Critical Behaviors for Perioperative Improvement Teams

Effectively leading perioperative safety and quality improvement requires a multidisciplinary team approach. However, leaders are often left without clear guidance on how to assemble and manage teams in these settings. We employ a Delphi process to prioritize specific behavioral strategies surgical safety and quality leaders can use to improve their chances of success implementing improvement efforts. We present the panel’s consensus practical guidance on designing, managing, sustaining, training their teams as well as managing team boundaries and the organizational context.


INTRODUCTION
When implementing perioperative improvement projects like enhanced recovery pathways, a common recommendation is to assemble a multidisciplinary team to lead the effort.Involving key stakeholders, building shared visions, and establishing a collaborative environment can increase uptake of interventions. 1 However, it is not enough to acknowledge the need for a multidisciplinary team; leaders must know how to effectively design and manage these teams.Literature on team performance suggests many factors contribute to high-functioning teams, such as mindfully composing teams, effectively managing relationships, and promoting team learning. 2What remains unclear is what behaviors should be prioritized and how to enact them in perioperative services.The existing science of teams and leadership is vast, and the guidance it provides can be ambiguous.These represent significant challenges to the translation of this science to perioperative improvement.We sought to generate parsimonious, practical, consensus-based guidance on how to manage perioperative safety improvement teams.

METHODS
We conducted a Delphi study between October 2018 and March 2019, with a 14-member panel of recognized experts in research, management, or perioperative improvement.Participants were selected to represent a range of professional roles (surgeons, anesthesiologists, nurses, health care administrators, and researchers) and hospital types, which varied by teaching status, size, and geographic location.
The Delphi method is a systematic, in-depth qualitative methodology to elicit expert opinions and generate consensus on a topic. 3Three rounds of surveys were administered using Qualtrics.In Round 1, panelists ranked the importance of specific factors from the team performance literature, including team leadership structures and processes, 4 characteristics of externally oriented teams (X-teams), 5 the Team Diagnostic Survey, 6 and the Organizational Readiness to Change Assessment. 7anelists were also given the opportunity to suggest additional factors.The 63 factors for Round 1 were organized into six critical domains: (1) design and define, 2 manage, 3 sustain, 4 training and feedback, 5 manage boundaries, and 6 manage organizational context (Fig. 1).For each domain, panelists selected what they believed to be the top 5 factors for high-performing teams.We defined consensus as >50% agreement among panelists.In Round 2, panelists received the list of top-rated factors from Round 1 and were asked to "provide practical guidance on how leaders can support these critical drivers of high-performing teams."Practical guidance was defined as tips, tactics, or approaches based on the panelist's first-hand experience in improvement efforts.In Round 3, participants were asked to rate the practical guidance provided in Round 2 as either critical ("Must Do"), facilitating ("Usually important, but not always"), or non-critical ("Nice to do but not essential").

Analysis
Four (CY, TL, BE, MR) study team members with expertise in patient safety, quality, and team science synthesized the qualitative responses from Round 2, grouping overlapping recommendations.A list of 50 "leader behaviors" and practical tips were generated for Round 3.All 14 panelists participated in all 3 rounds.

Round 1: Rating Factors From the Team Performance Literature
Delphi panelists reached consensus on 25 critical drivers of high-performing teams.In the "Define and Design" domain, the highest ranked factors were to articulate a clear team purpose (86% consensus), select the "right mix" of skills (86%), and include highly motivated team members (86%).Other highly ranked factors included project leaders setting challenging but realistic goals (79% consensus; "Manage" domain), representing the team when engaging other parts of the organization (86% consensus; "Manage Boundaries" domain), and seeking different perspectives when solving problems (79% consensus; "Sustain" domain).

Round 2: Generating Examples of Leader Behaviors
This section provides some of the leader behaviors with supporting quotes from panelists organized by the 6 critical teamwork domains.

Domain 1: Design and Define
One leader behavior was "involving key stakeholders and roles."One panelist provided the following practical guidance: "We try to include both early adopters as well as our skeptical team members.By including those who are not on board yet, or don't think a change is needed, we can better understand what challenges we face as we try to expand the program.And in this way, hopefully we can engage our skeptics and even help them become believers."Domain 2: Manage "Collaborating on the best approach to getting work done" incorporates suggestions such as "listen to the boots on the ground" and to "provide guidance, but allow the team to come up with the solutions."One panelist noted "We all try to learn from each other and build on our experiences.I try to share successes and failures, my own and the teams, so we all know that these small set-backs should not derail us or the project."Several panelists also noted the importance of "setting stretch goals" when managing a team, with one panelist recommending the SMART framework (Specific, Measurable, Attainable, Relevant, and Timely) to identify challenging but realistic goals.

Domain 3: Sustain
Some panelists noted that it was not only critical to monitor team performance, but to communicate the data.As one panelist commented, "We know that teams and frontline staff are eager to learn the impact of their efforts; providing frequent data to leaders, managers, and frontline staff is essential.What I've seen work well is for hospital teams to start their meetings off by reviewing performance data together to develop a collective understanding of how well things are going and whether there are any trends (up or down)."Several panelists also noted the importance of making decisions as a team in order to promote sustainability, with one panelist reflecting, "Individuals in a team are more likely to agree with a shared solution if they feel that their perspectives or ideas were acknowledged and considered."

