The most significant change to health care over the coming decade will not be Obamacare. It will be the consolidation of the private practice of medicine as thousands of previously independent physicians move into employment arrangements, most of them under the auspices of hospitals. This shift, already well under way, represents nothing less than a revolution in the structure of the industry.
For the most part, hospitals have supported this transformation not out of altruistic commitments to improve quality or reduce the cost of care but to protect utilization and referrals. Physicians largely have been motivated by rising overhead and declining incomes as well as the growing complexity and uncertainty of an increasingly regulated profession. Motivations aside, the result is that many hospitals now have hundreds of still largely disconnected and uncoordinated physicians milling about inside their castle walls. Lift the organizational roofs off the hospitals’ newly assembled physician "groups" and you’ll usually find very little meaningful collaboration.
Today, the biggest challenge facing health care leaders is the transformation of once proudly independent physicians into a more coherent and purposeful whole. While the future always will be an uncertain proposition, one thing is clear: It will be a team sport. There are earnest efforts to connect physicians with information and consistent compensation systems. This is essential, but it is also insufficient. Information sharing and compensation standards do not a team make.
While collaboration throughout health care must become a priority, it is physician teamwork that holds the greatest potential for significant upside improvements. Harvard business professor and physician Richard M.J. Bohmer, M.D., makes the point in a recent article in the Harvard Business Review, "Fixing Health Care on the Front Lines":
"Many administrators do not know enough about the details of medical care to work with physicians in developing protocols and learning systems. And people who were appointed to boards of directors because of their community standing or fundraising abilities often don’t have the capabilities needed to govern clinical operations."
There are prerequisites for the formation of a team. One is purpose. Teams exist to accomplish something. What teams produce is combined and coordinated effort that generates value beyond what individuals can produce. Humans have a natural, perhaps instinctual, tendency toward teamwork. In his book, The Social Conquest of Earth, Harvard biologist E.O. Wilson suggests that "[f]rom infancy we are predisposed to read the intention of others, and quick to cooperate if there is even a trace of shared interest. … [H]umans, it appears, are successful not because of an elevated general intelligence that addresses all challenges, but because they are born to be specialists in social skills."
Humans are not alone in this tendency, which they share with wolves, ants and other primates. While such social creatures represent a relatively small percentage of living things, they enjoy a disproportionate, often dominant influence across their environments. For humans, what Wilson calls "eusociality" has made civilization possible. According to Nassim Nicholas Taleb, in his book Antifragile, "[C]ollaboration has an explosive upside, what is mathematically called a super additive function, i.e., one plus one equals more than two, and one plus one plus one equals much, much more than three. … "
Productive collaboration will become an essential ingredient for success in a future that demands demonstrated results across complex illnesses and diverse populations. This is not a controversial assertion. Yet, health care remains uniquely devoid of real teamwork.
Physicians, nurses and administrators cooperate, but this is different from teamwork. Cooperation lacks the intentionality of teamwork. People who have little or no familiarity with one another can, on an ad hoc basis, cooperate at the scene of an accident, for example. But productive collaboration requires teamwork that is purposeful, has coherence and exhibits coordinated effort over time. Where teams do exist within health care, they are overwhelmingly focused on relatively narrow tasks with limited time horizons. These are "task-based teams."
As a strategy consultant, my interest in teamwork relates to its role in effectively implementing high-level strategies across health care organizations. Today, such strategies require far greater connection and coordination among physicians and other caregivers than has been the case in the past. Implementing such strategies is not the work of a task-based team focused to a discrete time-limited problem or objective. It is the teamwork necessary to support purpose, coherence and coordination across an entire organization. It is strategic teamwork.
A Central Compass
In strategic teamwork, connection and coordination must crosscut the organization. Strategic teamwork aligns and unifies the organization so it can achieve sustainable advantage over time. It integrates task-based teams into a "team of teams." Its development requires a focus on the "white space" between task-based teams. As Wilson observed, "The social world of each modern human is not a single tribe, but rather a system of interlocking tribes, among which it is often difficult to find a single compass."
A team of teams has a central compass — a broad purpose, an organizational purpose. Organizations cannot exist for themselves. When they do, they quickly collapse. They exist for a purpose. That purpose is not emergent. It does not bubble up from the organization. The organization bubbles up from its purpose. Absent coherence for a broader purpose, task-based teams often ricochet off in unintended directions and work at cross-purposes.
Teamwork has a dark side where its advantages can transition into liabilities. Just as our natural tendencies facilitate the development of task-based teams, our natural tendencies also tenaciously resist and undercut the development of a team of teams. The propensity of task-based teams to quickly and steadfastly default to an "us" and "them" stance is so consistent and pervasive, some experts suggest it reflects an instinct born in our tribal past. According to Wilson, social psychologists have conducted experiments that show how quickly people divide into groups and discriminate against those in other groups: "They judged their ‘opponents’ to be less likable, less fair, less trustworthy, less competent."
