Hello, and welcome to today's webcast, the science behind building a high-performing team. My name's Dr. Judy Jacoby, I'm an experienced board-certified critical care pharmacist and now a senior consultant at VSUNT, focusing on the pharmacy practice model for inpatient pharmacists with an emphasis on comprehensive medication management. I'm a past president of the Society of Critical Care Medicine, was the first pharmacist to serve that role, and the second non-physician. I've otherwise been a founding member of that clinical pharmacy and pharmacology section. I'm involved on the editorial boards of Critical Care Medicine and Critical Care Explorations, and I'm most excited, as you will be hearing, that I'm leading the task force for non-clinical and leadership training, and I will be moderating today's webcast. This webcast is being recorded. The recording will be available to registrants on demand within five to seven days. You would log into mysccm.org and navigate to your My Learning tab. Thanks for joining us. A few housekeeping items before we get started. There will be a panel discussion after a brief presentation. To submit questions throughout the presentation, type into the question box located on your control panel. This presentation is for educational purposes only. The material presented is intended to represent an approach, view, statement, or opinion of the presenter that may be helpful to others. The view and opinions expressed herein are those of the presenters and do not necessarily reflect the opinions or views of SCCM. SCCM does not recommend or endorse any specific test, position, product, procedure, opinion, or other information that may be mentioned. So as I said, this is the first activity of our new task force, the Leadership Empowerment and Development, or LEAD, task force. And we've actually been at this for a while. We have a dedicated group of volunteers who've been working on it since 2019. And although COVID delayed its launch, it really hasn't diminished their enthusiasm for programming to assist individuals and teams in expansion of non-clinical roles and skills. And so here are our objectives, things we're going to be focusing on initially, areas around team support, thus today's webinar, individual and team well-being, mentorship, leadership, skill development, unit finance, quality improvement, and personal finance aspects. And we're planning a variety of different modes of education, including webinars on a regular basis like this, podcasts, micro-learning, a variety of opportunities for you to sample on demand the content that you might need at any particular time. My thanks to our LEAD task force members, in addition to Frederick Agnabenny, who is my co-chair, for all the work they've done so far and work that is yet to come. And look for, on the SCCM website, our new LEAD logo when we have one and opportunities for you to submit your stories, videos, podcasts, things to help share what you've learned in these areas over time. So now I'd quickly like to introduce your speaker and panelists for today. Dr. Sergio Zanotti is a specialist in critical care medicine and chief medical officer for sound critical care, sound physicians, as well as a practicing intensivist at Memorial Hermann, Memorial City Medical Center in Houston, Texas. He's the host of Critical Matters, a podcast that covers a wide range of topics related to the practice of critical care. Dr. Zanotti is a member of the Alpha Omega Alpha Honor Medical Society, has received numerous awards for excellence in medical education and multiple presidential citations from SCCM. He's served as editor-in-chief of the yearbook of critical care medicine and has authored over 100 articles, book chapters, and abstracts. He's certified in Lean and Six Sigma and has championed the concept of Lean ICU within sound physicians. Our first panelist will be Dr. Moja Hebner, and she's an associate professor and vice chair for clinical services at the University of Maryland School of Pharmacy in Baltimore, Maryland. She practices as a clinical pharmacy specialist in the medical ICU at the University of Maryland Medical Center and is the coordinator for pharmacotherapy PGY 1 and 2 residency program. She completed her PharmD at the University of Maryland School of Pharmacy, did residencies at Yale New Haven Hospital, and worked there for a time as their medical ICU clinical pharmacy specialist and residency program director. And our second panelist is Dr. Jerome Lee, and he serves as the medical director of the Blake 12 intensive care unit and director of surgical critical care at Massachusetts General Hospital in Boston, Massachusetts. Dr. Lee co-leads the biomedical equipment aspects of the COVID-19 response for the overall multi-hospital system. Furthermore, he regularly trains and deploys as a medical officer for the U.S. government in response to disaster relief and other major events. He practices both emergency medicine and intensive care medicine and has over 150 research publications and book chapters. Our third panelist is Dr. Lynn Kelso, and she's an assistant professor at the University of Kentucky College of Nursing and also in the University of Kentucky Department of Pulmonary Critical Care and Sleep Medicine in Lexington, Kentucky. So thank you, everyone, for joining us for today's webcast. And now I'll turn things over to our speaker, Sergio Zanotti. Thank you, Sergio. Thank you, Judy, for the kind introduction and thanks to Society of Critical Care Medicine for the opportunity to participate in this activity and be part of the lead task force. So as we said earlier, today we're going to dive into the science behind building a high-performing team, something that we all believe, obviously, to be critical to our ICU's success and something that COVID, of all things, has heightened and taught us how important it really is. So what I want to do in the next 30 minutes or less is to go over an introduction of some basic concepts about teams that I think will set the stage for how important it is for the success of what we do, but also for the individuals who work in our ICUs. I'll go into some of the science behind what makes a team great. And finally, I want to share with you some actionable concepts of how to move the needle and really make a difference in your teams. And hopefully, these will be very practical and they're items that you can actually take back to the bedside today and start moving the needle in the right direction. Our story starts in 1930s in the coast of Indonesia with Dr. Smith, a prominent scientist from the era who was exploring Southeast Asia and on a night trip through a river saw the whole forest light up at once