36. Perfecting Teamwork: Building High-Performing Teams By Encouraging Learning

Matt Abrahams: Effectiveness in high stakes situations often boils down to expert teaming and communication. Yet, many teams miss the mark and perform suboptimally. Hello, I’m Matt Abrahams and I teach Strategic Communication at Stanford Graduate School of Business. Welcome to Think Fast, Talk Smart, the podcast. Today I am thrilled to speak with Sarah Singer, who is a professor of medicine at Stanford School of Medicine, and a professor by courtesy at the GSB. Sarah teaches the popular course, leading and managing health care organizations, innovation and collaboration in high stakes settings. Her research focuses on measuring and improving organizational culture, learning, teamwork, patient safety, integrated patient care, and culture of health. Welcome, Sarah, thanks for being here.

Sara Singer: Thanks for having me, I’m excited to speak with you.

Matt Abrahams: Great, let’s get started, your research addresses the impact of organizational culture in learning on teamwork, can you share some insights into what makes for high functioning teams?

Sara Singer: When I try to boil the lessons down, I say that high performing teams require cultures with three key characteristics. So they need to be team oriented, learning oriented, and systems oriented. By that, I mean first a team oriented culture suggests that leaders need to create conditions that support teamwork. Including strategies that overcome professional silos and hierarchies which you find in spades and health care organizations. So for example, by establishing clear roles and responsibilities and making sure that people have or understand the shared goals of the group and supportive practices like offering team time so people can work together. The second key characteristic is a learning culture where team members learn from mistakes and experimentation so they can adapt and change and innovate — all key factors for not just health care settings, but lots of organizational settings. Learning requires leadership that reinforces learning, a supportive environment, including especially psychological safety, but also an appreciation for differences when you’re working with people of lots of different backgrounds, and openness to new ideas. These environments need setting aside time for reflection, and a learning environment also requires learning practices and processes that promote training, knowledge acquisition, performance monitoring in order to facilitate learning in the team.

And that third key characteristics was a systems oriented culture. And by systems orientation I mean an orientation that keeps people focused on whole systems and addresses problems across conditions and across units and over time so that we overcome fragmentation and we integrate across boundaries in order, I think of the systems around the patient so we’re caring for the whole patients, so there’s a lot underlying these insights but these are some of the essentials for high performing teams.

Matt Abrahams: Wow, so it really sounds like it’s about taking time to define clear responsibilities, set up support and time for reflection and really look beyond your specific. Focus or silo, I often think it’s about people process and infrastructure, and it sounds like all three of those play out to helping high functioning teams be successful.

Sara Singer: Absolutely, especially in the accomplishment of what I was describing is that learning oriented culture, you need the leadership, you need the environment and you need those processes and practices and all of them need to be aligned in a way that supports people’s willingness to speak up, to discuss mistakes, to raise questions so that there is learning that occurs and that kind of open communication is essential.

Matt Abrahams: You know, two decades ago before returning to academics, I ran learning and development groups for high tech companies and I know that you’ve done some research in that area. For example, you looked at how people learn new tools and techniques when the situation changes, and existing expertise is no longer as useful. Can you share what you found and what lessons we can take away when it comes to learning new skills for ourselves?

Sara Singer: Sure, so this is recent research that I did with Kate Kellogg from MIT where we studied managers approaches to dealing with this challenge of teaching, new tools, and techniques. And in this case, we work with a large health-care system that wanted to introduce a series of new, new processes. So for example, standard patient rooming was one of the processes. And historically the process of bringing a patient into an exam room was just all over the map. And the organization wanted everyone to do it the same way and to document it in the electronic medical record, the same way so that they could bill more accurately for it. Another kind of standard process that they were trying to implement where standards or standard processes, standard timeframes, and documentation requirements for following up with a patient who visited the emergency department or had been discharged from a hospital. So I’ll keep things that organizations needed to do more consistently in the era of electronic records. So the managers in this case, recognize that the newer and often younger workers were more agile learners and less committed to the status quo.

But the problem was that they were also junior to the workers who had long tenure there. And the more senior workers considered those more junior workers as illegitimate in the trainer role. So in those units where managers assigned the new workers to be the trainers, there was a strong backlash, and the new processes weren’t taken up by the workers generally. But in a few of the units what we saw is that the managers rotated the trainer role giving everybody a chance to be the trainer. And when the managers offered the promise of this call it status mobility, the senior worker trainees were willing to learn from the junior trainers.

Just cause they knew that they would have the turn to be the trainers on themselves later. So there’s trainee status mobility, we describe as a mechanism that managers can use when they need to teach more tenured workers new skills.

Matt Abrahams: Wow, and so that goes back to that point of psychological safety that you also mentioned earlier, and that’s a topic that’s come up before on this podcast. So. by helping people feel more comfortable, you’re actually allowing them to learn and grow.