Domain 4: Train and Feedback
Listening and asking good questions was one of the most highly-referenced behaviors in Domain 4. As one panelist noted, "At our multidisciplinary meetings, I make sure to have everyone participate and be heard.There are usually the vocal team members, and some of the less vocal members can be left unheard due to others that may dominate.I like to spend part of the meeting where we go around the room and each person gets to speak.I also let them know in advance what type of feedback I will be asking from everyone, so that those who are shy or less vocal have time to prepare, and can even submit it in advance so that I can read it to the group if they don't feel comfortable.Everyone needs a voice!"Domain 5: Manage Team Boundaries Serving as a liaison between the core project team and other groups and departments was perceived to be an important element of managing team boundaries.A behavior mentioned by several panelists was obtaining senior leadership buy-in through meetings with executives in the early phases of the project, with regular updates about the progress, potential barriers, and successes of the project.Several noted the need for messages to key executives to be "tailored to their particular interests, particularly cost and patient satisfaction" and to "be able to articulate key achievements in less than one minute."

Domain 6: Manage Organizational Context
A key behavior related to managing the organizational context was ensuring access to data the team needs to do their work.To remove barriers to data sources, one panelist commented that his hospital has instituted, "'Senior Leader Rounding'" where senior leaders visit departments throughout the hospital on a quarterly basis.In this way, "it provides each department [an opportunity] to get to know a different senior leader each quarter, and also an opportunity to ask questions and get information as needed."

Round 3: Ranking Leader Behaviors
In Round 3, 24 of 50 leader behaviors achieved group consensus as critical "Must do" behaviors.Table 1 describes the 24 critical behaviors for supporting perioperative improvement teams and examples of how to enact these behaviors.For example, in the design and define domain, high-performing teams make room for flexibility, and enact this behavior by ensuring that roles are not too rigidly defined.In the train and feedback domain, high-performing teams appreciate a good failure and enact this through reflecting on challenges and incorporating that into planning.

DISCUSSION
Too often perioperative improvement teams fail to achieve their goals. 8Frequently this is ascribed to resistance to change or lack of resources. 9,10We argue that taking time to preplan and continually reflect on the "how" of enacting team leadership behaviors within each teamwork domain is an important, yet often overlooked, way to engender success.This study integrated recommendations from thought and team leaders entrenched in perioperative work, producing a set of practical behaviors to consider when planning and implementing perioperative improvement initiatives.Based on our findings, leaders should spend time on designing the team, creating a shared vision and collaborative approach to "getting work done," and having a structured training and feedback process.Although our findings point to areas of consensus across diverse roles, the small number of participants in each role may have obscured differences in role-specific priorities, limiting the specificity of behaviors generated.Nevertheless, by identifying critical team behaviors and distilling practical tips from experts, this work highlights key drivers of team performance in perioperative improvement efforts.As such, this study contributes a framework for translating the science of teams and leadership into actionable guidance.

Respect and value each team member
Valuing team members equally is essential and will build confidence and buy-in from the team Engage with executives to remove barriers to data sources (eg, providing resources to participate in data registries, prioritizing changes in the electronic health record system)

FIGURE 1 .
FIGURE 1. Six critical teamwork domains for perioperative improvement teams.
Listen and ask good questions Pause, listen, then offer thoughts.Ask open-ended questions, inviting input.Give everyone time to speak at meetings Create a space for ownership of the work Have team members present their own work.Develop goals and timelines together as a team, not as a top-down approach Have a structured approach to learning Plan forward, reflect back, and act on the learning.Periodically assess team strengths, weaknesses, opportunities, and threats Appreciate a good failure Implementations often start and stall.When planning next steps, it is vital to learn from what did and did not work Respond with encouragement Be aware of "initiative fatigue."Make every team member feel their contributions are important Domain 5: Manage Team Boundaries Publicize the value of the team's work Describe project benefits for other groups in the institution.Report accomplishments at all department/quality meetings Obtain senior leadership buy-in Meet with executives at least quarterly and during budget planning to maintain project support.Regularly email project updates to keep them engaged Domain 6: Manage Organizational Context Ensure access to data the team needs to do their work

TABLE 1 .
Critical Behaviors for Supporting Perioperative Improvement Teams and Examples of How to Enact the Behaviors Sustain Give them voice Create a culture of empowerment.Stress that all opinions, positive and negative, will be heard without being judged Communicate the data Begin team meetings by collectively reviewing the data.Report data to frontline staff via managers and department leads Lead by example Do the work to show commitment and motivate others Promote team learning Create open-learning venues; frame it as dynamically learning from successes and failures as opposed to seeking compliance Make decisions as a team Invite ideas from a broad spectrum of stakeholders.Then work together to reach a consensus on the path forward Domain 4: Train and Feedback