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Editorials |
1 From the Department of Radiology, Yale-New Haven Hospital, 333 Cedar St, PO Box 208042, New Haven, CT 06520-8042. Received December 27, 2003; accepted January 5, 2004. Address correspondence to the author (e-mail: jeffrey.weinreb@yale.edu).
Index terms: Editorials • Radiology and radiologists, departmental management
Academic radiology departments are being challenged as never before. Market-driven forces and increasing regulation are resulting in diminishing reimbursement, and more time and resources are being devoted to work with no added value. At the same time, academic departments are being asked to dramatically improve the quantity and quality of their clinical services. While their community-based counterparts are experiencing many of the same pressures, academic departments carry the additional burdens of teaching and research, higher case mix acuity and complexity, and more Byzantine and rigid organizations.
In an effort to cope with these realities, academic radiology departments have adopted a number of different strategies, including attempts to institute management techniques that have been successfully employed in other businesses. This has led to an unprecedented migration of radiologists into business and management courses and postgraduate programs. Concurrently, there has been a proliferation of articles in the radiology literature concerning such business-oriented topics as total quality management and process redesign and/or reengineering, which are intended to provide advice and tools to reduce costs and improve workflow (1).
While the leaders of many academic departments have begun to recognize that such efforts may be crucial to ensure survival, they have often not yet fully assimilated one of the most fundamental tenets of business—the primacy of teamwork. Work in reengineered organizations often involves teams and empowered employees (2).
Teams get more done, and most people are smarter, make fewer mistakes, and are more effective together than they are alone (3–6). Many will agree to the effectiveness of teams, and one of the key recommendations of the Institute of Medicine report To Err is Human is the need to promote effective team functioning (6). Without focusing adequate attention on building and sustaining the teams, however, there is little chance of success.
The concept of teamwork may seem intuitive, but in many academic radiology departments, teamwork is anathema. The traditional academic radiology department organization does not foster teamwork and may actually discourage it, and there may be little or no reward for working together in a task-based environment that encourages independent accomplishments.
What Is Different About an Academic Department?
Michael Hammer, co-author of Reengineering the Corporation (2) and guru of business process redesign, has commented that reengineering in an academic medical center is essentially the same as reengineering in any other business enterprise. Nevertheless, there are some unique attributes of the academic enterprise that need to be taken into account. This is particularly relevant to teams.
There are three fundamental differences between academic radiology departments and other businesses, including private practice radiology, that affect teamwork: (a) mission, (b) mentality, and (c) organizational structure.
In a service-oriented business, such as a private practice radiology group, the mission is fairly straightforward: to provide a product (eg, an examination and interpretation) and be profitable. In a private practice setting, radiologists usually understand that their primary role is to provide a service, which generates income.
In an academic radiology department, the mission is more complicated. It is not enough to simply provide excellent care. To distinguish care from the private practice competition, it has to be innovative and must employ cutting-edge technologies. It is not enough to be profitable. The academic department has to be so profitable that it can support the infrastructure, resources, academic time, and faculty mandated by its other two missions, research and education. Furthermore, although members of every hospital-based radiology department participate in hospital and professional committees, the administrative obligations and time commitments tend to be greater in academic departments.
The complexity of the mission in an academic radiology department often results in less clarity about values and roles. There is sometimes an amazing lack of comprehension on the part of academic radiologists about the relationship between value-added product, efficiency, and income. This is a legacy of a not-too-distant past when reimbursement rates were set at a level that permitted academic departments to thrive, even in the face of enormous waste and inefficiency. A work environment characterized by confusion about values, mission, and roles, which has been exacerbated by the dramatic changes in the health care delivery system in the United States, is not an ideal place to build a team for change. The noble objectives of excellence in clinical care, education, and research may not always be consistent or even possible with the parsimony of the home institution.