In my experience, confusion, anxiety and dysfunction too often inhabit the white space between task-based teams, hindering, and in some instances preventing the development of a productive team of teams. When there is an absence of purpose in the white space, the space doesn’t remain empty. It gets filled with uncertainty, rumors and anxiety. When there is a lack of clarity, intentions are often invented. Such ambiguity undercuts broad organizational cohesion. People end up standing in the hallways wasting precious energy and emotion on speculation.
Within most organizations, the attention channeled to internal intergroup conflicts invariably exceeds that allocated to legitimate threats external to the organization. Even otherwise cooperative individuals find themselves coerced into counterproductive behavior. Many subordinates soon learn that self-preservation requires accepting that "the enemies of my boss and my teammates must become my enemies as well." Unless such internecine conflicts are dampened, the prospects for organizational progress will be limited.
The challenge of building a team of teams involves harnessing and directing the inherent power of teamwork while neutralizing its tendency for conflict. There are several critical imperatives for accomplishing this:
Fill the white space with meaning. A team of teams must have an appreciation for the broader context in which its purpose is pursued. This is called "sensemaking."
In 1949, a lightning storm that passed over Mann Gulch in Montana is believed to have ignited a small fire which, driven by winds and dry conditions, exploded into a conflagration. Thirteen smokejumpers died fighting the fire. The incident provided the basis for Norman Maclean’s prize-winning book, Young Men and Fire.
Karl E. Weick, a professor at the University of Michigan, used Maclean’s book to better understand what holds teams together. According to Weick, the team of 16 smokejumpers lacked critical characteristics necessary to its effectiveness. The leader of the team, foreman Wagner Dodge, had not had an opportunity to get to know his team. They were essentially strangers.
When Dodge saw that the fire had jumped across the gulch and was roaring toward his crew, he ordered them to turn around. They followed his order and began to angle up a steep hill toward a ridge. They also complied when he told them to drop their tools. But without their tools, they ceased to be firefighters and became escapees. So, when Dodge lit a fire in front of them and ordered them to lie down in its ashes with him, no one complied. Instead, the team tried to outrun the fire. Only Dodge and two others survived.
Although lying down in the ashes of Dodge’s fire might have saved the team, it made no sense to them. Sensemaking by a team occurs when they are able to see patterns in their situation that translate into meaning. According to Weick, "The world of decision-making is about strategic rationality. It is built from clear questions and clear answers that attempt to remove ignorance. … Sensemaking is about contextual rationality. It is built out of vague questions, muddy answers and negotiated agreement that attempt to reduce confusion."
Filling the white space with "contextual rationality" that makes sense is critical to fostering and facilitating productive collaboration across a team of teams. Physicians need to see how they fit into the broader purpose of a health system in a complex environment.
Fill the white space with strategic questions and answers. For a team of teams, the most important questions push beyond the vague and the muddy toward negotiated agreement that reduces confusion. They deal with who the organization is and how it must change:
- Why do we exist? (purpose or mission)
- How will we behave? (values)
- Where are we headed? (vision)
- What path will we take? (strategies)
- What are the important realities of our situation? (issues)
In another recent Harvard Business Review article, Thomas H. Lee, M.D., president of Partners HealthCare, addresses essential ingredients for the vision necessary to generate cohesive physician commitment in the white space:
"Change is hard in any field, and medicine’s altruistic core values actually reinforce practitioners’ resistance to disturbing the status quo. … So the vision expressed by leaders in health care must convey both understanding and resolve."
Lee added that leaders should acknowledge the importance of clinicians’ current work, but make it clear that they will have to work differently. They should also provide measures for how clinicians will succeed. And they should be realistic, though upbeat — confident that the care can improve, and that improved care is good for business.
Make teamwork an attitude. A few health care organizations have succeeded in filling the white space between their task-based teams. Chief among these has been Mayo Clinic as well as a dozen or so organizations founded on Mayo’s multispecialty group practice model, including Cleveland Clinic, Lovelace, Ochsner, Scripps, Lahey, Geisinger, Dean, Carle and Guthrie. It is no coincidence that these organizations are regularly cited for their accomplishments related to quality and efficiency — results that rely on organizationwide collaboration. But development of their team of teams was hard-won over more than a century.
W.W. Mayo frequently reminded his sons, Will and Charlie, that "[n]o man is big enough to be independent of others." The Mayos characterized their model as "cooperative individualism," making the argument that it allowed the strengths of individual physicians to shine because clinical accomplishments were not dimmed by the burdens of competing alone for fees or shouldering the full costs and hassles of their practice’s business obligations. Teamwork was also persistently described as serving the best interests of the patient as it brought to bear many minds.
