View more articles in
Team Culture >

An Interview with Roger Coleman

Since "team" is a word bandied about frequently among healthcare managers and staff, especially in the application of healthcare redesign, what does the concept of "team" really mean in ambulatory health care? For the answer, we interview Roger Coleman, General Manager of Coleman Associates, the Patient Visit Redesign™ specialists.

Q: Good morning, Roger. Before attempting to answer the burning question, "What is a team," I'd like to ask you a seemingly unrelated question. In an era of "President & CEO" titles, why is your title, General Manager, so retro? LOL.

RC: LOL. It's a fair question. There's little we do at Coleman Associates that isn't deliberately crafted, and that includes my title. I borrowed this from Tom Kelley, the "general manager" of the most prestigious design firm in the world today, IDEO. He's brilliant but down-to-earth, an incredibly rare combination. As Tom would say in explaining how IDEO continues to be enormously innovative —year after year: "You're not going to do anything creative with a bunch of stiffs walking around."

Titles are important, perhaps. But they shouldn't be shaped around the ego of the individual. "General Manager" has not one iota of glamour to it. It does, however, explain what I do without any pretense.

If the head of your organization is the "President & CEO", then from the title alone you can see the big office, the preordained agreeable nodding of subordinate managers around a conference table, and the endless meetings—because everything is organized around that person's ego. I'm not trying to offend anyone here, I'm just sharing my own observations.

At Coleman Associates, each Associate plays three roles concurrently: Worker, Manager, and Owner. And that includes me. I don't sit around in meetings, delegating work to Associates. My day is largely comprised of getting things done.

And this is the prerequisite and foundation for teamwork: Everyone does real work! And no one is above the team just as no one is above the law in this country. It would not occur to me to make any significant decision nor do any significant piece of work without subjecting it to the scrutiny of my teammates.

Q: So, are you being critical of the way the typical healthcare entity is organized and managed?

RC: Are you kidding? Yes! LOL. Let's talk about the typical hierarchical organization chart. It was invented during the Industrial Revolution. That tells you everything you need to know! If we hired only people with fourth grade educations, and they only performed rote work—rather than work made rote—then I'd agree that an exquisitely layered hierarchy is a great way to organize people to accomplish work. But that's not our situation in healthcare.

A hierarchy breeds control rather than creativity, internal politics rather than teamwork, handoffs rather than cogency, and indecision rather than results. So teamwork and creativity are stifled while errors and rework are common.

A hierarchy is like a giant tree chipper that turns trees into unidentifiable fragments. In this case, "trees" is the core work of the organization: Increasing the health status of its patients. Hierarchy translates into managerially well-populated functional "silos", or departments, and silos divide people and fragment work. So they are formidable barriers to teamwork, quality, and effectiveness. And that results in a horrendous level of errors in clinical and non-clinical work alike, which is exactly the situation in healthcare today. You can't create, foster, and sustain cross-functional teams in such a culture.

Q: So, I guess that now leads us to the proverbial meat of the matter, what is teamwork, and what is a team?

RC: If you Google for definitions, teamwork is defined as: "A cooperative effort by members of a group or team to achieve a common goal." This tepid and diluted definition can be applied to three types of workgroups we see in health care organizations: committees, groups, and teams.

In fact, a committee is really a kind of group, a category of groups, I think. So really you find only groups and teams in our organizations. And I rarely ever see teams. Health care organizations are 95% groups.

A committee is an attempt to bridge the silos to get something done. It's often comprised of a person or two from each silo who, together, look for solutions to which no one objects but in which no one believes.

If you see a group of people sitting around a table and there's no passion whatever, in all probability you've got yourself a first-rate committee. By the way, given that description, your typical health care "executive management team" is—you've guessed it—a committee. And a committee is most definitely not a team.

And a "group" differs substantially from a "committee". A group tends to be a bunch of people who work together shoulder-to-shoulder in real time. The folks working in your pediatric clinic, Pod A, would probably constitute a group. They work cooperatively to get through the day. Within this group, there may be some small teams, but they aren't cross-functional teams. You may have the medical assistants in Pod A working very closely with each other, but not working well with folks in other functions, for example. Here you see a "functional team" within a larger group.

A group is a real step up from a committee because real work is being performed—meaning work that directly benefits the patient, our customer. People in the group, in general, have emotional ties with one another—they share a very real intimacy and purpose.

The problem with groups is that they don't have explicit outcomes that they pursue passionately. This is a key distinction between groups and teams. Groups have immediate goals like "survive the day", but rarely have longer time horizons.

And here's another difference between a group and a team: A group's membership is often the product of happenstance. People leave and are replaced by other people on Pod A. In stark contrast, a team's membership is deliberately and thoughtfully crafted to create a small, highly capable, and highly skilled force to be reckoned with.

And that qualifier "small" is probably the third difference between a group and a team. A group in a health care setting most typically has a membership of maybe 10-30 people, whereas teams operate optimally around 4-6 people—results rapidly deteriorate with teams smaller or larger than that. Five is my favorite team size. Its small size allows maximum tactical agility and yet it has enough resources to overcome even the thorniest problems.

