I attended the annual meeting of Team STEPPS in Cleveland in June. STEPPS stands for Strategies and Tools to Enhance Performance and Patient Safety. The initiative has been developed by the Department of Defense, and superbly practiced within most, if not all, army health centers. For any one not familiar with its key principles, it’s worth checking out the Agency for Healthcare Research and Quality website (https://www.ahrq.gov/teamstepps/index.html) to learn more about its 4 teachable-learnable skills: Communication, Leadership, Situation Monitoring and Mutual Support. Further, the STEPPS team perception questionnaire is a useful and validated assessment tool for evaluation of how providers think they are doing with teamwork and safety.
Abundant research reveals that the performance of teams trumps the performance of a group of individuals, but for many teams in the healthcare arena, a high performing team remains only an aspirational, and too often, an elusive goal. The processes extolled within Team STEPPS ensure patient safety and optimal performance if executed with deliberation and care, but the diversity of our teams, and the infrequency with which they meet (for example, we may see our team once a week in the operating room at the hospital and once a week at the surgery center) may interfere with the type of esprit de corps that may transparently arise on teams that see each other and work closely together daily.
I participated in a workshop at the Team STEPPS meeting that addressed conflict management on teams—-anything from differences of opinion regarding patient positioning, to how to deal with a difficult personality or a process problem. Here’s what I appreciated after the session: Conflict on teams is inevitable. The question is whether it is dismissed/ignored, viewed as bad–with blame attributed to an individual or individuals–or deliberately mined, discussed and leveraged as an opportunity for learning, growth and team development. We all bring different optics, personality types, and biases/baggage to our jobs. So, to have the expectation that a “conflict” reflects a de facto problem on the team is not an accurate or productive way to view conflict.
As part of the Mutual Support principle of Team STEPPS, processes such as Feedback, Advocacy and Assertion, the Two-Challenge Rule, CUS statements and the DESC script operationalize behaviors that seek to provide information to team members with the purpose of improving performance and ensuring safety. When interpersonal conflict arises, the DESC script is particularly relevant to management and resolution: D=describe a behavior or situation; E=express how the behavior/situation made you feel and what your concerns were; S=suggest other alternatives and seek agreement; C=consequences should be stated in terms of impact on established team goals.
Now—if you are honest with yourself, consider how effectively the norms/culture on your team currently enable a process like the DESC script to be utilized effectively and respectfully. First, it requires, at the very least, substantial familiarity/kinship with each other, otherwise I would expect defensiveness and hurt feelings. This is why it is so easy to dismiss or ignore conflict. Second, it requires emotional intelligence skills like self-awareness, self-regulation and empathy. And, if the culture of your workplace views conflict as inherently “bad”, then why would anyone have the courage to identify conflict, let alone attempt to discuss it?
One thing that came out clearly at my workshop was that conflict is pervasive, and that when it is not viewed as an opportunity for iteration and development of the team and its members, then high performance will remain unattainable. Here’s the take away (and Patrick Lencioni underscores this in his book “The Five Dysfunctions of a Team”): High performing teams deliberately identify, discuss and leverage conflict continuously as a means of not only improving operational performance and efficiency, but to develop mutual trust, team efficacy and an optimal “social climate.” Michael West refers to the later process as social reflexivity—a review of the social milieu which exists as the work is getting done. He insists that high performing teams are not only proficient with task, but everyone gets along well, appreciates the value of diversity and strives to subordinate self-interest. The fundamental ingredient for this to occur, however, is trust. There must exist significant trust between team members, which according to Lencioni, is predicated on it being okay to be vulnerable—to admit mistakes. As you think about the nuance of giving constructive feedback to a team member, soliciting feedback from a team member, or having the equanimity to listen to disparate points of view or deal with a difficult personality, relationship equity is the currency which fuels the process. Without relationships, managing conflict, while possible, is more challenging.
So, in conclusion, discussing and leveraging conflict requires deliberate attention to relationship building. While this is possible during one’s operative day, focus on task may understandably dominate our mind share. As we accomplish task it becomes critical to manage our behaviors to minimize any misperception of our appreciation of the efforts of other team members. At the start of each day Team STEPPS advocates a “brief” to succinctly go through the day to ensure that there are no loose ends and to create a shared mental model for the day—aka everyone is on the same page. At the end of the day Team STEPPS advocates a “debrief” or after-action review—to effectively review the day to assess where things might have gone better. This is the opportunity to look for opportunities to “mine” conflict—including interpersonal. While six sigma processes in manufacturing seek to squeeze out every bit of variance from a process, identifying and discussing conflict is not aimed at eliminating it—rather it’s the iterative process of dialogue, compromise and resolution that builds relationships and team identity/efficacy, and spirals performance upward towards “high performance.” Even the Blue Angels grill each other after every, seemingly flawless, performance—for continual improvement. These processes deliver a significant opportunity for building relationship equity and trust. Ideally, we would interface and interact with our teams daily. To maintain connections and build relationships, I have been using “social media”, if you will, to compensate for the realities of not seeing the team regularly. We all communicate with group texts—even if only to wish each other a good weekend. It has really contributed to an esprit de corp.