Magrane, Diane MD; Khan, Omar MD; Pigeon, Yvette EdD; Leadley, Jennifer; Grigsby, R. Kevin DSW
Academic health professions teams have become increasingly important as organizers of complex and dynamic systems.1,2 However, implementing teamwork in traditionally hierarchical organizations presents a challenge to academic medicine. Although the rewards to faculty are gradually changing to acknowledge collaborative achievements, academic success has traditionally been measured and rewarded by individual accomplishments.3–5 Adapting to academic policies and practices that support nonhierarchical, collaborative models such as teams is important in supporting academic medicine's vital missions of education, research, and health care.6
A variety of approaches currently encourage team development in academic health centers.7–9 Katzenbach and Smith,10,11 leading scholars on team development and effectiveness, describe team practices as disciplines essential for effective team outcomes. These practices include establishing groups whose members have complementary skills and experience, defining common goals and approaches for the work, and promoting both individual and group accountability. Incorporating team practices into leadership development and continuing education programming can help institutions reward both individual achievement and collaboration across specialties and professions. Such an approach must incorporate lessons from professional development in the health professions to improve research, teaching, and clinical practice.12
With these issues in mind, we designed and evaluated a professional development program to improve the team skills of individual members of diverse academic health professions teams and thus contribute to the effectiveness of participants' work on teams in their own institutions (medical schools and teaching hospitals). Our program was based on a model called Learning in Teams13 that relates principles of team productivity and experiential group learning. We measured program effectiveness based on participants' feedback on the lessons, their overall satisfaction, self-reported changes in their own behaviors and in the behaviors of their institutional team members, and by outcomes of their institutional teams. We designed the project evaluation to address two questions:
* How does the enhancement of team skills of one or two members of a team affect the overall performance of the team?
* How do improvements in an organization's team process contribute to improved outcomes for the organization that commissions the team?
Our program was sponsored by the Association of American Medical Colleges (AAMC). The first administration of the program, Enhancing Team Effectiveness, was offered in 2006–2007; the second, TeamWorks, was offered in 2007–2008.13 We describe here the results of both administrations; where programs are similar and results are aggregated, the program in its entirety is referred to as TeamWorks.
Between 2006 and 2008, we used the Learning in Teams model to design and implement two iterations of a national professional development program for 57 members of academic organizations' teams to foster individual skill development in collaborative work in teams. We designed the programs based on established concepts of group process, team performance, and professional development.14,15 The challenge in the design was to provide sufficient practice in team skills and practices that participants could incorporate these into the work of their academic health organizations' teams at home. The Learning in Teams model of team-based learning (see Figure 1) facilitated both instruction in, and application of, learning about effective teamwork. The model recognizes that individual team members enter into the group process with unique characteristics, experiences, and approaches to learning and to leadership. The model describes the relationships between the dynamics of team development and effective management of group tasks and processes, such as enrolling team members who have skills that contribute to the team's ability to accomplish its work and who are sufficiently diverse to promote creativity and exploration.14,16 In evaluating the program, we accounted for team process, task management, group dynamics, and the process of individuals learning to be effective team members, and we judged each of these elements by the outcomes of the teams of the participants' home institutions.
The human subjects board of the American Institutes for Research reviewed and approved the project design and evaluation tools. All participants received full explanations of the program and its requirements when they registered and consented to have their materials, including institutional team progress reports and team performance survey responses, collected and analyzed in aggregate fashion.
Program development: Curriculum design, recruitment of faculty and participants, and implementation of lessons
The program content for the TeamWorks' seven months of on-site and online lessons is indicated in List 1. We recruited participants through mailings and presentations to a variety of academic audiences to all U.S. and Canadian teaching hospitals and medical schools. We accepted applications from no more than three staff or faculty members from the same institution, and we asked applicants to describe their institutional teams and provide a statement of support from an institutional executive (medical school dean or teaching hospital chief executive officer). All individuals who completed the application process were accepted into the program.