and thought that lightning had struck. To his surprise, a couple of seconds later, lightning struck a second time, then a third time, then a fourth time. And eventually, he realized that what he was witnessing was millions of fireflies lighting together in synchrony. He wrote a paper about this. And when he returned, he presented it to the scientific community, who mocked him, arguing that it made no sense for fireflies to light up synchronous in terms of, first, it would decrease their chances of finding a mate, since that's why they usually light up is to find a mate. And second, there is no way that they could coordinate that in such a scale. So for many years, he kept arguing that this is what he had witnessed and started to research it. And over time, many other scientists witnessed this effect, and it becomes something that has been recognized. Recently, however, a group out of MIT was able to create a very interesting experiment that proved that the chances of a female finding the right mate and the chances of that male finding a female mate are significantly increased when there is synchrony in terms of multiple fireflies lighting up together. And when there is random clusters, so each one does their own thing, the chances of finding a successful mate drops drastically. So the point of this story is that nature is telling us in a very clear way that individual success and survival are most dependent on our ability to work as a team. And if nature says that, I think it's worth for us to pay some attention and see how that applies to our work life. One of the issues that I feel is a big gap in education systems is that since we're all very young, what is praised and valued is individual achievement, right, is how well you do at school, your success in a spelling bee, your success in sports, you graduate with honors, you go to a great, you get into a great residency, postgraduate program, and so on and so forth. But once you get to the real world, what is expected from you is to be part of a team and to either be a great team member or be a great team leader. And that dichotomy is something that we haven't solved for yet, but I think is also why it's so important for us with LEAD to start with discussion on how to be better team members and team leaders. One word I'll say about leading, leaders are not made by titles. Leaders are defined by a singular entity, which is followers. So I am a strong believer that if you're part of a team, you can lead that team. And we can lead from any seat in the house. And ultimately, what we're doing is we're showing a path forward to make the team's performance better. And that's what leading is about. So let's look at what happens in medicine. Very commonly, we have seen our colleagues in CT surgery and other surgical specialties really put a lot of weight during their training and during their learning on their surgical abilities. There's been this conception that the surgical ability of a surgeon really determines in great form what happens to patients. This has actually been studied in cardiac surgery, which is very interesting. This is a Huckman and Pisano have looked at this, and they were trying to evaluate how freelancers perform when they move from firm to firm, which is institution to institution. And what they did is in a very small and compressed timeframe, looked at cardiac surgeons that would operate in more than one hospital compared to cardiac surgeons that operate only in one hospital. A common concept of volume in surgery states that the higher the volume, the more likely that you'll have better outcomes based on experience. What this study found, which is fascinating, is that the volume of cases of a given surgeon in CT surgery do not translate when they move from hospital to hospital. So ultimately what really matters is the volume of cases that a specific CT surgery team has together. And this really gives us the first concept around teams, which is that the team is more important than the individual in terms of determining outcomes and performance. For many years, psychologists in the cognitive behavior area have recognized that general measures of intelligence in individuals can actually predict how they will perform on a vast variety of tasks and problem solving issues. A group that was a conglomerate from MIT, Carnegie Mellon, and University of Pittsburgh worked very, very hard to try to figure out what they called the C-factor or a measure of collective intelligence. And the hypothesis was that groups like individuals have measurable characteristic levels of intelligence, which can be used to predict group's performance on a variety of tasks. And they studied over 700 people in teams of three to five, multiple tasks. And what they found was that they could measure what they called the C-factor, collective intelligence, and that that was not correlated, as you can see in the graph, with the average member intelligence, and was not correlated at all with the maximum member intelligence, and that was independent of those measurements. The two factors that had the greatest impact on the C-factor, or the collective intelligence of a group, are their social sensitivity, which is our ability to read the facial cues of others, and the second was the distribution of conversational turn-taking, which is those teams in which the members speak at equal amounts of times are usually much more successful in resolving these problems and have a higher C-factor. So the second thing we learned from the data and the science is that the team or the performance of a team is usually much more than the sum of the individual parts of that team. Traditionally, when we want a great team, we look for great individuals, we put them together, and we think that we have our problem solved. So what this is showing us is that that is not true, and actually, the team has an individual IQ, let's call it, that is not dependent on the intelligence or the talent of the individual members. ADP did a very large global study of engagement a couple years ago, over 20,000 knowledge workers from around the world in multiple business areas, including healthcare, and they found a lot of interesting findings. Number one is that 85% of people in the workforce today are part of a team, 72% of people in the workforce are part of more than one team. What they did find that I think is important when we look at the role teams have in individuals is that those who are part of a team are 2.3 times more likely to be fully engaged, which is obviously what we're seeking for in our healthcare teams, and those who trust that their team leader are 12 times more likely to be fully engaged, which I think also speaks to the