CM6 – Plectica Map & Waypoint Presentation

Discuss the typology of teams in health care. Provide an analysis of each element.

To understand teams in health care and their characteristics, it is helpful to use a specific typology (grouping by dimensions) that has seven (7) elements: 1) Function or Purpose, 2) Decisional Authority, 3) Temporal Nature, 4) Time and Space, 5) Diversity, 6) Accountabilities, and    7) Membership Fluidity and Boundary Permeability.

1. Function or Purpose: Why a Team? – An important question worthy of attention is whether it is desirable to have a team, rather than an individual, accomplish a task. In many settings, it is routine for a manager, faced with a difficult decision, to assign a team to analyze the options and make a recommendation. That is, if a complex task is to be accomplished, a team is the most appropriate vehicle for accomplishing the work. It is not an exaggeration to say that teams are the building blocks of organizations. Types of Teams:
   • Work Teams – groups of people responsible for producing goods or providing services. These teams are directed at the primary mission and objectives of the organization: treating emergency department patients, providing immunizations and other preventive services to children, and developing a new pharmaceutical product, among others.
   • Support Teams – provide support for the primary functions of the organization. They enable others to do their work, and serve many functions such as quality improvement, strategic planning, and search committees hiring new employees.
   • Parallel Teams – typically composed of people from different work units or jobs who carry out functions not regularly performed in the organization. Parallel teams include quality improvement teams, employee involvement groups, and task forces. By their nature, they are often multidisciplinary.
   • Project Teams – are usually time limited, producing one-time outputs such as a new product or service or a new information system. In health care, such teams may exist for purposes of planning a new hospital, developing a new Alzheimer’s drug, writing a new employee handbook, or developing a hospital disaster preparedness plan.
   • Management Teams – coordinate and provide direction to the subunits under their jurisdiction. Management teams may exist at multiple levels, such as board, senior management, or departmental levels. Management teams may also include members from multiple levels of the hierarchy.
2. Decisional Authority – Refers to a continuum of roles that teams may play in decision making. At one end of the continuum, teams may have the authority to make decisions. The hospital board of trustees fits into this category. At the other extreme are teams with no decisional authority. These types of teams are frequently established to make recommendations, or to generate options for decision making.
3. Temporal Nature – Teams can be relatively permanent and ongoing, or time-limited and focused on a project or task. The use of time-limited teams is becoming more common in large part because of the rapidity of change and the need to respond quickly. In the area of new product development, for example, changes in technology, shorter product life cycles, and globalization require quick and efficient development of new products. The health care industry faces similar changes brought on by technological and other environmental changes.
4. Time and Space – The vast quantity of research and literature on teams is predicated on teams that exist and function in a time and place. Advice offered on managing team meetings is based on the idea that meetings have set starting and ending times; some of this literature prescribes physical details of team management, such as optimal seating arrangements, mechanisms for ensuring full participation, and methods of dealing with people who arrive late and leave early.
5. Diversity – Provides both opportunities and challenges for teamwork. The advantages include the opportunity to obtain multiple perspectives and expertise that are necessary for effective decision making. A major challenge resulting from diversity is managing these multiple viewpoints and worldviews and the conflicts that may result from interactions among diverse team members.
6. Accountabilities – Teams may be internally accountable, externally accountable, or both. In well-functioning teams, team members perceive that they are accountable to each other for their individual contributions. Team communication, coordination, team outcomes, and discipline become the responsibility of team members, largely eliminating the need for external team management.
7. Membership Fluidity and Boundary Permeability –
   • Membership Fluidity – It was noted earlier that teams may be temporary or permanent. Membership may also be relatively stable over time, or fluid. Fluid membership may bring a continuous influx of new ideas that may benefit team performance and keep the team from becoming so inwardly focused that it loses touch with changes in the external environment.
   • Boundary Permeability – Some teams have a specific core membership that is sustained over time. A team that is planning a new hospital wing will likely have a core membership that is relatively stable (i.e. the board of trustees) but will call upon additional team members as the need arises in the course of the building project. Some members of this team may enter and exit the team several times according to the team’s needs.