We presented the lessons initially as interactive workshops to highlight individual skill and knowledge. Participants then applied the lessons to the work of internal program learning teams (described below). They then applied selected practices to teamwork at their home institutions. As preparation to discern personal leadership styles and learning preferences, each participant completed the Keirsey Temperament Sorter,17 the Thomas-Kilmann Conflict Mode Instrument,18 and the Kolb Learning Style Inventory.19 We incorporated the results of these self-evaluations into program lessons to highlight the value of individual differences in team functioning.
Eight faculty instructors were selected for their experience with teams and professional development. Each of these faculty members taught one of the nine workshops with at least one other faculty member. In addition, each instructor guided one of the program learning teams as a faculty “team coach” who was responsible for guiding that group's team-learning process.
Program teams consisted of five to seven participants and a faculty coach. Figure 2 provides an example of a TeamWorks learning team. No participant was assigned to the same program learning team as any other member of his or her institutional team. Institutional team goals addressed challenges such as multidisciplinary translational research development, interprofessional curriculum development, and cross-disciplinary clinical improvement teams. Thus, members of program learning teams represented a variety of potential academic institutional missions. Members of program learning teams practiced the skills of collaborative teamwork in the course of providing peer consultation for the challenges of each other's institutional teams. Course participants then continued to act as a supportive problem-solving group for each other after returning to their home institutions to implement new team approaches and skills. Team members maintained contact between sessions through monthly conference calls and weekly online discussions. Participants set goals (both personal and for the learning team) to support reflection and action planning and to periodically assess effectiveness.
We collected program evaluation data from three sources. Participants completed a formal assessment designed to fulfill continuing medical education requirements (determining whether learning objectives were fulfilled and how the program was received), completed sequential team performance surveys to identify behavior and attitude changes toward teamwork, and submitted narrative progress reports of institutional teams' outcomes. Our report focuses on analysis of the program outcomes rather than on the formative evaluation used for program improvements.
Two of us (D.M. and J.M.L.) compiled descriptive characteristics for individual participants and their institutional teams from information in program applications and institutional team progress reports submitted for program requirements. Because all participants were enrolled in the project and no control population was available for comparison, we did not calculate inferential statistics. The numbers of respondents in discrete categories are small because analysis is based on the participants in the first two administrations of the program. We limited our comparisons to changes over time within the population of participants.
Pre/post surveys of team performance
We derived item content for the Survey of Team Performance from parallel elements in the Learning in Teams model and from a questionnaire used to assess team members' perceptions of the team effectiveness of the Pennsylvania State College of Medicine and Milton S. Hershey Medical Center Unified Campus Teams.7 The faculty developed an 11-item survey to assess achievement of team goals, effectiveness of team behaviors, and team practices (see Table 1). Eight items (Table 1A) required response on a four-point Likert scale as follows: 1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree. Three questions (Table 1B) required the respondent to select from a list of team skills and behaviors needing further development to enhance team effectiveness. Program faculty pilot-tested the survey and made minor adjustments; we then disseminated the survey to the program participants via an online delivery using Blackboard Academic Suite 1997–2009 (Washington, DC).
We used the same survey instrument to assess participants' perceptions of their program learning teams' performance and of their institutional teams' performance. We asked participants in both program cohorts to respond to the survey when beginning the program in September, at the midpoint of the program in November, and at the conclusion of the program in February. In addition, after we reviewed the progress of the 2006–2007 cohort, we asked the second cohort of participants to respond to the survey at the conclusion of the first week of the program. We completed pre/post program analysis, using descriptive statistics of mean responses calculated using Excel 2003.
Narrative progress reports
Each participant also submitted a narrative progress report on his or her institutional team's work at the conclusion of the first set of workshops in September and again at the end of the program in February. These reports requested narrative information on the following elements of team performance: (1) team charges, goals, and expectations of institutional impact; (2) team membership, including diversity of styles, skills, and experiences; and (3) plans for interventions to address institutional team challenges by changing one's own behavior and adopting more effective team practices. Participants submitted reports at the conclusion of the program describing outcomes of the previously identified interventions and analyzing lessons they learned from the process.