So, to summarize, a team has three distinctive characteristics:

• It is small in size, most optimally five to six people.
• The membership is deliberately and highly crafted to ensure a robust balance of technical, interpersonal, and other skills.
• Its members are emotionally bound to each other and to the team's purpose and goals.

Let me just finish this by commenting on the last point. Teams and teamwork are emotional. There's no way around it. Team members grow to rely on each other heavily, so that the four worst words you could ever hear from a teammate are: "You let us down".

And the team is just as emotionally tied to its purpose and outcome goals. That's why true teams fail so rarely—because you have a small band of highly capable people who passionately believe in their mission. It is this very set of conditions that make failure so untenable to a team, and therefore so unlikely. Now, contrast that with a committee. Ouch!

And one last point: The goal has to be crafted so people can emotionally bind to it. It has to be deeply meaningful to the team members. (See Setting Goals For Patient Visit Redesign™ In Seven Steps in the Techniques section of this website.)

Q: But only five employees on a team? Like a Patient Visit Redesign™ team? I'm sorry, but that seems like a pathetically small number of people to get challenging and big jobs done.

It does, doesn't it? But you're wrong. It's plenty big enough. The trick is to put no fodder on the team. Choose only highly capable and highly skilled individuals. Make sure the mix of technical and other skills—like analytical capabilities, communication skills, decisiveness, math skills, interpersonal skills—are well represented on the team. And make sure you only put people on the team who will be unquestionably passionate about the goal, the outcome you are seeking. There's no substitute for passion.

Margaret Mead said it best: "Never doubt that a small group of thoughtful committed citizens can change the world; indeed, it's the only thing that ever does." It's so true!

By the way, we never use the word "employee". It clearly designates someone as a worker and worker only. The only way you can have a culture that allows for these highly functioning, self-managing teams is for each team member to feel that she or he plays the worker, manager, and owner roles concurrently. This is key to any successful teamwork.

These roles are always tied to time horizons. As a worker, you need to get something done now. Period. As a manager, you're responsible for moving the whole team forward—both developmentally and with respect to overall results. As an owner, you're concerned about the future, so you actively help shape it.

And all of this applies to any healthcare team whether you are talking about a surgical team, a Patient Visit Redesign™ team, a patient care team, a management team, or whatever.

Q: So how do healthcare managers go about putting teamwork in place?

RC: That's the most complex question you could have asked. First, you can't put teams in place with rigid, hierarchical structures, which we've already talked about. Second, you can't implement teamwork in a status-conscious organization, which we've already talked about. Third, before you can succeed at creating teams and teamwork as a manager, you probably have to change yourself first.

Most healthcare managers have no formal training in management or any experience in other industries. What they know is what they have seen in their 5, 10, 15, or 25 year healthcare career. And so they perpetuate it. Not out of spite, but definitely out of ignorance. When we're working with an audience of managers, it's rare for more than a few of the participants to have read any—and I do mean any—current business literature. Most managers appear not to see the need for continual education and the honing of their skills. It's sad but true.

The methods of redesigned work processes (reengineering) and self-managing teams are now 13 years old, but most healthcare managers remain untrained around these very powerful tools. But if every person in your organization was on a self-managing cross-functional team, your overhead would plummet and your outcomes would soar. Why? Because like many other industries have discovered, self-managing teams radically reduce the need for supervisory and managerial personnel.

And because you can only have talented and capable people on self-managing teams, you have to fire all the folks who don't pull their weight. We have a dozen Associates, which is a small number of people for all the work we do. But six of them do 75% of all the work! It's unbelievable how much you can get done with only a few people if every person is highly capable and self-managing—regardless of what position you're talking about.

And, the results are so much better with self-managing teams. You get much higher staff satisfaction because rock stars like to work with rock stars. You get much better quality outcomes because there's a lot fewer handoffs which translates into much less stuff falling through the cracks and dramatically reduced error rates, however you choose to measure them. And, patient satisfaction soars—there's just so much more cogency and continuity of care with self-managing teams.

Q: Final Question. Are teams a panacea?

No, nothing's a panacea for all the challenges we face in health care today. But we have seen Patient Visit Redesign™ teams reduce visit cycle time from a 150 minute public hospital average to less than 60 minutes (and down to 30 minutes in other kinds of organizations).

And we've seen our RevMax (Revenue Maximization) teams generate amounts of additional cash for their organizations that totally defied the predictions of top leaders. And our marketing teams use shoestring tactics to ramp up demand for new clinic sites. And all these results have been produced by five to six member teams. And there's tons of evidence about small chronic care teams that have produced similarly dramatic gains.

If you can have that kind of impact with one team of five to six folks, what could you do with 10 teams? Or 20 teams? Or 100 teams? It would be the organizational equivalent of nuclear power! That's our mantra: Unleash your talent, liberate your people!

Q: Thank you for your time, Roger, and for sharing your experience with us.

RC: Well, thanks for the opportunity to share. I'm so excited about this potential, I do love talking about it. So, thank you!

This interview was conducted in New York City on January 6, 2006 with Roger Coleman interviewing Roger Coleman. Roger is a Gemini.