charismatic, act bol dly, are undeterred by risk, and takecontrov ersial stands. Richard Brans on,Virgin Airli nes Strong entrepreneurial s pirit Decisions may become too centralized; leader maymic romanage. Sus pic iou s General atmosphere of distrust and paranoi a; hyperalertnessfor problems and enemies. J. Edgar Hoov er,Federal Bur eau ofInvestig ation Knowledge and awarene ss ofexternal threats and opportunities Punitive policies; encourag essubterfuge and informat ion hoarding. Co mp ulsi ve Preoccupied with rules; exhaustive evaluati on procedures.Relationships defined by cont rol and acquiescence. John Akers, IB M Efficient operations, stro nganalytics, thorough pr oblem-solving approach Risk of analysis paralysis. Sty le Description Illustrativeex ample Strengths Weaknesses Det ach ed Cold, unemotional; lack of involvement; indi fference to praiseor criticism; intolerance of dependency. Howard Hugh es,HughesCor poration Open to ideas and influe nce frompeople at all lev els and outsidethe organ ization Leadership vacuum induce smanagers to create indivi dualfiefdoms. De pre ssi ve Inactivity, passivity, powerlessness, insularit y; lack ofconfidence in ability to effect chang es. Many govern mentsectororganiz ations Consistent internal proc esses Focus on maintenance of i nternalprocesses; can beco me detachedfrom the mar ketplace. Source: Kets de Vries, M. (2003). Organizations on the couch: A clinical perspective on organizational dynamics. Retrieved August 19, 2013, from INSEAD Faculty & Researc h website: http://www.insead.edu/facultyresearch/research/doc.cfm?did=1321 Organizational Dysfunction Prognosis Leaders in dysfunctional organizations often struggle to understand why people in the organization continue to behave in cou nterproductive ways that result in poor strategicdecisions, ineffective execution of strategy, factionalized management teams a nd business units, hiring mistakes, inadequate succession planning, and low productivity. Too often,however, they blame other s for their own lack of communication and problem-solving skills. Organizations that are in a state of decline or experiencing rapid and unsettling change display a variety of similar dysfunction al characteristics when they lose resources(revenue or market share) and employees, which Cameron (1994) identified as the “dirty dozen” (p. 183): 1. 2. 3. 4. 5. 6. Decision making is centralized, as employee empowerment is constrained. Long-range planning is neglected in favor of focusing on short-term survival and crisis management. Tolerance for risk taking and learning from mistakes decreases. Employees become more resistant to change in order to protect themselves from loss of jobs, benefits, and perks. Morale drops as employees become suspicious and angry. Special interest groups become more visible and outspoken. 7. Across-the-board cutbacks are used to minimize organizational resistance. 8. Organizational leaders lose credibility with subordinates. 9. Organizational competition for shrinking resources leads to conflict and infighting. 10. Information, especially bad news, is suppressed rather than passed up the hierarchy. 11. Teamwork declines as employees focus on individual performance and rewards. 12. Leaders are blamed for organizational uncertainty and decline. Astute professionals will be aware of and alert to these warning signs of organizational dysfunction and take steps to address t hem promptly to prevent further deterioration andimprove organizational functioning. Organizational Dysfunction Treatment The remedy for organizational dysfunction is evidencebased management, which involves using leadership practices supported by solid research. Walshe and Rundall (2001)observ ed that just as clinicians have been slow to adopt an evidencebased approach to their own practices, so have health care managers: They also tend to overuse ineffectiveinterventions and u nderuse effective ones. Shortell (2006) named ineffective health managerial decision making as a significant contributor to the quality deficiencies, excessivecosts, and overall underperformance of the U.S. health care system. A later study by Kovner and Rundall (2006) found that improving the quality of management decision makingreceived little attention, even when a manage ment mistake results in significant harm to patients or financial loss, such as the failed merger of Stanford University and Univ ersityof California hospitals that cost $176 million over a 29-month period. Healthsystem leaders believed that their organizational cultures promoted the use of evidence-baseddecision making— but their definition of evidence consisted mostly of personal and anecdotal experience, information from Internet sites, and ad vice from consultants or servicessuch as the advisory board. None reported any oversight or regular review of the decisionmaking processes in their organizations. Health organization executives and managers have been reluctant to acknowledge their mistakes for the same basic reasons th at prevent clinicians from doing so: They areembarrassed and do not want to lose face with colleagues. They may also lack fina ncial or staff resources or time to adequately research, analyze, or monitor the effects of adecision, or they may be under press ure from superiors, medical staff or regulatory agencies. Some executive decisions seem reasonable at the time they are made but turn outbadly. Furthermore, it often takes a long time before it is clear that a specific decision is not working out as planne d. Hoffman (2002) urges health organizations to encouragemanagers to disclose and learn from their mistakes by taking the fo llowing actions: • • • 1. 2. 3. 