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Speeding Up Team Learning
Speeding Up Team Learning
Speeding Up
Team Learning
The most successful teams adapt quickly to new ways of
working. Now, a study of 16 cardiac surgery teams offers
intriguing insights on how to make that happen.
we studied wryly put it, the new surgical late 1990s, held out the promise of a cal team's work. Obviously, individual
procedure represented "a transfer of much shorter and more pleasant recov- team members need to leam new tasks.
pain-from the patient to the surgeon." ery for thousands of patients - and a po- The surgeon, with the heart no longer
But if that came as no surprise, we were tential competitive advantage for the laid out in full view, has to operate with-
surprised at some of the things that hospitals that adopted it. (For a descrip- out the visual and tactile cues that typ-
helped, or didn't help, certain teams tion of the procedure, see the sidebar ically guide this painstaking work. The
learn faster than others. An overriding "A New Way to Mend a Broken Heart.") anesthesiologist has to use ultrasound
lesson was that the most successful Although the scene and players re- imaging equipment, never before a part
teams had leaders who actively man- main the same, the new technology sig- of cardiac operations. But the mastery of
aged their teams' learning efforts. That nificantly alters the nature of the surgi- new tasks isn't the only challenge. In the
finding is likely to pose a challenge in
many areas of business where, as In med-
icine, team leaders are chosen more for
their technical expertise than for their
management skills.
Teamwork in Operation
A conventional cardiac operation, which
typically lasts two to four hours, unites
four professions and a battery of spe-
cialized equipment in a carefully chore-
ographed routine. The surgeon and the
surgeon's assistant are supported by a
scrub nurse, a cardiac anesthesiologist,
and a perfusionist-a technician who
runs the bypass machine that takes over
the functions of the heart and lungs.
A team in a typical cardiac surgery de-
partment performs hundreds of open-
heart operations a year. Consequently,
the well-defined sequence of individual
tasks that constitute an operation be-
comes so routine that team members
often don't need words to signal the
start of a new stage in the procedure;
a mere look is enough.
Open-heart surgery has saved count-
less lives, but its invasiveness-the sur-
geon must cut open the patient's chest
and split the breastbone - has meant a
painful and lengthy recovery. Recently,
however, a new technology has enabled
surgical teams to perform "minimally The challenge of team
invasive cardiac surgery" in which the management these
surgeon works through a relatively
days is to implement
small incision between theribs.The pro-
new processes - as
cedure, introduced in hospitals in the
quickly as possible.
new procedure, a number of familiar Isolating the "Fast Factors" rtx>m time costly and profit margins for
tasks occur in a different sequence, re- cardiac surgery relatively high, cash-
quiring a team to unleam the old rou- The 16 teams we studied were among strapped hospitals want to maximize
tine before learning the new one. those that adopted this demanding new the number of operations cardiac teams
More subtly, the new technology re- procedure. Given its complexity, they perform daily. •
quires greater interdependence and exercised great care in carrying it out, As teams at the various hospitals
communication among team members. checking and double-checking every struggled with the new procedure, they
For example, much of the information step. As a result, the rate of deaths and did get faster. This underscored one of
about the patient's heart that the sur- serious complications was no higher the key tenets of leaming, that the more
geon traditionally gleaned through sight than for conventional procedures. But you do something, the better you get at
and touch is now delivered via digital the teams were taking too long. At every it. But a striking fact emerged from our
readouts and ultrasound images dis- hospital we studied, operations using research: The pace of improvement dif-
played on monitors out of his or her the new technology initially took two to fered dramatically from team to team.
field of vision. Thus the surgeon must three times longer than conventional Our goal was to find out what allowed
rely on team members for essential open-heart procedures. certain teams to extract disproportion-
information, disrupting not only the Time is important in cardiac surgery. ate amounts of learning from each in-
team's routine but also the surgeon's Long operations put patients at risk and crement of experience and thereby leam
role as order giver in the operating strain operating teams, both mentally more quickly than their counterparts
room's tightly structured hierarchy. and physically. And with operating- at other hospitals.