The culture that that has been in existence in academic medical centers in the United States can be characterized as a "silo mentality." This means that every academic department lives in its own small world and views the rest of the world through tunnel vision. Academic departments have been primarily concerned with themselves and have had little knowledge or interest in other departments. The academic department mantra is "I want what is mine." This type of thinking applies not only to the departmental level but also to the sectional level within a department and even the individual physician level.
For example, in some academic radiology departments, the neuroradiology and interventional sections sometimes behave as if they were independent entities. The members of the mammography section are sometimes perceived by others in the department as parasites and are treated as pariahs. There is little appreciation of a vested interest in the overall health of the department and, thus, little concern for what transpires in the other sections (unless, of course, it has a negative impact on their income or lifestyle).
This is not surprising. After all, in academic departments, incentives have traditionally been geared toward individual rather than group achievement. From the time a future physician enters medical school to the conclusion of his or her postgraduate training, independence is a trait that is valued and nurtured. Indeed, many physicians will say that they chose an academic medical career because it allows them a great degree of independence. Unfortunately, the result is that physicians, including radiologists, have little experience with teamwork and may not do well on teams. Hospital administrators have the impression that getting physicians to work together is like "trying to herd a flock of eagles."
Another aspect of the academic department mentality that is detrimental to teams is the inability to accept failure. In any ambitious and difficult undertaking, there are going to be ups and downs. Academic departments reward individual success and do not tolerate failure well. There is a tendency to start pointing fingers the moment a setback occurs. This does not engender trust, which is a prerequisite for teamwork, and it is another reason that academic medical centers have not heretofore been fertile ground for teams.
Because of the historical prestige and protection of academic medical centers in the United States, many of them were able to maintain the status quo for years while the rest of the health care world was changing. Their organizational structures, finances, and people were ill-equipped to cope with the rapid pace of change in the health care system. As an example, departmental chairmen were, and sometimes still are, selected for their academic achievements rather than their administrative skills or business acumen, despite the fact that a successful track record in research is not a predictor of success in managing a complex organization and clinical service.
What Is a Team?
In their classic The Wisdom of Teams: Creating the High-Performance Organization (an excellent text for those interested in learning more about teams), Katzenbach and Smith (4) define a team as "a small number of people with complementary skills who are committed to a common purpose, performance goals, and approach for which they hold themselves mutually accountable." A high-performance team is one that outperforms all other teams by an order of magnitude and also outperforms all reasonable expectations. There cannot be a team unless the purpose, goals, and approach are clearly defined, communicated, and agreed on.
Most organizations intrinsically prefer individual to group (team) accountability. This is especially true of teams that include physicians. Team performance requires both individual accountability and mutual accountability. In other words, the team members must hold themselves accountable for their individual contributions to the team, their collective contributions to the team, and the team’s overall result. A team knows that it is a team and acts accordingly.
How to Build a Team
According to Katzenbach and Smith (4), the disciplined application of team basics (size, purpose, goals, skills, approach, and accountability) is often overlooked, and this is a common cause of team failure. A strong foundation is required to build a successful team. The foundation consists of the right leadership, clear goals, appropriate membership, and tools to run effective team meetings (7).
Every team needs a sponsor. Without appropriate oversight and management support, the team will never be able to overcome the formidable roadblocks they will inevitably encounter.
A team leader must be identified. The best choice is probably not the boss or someone at the top of the hierarchy. It should also not be the senior departmental member who has a lot of free time. Rather, the team leader should be someone who can guide the team to be in control of its destiny and performance by striking the right balance between action and patience. The job of the leader is to empower the team to act by creating and communicating the vision, establishing a sense of urgency, removing roadblocks, providing resources, and coaching and advising only when necessary. Effective team leaders are always distinguished by their attitude that they really do need the team to succeed. Generally the best person to select is someone who has charisma, people skills, an accomplished track record, and respect in the institution.
One cannot expect the leader to succeed if the team leadership job is simply added on top of their other responsibilities (8). The team leader must be given adequate time and resources. This may mean a budget, dedicated space, and support staff that understand that the work of the team is a priority and not just an added chore. The team leader, no matter how experienced and accomplished, will have much to learn, and the team sponsors must pay at least as much attention to helping the team leader succeed after selecting him or her than to the choice itself.