Using the model of team effectiveness, describe each element.

I. Multi-Factors: There are three (3) sets of factors that are associated with team effectiveness: 1) Team Characteristics, 2) Nature of the Work, and 3) the Environmental Context.

1) Team Characteristics:

• Team Size, Composition, and Diversity: Team Size – In general, team size has an inverted U-shaped relationship to effectiveness so that too few or too many members may reduce performance. As teams grow, communication and coordination problems tend to increase, and a climate of cohesiveness may decrease. However, a team must be sufficiently large to accomplish its work. A useful rule of thumb is that teams should be staffed to the smallest number to accomplish the work. Composition – Team composition may vary along a number of dimensions, such as age, occupation, gender, tenure, abilities, personality, and experience. Diversity – or the distribution of personal attributes among team members, is likely to affect the way individuals perceive each other and how well they work together. Diversity can help to promote quality and competitive advantage by including staff who can best understand diverse cultures, and generate a broader perspective on a problem, which may lead to superior problem analysis and suitable solutions.
• Status Differences – Status is a measure of worth conferred on an individual by a group. Status differences are seen throughout organizations and occur in all teams. It may have the effect of motivating people and providing them with a means of identification; it may be a force for stability in the organization or it can also be a negative force and a source of conflict and tension. These differences exist in all teams and cannot be eliminated, but if well managed, can mitigate negative impacts.
• Psychological Safety – Describes individuals’ perceptions about the consequences of interpersonal risks in their work environment. In psychologically safe teams, people believe that if they make a mistake, other team members will not penalize or think less of them for it. This belief fosters the confidence to experiment, discuss mistakes and problems, and ask others for help. Psychological safety is created by mutual respect and trust among team members, and leader behavior is a powerful influence on the level of psychological safety in teams.
• Team Norms – Standards that is shared by team members and regulates member behavior. Behavior norms are rules that standardize how people act at work on a day-to-day basis, while performance norms are rules that standardize employee output. Behavioral norms in teams are far reaching and may vary substantially from one group to another in the same organization. Norms may govern how much each individual participates in the team’s work, how humor is used, the use of formal group procedures, and responses to absence and lateness.
• Team Cohesiveness – Cohesiveness is the extent that members are committed to the group task. The focus is on the decision to produce, and it acknowledges that members can be committed to a common task. This is particularly important for focusing on the management of teams in which members, such as nurses, physicians, psychologists, and social workers, are already highly committed to professional standards. Highly cohesive teams may exhibit higher levels of performance, greater member satisfaction, and lower levels of turnover.

2) Nature of Work:

• Team Goals – Team goals and their accompanying tasks can be categorized according to goal clarity, complexity, and diversity. Each of these dimensions has implications for the manner in which a team is organized and managed. Where goals and tasks are relatively predictable, and where team members understand exactly what is to be done, the work of a team can become highly routine.
• Task Independence – Refers to the interconnections between tasks, or more specifically, the degree to which team members must rely on one another to perform work effectively. A useful way of classifying task interdependence is the hierarchy of task interdependence based on exchange of information or resources: Pooled interdependence – is a situation in which each member contributes to the group output without the need of interaction among members. Since each group member completes the whole task, team performance is the sum of the individual efforts. Standardized rules and procedures are needed to enhance coordination of team outputs. Sequential interdependence – is a situation in which one group member must act before another one can. Group members have different roles and perform different tasks in some prescribed order, with the work flowing in only one direction.  There is always an element of potential contingency since readjustment is necessary if any member fails to meet expectations. Coordination using schedules and plans is needed to keep the team on track. Reciprocal interdependence – is a situation in which the outputs of each member become inputs for the others, such that each member poses a contingency for the other. Group members often are specialists with different areas of expertise and have structured roles; therefore, they perform different parts of the task in a flexible, “back-and-forth” order. Leaders must provide for open communication between members and scheduled meetings as necessary. Team interdependence – is a situation in which team members must actively coordinate to diagnose and solve problems, or otherwise carry out work or work-related activities. The workflow is simultaneous and multidirectional.