The crosscutting of a team of teams is more an attitude than a process or method. At Mayo, in particular, an orientation toward teamwork and groupness has been designed into the culture through physician and employee selection processes that emphasize such characteristics. This is supported by methods and infrastructure that have been engineered, tested and improved through decades of application.
Move beyond money. For at least two decades, the need for "economic alignment" has been a largely unchallenged article of faith in health care. Economic alignment asserts that the only persuasive and effective way to create shared purpose is to provide a financial incentive to gain desired behaviors. This is a particularly hollow and simplistic view of human nature. The proof is in the results. Over those 20-some years, how much alignment has been economically generated among physicians? Any honest assessment will suggest very little.
Money is part of the answer, but it is not all of the answer. In David Lean’s film "Lawrence of Arabia," Lawrence is asked whether he believes the Arabs will return to the fight without the enticement of gold. He answers, "The best of them won’t come for money, they’ll come for me." And by this he meant the ideals he represented, including a cause greater than money, the creation of a unified Arab state.
In their article in Harvard Business Review, "Collaboration Rules," the Boston Consulting Group’s Philip Evans and Bob Wolf underscore the ability of those associated with the Linux operating system and the Toyota Production System to achieve extraordinary teamwork in the white space and do so without defaulting to monetary rewards as the primary motivator. They note that at both organizations money was not connected to collaboration and results, yet high motivation levels were generated. Admiration and kudos are much better at encouraging people to go above and beyond than are money and discipline, which encourage people to focus on specific tasks.
Support swarming leaders and followers. A team of teams may consist of hundreds of task-based teams and thousands of individuals. Like all teams, it is purposeful, coherent and coordinated. But rather than acting against a task, it swarms toward a purpose.
The object of a team of teams is not a task but a concept. The precision with which fish and birds swarm reflects a few very simple rules — a set of minimum specifications that preserves a high degree of autonomy while achieving remarkable coordination. In flocks of swarming birds and schools of swarming fish, it takes only 5 to 10 percent of the participants to lead the group. And the leadership role shifts continuously across the swarm. Such swarming is not subject to command and control.
Much attention is dedicated to the challenge of cultivating physician leaders. Too little is focused to physician followers. Physicians, as a rule, don’t respond well to command and control leadership, which is not to say that they are ineffective followers. They simply respond to a different kind of leadership, one often characterized as "first among equals." When physician outliers shift their behavior to move closer to their colleagues on a scatter gram, they are following the leaders.
Lee describes the challenge of encouraging change among physicians by relating his experience when he and James J. Mongan, the former CEO of Partners HealthCare, sought to encourage the adoption of consistent practice standards.
"We hesitated because we knew we’d anger some physicians by curtailing their autonomy. … In both instances, though, Mongan brought the discussion to an end by saying, ‘I really think this is the right thing to do.’ No one could argue with him, and no one did."
Physicians will defer to a leader who has authenticity, and most will swarm to the "right thing."
Demonstrate utility. There is among physicians a phenomenon I call "demonstrated utility." Physicians will adopt methods and technologies only when they have seen their value well-demonstrated, and they will usually adopt them very quickly.
The Cleveland Clinic was an early adopter of information technology and demonstrated its utility with the hundreds of salaried physicians who comprised its multispecialty group practice model. Once independent physicians in Cleveland saw the benefits of the clinic’s information system translate into increased productivity, they soon began to lobby for such systems. Physicians look for proof in the experience of others, and they look for it in the data. Lee suggests using data: "The fact is that they are mesmerized by data and cannot look away," he says. He cites Brent James, M.D., of Intermountain Healthcare, who erodes physicians’ resistance to change by showing how their processes differ from the norm.
Don’t let individuals hide behind a team. Encourage personal commitment and peer pressure. According to Evans and Wolf, "When information flows freely, reputation, more than reciprocity, becomes the basis for trust." Constant scrutiny that is challenging rather than hostile lets workers know their reputations are at risk, and they behave accordingly.
In a sidebar to Lee’s Harvard Business Review article, Kelly W. Hall, an executive with Partners Community HealthCare Inc., observes that peer pressure can reward where money cannot. "Doctors are very competitive and want to be A students," Hall writes. Professional pride forces many to improve their practice; but they must trust the data, or resentment will result.
Ensure that task-based teams are effective. Borrowing a biological metaphor, a task-based team can be thought of as a cell: one cell in a republic of cells — a team of teams. As Kevin Kelly suggested in his book Out of Control, big things that work are made up of many small things that work. The task-based team is that small thing that must work effectively if the team of teams is to work.