fact that people don't leave organizations, they leave their team leaders, right? So if you can revert that and really as a leader create that trust, you have significantly more likelihood that your people will be highly engaged, which is ultimately what we want. Finally, I think it's important as we set the stage on this introduction to differentiate a working group from a team. Most of what we do are working groups, and where there might be a clear focus leader, there's individual accountability, there's individual work products, we run efficient meetings, we measure performance by its influence on others, and usually when we meet, we discuss, we decide, and then we delegate and go and work in separate places. Teams have a different functionality, they share leadership roles, there's individual and mutual accountability, a lot of times the specific purpose of a team might be very granular and it might fit within the greater purpose of an organization, but it's not just fully aligned with that, it might be very specific, the work product is a collective work product, the measurement of performance is directed by assessing the work product as a whole, the deliverable, and when these teams are meeting, they discuss, they decide, and they do real work together. So rounds is an example of real work being done at the bedside. And we are part of teams, but we're also part of working groups, and I think making that differentiation is important, because ultimately, what we're really focusing on is how to make our teams better, and how to drive performance at this level. So the second portion of our talk is what makes a team great? And I think we can start with an interesting experiment designed by Peter Skillman called the Marshmallow Challenge. Some of you might have heard of this, I think it's quite insightful and fun. The idea is you've got 15 minutes, 20 sticks of spaghetti, a meter of tape, and one meter of string, and one marshmallow, and teams of three are challenged to build a freestanding structure with these elements that at the top holds the marshmallow. This has been reproduced and deployed all over the world, and consistently, what the results indicate is that on average, the worst performance measured by height of the structure is by MBA students, second worst are lawyers, the CEOs do a little bit better, but there's a singular group, Group X, that consistently, on average, will beat the other teams. And learning from this Group X, I think, can start by telling us in what direction we should be when we're trying to improve the performance of our teams. So the Group X, the winners, are recent kindergarten graduates, and here you can see some of these very successful teams with their awesome products for this challenge. And what was observed in the kindergarten group is that the way they communicate is very different than all the other professional groups. They usually talk in equal amounts, they usually talk directly of what they're trying to do without any preconceived notions or second thoughts, whereas when you look at the MBAs, there might be some jostling for who's in lead, what is my role, people are afraid to say something that's stupid, they want to make sure that they sound smart. The other thing that the kindergartners do very well is they're not afraid to fail. So they try things, and when it fails, they try something new, and they basically go through very quick cycles of build, fail, reiterate, build, fail, reiterate, until they're successful. Whereas the other groups, in many times, would keep a lot of discussion, would start building, and at the end, when the time was almost up, they would put the marshmallow on the top, and just to realize that the weight of the marshmallow was too much for their structure, their structure would collapse, and they had zero to show for. So some interesting insights that we can learn from our kindergarten colleagues, and this has actually been taken further, and insights from an experiment have really been captured with rigorous science and a lot of data. So this is data I'm going to share from Alex Pentland and the Human Dynamics team in the MIT Media Lab. They have devised over the years what's called a sociometric batch to really understand the science of team dynamics. These are little badges that are basically like your ID badge that have come through seven iterations, so they've really evolved, and they can capture over 100 data points per minute. They've deployed them over multiple organizations for over seven years, measuring communication of thousands of people up to six weeks at a time, and what these badges can collect are information like when people are talking, the tone of their voice. They can look at body position in relation to other people you're talking to, body language, geographically location, but they don't capture the content of the conversation or the communication. But it's very impressive when you look at the data that this team can now reliably and reproducibly identify high-performing teams and predict who will do better in negotiations, who will do better in competitions, who will do better in sales, based on the visual patterns of communication. And what they're really saying is, similar to what we saw with the kindergarten colleagues, is that form and the dynamics of the communication is much more important in team performance than the actual content of what is being said. And here you can see on the left, a low-performing team, and there's some asymmetry here, so not everybody's participating, and on the right, you see a high-performing team and a much more balanced or symmetric interaction between the team leader, the team members, and the team members themselves. When they dissected this data in more detail, the team identified three domains that ultimately are key elements of team communication. Number one is energy, how team members contribute to a team as a whole. And you can see here, there's a very low-performing team, actually, and it seems that there's a leader who dominates most of the energy, and there's two people who probably report to that leader that actually are the second, and there's a lot of empty space in terms of the energy, so what you want there is more balance. Engagement measures how team members communicate with one another. And again, here you can see that a lot of the communication goes towards the leaders, but there's not a lot of symmetry, and this again is an example of a low-performing team. And what we want to see here is that both the energy and the engagement are much better distributed and much more balanced. The third domain, which I think is very important, is exploration. And what this measures is how