3) Environmental Context:

• Intergroup Relationships and Conflict – An important part of a team’s external environment is the presence of other teams. In many situations, effective team performance is dependent upon a team’s ability to form intergroup relationships with other teams in a positive and productive manner. In complex organizations, one of the most challenging tasks of many teams is to interact with other teams whose work is related to theirs.
• Organizational Culture – For teams to function to their maximum potential, it is extremely important that a suitable culture exists – one that values and emphasizes teamwork and participation. It is critical for the senior management needs to internalize the concept of a team culture; to communicate it throughout the organization; to believe that employees want to be responsible for their work; to be able to demonstrate the team philosophy; to articulate a coherent vision of the team environment; and to have the creativity and authority to overcome obstacles as they surface.
• External Environment – Teams are affected constantly by influences from the external environment as well. This makes it important to understand how external factors influence team process and effectiveness. For many groups, the greater external environment may exert influence equal to or greater than the internal organizational environment. This is particularly true for multidisciplinary, interagency groups that interact with and depend on not only member organizations but also the community environment and local service network for critical resources and support.

II. Team Process: Team Process refers to the methods of interacting and performing work by team members alone and in interaction with each other. Team Process consists of five (5) factors: 1) Leadership, 2) Communication Structure and Interaction Patterns, 3) Decision Making, 4) Learning, and 5) Stages of Team Development.

1) Leadership – Refers to the ability of individuals to influence other members toward the achievement of the team’s goals. There are two types of leadership:

• Formal leadership – refers to legitimate authority given to a team member. In some cases, an external individual in a position of authority can assign leadership, or in other instances, leaders may be designated by team members through voting or other forms of consensus.
• Informal leadership – refers to individuals who assume leadership roles based on some personal characteristic. A number of factors can give rise to informal leaders, including expertise, experience, or personal charisma.

2) Communication Structure and Interaction Patterns – A team cannot function effectively unless members can exchange information. Team leaders are usually best positioned to help manage communications within a team and between the team and external teams and other entities. Without workable communication structures, important information may be lost or inaccurately communicated. The evaluation and design of communication processes are important components of many quality improvement projects.

3) Decision-Making – Managers should clarify to team members the role of a team. In particular, team members need to understand clearly the team’s role in decision making. Some teams provide input to decision makers, while other teams have the authority to make decisions. Team leaders should clearly understand the decisional authority of the team and communicate this accurately to team members.

4) Learning – Team Learning is an interactive process of reflection and action through which teams may discover and correct problems and errors in their work processes. Learning processes consist of activities carried out by team members through which a team obtains and processes data that allow it to adapt and improve.

5) Stages of Team Development – The effectiveness of a team is affected to varying degrees by its maturity, or stage of team development. Teams go through predictable stages of development, although the speed with which they mature varies. Teams progress through five stages: 1) Forming, 2) Storming, 3) Norming, 4) Performing, and 5) Adjourning.

What is context? What is environmental context and describe it in health care?

Merriam Webster Dictionary defines “context” as: 1) The parts of a discourse that surround a word or passage and can throw light on its meaning, and 2) The interrelated conditions in which something exists or occurs: environment, setting.

Teams do not exist and function in a vacuum but operate within a broader environmental context. They are affected by pressures and events from outside of the immediate team.

In health care context, health care organizations have moved away from rigid hierarchical structures to manage work, and as they have become more specialized, the need for new coordination mechanisms has increased such as cross-team training, virtual team updates, and joint meetings for planning and coordination. Given the uncertainty and heterogeneity of inputs in health care, it is virtually impossible to design all work processes in advance in such ways as to ensure that the work of all groups mesh perfectly with the work of other groups. When conflicts or disagreements occur among groups, it is important that team members possess a repertoire of conflict resolution strategies. In some cases, the interfaces among teams require only finetuning; in the worst situations, work processes may need to be overhauled to achieve functional intergroup relationships.