The team must have a clear purpose and goal, and the objectives must be clearly defined by the sponsor and team leader. These key performance objectives function as the team charter. They serve not only as a challenge to the team but also as the yardstick to measure their success. Quantifiable goals help incentivize the team, and aggressive numeric targets help the team focus and create a sense of urgency.
By using the key performance objectives as a guide, the skills and knowledge needed on the team are identified and used as the basis for team member selection. Depending on the project, requisite skills may include clinical, financial, technical, operational, project management, communication, market analysis, benchmarking, and strategic skills. Look for individuals who exhibit creativity, willingness to challenge the status quo, ability to think differently, high energy, ability to function as a team player, a short learning curve, out-of-the-box thinking, innovation, self management, results orientation, and comfort with uncertainty and ambiguity. One last key component in recruiting team members is finding those that are motivated by change and feel that the path may be difficult but that the final improvements will be worth their efforts.
Although the concept of a team may be intuitive, and the team members are handpicked for their ability to work together, do not assume that they will know how to work as a team from the start. Once the team is selected, ample time and resources must be set aside for members to define a shared vision, create meeting ground rules (including how to make a decision), build cooperation and trust, identify individual and team gaps in skill and knowledge, and identify the budget, personnel, and space that the team needs to succeed (9). An experienced facilitator (consultant) may be useful to help the team get started. Such an individual may be skilled in employing standard tests and exercises that are used by the industry for team building. Among the most useful is the Myers-Briggs type indicator, which helps individuals learn about their personal preferences and understand how other team members think, perceive, and react (10).
Teams are built on trust, and the best way to build trust is to work together and achieve real results. It is useful to identify some "quick wins," substantial goals that are achievable in a short time frame with relatively little effort. These have also been referred to as "low-hanging fruit," and they help to build confidence in the team concept. Keep in mind that it may be more difficult than anticipated to identify and then harvest these quick wins. Much of what first appears to be low-hanging fruit is actually always just out of reach.
Another vehicle that can be extremely useful is the retreat. Ideally, a retreat means that the team travels at least several hours away from the medical center for at least two nights. No phone call or beeper interruptions are permitted. A retreat allows the team members to focus and work without distraction, and it helps the members to bond and build trust. By going to a place other than their normal work environment, it sends a message that this effort is different, and it is easier for team members to release their inhibitions about working together. It also fosters creative thinking. Retreats can be instrumental in helping the teams build a commitment to change and make breakthroughs in thinking that would have been impossible at the home institution. Successful retreats require preparation, institutional commitment, and an experienced facilitator.
Surprisingly, one of the biggest knowledge gaps in teams is the logistics of running an efficient and productive meeting. This may become apparent only after one realizes that meetings take too long and, often, enough is not accomplished. A properly run meeting can have a major positive effect on work and group dynamics. There must be agreement that most of the work should get done outside of meetings, that meetings should occur only when necessary, that meetings should have written agendas with time blocks that should be distributed days before the meeting, and that meetings should usually be used primarily for sharing information and making decisions. You may start out thinking that you have to vote on each decision to move forward, but you will learn that effective teams do not seek consensus. They seek the best answer. They argue, debate, and work to a decision sometimes made in common, sometimes made by the leader, and sometimes made by the people with the most logical skill set.
Caveats
Here are some additional caveats about teams in an academic setting.
1. The ideal team size is no more than 10–12 people. Large teams are difficult to manage, and small teams can limit dialogue and diversity of input.
2. Share the credit and spotlight. The team works very hard, individually and as a body, and the successes should be shared and communicated. Even though only a few team members may be the voice to the management and the institution, it is their responsibility to make certain that the team as a whole is publicly recognized for their efforts.