team communicate with other teams. So does your team leave, team members leave your team, get information, let's say you're the ICU team, you go to the ED, you interact with the ED, and you come back with useful information for your team. And exploration is also something that has been shown to be very, very valuable for those teams that have to work on creativity. So these are the three domains that really make a difference, and we can use these insights, even if we don't have the sociometric badges with the visuals, to really move things forward in terms of improving the form of communication. The conclusion from their years of data is that they are defining characteristics of every successful team, no matter where they are, and they share these in common. One of them, which we already heard earlier in the data I presented the first part, is that everyone on the team talks and listens in roughly equal measure. So that symmetry and balance of taking turns to talk is super, super important. And that is something that we can actually promote deliberately. Members face one another in their conversations and gestures are energetic, which probably speaks to what we're going to see is the key ingredient here, which is psychological safety. Members connect directly with one another, not just with a team leader. So there's a lot of what we call back-channel and side conversations within the team. Everybody's talking to everybody and learning and sharing. And then finally, that exploration concept that members periodically break, go exploring outside the team and bring information back. So if you found ways to promote these five things, I can guarantee you that the communication dynamics in your team would improve, and over time, you would definitely see an impact on your performance. Let's go back to medicine. So from marshmallows to medicine, this is another study from Amy Edmondson, who's out of Harvard Business School, had really been the pioneer on studying psychological safety, which is really the key topic of today's discussion. And she looked at 16 high-performing cardiac surgery teams that were learning a new technique, minimally invasive cardiac surgery, and this was a study on the success of implementing this new technology for minimally invasive cardiac surgery. And you can see here, you have the names of the hospitals are obviously fictitious, but these are real CT surgery teams. You can see the number of, I don't know, bypass cases, type of hospital, academic versus community, the region, and then who was the person adopting, the surgeon adopting the new technique. And probably if we used our common knowledge, we would all argue that a high-volume academic center led by a prominent surgeon would be the best, yet the data did not reveal that. And what you can see here is that these are ranked actually by implementation success index. And you can see that the top-performing teams, those that are 26 and above on this index, are a mix of large-volume, low-volume, community and academic throughout the country, department head, junior surgeon, and senior surgeon. So really, the common preconceptions we have do not predict who's going to do better. What does predict who's going to do better are two things. One, psychological safety, which is what we're going to talk about for the rest of the talk. And number two, the form of communication or coordination between the clinical areas. So again, reinforcing communication style, right? So it's form over content here and the psychological safety. So one of the things that's very important as we start exploring psychological safety for us to be aware in the ICU is that according to the roles that people play within the team, there might be different mean psychological safeties. And this is probably vestiges of old, outdated hierarchical models, but it's very important for us to recognize that not everybody in our team with different roles and different backgrounds might have the same level of safety to speak up. So as leaders or as team members, our job is to be inclusive and break down those barriers. Another interesting study that I think is worth exploring is Google's Project Aristotle. So they were really interested in defining the best team and building better teams for their own, obviously, success. Now having access to so much data, they really kind of embarked in this very, very ambitious project looking at over 180 teams at Google that ranged from three to nine members. And they really looked at every single piece of data they could get their hands on, literally thousands to millions of data points and analyzed how can we figure out the factors that make the perfect team. And some might say there's no surprise, others might have been surprised, but what their data showed that far and above teams, again, the whole of a team is greater than the sum of its parts. And the most important thing by far, actually being more important than everything else together is does that team member feel psychological safe? So do the team members feel safe to take risks and be vulnerable in front of each other? That is the key ingredient or the most important factor that also Google found in defining which teams are high performance within their organization. So the final part of our talk really relates to what are the actionable steps that we can take as team leaders or as team members to move the needle and make our team better? And the answer, as you by now have figured out, is simple. The thing we need to do is increase psychological safety. So let's explore a little bit more about psychological safety. And then I'll finish by giving you some very actionable suggestions of things that you can implement today to move the needle on this topic and move your team towards a higher performance. So psychological safety is a shared belief that the team is safe for interpersonal risk taking. We have all been part of teams on the left that actually live in an area of psychological danger where there's fear of admitting mistakes. There's blaming of others when things go wrong. We're less likely to share different views. Right. People say nobody ever got fired for keeping silence or things along those nature. And there's also what we call the common knowledge effect where we assume that everybody knows what we're talking about. And we assume that everybody's on the same page. This type of team are very prevalent, obviously in healthcare, but also throughout. And they can lead to very disastrous consequences for our patients. So we need to break that mold and move to the right. And ultimately a team that is psychological safe or has psychological safety where each team member is gonna be comfortable