The adoption of the new technology the same three-day training program level management support for the min-
provided an ideal laboratory for rigor- in the new technology. This consistency imally invasive technology wasn't deci-
ously studying how teams learn and among teams in both their traditional sive in hospitals' success in implement-
why some learn faster than others. We work practices and their preparation for ing it. At some hospitals, implementation
collected detailed data on 660 patients the new task helped us zero in on the was unsuccessful despite strong vocal
who underwent minimally invasive car- "fast factors" that allowed some teams and financial support from senior offi-
diac surgery at the 16 medical centers, to adopt the technology relatively cials. At others, teams enjoyed tremen-
beginning with each team's first such quickly. dous success despite support that was
operation. We also interviewed in per- ambivalent at best. For example, one
son all staff members who were in- Rethinking Conventionai surgeon initially had difficulty convinc-
volved in adopting the technology. Then Wisdom ing hospital administrators that the
we used standard statistical methods to We were surprised by some of the fac- new procedure should be tried there;
analyze how quickly procedure times tors that turned out not to matter in how they saw it as a time-consuming dis-
fell with accumulated experience, ad- quickly teams learned. For instance, traction that might benefit surgeons
justing for variables that might influ- variations among the teams in educa- but would further tax the overworked
ence operating time, such as the type of tional background and surgical experi- hospital staff. Even so, the surgeon's
operation and the patient's condition. ence didn't necessarily have any impact team became one of the more success-
Using these and other data, we also as- on the steepness of the learning curve. ful in our study.
sessed the technology implementation (For a comparison of teams at two med- The status of the surgeon who led the
effort at each hospital. ical centers, see the sidebar "A Tale of team also didn't seem to make a differ-
Because teams doing conventional T\vo Hospitals.") ence. Conventional wisdom holds that a
cardiac surgery follow widely accepted We also turned up evidence that coun- team charged with implementing a new
protocols and use standardized tech- tered several cherished notions about technology or process needs a leader
nology, the teams adopting the new pro- the ways organizations-and, by im- who has clout within the organization -
cedure started with a common set of plication, teams-adopt new technolo- someone who can "make things hap-
practices and norms. They also received gies and processes. For one thing, high- pen" in support of the team's efforts.
BEST PRACTICE • Speeding Up Team Learning
But we saw situations in which depart- At one extreme, the leaders-the sur- organizational challenge rather than a
ment heads and world-renowned car- geons-took little initiative in cboosing technical one. Tbey emphasized the im-
diac surgeons coirtdn't get their teams toteam members. At one hospital,the staff portance of creating new ways of work-
adapt to the new operating routine. At members chosen for training in the pro- ing together over simply acquiring new
other sites, relatively junior surgeons cedure were, essentially, those wbo hap- individual skills. They made it clear that
championed the new technology and, pened to be available the weekend of this reinvention of working relation-
with little support from more senior tbe training session. ships would require the contribution of
colleagues, brought their teams quickly In a few teams, however, selection every team member.
along the learning curve. was much more collaborative, and tbe By all accounts, tbe difficulty of the
Finally, the debriefs, project audits, choices were carefully weighed. An new procedure makes cardiac surgery
and after-action reports so often cited anestbesiology department bead, for even more stressful than usual, at least
as key to learning weren't pivotal to instance, might get significant input initially. But many surgeons didn't ac-
the success or failure of the teams we from the cardiac surgeon before choos- knowledge the higber level of stress or
studied. In fact, few surgical teams had ing an anesthesiologist. Selection was help their teams intemalize the ratio-
time for regular, formal reviews of their based not only on competence but also nale for taking on tbis significant new
work. At one hospital, sucb reviews were on sucb factors as the individual's abil- challenge. Instead, tbey portrayed the
normally conducted at midnight over ity to work with others, willingjiess to technology as a plug-in component in
take-out Chinese food. Some research- deal witb new and ambiguous situa- an otherwise unchanged procedure. As
oriented academic medical centers did tions, and confidence in offering sug- one surgeon told us: "I don't see what's
aggregate performance data and ana- gestions to team members witb higber really new here. All the basic compo-
lyze the data retrospectively, but teams status. nents of tbis technology bave been
at these hospitals didn't necessarily im- Another critical aspect of team design around for years." Tbis view led to frus-
prove at faster rates. Instead, as we willwas the degree to which substitutions tration and resistance among team
discuss, the successful teams engaged in were permitted. In conventional sur- members. Another surgeon, who char-
real-time learning-analyzing and draw- gery, all members of the surgical de- acterized the procedure as primarily a
ing lessons from the process while it was partment are assumed to be equally technical challenge for surgeons, was as-
under way. capable of doing tbe work of their sisted by a nurse who, with grim humor,
particular discipline, and team mem- said sbe would rather slit ber wrists than
Creating a Learning Team bers within a discipline are readily sub- do the new procedure one more time.