3. Let the team know that it is acceptable to struggle or even fail. All teams go through various phases in their development, known as "forming, storming, norming, and performing" (11). Many teams die a quick death because they are not given the support and tools to successfully negotiate these phases. For the team to ultimately succeed, sponsors should be willing to support the team through failed efforts.
4. Make sure the vision and mission are clear. Academic institutions are already challenged with trying to prove efficient service with conflicting missions from various constituencies. Unless the vision of the institution is clear to those who are trying to make the changes, the team will flounder. Continually review team progress against the mission with all the key stakeholders.
5. Ensure management support. Often, sponsors are actively engaged in the team’s efforts initially, but that engagement eventually wanes when other pressures or projects require their attention. Do not let the team disappear into the woodwork. As time goes on, make sure the team members are held to their goals and are still getting the sponsor support they need.
6. Provide rewards and incentives. Rewards and incentives provide motivation for team success. The incentives can come in the form of monetary bonuses for reaching target goals, gifts for completing phases of a project, promotions, or even something as simple as public recognition. It is important to determine what motivates and drives different team members to actively participate in the team and to tailor the rewards and successes to maintain team momentum.
7. Develop metrics, monitor them, and hold individuals and the team accountable (12,13). As stated earlier, key performance objectives need to be established. It is not an exaggeration to state that without metrics there can be no improvement. Without clear quantifiable goals, it is very difficult to measure the success of the team, support the team’s efforts, and provide the adequate funding and resources team members may need. It is important to review the goals and progress regularly and identify what needs to be done to ensure team success.
8. Pick only the people that you need for the team. As difficult as it may be, do not add members to a team to appease institutional or personal politics. People should be appointed to the team only if they are going to be active, productive members and provide input necessary to the development of the final product. One should be especially wary of the very intelligent "lone ranger." Some very smart and successful people are constitutionally incapable of subjugating their ego to the will and the work of the team. While the team should make every effort to benefit from their knowledge and experience, this can be done more effectively outside of team meetings.
9. People will surprise you. Team members or active supporters may come from the least likely sources. Do not discount a potential team member because they are not from the department, do not hold a leadership position, or heretofore have not excelled. The most unlikely candidate can be your best ally if they are self-motivated to participate. Discover what each can bring to the table to make the team a success.
10. Flexibility is key. In an academic radiology department in the United States, team membership has to be flexible. Team membership may need to change depending on the phase of the project and the contributions (or lack thereof) of each individual member. Do not be afraid to disband and start anew, but remember to refocus on team basics each time the team is reformed.
11. Create a resistance and a communication plan. You cannot overcommunicate. The team cannot succeed without support from co-workers and the institution, and that can only be achieved through regular communication and by using varying mediums to reach your audiences, such as special presentations, focus groups, newsletters, question and answer meetings, regular updates, and presentations. Resistance can generally be countered through regular communication and by asking for input when needed.
12. Find out what motivates people to participate. When trying to get busy radiologists to participate, you need to find a goal that they can buy into. No one wants to devote their valuable time out of the goodness of their hearts. Find out what they define as important and what is in it for them.
13. Do not be afraid to ask for experienced help. Many institutions are unfamiliar with how to work in teams or think creatively for making changes. Use of outside facilitators may help provide the necessary launch and structure. One warning, do not let your team become too dependent on consulting support—after the groundwork is set, the team needs to learn, struggle, and develop themselves, or they will never function effectively as a team.
Conclusion
Building a team to manage change is like trying to lose weight. It is always easy to lose the first few pounds, but if you do not make fundamental changes in your lifestyle, you will not lose as much as you want, and you will almost certainly gain it all back before too long. Similarly, it is easy to put people on a team, but if you do not pay enough attention to team basics and do all the things necessary to make a fundamental change in the team culture, you will not be able to make major changes, you will not be able to sustain the small ones, and you will probably revert to your old way of doing things. Making changes and developing teams in an academic setting poses its own sets of challenges, but by following some basic precepts and addressing those issues, the team can be successful. A few academic radiology departments have already figured this out, but many may still be in the dark.
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