admitting the mistake because the goal is to learn from these mistakes and improve. Everyone openly shares their ideas. Even if you think your idea might not be adopted, you're happy to share it because it might change somebody's mind. And these teams who are more interested in what we call the growth mindset, which is in improving their skills and learning together are the ones that are gonna be much better in innovating and decision-making. And boy has COVID taught us the need we have in the ICU to be better innovators and take better decisions. And that is something that is gonna continue for the time being in terms of medicine is changing so rapidly that we have to be able to not only learn as a team, but to keep improving and improving how we perform, but also how we make decisions. And the only way we can do that is by creating psychological safety within our teams. Psychological safety needs to be associated with accountability. We talked about one of the big differences between teams and working groups is that in a team, we share accountability. We are all accountable for the results of our patients. And we have to really look at this as our work product. When you have low psychological safety and low accountability, you're in the apathy zone. That's a step away from disengagement and burnout. When you have high psychological safety, yet accountability is low, you're in the comfort zone. And we all know that there's no magic in the comfort zone. That's where average lives, right? That's where mediocre teams will live. On the other hand, if there's a high level accountability, but there's no psychological safety, that's the anxiety zone, and that also leads to burnout. And it's something that we have to avoid. What we ultimately want is a high level psychological safety with a high level of team accountability. And that creates kind of the magic area, which is the learning zone. And that is how we not only learn, but we perform at a high level and make a difference for our patients. So three steps to creating psychological safety. But before that, I just wanna talk about a couple of things. One is within psychological safety, there's different domains that I think are important to recognize. Number one is learning safety. Does the team and the individual members of the team feel comfortable saying, I don't know this, I wanna learn this. It's about learning, right? Becoming is more important than being. So having that safe to say, no matter who you are is, I really don't know this, could you teach me? Every single person you meet knows something that you don't know. And they can teach you something if you give them the opportunity. Challenging safety. If I'm not in agreement, or I think there's a better way of doing it, do I feel safe to bring that to the team and say it, right? This is the reason when challenging safety is lacking is the reason why we have sentinel events like the wrong amputation in the OR. These are the type of things that can be prevented with this type of psychological safety. Collaborating safety. Do I feel safe that if I share an idea, people will consider it and I won't be ashamed. I can just share whatever comes to my mind, whatever I think might be a good idea. And I can think like they say out of the box. And then finally, I think a topic that is ever, ever growing in the workforce, but also in medicine is the safety to feel included. We all wanna belong to the team, right? And I think that this is very important. Do I feel that I'm an important part of this team? Do I feel that I'm appreciated? And do I feel that my team and my leader have my back? So those four domains can be improved by what I call building safety, sharing vulnerability and establishing purpose. So in terms of building safety, it's important to recognize that we dial into small, subtle moments and deliver targeted signals at key points. So you build safety every day by the actions that the team leader has and the team members have. The first one is oral communicating your listening. We are not good at listening to our patients. We are not good at listening to others. Listening is more than just waiting for your turn to talk and then making your point. Listening is trying to really understand where somebody is coming from and how could what they say be true and what you believe be wrong. So it's really opening your mind to what people are sharing. Overdoing your thank yous. Gratitude has been shown over and over again to be an important determinant of wellbeing, but also it's the way we create psychological safety. When we thank somebody who did something that was valuable for the team in front of others, we're giving them that recognition, that inclusion. And I think that the more we exhibit gratitude, the more we probably will receive gratitude from others. Dealing with bad apples. We don't have a good track record in healthcare. I think sometimes with dealing with bad apples, that is changing. But obviously if we tolerate behavior that breaks down psychological safety, we are never gonna move the needle because people are gonna assume that that's the way the team's gonna function. And then finally, making sure that everybody has a voice. If you're rounding, everybody should have a comment on that patient. If you're in a meeting and somebody's quiet, you should actively seek for them to give their opinion and create that safety. And again, we've seen over and over again through the data that equal talking time is an important determinant of team performance because it ultimately drives the dynamics of how safe that team feels to give opinions. The second group is to share vulnerability. So group cooperation is created by small, often repeated moments of vulnerability. And as a leader, you wanna be vulnerable first and often. I do believe that the most powerful words a leader can say are, I got this wrong, or I don't know. And I think it's important for people to see even that the leaders have doubts and that they are vulnerable, that they're vulnerable to really, I mean, a lot of things that everybody else is. And that opens up, I think, a level of psychological safety where people can openly share what they're struggling with, what they need help with. Over-communicate your expectations. We should not assume that people understand what the expectations are for the team. And we should be very clear on choosing key expectations that are aligned with our purpose as a team and make sure that we communicate that over and over again in different ways. And then there's a lot of activities that debriefings, people circle up is another great example. And you've seen people after activity reviews that the SEAL teams does, which are