Sara Singer: Absolutely, and I’m not surprised that psychological safety has come up before on this podcast. Because it’s just so critical for the kind of learning that needs to happen on any team that wants to adapt or change or innovate. So making people feel comfortable to be a learner, at any state; leaders need to learn all the time, too. And so making people comfortable and confident that they can reach out with questions or raise concerns, and to just be a learner is something that every team needs in order to be successful.

Matt Abrahams: So true, so true. And I’m hoping that this actual podcast serves some of that need to help people learn more. Let me ask another question about another one of your projects, in that project, you noted that high functioning health care teams simultaneously focus on functional and cultural change. Can you define these two types of change and share why addressing both is so helpful to teams?

Sara Singer: Yes, certainly, so in this project, I studied primary care practices working to transform the way they delivered care. Moving from doctors is the focus of the work to team based care where doctors work with a medical assistant and nurse, maybe a social worker and others to dress the holistic needs of the patients. So our question was, what made some practices more successful than others at making this transition to team based care? And what we found was that the teams use different approaches. So one form of approach was a functional approach and the other was a cultural approach.

So these are further the way that primary care practices approached effecting change. And by the functional approach, we mean an approach that focused on the practical operational aspects of teaming. Things like making sure that there was clear role definition, supportive structures, and ensuring shared access to clinical data all critically important. But that the cultural approach in contrast, was an approach that addressed the more normative and relational aspects of teaming. Including things like making sure that the hierarchy was flattened sufficiently so that everybody felt they could provide some leadership. And that there was openness to experimentation on the team.

What we found was that the groups that pursued one or the other didn’t do as well as the groups that pursued both. That these were mutually reinforcing. So for example to successfully establish new roles which was a functional goal. That required sharing authority and flattening traditional hierarchies, which were both critical aspects of culture. And there was also this recursive relationship between the two approaches. In that, the cultural changes created an environment that were conducive to the functional change. And that functional changes then, in return, supported the systems for cultural changes. So by undertaking both simultaneously, a practice say could create a positive upward spiral that just got them better and better at making the change. So primary care practices that prioritize both types of change processes and pursuit them simultaneously, were the most effective.

Matt Abrahams: Wow, I can see how that could help not just in primary care, but in all organizations. And in my mind as you were describing it, I don’t know why this happened, but I flashed to a Yin Yang symbol where both parts blend together to bring out the whole. And it sounds both a functional and cultural approach are really critical to being successful. Now you know Sarah that this podcast really focuses on communication. So I have to ask you, what role does communication play in effective teamwork? And are there any best practices that you suggest that can help all of us be more effective in our teaming?

Sara Singer: Absolutely, communication plays a critical role, especially in situations that are stressful where people are under duress. So think about the critical moments in a surgical case, or when a patient is experiencing cardiac arrest. There are all sorts of critical moments in health care where communication is key. One best practice, for example, that we advocate is closed loop communication. Where one person says something and another person repeats it back just to make sure that they’ve gotten the information correct. So you say we’re ready for bypass, and the person responds, I’m putting the patient on bypass. I administer 10 ccs of x medication, I’m administering 10 ccs of x medication just to make sure that communication is received in the way it was intended. Another example is structured forms of communication, and there are lots of them. I spent tremendous amount of time trying to promote the use of surgical checklists, which have been made famous by Atul Gawande, who is a colleague of mine from Harvard and we work together on trying to spread this, and I was responsible for the evaluation of the implementation of that work. But the basic idea is that misunderstandings are possible, and especially where there is hierarchy, information doesn’t often transmit. And so making sure that you have information kind of listed out that you know you need to review, and that encourages not just kind of the checks of the things that you need to make sure that happened.

But also to prompt discussion including an important prompt that says I can’t do this case alone, I need you to speak up if you see a problem. So extending that invitation and creating the psychological safety in the space, those forms of structured communication so that it happens reliably, every time, can be a critically helpful.

Matt Abrahams: So much in what you just said. So the first part about inviting and almost requiring that instant response increases what I call the F word of communication. And that is fidelity — the accuracy and clarity. By building in that repetition, you actually confirm that the other person heard what you were saying. There’s a very simplistic model of communication called the transactional model, where a sender sends a message to a receiver who gives feedback. And insisting on that external verbal response, you really do highlight fidelity and reduce the noise that can get in the way. And the point of checklists and having as part of those checklists, the structure, the outline having part of it that it demands that others involve and collaborate, I think is so important.

We see in best practices around how people actually meet, so teaming often occurs in meetings. And having those explicit rules that everybody sees and you go through those steps, can be very helpful to being effective, efficient, and making sure that you achieve the goals. So really, really helpful ideas for communication there. So I’m wondering if you have any last thoughts or best practices that you’d like to share with us on how we can be better in the teams we participate in.

Sara Singer: Let’s see, so I can think of a couple.

Matt Abrahams: Sure.

