January 2020
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Fluid Teams Could Mean Permeable Group Dynamics
TD Magazine

Fluid Teams Could Mean Permeable Group Dynamics

Thursday, January 2, 2020

The nature of shift work makes forming collaborative teams a challenge.

The healthcare industry requires 24/7 coverage, simultaneously facing staffing shortages and the need to continuously improve processes and capabilities. As a result, the modern hospital is a shift-based workplace. For the staff providing care, this may mean that the people they work with today may not be the same individuals they work with tomorrow. Although there is typically a core group that remains the same, there may still be a constant parade of professionals, including employees, physicians, and volunteers—all of whom come from various disciplines, have different skill sets and certifications, and a wide range of experience. There is also a mix of part- and full-time staff.


For example, hospitalists may rotate one week on and one week off. Some nursing units have 12-hours shifts, with staff working three days per week. There are also staff who rotate across different hospitals, depending on the need. Meanwhile, many different physician specialties have to cover multiple hospital campuses, and some physicians provide telehealth services and are only available via video consults. And, of course, there is the general staff turnover that most organizations experience.

While the quality of work tends to be high, all those factors contribute to a fluid team. With such high stakes, there's a lot riding on getting the team dynamics right. Therefore, it is critical for health system leaders to cascade system priorities, goals, and expectations. Leaders also need to ensure two-way communication throughout the organization. Having an intentional change management approach is key with fluid teams.

Teams that understand the organization's strategic priorities, annual objectives, and long-term plans will better connect with each other to achieve the collective goals. Also, they will be in a better position to be collaborative and agile. In the end, patients and their loved ones are the benefactors.

Indeed, in healthcare, patients are at the center of every decision. If healthcare organizations do not have a clear vision, strategies, operational priorities, and goals, each team member will feel acute challenges. Thus, the leader's role is to remove obstacles and create a work environment where all employees are empowered, engaged, and working cohesively with their teams.

Start with purpose and cascade a shared vision

It's important for any company—not just in healthcare—to share its purpose, which is usually reflected in its mission statement. In addition, firms must share their vision so that all departments and employees understand how they play a part.

Knowing the big picture helps staff members understand how their work matters. This is especially critical when the teams are always changing. Although the faces may be different day to day, the company's purpose and mission remain the same.

At Lee Health, we have more than 13,000 employees, 4,000 volunteers, and approximately 2,000 medical staff members. One strategy for focusing and cascading our mission, vision, and values throughout the organization is to use the Baldrige framework, which is based on the Malcolm Baldrige National Quality Award. The framework centers on achievement and improvement in seven performance areas: leadership, strategy, customer, workforces, operations, measurement analysis and knowledge management, and results. We formally cascade the mission, vision, and values into four strategy pillars measured by annual objectives (key performance metrics), which we execute through our operational priorities and department initiatives.

Ultimately, the Lee Health team exists to serve our patients. Staff members still need to know the daily objectives, though, so they can support one another to best serve patients. One strategy for doing so is to use daily huddles and huddle boards to focus in on and display the department's performance, performance gaps, where staff need support, and fresh ideas. An example may be the need for extra IV pumps or other equipment for a specific department. Huddle observations, ideas, and requests need to go to leaders as well, so there is a two-way exchange with staff and managers.

These huddles are an excellent way to build trust and reduce any friction. By doing these daily rounds and making huddles a priority, we find that teams can stay more positive and be resilient.

Offering feedback to each other is also a powerful way to strengthen team dynamics and agility. However, few people regularly solicit feedback, graciously accept it, and then make changes accordingly. Leaders should reflect on how they can improve their leadership by role-modeling how they solicit and accept feedback. After all, enhancing the patient experience starts with the relationships leaders have with their teams and themselves.

Develop team norms

Each Lee Health hospital is responsible for its day-to-day operations; the hospitals also are bringing in additional experts and engagement with nursing and medical staff. That can get complicated. Therefore, a couple of years ago, we changed our hospitals' leadership structures to include dyads. Each hospital dyad comprises a physician and nurse executive with equal accountability of their hospital's operations.

The dyad's role is crucial, because it brings together the various fluid teams, which may differ by each shift. Also, all the physician executives were new at the time, so it was a great opportunity to have the dyads of our four acute care adult hospitals together.

For example, all medical staff making rounds on patients are expected to also round with the nurse overseeing each patient's care. That helps improve consistent adherence to each patient's care plan and enhances nurse and physician communication with their patients. It likewise contributes to a greater patient experience and strengthens patient, family, and community loyalty.

Before rolling out the new dyads, all staff reached a consensus on the ground rules and behaviors expected from each other. To do that, we used LeadQuest Founder Mark Sasscer's 10 Principles of Personal Leadership. The principles are certainly common sense yet still challenging to consistently follow:

  • Be in the moment (be present).
  • Be authentic and humanistic.
  • Volunteer a discretionary effort constantly.
  • Model high performance—desired behaviors that drive desired results.
  • Respect and leverage separate realities (appreciate and understand where your colleagues stand on issues).
  • Be curious versus judgmental.
  • Look in the mirror first—be accountable.
  • Have courageous conversations.
  • Provide timely, clear, and specific expectations and feedback.
  • Teach, coach, and mentor.