basically candor generating practices. And this is not the typical root cause analysis that we only do when there's a horrible outcome. The idea really is that after anything that we do as a team that's valuable for us to really understand what did we do well, what was our objective? Did we meet our objective? What should we do next? What should we do different? And really open it up so people to give opinions, post-code, post-rounding, post-project, and really generates an environment where people could really reflect on what we did as a team and learn together. Finally, purpose is obviously key to driving team performance and creating that psychological safety. People don't buy what you do, they buy why you do it. So I'm a big believer in naming and ranking priorities Priority was a singular world when it first came out. Now it just, I mean, with the time we have priorities, but I think that there's really only one, three, maybe five things that are really priority for an ICU team. And you should be very clear on what those are and share those very frequently and repeat, repeat, repeat so everybody's on the same page. So as we saw, building safety is a very important part building safety, sharing vulnerability and establishing purpose are all actions that we can deliberately do today where we're the team leader or we're part of a team. And that will help us move the needle in psychological safety by impacting our learning safety, our challenging safety, our collaborating safety and our inclusion safety. In summary, we talked about some very basic and important concepts of teams. Teams are more important than individuals in healthcare and in every domain, probably in the world today. Teams are much more than the individual, the sum of the individual parts and ultimately being part of a team that's successful and that we trust is much more likely to help us be engaged at work. What makes a team great? Communication and psychological safety. And finally, if we wanna move the needle, what we need to do is take steps on a daily basis to increase psychological safety and those that work with us. So with that, I'll stop. I wanna thank everybody for their attention and we will move to the panel. All right, I'm back. Hopefully our panelists will pop back in here. Sergio, I do have one question for you that I just wanted to clarify. When you discuss the attributes of a successful team, you mentioned back channel and side conversations. Obviously, at least I can assume that these are not things going on in the middle of rounds that distract from the topic at hand. These are ongoing communications throughout the day. Absolutely, and I think that obviously I used the round example just as something that I think is pertinent to all of us. But yeah, the other part of being a high performer, whether you are working yourself with a team is focus and avoiding distraction. So that would be a distraction, right? But what I mean is that if I'm the team leader, I don't want everybody just talking with me. I want people talking amongst themselves and figuring out how they can improve their interactions, learning from each other. What can the nursing colleagues learn from our RT colleagues? What can the RTs learn from our pharmacists? What can the pharmacists add to the physical therapist? I mean, these are all parts of our team, right? What can we, the ICU team, learn from our ID colleagues? That's all the way, those are the back channels interactions that we really need. That's a great point, Judy. All right, we do have one question from the audience and really anyone is welcome to answer this. That the biggest challenge in medicine is that if you make a mistake, you're the team, the patient pays and that can limit some trial and error methods. And so as you're working on a safe psychological zone for your team members, is everyone responsible for patient safety and outcomes or would you suggest putting somebody in charge of that? So I'll go first and then I'll defer to the panelists. One of the fascinating findings from Amy Edmondson's research was that the safest teams are the ones that have the most reported mistakes, right? So at first glance, that was a problem, but then what she realized and her team realizes that that's because they feel safe to discuss and learn. So I think that safety is everybody's responsibility and we can do everything right and the patient still might die. That's a reality of what we do. We don't control the outcome, we control the process. So anything that we do to improve that process will ultimately benefit patients. I will jump in for a second and say that, yeah, that's a great question. And in many ways, unfortunately, in medicine, we're still in a zero fail environment culturally that we do have to think about and change. If you think about what we focus on M&Ms and everything else, or if we get called into the principal's office, it's not because you're about to get an award, it's usually because you have to discuss something that's not good. I'll say that our nursing colleagues are probably much better at this and giving rewards and pluses than we are on the physician side, unfortunately. But we have to change this culture, right? And this all goes back to first principles of what we were talking about earlier, which is that we have to change the culture and the first principles of what we were talking about with psychological safety. Tie into that. So I think definitely going along with the psychological safety theme and the ability of all team members to speak up if they disagree with the plan, I think that's really important. Because again, it really, I do think the decisions that we make are the responsibility of the entire team, not one person who's leading the team. And so if there are actions that the team takes for patient care that don't end up optimally, I think that goes back to all of us. So it is really, the onus is on every single one of us, the pharmacists, the physicians, the nurses, the RTs, the dieticians, every single person who works in the ICU to speak up if there's something that they identify that maybe isn't optimal. But again, to Sergio's point, sometimes we do everything right or we think we've discussed everything at length and we all agree with the plan or we've considered the risks and benefits and even then it doesn't go well. And I think that is just a consequence of how healthcare, how medicine works and patients are unpredictable. But at least we can go home that day feeling confident that we had the appropriate approach to patient care. And then also I think it's important after the fact to reflect on what went wrong, potentially that we didn't see in that moment. And I