AMA Journal of Ethics^®

Do effective endeavors require hierarchy, a chain of command with relationships defined by subordination? Rather than hierarchy, I suggest that what groups really need to be effective is clear structure: defined relationships (leadership and goals), set standards, shared respect, and a means for managing conflict.

Hierarchy is one form of structure, and the team is another. They often coexist, with expression depending on circumstances. In high-risk environments—those marked by sensory overload, an intense climate, time urgency, and distractions—a collaborative team model is more effective. Examples include the airplane cockpit, trauma bay, and combat.

Hierarchy connotes different levels of skill and importance among personnel; team members are considered equally competent and key to success. In a hierarchy, reporting relationships are vertical, as on an organizational chart; team relationships are represented horizontally on a position diagram like a playbook. Hierarchical reporting and decision making must be observed inflexibly; teams are more adaptable. In endeavors such as clinical care that involve many professionals from various disciplines, hierarchy can generate mistrust and resentment when status is a barrier to communication, while team organization makes better use of talent from all team members and promotes mission focus.

So what is a team? A team is a group of people committed to achieving a shared goal (i.e., a mission) together through interdependent actions and accountability to each other. Too often, the word “team” is used wishfully to describe mere groups of people who are not really collaborating [1]. In sports, for example, what distinguishes a Super Bowl champion team from a high-priced group of football players? Three elements come together: a collective goal that trumps discordant individual desires; collective practice that synchronizes actions; and collective performance that is measured and evaluated.

There is another aspect to team accountability: it keeps the team together. Well-functioning teams do not disintegrate under pressure; rather, team members are motivated by responsibility to each other. Team members do not act independently; they recognize that they work in the context of those around them and are interdependent. In teams, individual performance multiplies to a collective outcome greater than the sum of those performances [1].

Team structure serves as the foundation upon which essential processes for mission accomplishment—planning, communication, execution, and performance improvement—can occur. Planning is developing a mental model shared among team members that guides actions and includes common language, synchronization, and expectations for team members. With rehearsals, planning becomes readiness. Communication creates situational awareness through closed-loop messaging (speak, listen, and confirm), assertiveness (i.e., speaking up politely to be heard), and checklists, hand-offs, briefings, and huddles. Execution entails team members monitoring performance together, providing each other with back-up to prevent errors, and undertaking workload management, which requires vigilant adaptability when workload is low and prioritization when workload is high. Improvement results from timely feedback and debriefing to learn lessons. This latter point bears emphasizing: too often, we “identify” lessons rather than learning them. Lessons are learned when they result in team process changes. Improvement promotes accountability through measurable outcomes and processes [2].

The Leader’s Role

Hierarchies and teams get direction from their leaders. Leadership style has a profound effect on organizational climate, which can enhance or reduce individual motivation. Different structures and circumstances may promote or require different leadership styles.

There are six general styles of leadership: directive, visionary, affiliative, participative, pacesetting, and coaching [3]. Directive, as the name suggests, is based on orders and consequences for failure. Visionary puts mission into context and communicates why one course of action is better for achieving shared goals. Affiliative is empathic, focuses on listening, and aims to meet the emotional needs of individuals in the organization. Participative is collaborative and builds consensus. It is inclusive in decision making, though not necessarily democratic. Pacesetting is marked by personal heroics that define standards and set the example, yet can be overachieving. Finally, coaching promotes long-term professional growth [3].

Again, there is no single leadership style that works for every situation: different structures will emphasize different leadership strategies. In my experience, leaders in hierarchal structures tend more toward directive, pacesetting, or visionary leadership approaches, while team organizations rely on a combination of coaching, participative, and affiliative styles.

The overall leader of a team inspires the group to achieve the mission, while supporting its members, and takes responsibility for the team’s success or failure. Yet each member within the team may take the lead on a particular task needed to accomplish a goal.

Teamwork in Health Care

Until the current focus on reform [4], health care has been delivered as a loose affiliation of health professionals in various independent settings, leading to fragmentation as patients move through episodes of care. Hierarchy has dominated interprofessional relationships. As a complex adaptive system, though, health care delivery works optimally when it is collaborative [4]. In patient care, teamwork has two goals: improving patient outcomes by delivering quality care (defined by the Institute of Medicine as safe, timely, effective, efficient, equitable, and patient-centered [4]) and fostering team well-being through ensuring respectful interactions among all team members. In health care, the second goal is commonly forgotten. If team cohesiveness is not maintained, then missions do not get accomplished successfully over time.

An environment that supports teamwork cultivates professionalism, which keeps the focus on the most important person in health care, the patient [5]. When health professionals work collaboratively, scope of practice becomes more about defining roles and responsibilities among team members than about maintaining separate territories. Health professionals and patients exist in a health care ecosystem marked by interdependence and mutual accountability, whether we recognize it or not. The time has come to think of caring for the patient as a “team sport.”