There is some "right number" of physicians to constitute a productive task-based team. Most physicians I’ve talked with have suggested that the number is probably somewhere around seven. Beyond that number, communication and cohesiveness start to break down. Below that number, there is insufficient robustness and scale. And Lee’s advice pertains to task-based teams as well as the team of teams. He notes that health care teams can’t be limited by time or focused on a single project, as improvements always need to be made.
Build virtual proximity. Teams depend on proximity to generate the connections that make collaboration possible. Until recently, the most productive form of proximity has been physical.
Given the geographic spread represented by most large physician groups today, productive proximity increasingly will become virtual and will be supported electronically. Electronic connections, including portals, videoconferencing and telehealth, already provide practical vehicles for supporting collaboration. Online communities can provide a productive forum for collaboration, and they tend to wash out many of the effects of subgroup rivalries while letting people get to know each other and encouraging more forthright input.
Across the Toyota and Linux communities, proximity was virtual, yet collaboration was remarkably robust and rewarding for participants. According to Evans and Wolf, the collaboration creates good psychological motivations for participants and powerful competitive ones for their organizations. The Linux programmers make their own decisions about how they are going to contribute, and they enjoy producing something that they believe in, not something approved by the marketing or accounting departments.
A survey of more than 800 Linux user-developers showed that more than half said that their open-source work "is the most valuable and creative endeavor in their professional lives."
Call out team conflicts that threaten the organization overall. Too many leaders tolerate or fail to even recognize petty counterproductive conflicts when they arise. But adults often can be embarrassed into productive behavior by calling them out.
On the battlefield, "unit cohesion" causes members of small task-based teams to fight tenaciously for one another, but it can translate into broad dysfunction when the units demonstrate their natural tendency to regard one another with suspicion. Such dysfunction has frequently marginalized entire military branches, with disastrous results, as marines, sailors, soldiers and aviators refused to communicate and support one another. Too often this behavior was permitted, even encouraged, by officers who had a moral obligation to save lives by preserving the advantages of cross-team collaboration. Health care leaders have a similar moral obligation.
Teams of Teams Outside Health Care
Is a team of teams comprising physicians a realistic aspiration? Evans and Wolf shared two examples that reinforce the potential.
In 1997, a fire broke out at Aisin Seiki Co., a major Japanese supplier of automotive parts. The plant produced a valve required by every vehicle built by Toyota. Toyota, relying on its just-in-time inventory system, had less than a day’s supply of the part. It faced the possibility of a total shutdown of auto production lasting months. But within hours, engineers from the destroyed plant met with their counterparts at Toyota.
Word of the fire was spread to Toyota’s suppliers, along with an offer to provide blueprints for the valve along with undamaged tools, raw materials and work in process. Aisin and Toyota engineers collaborated to jury-rig production lines in 62 locations. Suppliers volunteered to help with production and logistics. Within 85 hours, a small supplier delivered 1,000 valves to Toyota, and within roughly two weeks, an entire valve supply chain was in full production.
Six years after the Aisin Seiki fire, a hacker attacked the Linux operating system. Linux is a robust product. It runs on more servers than any other operating system. It is also an essentially free product created, maintained and improved by "a voluntary, self-organizing community of thousands of programmers and companies."
The attack first was detected by a system administrator at the University of Trieste. It held the potential to compromise files on thousands of servers worldwide. Calls went out to colleagues and programmers in Atlanta, California and Australia. A loose affiliation of Linux amateurs and professionals got to work. Within hours the precise location of the attack was determined, and an early advisory warning was posted.
Two Australians worked through the night to write a patch, and within five hours, user-developers started testing the first version. By the end of the second day after the hacker’s attack, the patch was distributed to Linux users worldwide. Then the Linux community set up a system of "vulnerable" servers designed to lure the hacker into revealing himself. According to Evans and Wolf, at Linux there was no project director, no pay, no threat of job loss, and yet:
"A group of some 20 people, scarcely any of whom had ever met, employed by a dozen different companies, living in as many time zones and straying far from their job descriptions, accomplished in about 29 hours what might have taken colleagues in adjacent cubicles weeks or months."
At both Toyota and Linux, people found each other and took on roles without any established structure, legal contracts or pay: "An extended human network organized itself in hours and ‘swarmed’ against a threat. … And despite the lack of any authoritarian stick or financial carrot, those people worked like hell to solve the problem."
Physicians have much in common with individualistic engineers and programmers. Still, skeptics may find it impossible to imagine physicians achieving the degree of collaboration exhibited at Toyota and Linux. But then, does the road ahead allow imagining anything less?
Dan Beckham is president of The Beckham Company, a strategic consulting firm based in Bluffton, S.C. He is also a regular contributor to H&HN Daily.