think that's where it's important to, that event reporting or near misreporting really even before the events actually happen and identifying the system things that maybe affected our team performance. And I was gonna add that I think, one of the safest teams you can work with are the ones where someone can bring up something, we've tried all these things, this hasn't worked. Hey, I read this little thing over here about another type of procedure we can try or another med we can try. And they feel safe bringing that up and then the team can discuss it and then they can go forward deciding on, is this maybe something that we can use to benefit the patient because maybe something else we've done really didn't do what we wanted it to do. All right, gosh, we have a lot of questions coming in. And so let me take one of those. How do you continuously keep your teams perhaps somewhat engaged, but also just keep the goals of the team fresh. And so, if you have identified some challenges or ways that you wanna work as a team, and clearly we're in an era where we've got new people joining the team daily, weekly, as we have travelers and clinicians in and out. How do you keep that team dynamic moving forward when some of the players change frequently to keep things fresh and not redundant? Well, I think one thing that you really have to look at is understanding where the team members are coming from. So recognize who are the members of the team and partly helping them along. We've had days where almost every nurse in our unit is a traveler. So you have to really change your dynamic when you're rounding and really try to work with them and pull them into the team to try to make them a part of the team because when they first start, they aren't, and they don't feel like it. And the team really doesn't feel like that they're a member either. So pulling them in and trying to utilize some of the experience that they've seen in other areas and other places, what have people done in other institutions that they can bring another flavor to the team. And sometimes also being able to recognize how the team is doing at a time. There've been times we've rounded on patients and it seems like rounds have taken forever and you just start seeing people get glassy eyed. You're just going, you're doing a little too much at that point in time and you really kind of need to refocus on what is at task for that patient that you're talking about. I recently heard a concept of the lone ranger syndrome and it really, what you said reminds me of that because we do have a lot of new hires right now. There is a lot of turnover in healthcare, a lot of new team members who maybe don't feel as engaged and yes, they're part of the team, but have they fully been embraced as part of the team? Do they really feel like they're part of that cohesive whole? So I think we just have to, we all have to be aware of that at all levels and trying to engage those new practitioners to making sure that they feel like they can speak up as well. I think that to the point that we're discussing with the challenges that we're seeing with COVID and all these new team members, there's data from some of the studies I showed that identifies what they call the charismatic connectors. So you don't have to be in charge of a team to make a huge difference, right? So if you walk around the unit and you take the time to meet new people, to ask them how they're doing, to ask them if there's anything that they need help with, to ask for their opinions, like a lot of the travelers have been in other places. So I've always liked to ask, so what have you learned? Where were you before? What was the biggest challenge there? Is there anything that you learned there that you think we should be doing here? I think you can be that connector, right? To really, I mean, start making people feel part of that team. And it's unbelievable how much that can move the needle and people sometimes don't really appreciate that. So I think it's really where you are in charge of the team or you just wanna make a difference, I think you can be a charismatic connector and really help the team coalesce. Yeah, and regardless of if it's on rounds or even committees or everything else in healthcare, I think these principles apply, right? Because we live in siloed, highly matrixed, complex environments where folks come in and out even without COVID and traveling clinicians. It's just, it's sort of the reality of what we do. And so without repeating whatever, I of course fully agree with everyone on the panel. I'll say that one thing to do is definitely to be sure you call them out and bring them into the conversation whether it's during the meeting, during rounds, or just give them the stage and they could say no, they can pass and then check in with them after like Sergio said. All right, so there's a question about how do the best teams handle conflict? And it may be vision for the team, how resources are used, when people are perhaps reluctant to work together for a variety of different reasons, financial or otherwise. And it kind of dovetails with another question in terms of having a colleague who, they have trouble encouraging a high psychological safety where a colleague is pursuing accountability at the expense of the team dynamics. So where you have issues and challenges within a team, how can somebody begin, you can't always fix it, but how can you begin to address it to improve the functioning and communication of a team? So I'll just comment on the data. And what the data shows is that it's the mode of communication that Reproducible performs at. Now, different teams have different norms. There are teams that if everybody's speaking equally, they might be yelling at each other. It feels like they're at each other's throat, but at the end of the day, they have a good dynamic where everybody says what they wanna share. Everybody takes everybody's opinion as a valuable one, and then they have a process for making a decision. There might be teams that appear to be much more professional, yet they have no resolution of the conflict. And the worst conflict is the one that's hidden under the rugs. So I think that we have to be very, very careful with that as well. Oh, go ahead. Okay. And I think it's interesting, the concept of conflict and our perception of what conflict may mean may be different between individuals. So like as a pharmacist, sometimes I bring up things that are maybe uncomfortable because I'm disagreeing with something. And I don't bring that up as a way to create conflict in a negative way. I bring it up to have a productive discussion. And so it's sort of like, what is that conflict? Is it healthy conflict