NHS team work - apple pie in the sky

Michael West

Cultures of quality and safety require a strong value of team working. Health care staff have to work interdependently to provide high quality and safe care for patients because health care requires staff from across professional boundaries to collaborate and coordinate their efforts. It’s obvious.

And the evidence shows that where multi-professional teams work together, patient satisfaction is higher, health care delivery is more effective, there are higher levels of innovation in the provision of new and improved ways of caring for patients, lower levels of staff stress, absenteeism and turnover, and more consistent communication with patients. Developing and enhancing teamwork in organisations.

The apple pie analogy

Everyone agrees team work is (like apple pie) a good thing and most people in the NHS (91%) say they work in a team. However, the true estimate is probably nearer 40% at best. Illusions of team working in health care.

Around 50% of NHS staff say they work in teams but also say their teams do not have clear objectives or don’t work closely together or don’t meet regularly to review their performance. These are basic characteristics of teams. And the more people working in teams with those characteristics in a trust, the lower the levels of errors that could harm patients or staff, the fewer injuries to staff, the lower the levels of harassment, bullying and violence against staff, and the lower the levels of staff absenteeism and patient mortality. And the corollary is the more staff in trusts working in ‘pseudo teams’ (lacking one or more of those characteristics) the worse is trust performance on all those dimensions. NHS staff management and health service quality

So for a lot of NHS staff, teamwork is really more like pie in the sky. Why do so many staff appear not to work in well-functioning teams?

Primarily it is down to poor management and leadership resulting from of lack of knowledge of team working. We all think we understand what good team working is so we don’t need to do much to achieve it. Our research over the last 25+years shows that good team work in health care requires clarity about the basics of good team work and focused and sustained effort to achieve those basics in practice. The pay offs of such good team working are enormous. Here are the basics. Effective Teamwork

  • Good teams are clear about their task as a team and stated this as an inspiring (and where appropriate) patient-centred purpose.
  • They are clear about what skills they need in the team to achieve this purpose and therefore make appropriate choices about who should be the team members – not people with inappropriate skills, who display aggressive or disruptive behaviours or who are supernumerary.
  • Teams should be clear about who the members of the team are. Most teams we encounter in NHS organisations do not agree about who is in their team. It is as basic and problematic as that.
  • Team size is an issue. Once teams go above 8 or 9 members, effective communication and coordination become more difficult. We are often told that trusts have teams of 50+ - the equivalent of a small to medium sized enterprise, not a team.
  • Team members need to understand clearly their roles and the roles of other team members, so there is no ambiguity about who is responsible and accountable for what tasks.
  • Most important of all to effective team work in health care, our data shows, is that teams set five or six clear, challenging, measureable objectives every year.  The aim is not just to get the job done but to achieve significant improvements year on year in quality, safety and in patient experience (in the case of front line teams; but the need for improvement applies to all teams in the NHS). Where such objectives are set, health care teams are more effective, innovative and satisfied. And patients get better quality care and report higher levels of satisfaction. And those objectives constitute a core part of the agenda for regular team meetings.
  • Well-functioning teams in the NHS always have, as one of their objectives, significantly improving the effectiveness with which they work with other teams within (and sometimes outside) the trust.
  • Research shows that teams with a positive supportive, humorous, appreciative atmosphere deliver better care (doctors in such teams will make more accurate diagnoses for example) and staff are significantly less stressed. We have developed a new scale (Team Positivity Ratio) to measure the balance of positivity to negativity in teams and are keen for NHS staff to try out this measure (email me if you would like to use it - m.a.west@lancaster.ac.uk) and initial findings suggest that a positive balance is associated with better performance and higher levels of innovation. Positive teams are more optimistic, cohesive and have a stronger sense of their efficacy as a team.
  • Teams also have to meet regularly and have useful meetings that enable them to reflect on the quality of care they provide and how to improve it. Indeed, we have found that teams that regularly take time out to reflect on their objectives, strategies, processes, ideas for innovation etc, are not only much more productive but also more innovative than teams that don’t. ‘We haven’t got time’ is therefore an unacceptable excuse. Such teams are also better able to respond to work pressures and adversity by innovating rather than feeling overwhelmed and helpless.

Humans have worked in teams for thousands of years so we know it works – the challenge is to ensure team working is properly applied in modern NHS organisations. The payoff will be huge in terms of patient care, compassion, financial performance, errors, stress and almost every important measure of health service performance. We just need to do it!

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