A common conflict in health care is between teams whose orientation is primarily cost containment and teams whose orientation is focused more on quality concerns. At other times, differences in group culture may cause conflict between teams. Each group develops its own unique norms, communication network, and values, which collectively is referred to as a team culture. When these vary between teams, conflict often occurs.

What is a context analysis?  Using the context analysis model, provide an example in health care.

A practical meaning of “context analysis” is a method to analyze the environment in which an individual, a business, or an organization operates. Full consideration for the entire environment – internal and external factors, is very important.

Context analysis focuses on four (4) dimensions in any given context/situation: 1) Enabling Environment, 2) Actors and Inputs, 3) Interactions, and Outputs and Outcomes.

• Enabling Environment – Ex: Political, Legal, Cultural, Religious, Gender Aspects; Infrastructure, Market, and Business Conditions
• Actors and Inputs – Ex: Technologies, Users, Customers, Institutions, Community Bodies such as health workers’ associations, farmer organizations, or cooperatives.
• Interactions – Ex: Private Sector, Academia, Government
  1. How do they come together and how often?
  2. What do they do?
  3. What are their agendas?
  4. How do they relate to their Enabling Environment?
• Outputs and Outcomes – Ex: Outputs such as products/services and novel processes of producing goods/services; Outcomes such as wealth, health, and well-being.

All four (4) dimensions have three levels of impact: 1) Individuals/families, 2) Institutions, and 3) National.

Below is an Example of Context Analysis in Health Care:

What is the Nominal Group Technique? What is the Delphi Technique? Provide examples of both.

Nominal Group Technique (NGT) is defined as a structured method for group brainstorming that encourages contributions from everyone and facilitates quick agreement on the relative importance of issues, problems, or solutions. Team members begin by writing down their ideas, then selecting which idea they feel is best. Once team members are ready, everyone presents their favorite idea, and the suggestions are then discussed and prioritized by the entire group using a point system. NGT combines the importance ratings of individual group members into the final weighted priorities of the group.

Use Nominal Group Technique (NGT) when:

• Some group members are much more vocal than others.
• Some group members think better in silence.
• There is concern about some members not participating.
• The group does not easily generate quantities of ideas.
• Some or all group members are new to the team.
• The issue is controversial or there is heated conflict.

Nominal Group Technique (NGT) Considerations:

• The primary purpose of the discussion is clarification, not to resolve differences of opinion.
• Discussion should be equally balanced among all ideas.
• Keep all ideas visible. When ideas overflow to additional flipchart pages, post previous pages around the room so all ideas are still visible to everyone.
• See brainstorming for other suggestions to use with this tool.

Below is an Example of NGT Chart/Results:

What is the Delphi Technique?

The Delphi Method is a systematic interactive way of gaining opinions/forecasts from a panel of independent experts over 2 or more rounds. It aims to determine the extent to which experts or lay people agree about a given issue and with each other and in areas where they disagree, achieve a consensus opinion. Delphi technique is usually conducted through questionnaires. Where focus groups purposely use group dynamics to generate debate on a topic, Delphi methods maintain anonymity of the participants, even after the study.

Strengths of the Delphi Technique:

• A rapid consensus can be achieved.
• Participants do not have to be in the same room together to reach agreement.
• Individuals are able to express their own opinions as opposed to “Group think.”
• Can include a wide range of expertise.
• Relatively low cost to administer and analyze.
• There is the potential to gain large quantities of data.
• Offers a method which can be used where data are lacking.

Weaknesses of Delphi Technique:

• Does not cope well with widely differing opinions or large changes in opinions (paradigm shifts).
• The facilitator’s view may dominate in the analysis.
• Differing opinions may not be sufficiently investigated.
• Can be time-consuming.
• Needs high participant motivation.
• Success of the method depends on the quality of the participants.
• The written response format may be less suitable for some potential respondents.

Below is Delphi Technique Questionnaire:

What are the stages of team development?

