Message from the President

Build, Lead and Manage Your Team

Philip S. Barie, MD, MBA, FCCM
Professor of Surgery and Public Health
Weill Medical College of Cornell University
New York, New York, USA

Teamwork is an integral part of the delivery of critical care to our patients. The Society of Critical Care Medicine (SCCM) espouses the delivery of critical care by an integrated team of dedicated experts; the critical care team is part of the culture of high-reliability intensive care units (ICUs) and is part of SCCM’s “corporate DNA.” However, for something so crucially important to our collective professionalism, we spend relatively little time considering how we build and maintain teams, how to repair them when they become dysfunctional (as indeed they do). Let’s take this opportunity to consider team building from a managerial perspective.

What are the salient characteristics of effective teams? Effective teams have interdependent members whose productivity and efficiency are determined by the coordinated, interactive actions of all team members, thus making members more effective working together than alone. Effective teams outperform even the best individual; this attribute recruits and retains highly qualified individuals who value such a workplace arrangement. The interdependent nature of effective teams means that members nurture and support each other, providing integration, encouragement, and mutual accountability to all members. Effective teams may not always have the same leader, but rather leadership is shared and may rotate depending on the circumstance. Most of all, there is a high level of trust among members of effective teams. Success for one is success for all.

How are effective teams developed? Numerous models have been described, but one that is apt describes four stages: forming, conforming, storming, and performing. Each of these stages has characteristic team-member questions, interpersonal relationships, task issues, and effective leader behaviors. In the forming stage, members must become acquainted, trust must be established, and leaders must provide clear direction as to the team’s purpose, direction and boundaries. The conforming stage emphasizes development of cohesion and unity within the team as well as the definition of roles and responsibilities for members. Leaders foster a sense of commitment among members. In the storming stage, teams are faced with disagreements and the need to manage conflict. Challenges include violations of team norms and expectations, and overcoming groupthink. Leaders focus on process improvement,recognizing group achievements, and fostering of win/win relationships.

One always challenging aspect of team building in healthcare and healthcare organizations is the need to build your team from strength. Select your team members on the basis of knowledge, skills, attitudes and behaviors. High-performance teams require everyone to make real contributions. In healthcare settings where teaching and mentoring are part of the mission, practitioners are accustomed to incorporating junior members into their teams. In effect, such teams are perpetually at the forming stage. Within SCCM, the diversity represented by the multiprofessional team is one of our great strengths. Balancing expertise and diversity is a constant challenge to team building that is characteristic of, if not unique to, the healthcare setting and volunteer not-for-profit organizations such as SCCM. There is no easy solution. Teams that function well are by necessity not republics or participatory democracies. Sometimes leaders must make decisions, especially when teams become dysfunctional. Education and healthcare delivery are not inseparable, and new team members may require a period of seasoning before accepting an equal share of roles and responsibilities in the conforming period.

Performing teams must continuously improve and innovate; they must work with speed and capitalize on core competencies. Team leaders sponsor members’ new ideas, facilitating implementation and fostering extraordinary performance. Functional teams avoid wasting time talking about irrelevant issues and revisiting the same topics repeatedly. They make higher quality decisions, and more is accomplished in less time with fewer distractions. However, no team is perfect; even the best struggle at times. Recognizing and understanding how teams become dysfunctional are the first steps to successful intervention.

Dysfunctional teams exhibit five cardinal manifestations, according to team consultant and bestselling author Patrick Lencioni. First, there is an absence of trust, which often stems from an unwillingness on the part of one or more team members to “get with the program.” Team members who are not genuinely open with one another make it impossible to build a foundation of trust. The failure to build trust creates the conditions that lead to the second dysfunction – fear of conflict. The result is the avoidance of open, passionate debate of ideas, resorting instead to guarded, circumspect discussions. A lack of healthy conflict within the team ensures a lack of commitment. Without open debate, team members rarely will commit to decisions, although they may feign agreement during meetings in order to avoid conflict. This lack of commitment leads to the fourth dysfunction – avoidance of accountability. Without committing to a clear plan of action, even the most focused people may hesitate to challenge the other team members on actions or behaviors that are counterproductive to the team. Failure to hold each other accountable is conducive to the fifth dysfunction – inattention to results, which occurs when team members put individual needs (e.g., career advancement) before the collective goals of the team.

Successful teamwork is a combination of common sense and uncommon discipline and persistence. Team leadership addresses inattention to results by focusing on the achievement of collective results. Avoidance ofaccountability is addressed by confrontation of difficult issues. Lack of commitment is overcome by ensuring that there is clarity and closure for all issues that are raised. Fear of conflict is eliminated by actively seeking conflict so that it can be addressed. Absence of trust is overcome by leaders who literally lead. Go first! Lead by example!

Truly cohesive teams are obvious. They trust one another. They engage in unfiltered conflict around ideas. Highly functional teams commit to decisions and plans of action. Members hold each other accountable for deliverables according to plan. Foremost, they focus on the achievement of collective results. In critical care, the result is better quality care provided by teams that have self-awareness and a commitment to continuous improvement. If you are a leader, you can make your
team better by ensuring that all members understand and subscribe to the plan. Be approachable so that members can express their concerns. Achieve excellence by establishing norms of conduct and by leading the group to motivate itself. Act on concerns, and test relentlessly for better ways to function.

If you are a follower, you can make your team better by communicating with clarity, accuracy, and precision, and
by advocating your position comfortably. If effective communication is challenging, consider implementing some
form of structured communication, such as the situational briefing model (situation-background-assessment-recommendation). Monitor your environment and your fellow team members for problems. Participate fully using the best of your knowledge and skills, and have attitudes and behaviors appropriate to achieve the goal.

Collectively, get the right resources from your institution and use them wisely, for they are precious. Clarify your needs. Get better administrative support by making the administration part of the team. Collect data that reflects strengths and areas needing work, and don’t forget to build in time to learn.