Leaders and their teams regularly review those principles and ensure everyone is following them consistently. The principles are only a guide; team members must understand and agree to the expected ways they will work together.

Create the team's structure and implementation plans

The leadership team comprises the hospital dyads, controller, leaders in quality and safety, HR, and the ad hoc members. It takes all the strategic priorities, annual objectives, tactics, and focus action plans in our respective areas, which helps the shifting teams understand the priorities and plans that contribute to long- and short-term success.

Each of the four hospital dyads developed documents that include the key strategies and capabilities they expected to realize two to three years from now—and then backed into their annual plans with 90 milestones. Every dyad updates its line-of-sight document regularly; dyads also have monthly or bimonthly business unit reviews with each department leader to review their respective performance, challenges, and process improvement ideas. Lee Health used the documents to provide a roll-up of all its hospitals.


The hospital leadership team also reviews its collective performance on a monthly basis and looks for opportunities to spread best practices. The team stays focused on how to reduce unnecessary variation across the hospitals, which helps diminish pain points for staff who may work in multiple departments.

The exchange of ideas across the leadership team and staff is another way to reinforce an engaged and empowered team. In turn, staff will be in a better place to serve patients.

Listen to your team

About 25 years ago, while working at University Hospitals, my supervisor asked me to review why a department was struggling with its performance. He let me know the department had specific goals, and my role was to help the staff fix the processes holding them back from achieving those goals. I shadowed key team members and asked them what was working well and what would help them improve their outcomes.

Spoiler alert: They knew what they needed to change, but no one had stopped or cared enough to ask them. When my supervisor asked me how they improved their performance, I said, "We listened. They already had all the answers."

While it's so simple to do, not enough leaders and staff listen to each other when trying to identify and solve problems. Physician rounds with nursing staff and daily huddles among all team members are simple ways to combat this problem. This strategy enables teams to voice not only matters happening closest to the patient bedside that need immediate action but also long-standing issues that need to be surfaced. The key is to listen and support one another.

The huddles and leadership rounds also provide a practical venue for providing actionable feedback and address performance issues. What's more, they create a platform where staff and leaders can role-model behaviors they need to see in team members.

Put it all together

Yes, we have all worked in environments where staff and team dynamics have an impact—day to day, shift to shift. In the healthcare setting, that could be a daily friction point. The most effective ways for teams to work through this is to set ground rules and clear expectations first. Teams need to appreciate the differences among the team members, including the strengths each person brings.

But managing team dynamics is so much easier when you have the right members in place. That starts with selecting the best employees and consistently conducting stay interviews. During these meetings, we review departmental performance, their individual performance compared to their annual goals, and where they need support. I suggest conducting these meetings monthly or quarterly, and be sure to solicit feedback on ideas to improve the department, team dynamics, and even your leadership.

Any healthcare environment needs to be built on trust. That includes understanding yourself and your purpose—the strengths and limitations you bring. For example, some people are amazing at connecting with others yet struggle to write a plan or process the team could follow. Of course, there are others who are methodical and process-oriented, yet they cannot connect well with others. Connecting these two skill sets strengthens fluid teams.

In the end, the key to managing team dynamics starts with relationships. Leaders and staff understand the need to help their health system serve their patients and achieve the organization's annual objectives. Leaders should focus on creating an environment to foster and strengthen relationships so their teams can thrive. Leaders also should encourage staff to find ways to take care of themselves first, so they can help take care of others. You sit in the seat to be that role model for others. By focusing on relationships, the team's work environment—whether stable or constantly changing—will be in a great position to thrive.

About the Author

Scott Kashman, MHA, FACHE, is the chief officer of hospital operations for Lee Health. He joined Lee Health in August 2011. He also is the co-author of Mindful Healthcare: Healthy Team, Healthy Business.

Scott brings more than 25 years of experience numerous areas of healthcare. He began his career as a psychiatric counselor providing inpatient and outpatient therapy. Throughout his career, he has held many managerial positions, including vice president of outpatient services for the Rehabilitation Institute of Chicago and chief operating officer for Mercy Hospital Anderson in Cincinnati, Ohio. Most recently, Scott served as CEO at St. Joseph Medical Center in Kansas City and the chief administrative officer for Cape Coral Hospital.

Scott received his bachelor of science in psychology from the University of Pittsburgh in Pennsylvania and earned his master of health administration from Tulane University in New Orleans, Louisiana. He also completed a fellowship in the area of disability ethics in the Department of Rehabilitation and Physical Medicine at Northwestern University Medical School. He is a fellow (FACHE) and leadership mentor with the American College of Healthcare Executives and has been a presenter on numerous healthcare-related topics.

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