One of us (the primary author, D.M.) read, coded, and analyzed the reports using the constant comparative methods described by Glaser and Strauss20 and by Strauss and Corbin.21 We reviewed each participant's narrative institutional progress reports to identify the use of team practices as described in the Learning in Teams model. These elements included task management, member dynamics, and team outcomes. In addition, we categorized and analyzed comments about personal insight and organizational outcomes. We compiled team outcomes and impact as an aggregate listing of products and compared the frequencies with which participants identified elements of team effectiveness between the 2006–2007 and 2007–2008 cohorts.
Participants and institutional teams
Of the 57 participants enrolled in either the first or second administration of the program, 55 completed the program. Of the 37 who enrolled in the 2006–2007 program, two withdrew because of unanticipated personal events (family illness and job changes); all 20 enrollees completed the 2007–2008 program. These graduates represented 32 different institutions. They applied their lessons to 29 different institutional teams (21 in 2007; 8 in 2008) whose memberships included more than 265 faculty and staff team members.
Although medical school faculty physicians were the majority of participants in each cohort, seven (13%) were graduates representing nursing, social work, and pharmacy (see Supplemental Table 1 at http://links.lww.com/ACADMED/A21). Women made up almost two-thirds of each class and included professionals outside of medicine, such as dean's office staff, directors of faculty development, and education program directors. Twelve graduates worked on clinical teams, 29 on educational teams, and 14 on research teams.
The 2007 and 2008 cohorts did not differ substantially in terms of gender and professional degrees. Education teams were more heavily represented among the 2007 graduates (26; 71%); research teams were more heavily represented among the 2008 graduates (11; 55%). The participants of the 2008 class were more likely to attend with one or more members of the same institutional team (7 of 21 institutional teams in 2007 and 7 of 8 institutional teams in 2008).
Responses to assessments of team performance
Of the 35 graduates of the 2007 program, 25 completed pre- and postprogram team performance assessments for both their program learning teams and their institutional teams (a response rate of 71%). Of the 20 who completed the 2008 program, 15 completed the institutional team assessments and 9 completed program learning team assessments (response rates of 75% and 45%, respectively). Characteristics of participants who responded to the institutional team performance assessments are similar to those of the program graduates overall. Within each cohort, however, physician respondents are overrepresented relative to the professional representation of the 2007 group and are underrepresented among 2008 respondents. Because participants submitted midprogram survey responses over time and response rates were low, we deemed these responses unsuitable for analysis.
Table 1 compares survey results for institutional teams for both cohorts and for program learning teams for the 2007 cohort. Responses for the 2008 program learning teams were insufficient for analysis. Table 1A compares the mean ratings on eight Likert scale items, and Table 1B displays pre/post program results for the three items assessing perceptions of improvements needed for team effectiveness.
Entry ratings for institutional teams for the 2007 cohort were lower than or equal to ratings for the 2008 cohort. The 2007 cohort members' ratings on all items increased from the beginning to the end of the program; the greatest increases occurred in satisfaction with decision making and work products of their institutional teams. The ratings for the 2008 class increased most for items related to task management, especially action planning. However, the 2008 ratings decreased for items related to institutional team member communications regarding member effort, openness with ideas, and respectful challenges. Thus, greater pre/post improvements were noted for the institutional teams in the 2007 class.
We asked the 2008 class to respond to the same survey on the last day of the first week's session. Although we must interpret the results cautiously (because only eight participants responded), their mean ratings of their institutional teams' effectiveness decreased after this first week in several categories, including “meeting charge,” “member effort,” and “productive work.”