4. • • Establish and obtain governing board approval for a managerial disclosure policy based on criteria such as legal risk, regulator y agency requirements, board mandates,and ethical considerations. Analyze the root causes of the problem, the decision-making process, and its consequences. Discuss the analysis with the management team to determine how best to avoid repetition of a similar error, such as: articulating lessons learned, developing new or modifying existing policy, changing the decision-making process, and/or developing new or modifying training activities. Learn more about how to handle management mistakes from case studies of other health organizations and national professio nal development organizations’educational programs. Incorporate questions or discussions of mistakes and lessons learned into executive, managerial, and supervisory performanc e reviews. Cohen (2011) makes a business case for use of evidence-based humancapital management practices in health care organizations where at least 60% of budgets are allocated tolabor costs and notes the financial benefits of such practices for staff recruitment, selection, development, and retention. For example, a poor executi ve hire could cost theorganization 6 to 10 times that individual’s annual earnings. Pfeffer and Sutton (2006) recommend that managers relentlessly seek new knowledge from both inside and outsidetheir companies and industries so that they can keep updating their skills and knowledge, just as medical professionals must do. Because clinicians and health administrators have different professional cultures, research orientations, and decisionmaking styles, evidencebased practice concepts need to betranslated from the clinical to the management arena (Walshe & Rundall, 2001). “Until both components are in place—identifying the best content (i.e., EBM [or evidencebasedmedicine]) and applying it within effective organizational contexts (i.e., EBMgt [or evidence-based management])— consistent, sustainable improvement in the quality of carereceived by US residents is unlikely to occur” (Shortell, Rundall, & Hs u, 2007, p. 673). The following case study describes the use of evidencebased medicine and management toimprove patient safety. Case Study: Improving Responses to Medical Errors With Organizational Behavior Manageme nt A 146bed general acute care community hospital in southwest Virginia conducted an assessment of patient safety needs and the vari ous organizational behavioralmanagement techniques used by hospital managers in response to the nine most frequently r eported patient safety events. The most frequently reported category ofpatient safety events (errors) was procedure/treatme nt variance, and the least effective management responses were to witnessed falls. The organizational behavioralmanagement intervention therefore selected managers’ followup responses to procedure/treatment variance and witnessed falls as targets. Managers first received the results of the needs assessment, then were instructed to (a) respond to the two targeted event typ es with corrective-action communicationcombined with individual and group behaviorbased feedback and (b) use positive recognition to support behavior that prevented harm, including reporting events. Forthe 3 -month intervention period, researchers Cunningham and Geller (2011) reviewed 361 patient safety event followup descriptions, with a total of 527 interventionsthat achieved the following results: 1. Reports of targeted event types increased in the first month of intervention, then decreased in subsequent months, indicating t hat the intervention increasedemployees’ sensitivity to the need to report close calls and learn from them. 2. The two targeted events displayed opposite trends in impact scores associated with managers’ followup actions during the intervention phase. The impactscores for followup behaviors for procedure/treatment variance increased sharply in the first month, then gradually declined in the next 2 mon ths. In contrast,impact scores for followup behaviors for witnessed falls increased slightly in month one, then sharply in subsequent months. 3. Managers significantly increased use of individual and group feedback during the intervention phase and decreased use of no i ntervention, a significantimprovement in the management of patient safety errors. Especially significant was the increased use of group feedback. 4. Participating managers and health care workers expressed positive perceptions of the intervention techniques used and relate d outcomes. Managers receivedsummaries of the monthly events and intervention followup reports at monthly managers’ meetings and were encouraged to share them with their employees.Intervention perception survey results found that both managers and workers perceived an increase in managers delivering praise for behaviors to pre ventharm than delivering reprimands for errors. This study demonstrates the benefits of applying an evidencebased intervention strategy by teaching health care managers to (a) communicate more effectively infollowup responses to patient safety events, (b) more carefully document their followup actions to learn what intervention behaviors do most to promote patient safety,and (c) provide group rather than individua l feedback when appropriate. This intervention demonstrably improved patient safety and offers a model for managers inothe r organizations to follow. Reflection Questions: 1. How does the trend in impact scores for managers’ follow-up actions reflect the Hawthorne effect? 2. Why was the increase in managers’ use of group behavior-based feedback important? 3. What would you recommend to sustain the use of the intervention strategy? 