Her attitude was shared by many we
We found that success in learning came stituted for one anotber. It's logical to
interviewed.
down to the way teams were put to- assume that training additional team
gether and how they drew on their ex- members would allow for more cases to But that attitude wasn't universal. At
periences - in other words, on tbe teams' be performed using the new procedure, si>me hospitals, staff members were ex-
design and management. Teams tbat but we found that such flexibility bas cited to be "part of something new" as
leamed the new procedure most quickly a cost. Reductions in average procedure one expressed it. A nurse reported that
shared three essential characteristics. time (adjusted for patient complexity) she felt honored to be a member of the
Tbey were designed for learning; their were faster at hospitals that kept tbe team, in part because it was "exciting
leaders framed the challenge in such a original teams intact. to see patients do so well." The leaders
way that team members were bighly At one hospital where several addi- of teams with positive attitudes toward
motivated to learn; and the leaders' be- tional members of the nursing, anes- the cballenge explicitly acknowledged
havior created an environment of psy- thesiology, and perfusion staff were that the task was difficult and empha-
chological safety that fostered commu- trained in tbe new procedure sbortly sized the importance of eacb person's
nication and innovation. after adoption, the makeup of the team contribution. Tbe surgeon who talked
Designing a Team for Learning. changed with almost every operation. of the transfer of pain from the patient
Team leaders often have considerable Again and again, teams bad to learn to the surgical team belped his team by
discretion in determining, tbrougb from scratch how to work together. highlighting, witb light bumor,the frus-
choice of members, the group's mix of After the tenth time, the surgeon de- tration they all faced in this leaming
skills and areas of expertise. The teams manded a fixed team wbenever he per- cballenge.
in our study had no such leeway-car- formed tbe new prcKedure. Operations Creating an Environment of Psy-
diac surgery requires a surgeon, an anes- went more smoothly after that. chological Safety. Teams, even more
thesiologist, a perfusionist, and a scrub Framing the Challenge. When dis- tban individuals, learn througb trial and
nurse. But tbe leaders who capitalized cussing tbe new procedure with team error. Because of the many interactions
on the opportunity to choose particu- members, the leaders of teams that suc- among members, it's very difficult for
lar individuals from tbose specialties cessfully implemented the new tech- teams to perform tasks smoothly the
reaped significant benefits. nology characterized adopting it as an first time, despite well-designed train-
ing programs and extensive individual When individuals leam, the process observations, concems, and questions
preparation. The fastest-learning teams of trial and error-propose something, while using the technology, such feed-
in our study tried different approacbes try it, then accept or reject it-occurs in back often didn't happen. One team
in an effort to shave time from the op- private. But on a team, people risk ap- member even reported being upbraided
eration without endangering patients. pearing ignorant or incompetent when for pointing out what he believed to be
Indeed, team members uniformly em- they suggest or try something new. This a life-threatening situation. More typi-
phasized the importance of experi- is particularly true in the case of tech- cal was the comment of one nurse: "If
menting with new ways of doing things nology implementation, because new you observe st>mething that might be a
to improve team performance - even if technologies often render many ofthe problem, you are obligated to speak up,
some of the new ways turned out not skills of current "experts" irrelevant. but you choose your time. 1 will work
to work. Neutralizing the fear of embarrassment around the surgeon and go through his
As we have noted, this ieaming in ac- is necessary in order to achieve the ro- PA [physician's assistant] if there is a
tion proved to be more effective than bust back-and-forth communication problem."
the after-action analysis so often touted among team members required for real- But other teams clearly did foster a
as key to organizational leaming. Real- time leaming. sense of psychological safety. How?
time learning occasionally yielded in- Teams whose members felt comfort- Through the words and actions ofthe
sights that might have been lost had able making suggestions, trying things surgeons who acted as team leaders-
a team member waited for a formal re- that might not work, pointing out po- not surprising, given the explicit hier-
view session. During a procedure at one tential problems, and admitting mis- archy of the operating room. At one
hospital, for instance, a nurse sponta- takes were more successful in learning hospital, the surgeon told team mem-
neously suggested solving a surgical the new procedure. By contrast, when bers that they had been selected not
problem with a long-discarded type of people felt uneasy acting this way, the only because of their skills but also be-
clamp affectionately known as the "iron leaming process was stifled. cause of the input they could provide
intem."The use ofthe nearly forgotten Although the formal training for the on the process. Another surgeon, accord-
medical device immediately became new procedure emphasized the need for ing to one of his team members, re-
part of that team's permanent routine. everyone on the team to speak up with peatedly told the team: "I need to hear
BEST PRACTICE • Speeding Up Team Learning