Initially, more than 70% of the 2007 graduates perceived a high need for their institutional teams to increase their time together, increase the clarity of their team's charge, improve communications and action planning, and improve skills in collaborative dialogue and feedback. More than 70% of the 2008 class also identified entry needs of time together and action planning. They also identified a need to improve team process, collaborative dialogue, and team self-assessment. At the conclusion of the program, participants perceived the greatest improvements in increased clarity of team charge, improved team processes, and exploration of team processes and purpose. The greatest change among all items for both teams was a 58% decrease (from 79% to 21%) in need to improve “collaborative dialogue” for institutional teams of the 2008 class. The 13 respondents to the 2008 surveys also noted a 43% increase from 14% to 57% for the item “giving and receiving feedback” as a needed improvement in team behaviors.
In assessing their program learning teams, the 2007 graduates also reported improvements in clarifying team charge and in team process. These respondents reported improvements in managing conflict, incorporating member preferences and strengths, and skills in giving and receiving feedback. When institutional team performance ratings are compared with program learning team ratings of the 2007 class, the ratings of 2008 program learning team performance tend to be higher on both entry and exit assessments, and the pre/post program changes for the program learning team ratings are generally less.
Content analysis of institutional team progress reports
All 55 graduates submitted final progress reports on their institutional teams, ranging in length from 4 to 16 pages, writing an average of 8 pages of narrative response. (For the components of the progress reports, see Supplemental List 1 at http://links.lww.com/ACADMED/A21.) Participants most commonly cited as challenges clarifying team charge and purpose, obtaining the clear commitment of institutional leadership to team process and products, building trust among team members, and establishing and maintaining team ground rules and norms of practice (see Supplemental Table 2 at http://links.lww.com/ACADMED/A21). More than 50% of the 2007 graduates described the management task of clarifying the team's charge and purpose as a specific challenge. Several participants noted that they “revisited the team purpose on many occasions.” A member of a long-standing team was “impressed by how a group could meet for such a long time with so little agreement on what they were trying to accomplish” and noted that “the very simple step of setting [ground] rules turned out to be very powerful.” Nine of the 20 graduates in the 2008 cohort identified the organizational challenge of obtaining clear senior leadership commitment. Respondents perceived a contrast between the inefficiencies and dysfunction of their institutional teams and the highly collaborative teams they participated in during this program. One participant even described this collaborative approach as “a revolution in the academic medical world.”
List 2 summarizes the types of outcomes of teamwork and the impact on the institutions supporting each team. Participants reported outcomes ranging from improved planning process for ongoing teamwork to reorganization of institutional programs to funding of significant projects. Others described impacts of program activities and teamwork ranging from personal and professional growth to improved communication with family members and office staff to institutional expansion of programs and extension of team practices into new venues.
Our results suggest that educating one or two members of a team can advance the work of the overall team by introducing fundamental team processes into the team's work. Participants' perceptions of improvements in team performance and their identification of specific interventions to improve team task management and interpersonal dynamics demonstrate their active learning of institutional team behaviors and practices.
Our interpretation of the program evaluation results takes into account the limitations of the size and scope of the study. Although the response rate to pre/post progress surveys was high, the number of participants was small, and thus the data do not lend themselves to statistical interpretation. In addition, changes in institutional team behaviors were identified only by program participants. Neither the full membership of the institutional teams nor the organizational leaders commissioning the teams were invited to participate in the program evaluation. Participants in our program conveyed what they had learned about team development to peers on their home institutional teams, but members of those teams may have perceived team needs or outcomes differently than did our program participants. Thus, we have interpreted the survey results conservatively and have supported and expanded our interpretation with program participants' progress reports and with literature on team development.
The 55 graduates of the AAMC's initial two administrations of our professional development program on team effectiveness represented diverse faculty and staff of the type likely to be working in teams in medical schools and teaching hospitals. Although the demographic characteristics of participants in the two classes were similar, the response rates and survey results differed. This suggests that other factors such as mission orientation, institutional context, program expectations, and program experiences affected the two cohorts differently. The 2007 teams focused more on interdisciplinary educational change, and the 2008 teams focused more on collaborative translational research team development. The differences in assessment of institutional team performance between the two program classes suggest that the 2008 participants may have entered with a higher sense of confidence in their teams and then developed an awareness of team challenges after learning more about the behaviors of effective teams.