Sara Singer: I guess one is, to make sure that the work that you are asking a team to do actually requires a team to do it. We forget that lots of work doesn’t actually benefit from teams. If the work is interdependent, then of course, it benefits from a team, but if it’s not, if individuals can work independently, then I say let the individuals do the work. And avoid all the challenges associated with teamwork and the requirements of communication because that’s really hard and there are all sorts of ways in which we fail to communicate and so we suffer those process losses. And teams don’t necessarily do better than individuals. So I say, make sure the work requires a team. And then secondly, I’d say when work does require a team, make sure everybody fully understands and is on board with what the team needs to accomplish. So when they are, they’re more likely to do the right things. And sometimes they’ll do amazing things. A very small example of this that made me think of it is, yesterday I met with my research grant manager to discuss the budget I was pulling together for a new research study that I’m proposing. And I said, at the end, we were pulling things together … I said, so do you have any questions about the project itself? And I realized that they knew nothing about the project. And so I explained the project, and then they poured out with suggestions for how I might revise the budget to make it more appropriate. So that the funder would look at it and say, they’ve really given this some thought. It was so helpful to me, and I learn that lesson over and over again, everybody on the team has something to contribute. And they can only contribute it if they are on board with what the team is trying to accomplish. Especially the people who are lower status and we don’t necessarily have presence in all of the meetings. They’re important too.

Matt Abrahams: Absolutely, that’s a double A answer: you first need to make sure that teaming is appropriate and then you need to make sure that everybody is aligned so that the appropriateness of meeting and working in teams is the first question and then you have to make sure that everybody’s aligned. So thank you for that.

Sara Singer: Love that.

Matt Abrahams: So before we end, I like to ask everybody the same three questions. Are you up for answering them?

Sara Singer: Sure, I’ll try.

Matt Abrahams: All right, question number one: if you were to capture the best communication advice you ever received as a five to seven word presentation slide title, what would it be?

Sara Singer: Inspire change by telling great stories.

Matt Abrahams: I love that. So I like the inspiration part of that, and we have certainly heard across the many podcasts the value that story has. Bullet points lists, that’s hard for us to understand and take with us but a good story is something that sticks. So thank you for reminding about us, how a story can inspire.

Sara Singer: I have to remind myself of that all the time.

Matt Abrahams: Right, exactly. So question number two. Who is a communicator that you admire, and why?

Sara Singer: Nick Kristof, and maybe because I was thinking of the New York Times. But I really admire the way he tells stories of real people and real people experiencing real suffering. He clearly believes we need to hear these stories in order to affect change. And I think he’s brave at hearing, hearing the hard things. I think it’s not easy to hear them and to bring them to light, and share them with other people in the way that he does. I find that really tough and admirable.

Matt Abrahams: What are the three first ingredients that go into a successful communication recipe?

Sara Singer: I have some fear, trepidation to speak this to someone who teaches a course in strategic communication, but I’ll give it a shot. So the ones for me, I think are a message, an important message that you find meaningful that you wanna convey. And the second is a connection. So thinking about how does your message relate to the people that you’re trying to reach? And the third, as we’ve been talking about is a story that moves people to agree or to action. So climate change is a classic example of this. Reform advocates first talked about polar bears losing their ice, and it was less compelling than the kind of message that you’re hearing now, which is about, this is critical for the survival of your children and your grandchildren and we need to do something about it. And the most compelling storyteller I know in this genre is David Attenborough.

The one I like most recently was a show called The Life on Our Planet, which if you haven’t seen, you really must but, quintessential storyteller. And then in my field, the really compelling stories tend to be about opportunities for teams to save lives, or the lives lost. More often we hear about lives loss because teams have failed. And they’re often about ways that leaders fail to establish psychological safety, so teams don’t achieve their full potential, or about lack of reliably safe processes. So cardiovascular surgeon who shuts down a conversation in the surgical room by berating his trainees, and people don’t speak up, and something terrible happens to their patient. Or their primary care team that fumbles a positive test result and doesn’t act when they have information that they should act on, and they don’t catch the patient’s colorectal cancer until it’s progressed beyond the possibility for treatment. So super sad stories that are calls to action. And we use them because we need people to make processes better, make communication better for patients going forward.

Matt Abrahams: Well, you had nothing to worry about in terms of your strategic communication abilities. Those three ingredients are absolutely critical and can definitely be helpful, not just in a health care setting, but beyond. So Sarah, thank you so much. Your ideas and insights into teamwork and training and communication are incredibly useful and actionable. I appreciate your time, and your insight.

Sara Singer: Thank you. I appreciate having the opportunity to speak with you today.

Matt Abrahams: Thank you for listening to Think Fast, Talk Smart, the podcast. A production of Stanford Graduate School of Business. To learn more, go to gsb.stanford.edu. Please download other episodes, wherever you find your podcasts.