where we're discussing the merits of a study and whether we should be pursuing a certain therapy for our patients? Or is it personnel conflict, which obviously are a totally different beast? And I think what Sergio said about really making sure not to brush those things under the carpet is really important. So from a leadership perspective, whoever those leaders are, whether it's formal roles or informal roles in the ICU, I think it is important that when we identify that those kinds of conflicts do exist, that the bad apples are removed or dealt with, that those conflicts are really confronted head on. And I was gonna say one thing about, when there's particularly interpersonal conflict, it really depends on, is it within a team member or is it with the team leader? Because how you deal with that is really different depending upon where it is. And if it's a conflict with the team leader, there have to be members of the team that have enough psychological safety and that feel secure enough in their position to be able to confront that person in a secure area where they can really bring up the problems that are being felt by the team or what the team is dealing so that you can address those versus if it's a team member, then maybe then the team leader can, again, take them aside and talk about what kind of problems they're seeing or what kind of ways that they might be able to resolve that. I think that in the ICU, we live in a very unique situation. And if it's an individual who's causing the issue, of course, in some ways, that's sort of the easy focus in that we need to focus on that individual to correct their actions or even bring in other folks to help change those actions. I think what's harder is that there's multiple teams, consultants, whatever you wanna call them, that come in and we have a nice set team with everything working well within the ICU, but the culture in these other groups might be slightly different. And so that could be a clash in terms of the communication style within those teams might be different from the communication style that you have within the ICU. And that's a different issue that's greater to sort of think about as leaders. What I would say is for the second one, which is more difficult to move, is we just have to remember that changing things one to 2% at a time is key. Radical change sometimes will actually make things worse, but we have to sort of move towards that goal and a vision and try to get everyone together so to see the bigger picture. And one of the things I keep hearing is that it's recognition and communication, right? Be aware of the challenges, the issues, the communication defects and work as a team, obviously, to try and improve those, but certainly being aware of them and recognizing them is gonna get you started down that road. And I imagine that's been much more difficult in a COVID era. And one of our questions is, how are you doing team and group dynamic building with COVID when perhaps you can't even eat together or do the types of things that have been traditional team building opportunities? So I'll say that it's very hard to build psychological safety, but boy, is it easy to destroy it. And really the key here is that, yes, there are things that we don't have available maybe with what's going on. And I can speak for what we're seeing in Texas, we're seeing an upsurge on cases. And I think that at the end of a very long 15 months, what people are struggling the most is with a lack of empathy. It seems like it's hard for them to find empathy for people who have something that now they feel could have been prevented. And it's very a lot of cognitive dissonance. So I think it's just taking every opportunity you can to move the needle forward. So it's like Jerome said, you're not gonna solve this in a day, but every little step we take, I think helps somebody move in that direction. And it's hard. I mean, it's definitely been a lot harder with COVID, but I think it's, think about how you interact with people in rounds, how you interact in between rounds, during the rest of your shift. If you have the chance to go and talk with somebody if you don't know, it's just a new phase. You can do little, little moments, right? That can really make a big difference over time. Also, I think that, being in crisis with COVID is definitely different than being in sort of a peace non COVID environment. And so we just have to keep that in mind too, that it's completely different, right? Leadership in crisis might not work with leadership during non COVID area or non crisis moments. I think that what I would say is that, trying to build this as tough, right? With everyone sort of away and remote, but there's still ways to do it. We all sort of share the same experience and we could all come together around that. But I think a big part is definitely the debriefs, after action reports, hot washes, whatever you want to call them, around not even just specific events, but the whole thing itself, and possibly even as we go into another surge. But getting everyone together to chat about it, I think helps a lot. All right. We have another group of many more questions from the audience. And one of the things that, for those of you who perhaps came in a little bit late, the new task force that is launching this webinar on leadership, empowerment and development, will take your questions and use them as we can. To develop content for you, the members of SCCM, to be able to create better teams, interact more effectively with your teams, deal with conflict within your teams, and where you don't have one, help you create a team. And so I appreciate that. And you won't get a individual response to your question, but look for content in the future. I'd really like to thank you all, Dr. Lee, Dr. Hebner, Dr. Zanotti, and Dr. Kelso, for this wonderful discussion and exchange of ideas. And again, a reminder that the recording will be available of this session in five to seven business days at mysccm.org under the My Learning tab. And obviously there's a variety of other webcasts that are constantly being produced, and we hope to have a regular series of these. And again, if you have additional micro learning, perhaps you've read a great book or article or have a strategy or technique you've used and you wanna spend a few minutes recording your results and ideas, we would love to see them and have them. So this concludes our presentation for today, but please stay tuned for more. Thank you, everyone. Thank you.

high-performing team

teams in healthcare

communication

psychological safety

learning safety

challenging safety

collaborating safety

inclusion safety

conflict resolution

team dynamics