4.6 Summary and Resources Chapter Summary Much of the work in organizations is done by teams of people rather than individuals. Organizations need talented individuals who can work collaboratively with others. Being ateam player is an important attribute for success in most jobs, and being abl e to lead a team effectively is a critical success factor for managers and leaders. There are many different types of groups— formal and informal, permanent and temporary, structural and functional. An understanding of group dynamics and processes helpsmanagers effectively channel and coalesce the skills and efforts of their subordinates for maximum productivity and perf ormance. Not all employees are natural team players, somanagers also need to know how to deal with negative individual and group behaviors. Highperforming teams are results oriented, with managers who set clear performance expectations and hold them accountable. Eff ective team managers establish a climate oftrust, so that team members can be open with each other when asking for or offeri ng help. They also encourage and manage constructive conflict, so that members of the groupcan frankly debate their ideas an d consider a wide range of solutions. Without a free exchange of ideas, team members will lack commitment to the plan of acti on or fall victim togroupthink, a condition that occurs when group loyalty prevents members from expressing their doubts abo ut or opposition to an apparent consensus decision. Health organizations have many different stakeholder groups with which they interact and which have a vested interest in the organization. Stakeholders’ interests may align orconflict with those of the organization, so balancing their demands is a major challenge and responsibility for organizational leaders. Developing and maintaining positiverelationships with physician stak eholders is a critical success factor for leaders of most health organizations, as is attention to the experience of patient stakeho lders. Just as physicians are increasingly expected to make deliberate and thoughtful use of the current best clinical evidence when making treatment decisions, so should healthadministrators use management practices that are supported by solid research. I n addition, health organizations should create conditions that encourage leaders and managersto acknowledge and learn from their own and others’ mistakes. Critical Thinking and Discussion Questions 1. 2. 3. 4. 5. 6. 7. What are examples of task and maintenance roles for health organization group leaders, and why are both roles important? Can a group leader streamline the group development process? How can managers help a task force end on a positive note? How can managers hold teams accountable for results? Why is lack of conflict a sign of a dysfunctional team? Identify the key internal, interface, and external stakeholders for a general acute care hospital. Give an example of evidence-based management. Key Terms Please click on the key term to reveal the definition. Abilene Paradox (Harvey) An agreement to a group decision that none of the group members desires, but each member thinks the other members of the group prefer the decision. adjourning The final stage of group development process, when the group disbands after task completion. blocking roles Behaviors that hinder a group from accomplishing its goals. command groups Groups specified in the organization chart; members are responsible for a specific function. committees Formal groups that have permanent standing within the organization’s administrative structure, regular meetings, and elected or appointed members, often with specificterms. evidence-based management Management practices based on effectiveness supported by research. evidence-based medicine Clinical care practices based on effectiveness supported by research. external stakeholders Members of groups outside the organization, such as customers, suppliers, and regulators. formal groups Groups officially designated by the organization to fulfill certain functions and accomplish specific tasks. forming The first stage in group development process, when groups organize themselves and establish boundaries for task and relationship behaviors. functional role theory (Benne and Sheats) The observation that individuals in small groups played task roles, maintenance roles, or individual (blocking) roles. groupthink (Janis) Remaining loyal to a group position even when the policies are not working out or the members have misgivings about the position. identity group A group in which members share a common biological characteristic or experiences. independent practice association A medical group formed as an economic bargaining unit in a managed care delivery system. individual roles Behaviors that help a group accomplish its goals. informal groups Naturally formed groups of people who work together or who are drawn together on the basis of friendship or shared i nterests. informing A group process preparation stage that involves an invitation to membership and prospective group members forming opinions about the purpose of the group and itsmembers. interface stakeholders Stakeholders that function both internally and externally, such as the medical staff, governing body, and stockholders of for-profit corporations. internal stakeholders Employees, including executives and managers. maintenance roles Roles that are social in nature, focusing on process and relationships. neurotic organizations Organizations that are characterized by counterproductive behaviors that impede achievement of organizational goals. norming The third stage of group development process, when members develop feelings of cohesion and adopt new roles as gro up members. organizational behavior management Intervention techniques designed to improve managerial effectiveness. organizational groups Groups to which members are assigned based on the organization’s division of labor and its authority structure. performing The fourth stage of group development process, when members focus their energies on accomplishing the task for whic h they are responsible. role A key construct of psychology; the shared social expectations of how an individual behaves in a given situation. stakeholders Individuals, groups, and organizations that have a vested interest in the organization. storming The second stage of group development, when members compete for leadership or to control the group’s direction. task force A temporary group charged with solving a problem or responding to an opportunity. task roles Roles that are involved with completing a job and accomplishing an objective. 
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