Teams progress through five (5) stages:  

1. Forming – During the first stage, members become acquainted with each other and with the team purpose. Members attempt to discover what behaviors are acceptable and unacceptable, while establishing trust and familiarity.  This early stage is characterized by polite interactions and tentative interactions.  Establishing a clear direction is critical.
2. Storming – At this stage, the team is faced with disagreement, counter-independence, and the need to manage conflict. Members may attempt to influence the development of group norms, roles, and procedures; therefore, the stage has high potential for conflict. Focusing on process improvements, team achievement, and collaborative relationships can help overcome emergent conflicts.
3. Norming – During this stage, the team grows more cohesive and aligned in purpose and actions. Agreement on rules and processes of decision making, roles and expectations, and commitment emerges. Emphasizing the team’s direction or goals is essential for forward progress.
4. Performing – Once team members agree on the purpose and norms of the group, they can move forward to the task of defining separate roles and establishing work plans. The team is faced with the need for continuous improvement, innovation, and speed. Leaders must be ready to sponsor new ideas, orchestrate their implementation, and foster extraordinary performance from members.
5. Adjourning – For temporary teams, the adjournment stage is characterized by a sense of task accomplishment, regret, and increased emotionality.

Answer the questions on p. 154 (Questions 1-3)

Q1. To foster teamwork and a culture of quality improvement, a new director of an ambulatory care center in a hospital has begun holding twice-monthly management team meetings, consisting of several physicians, nurses, physician assistants, financial managers, and others. Attendance at these meetings has been erratic, and enforcing attendance is difficult because many of these people report to their discipline chiefs rather than to the director of the center. What advice would you give to this person to promote more consistent participation? Answer: I would advise the new director to become well-acquainted with the participants’ discipline chiefs with whom they primarily report to. Inform the chiefs of the meeting schedule and ask them to encourage their team members to participate. By doing so, he/she would get the people in-charge to be on board, be part of the effort to promote the events.

Q2. A community task force has been formed to improve the coordination of care for the frail elderly. Given the large number of people and agencies involved in providing services to this population, how would you balance the need for representation with the need to keep the task force size to a manageable level? Answer: The following steps would be helpful:

1. Create multi-disciplinary teams within the task force.
2. Each team will include a patient advocate to gather surveys and feedback from clients.
3. Divide the community into targeted sections/territories.
4. Assign each section to a multi-disciplinary team.
5. Each team or agency would have leaders.
6. Leaders of teams and agencies would meet regularly to report to the leaders of the task force for accountability and to monitor overall progress.

Q3. You are a member of a hospital project team assigned to develop a new pediatric oncology service line. Your team is expected to develop a business plan for presentation to the senior management team and the hospital board. A specific timetable has been established for producing a set of deliverables. The team leader is a well-known oncologist with a very strong clinical background and reputation. However, his team leadership skills leave something to be desired.  Among other problems, meetings are cancelled at the last minute, delegation of tasks is ambiguous, and the focus and direction of the project changes scope at virtually every meeting. As a team member, what alternatives do you have to improve team management? Which alternative would you select as having the best chance of success? Answer: I would politely approach the team leader personally to express my concerns about last-minute cancellations and task ambiguities. I would ask clarifying questions regarding what areas of the project does he need help with, and which are of the highest priorities. I would also ask him/her if our team can be broken down into sub-teams so we can divide tasks. I believe honesty and open communication will be helpful so that the project can move forward.

Chapter 5: CASE: Using Teams to Achieve Millennium Development Goals

What is the gist and database? How can you apply it?

According to Bunch, the concept of Fuzzy-trace theory (FTT) takes the role of “verbatim” and “gist” – they interact like that of an index for a database, where verbatim symbolizes large amounts of data, words, or numbers; whereas, gist is the one line, the essence, the key idea that summarizes the verbatim.

For example: The entire lyrics of a song is the “verbatim” while a few memorable lines or phrases from the song are the “gist.” If I entered the lines or phrases on Google Search, I would be able to pull the song’s lyrics in its entirety!