We were not surprised that participants reported differences in team behaviors between program learning teams and their institutional teams. The members of program learning teams worked to establish trust and transparency that helped them explore team behaviors in anticipation of more challenging interventions with institutional teams. Researchers have found that program team support and feedback from faculty coaches are essential to producing behavioral change.22,23 Team members find task practices easier to adopt when all team members have experienced the same lessons. In addition, team dynamics are less predictable but are easier to manage when explicit expectations guide building consensus and addressing differences. The support that our participants received in developing team processes and establishing effective team dynamics is infrequently found in academic institutional teams.
Our findings and published literature affirm the need for institutional leaders to recognize and support the work of team members.24 One study found that when the organization's leader is perceived as being supportive of team training, participants exhibit approximately 50% more team behaviors than do those with nonsupportive leaders.25 Literature on teams and organizational success suggests that creating space for team members to experience and process error not only makes a case for leadership patience but also is necessary for organizational growth.26,27 In the course of developing a new team, team members may need to clarify and redefine the team's purpose and charge among themselves as well as with senior leaders, and build trust among team members. Team membership may need to change to incorporate appropriate diversity and project-specific skills, and conflict is likely to arise as members negotiate approaches to problem solving and consensus building. Inefficiency inevitably results in new stages of learning as new behaviors are acquired and old practices are reinvented.
Successfully implementing a model based on individual professional learning required attention to research on experiential learning and simulation.22,28 Research using Kolb's experiential learning model shows that when leaders attend to the learning process, common team dysfunctions related to idea generation, planning, decision making, and taking action can be reduced and team productivity can be enhanced.29 Activities within the TeamWorks program fostered experimentation, observation, analysis, and team member improvements and drew on participants' varied learning styles. Program learning teams supported members in acquiring and practicing new skills through meaningful simulation. After the opening session, participants were able to remain in contact with their program learning teams, and this approach promoted problem solving focused on team development issues within varied institutional contexts or cultures. This approach addresses the common reason for an initiative's failure: Applying new programs, skills, and/or processes in new or varying contexts is difficult.30,31 The program approach provided participants with an established, ongoing group in which to share issues, challenges, and questions that arose as they applied their new learning.
The Learning in Teams model provides a useful framework for other professional development activities and for further research in team development. Faculty-guided learning teams applying fundamental concepts of teamwork have been adapted to national and regional programs ranging from one day to several weeks.23,32–36 Further research is needed to explore how team behaviors develop and how best to increase awareness of potential effectiveness of teams and to reinforce effective team behaviors in academic organizations. In addition, we need to compare the effectiveness of training individuals on teams versus training the entire team membership in terms of individual skill development, group process, and team outcomes.
Our results suggest that learning simple interventions such as establishing common expectations around communication and decision making, selecting team members with appropriate group skills and diverse perspectives, and competently managing time and agendas can move teams forward. Applying the fundamental concepts of team development and learning theory to professional development has the potential to make substantive and remarkable changes in our academic health centers.
The authors wish to thank AAMC staff member Hershel Alexander, PhD; staff and faculty of the two administrations of the program, including Deborah Davis, DSW, Clyde Evans, PhD, Linda Roth, PhD, Valerie Williams, PhD, Linda Pololi, MBBS, Ajit Sachdeva, MD, Steven Bogdewic, PhD, and Marilyn Raymond, PhD; and Diana Winters of Academic Publishing Services, Drexel University College of Medicine.
The Robert Wood Johnson Foundation provided grant #56487 to support program development.
The human subjects board of the American Institutes for Research reviewed and approved the project design and evaluation tools.
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