Bunch also said, “You need data and detailed memory to come up with the strategy, but you have to get it down to the essential thing.” Moreover, he says that it is the index triggering the database and great leaders possess a vast database (memory) but can cut to the chase by providing their people meaningful and memorable terse communication when needed.

What did you learn from watching The Strategic Leader in a VUCA World?

VUCLA stands for:

• Volatile – The nature and dynamics of change in the environment.
• Uncertain – Surprise, sense of awareness, and lack of certainty or predictability in the environment.
• Complex – Lack of a clear cause-and-effect and multiple interactions of a system.
• Ambiguous – Mass confusion, lack of understanding, mixed meaning, and unfamiliar environment.

Bunch said, “The battlefield is volatile, it is an uncertain place, it’s very complex, chaotic and ambiguous.”

I agree with this statement as I deal with volatile situations in the Special Education environment. I need to focus on the most important things/strategies that work in situations that demand quick response to prevent escalation. Sometimes, less is better. Direct to the point. In responding to children’s bad verbal behavior, a few calm and validating words are better than a slew of loud and rapid sentences; sometimes, a momentary pause or silence works best.

What is the difference between a Soldier and Scout Mindset?

A TED Talk by Julia Galef presented two (2) different mindsets that affect how we tend to judge and approach an issue.

• Soldier’s mindset aka Motivated reasoning: trying to make some ideas win and others lose; the drive to attack or defend ideas.
• Scout mindset: trying to get an accurate picture of reality, even when that’s unpleasant or inconvenient. Scouts are rooted in different emotions: being curious, being open, and grounded.

By putting these mindsets side-by-side, we can see how the dominating emotions decide which role we play- a soldier or a scout. Soldiers tend to be defensive and less objective as scouts. Scouts, on the other hand, are more likely to observe different sides of an issue before making a final decision or judgment.

What did you learn from watching and reading? Why you think you’re right, even when you’re wrong?

I realized that most of the times when I insisted that I was right (even when I was wrong), my desire to quickly judge and my pride dictated my reactions and decisions; I was in a Soldier Mindset. In moments where I stepped back and looked at the context of the situation and saw the bigger picture, I was in a Scout Mindset. It would be nice to find a balance between the two. However, I think I prefer employing the Scout Mindset more often to make well-informed decisions and take careful actions.

Josefina Howard’s Tableau – Data from 2017 CDC Healthcare Related Infections Progress Report (https://www.cdc.gov/hai/data/portal/progress-report.html.)

I am curious about the prevalence of infections occurring in Acute Care Hospitals. In 2015 while I was caregiving for my both my terminally-ill father and my frail elderly mother, I contracted a superbug called Klebsiella Pneupmoniae. I most likely had picked it up during one of our visits to the hospital. It almost killed me; I was in the ICU for five days with liver abscess, sepsis, and diabetic-ketoacidosis!

Below is the screenshot of the data I imported from CDC. I used the free one-year Tableau license for students. I downloaded the Tableau for Desktop software. I have ways to go to understand how Tableau works but I learned that importing data in Excel format into Tableau is a simple task. However, arranging the tables and making sense of the data is a huge challenge for me.

Josefina Howard’s Plectica Map/Presentation (https://www.plectica.com/maps/LM91FYKSV?present=1):

REFERENCES:

• Context Analysis https://en.m.wikipedia.org/wiki/Context_analysis
• Context Analysis Video https://www.youtube.com/watch?v=FDxaIWo1DM8
• Delphi Technique https://www.healthknowledge.org.uk/public-health-textbook/research-methods/1c-health-care-evaluation-health-care-assessment/use-delphi-methods
• Nominal Group Technique https://asq.org/quality-resources/nominal-group-technique
• Let’s Do This https://taskandpurpose.com/military-leader-leroy-jenkins
• The Strategic Leader in a VUCA World https://www.youtube.com/watch?v=Sxlc9n33hTQ
• Why “scout mindset” is crucial… https://www.youtube.com/watch?v=3MYEtQ5Zdn8