developing effective teams delivering effective services developing effective teams / delivering...

Developing effectiveteams

Delivering effectiveservices

Executive summary

Clinical Teams Programme

D E V E L O P I N G E F F E C T I V E T E A M S / D E L I V E R I N G E F F E C T I V E S E R V I C E S

Developing effective teamsDelivering effective services

Contents

1. Introduction 1

2. Context and overview 2

3. Findings 3

4. Outcomes 5

5. The journey to improved serviceprovision 6

6. Reactions from sponsors 8

7. Implications for people, teams andorganisations 10

8. Further reading 11

Published by the Royal College of Nursing, 20 Cavendish Square, London, W1G 0RN

© 2006 Royal College of Nursing. All rights reserved. No part of this publication may be reproduced, stored in aretrieval system, or transmitted in any form or by any means electronic, mechanical, photocopying, recording or other-wise, without prior permission of the Publishers or a licence permitting restricted copying issued by the CopyrightLicensing Agency, 90 Tottenham Court Road, London W1T 4LP. This publication may not be lent, resold, hired out orotherwise disposed of by ways of trade in any form of binding or cover other than that in which it is published, withoutthe prior consent of the Publishers.

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1. Introduction

This is a summary account of a teamdevelopment programme—the ClinicalTeams Programme (CTP). The goal of theCTP was to increase the effectiveness andfunctioning of health care teams, improveclient care and service delivery, andcontribute to organisations achievingrelevant strategic objectives in relation totheir wider modernisation agenda.

The importance of effective team working todeliver high-quality care, focused on theneeds of service users and their carers, runsthroughout the NHS policy agenda (DH2006, 2005a, 2004, 2003, 2001, 2000). Thebest and most cost-effective outcomes forpatients and clients are achieved whenprofessionals work together, learn together,engage in the clinical audit of outcomestogether and generate innovation to ensureprogress in practice and service (DH, 1993).

In the 2004 NHS Staff survey (HealthcareCommission, 2005), 91 per cent of staffstated they worked in a team; however whenthe survey probed more deeply and askedquestions about the structure and processesof their teams, only 43 per cent worked inteams that met the evidence-based criteriafor well-structured and effective teams.

To support the health and social care policyagenda and increase the number of peopleworking in effective teams, the NHSLeadership Centre commissioned the RCNInstitute (RCNI) to develop, deliver andevaluate a team development programme—the CTP.

This document is a summary of the keyoutcomes of the CTP. A more detailed reportof evaluation outcomes and findings isavailable. The report includes qualitativedata gathered on the impact of CTP fromteam representatives, sponsoringorganisational managers and programmefacilitators, together with quantitative dataon the extent to which teams increased theireffectiveness. The full report is titled TheClinical Teams Project evaluation report(publication code 003 068) and is availableonline at www.rcn.org.uk.

R O Y A L C O L L E G E O F N U R S I N G

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2. Context andoverview

Research shows that effective teamworking can make a substantialcontribution to reduced hospitalisationtime and cost, increased patient safety,improved patient health and innovationsin patient care, as well as enhanced staffmotivation and wellbeing (Borrill et al.,2002).

Designed and delivered by the projectteam at the RCNI, the CTP drew onevidence from the RCN ClinicalLeadership Programme (CLP) and fromresearch into team effectivenessundertaken by Borrill and West (2002).The CTP was designed to enableparticipating teams to enhance or developcritical aspects of team working in order toincrease their effectiveness. The fivesimple rules of the Modernisation Agencyalso provided a guiding framework for theCTP:

✦ see things through the patient’s eyes

✦ find a better way of doing things

✦ look at the whole picture

✦ give frontline staff the time and toolsto tackle the problem

✦ take small steps as well as big leaps.

The programme

Using a variety of processes, tools andtechniques the CTP created a structure inwhich teams examine the ways they areworking, identify what is going well andnot so well, and together make plans toimprove the service they provide forservice users. A further programmeobjective was to make explicit the inter-relationship between the organisation, theteam and the individual (in this case theteam representative) and the influencethese inter-relationships have on serviceprovision.

The programme consists of severalintegrated elements including workshops,action learning sets (a practical reality-led,action-orientated approach to learning,using reflection and the exploration ofissues and problems associated with work)and team events. The CTP alsoincorporates three specific interventions;the Team Performance Inventory (TPI),patient stories and observations.

CTP participants

The CTP is a 10-month programmedeveloped for multidisciplinary teamsworking in health and social care. BetweenJanuary 2004 and September 2005 a totalof 101 teams from 55 health careorganisations completed the CTP. Eachparticipating team nominated two or threepeople (team representatives) to lead theprogramme for their team. Teams and

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their organisations were supported throughthe programme by an experienced facilitatorfrom the RCN.

The programme was run in two cohorts—spring 2004 and autumn 2004. The springcohort contained 50 teams; 45 teamscompleted the programme and five teamswithdrew. The autumn cohort contained 57teams, one of which withdrew.

The 107 teams were from 55 different healthand social care organisations which includedPCTs, acute trusts, and social servicesdepartments, all providing a variety ofservices for a wide range of service users. Noteams from general medical or surgicalwards in acute trusts or midwifery teamsparticipated.

A total of 252 people across both cohortsregistered on the programme as teamrepresentatives. These individuals camefrom a wide variety of health and social carebackgrounds; 52 per cent were nurses andthe remaining 48 per cent were from alliedhealth professional (AHP), social work,medical, managerial and non-professionalbackgrounds (for example, support workersand clerical workers).

3. Findings

The CTP provided a unique and privilegedinsight into the reality of how teams operate,as team members strive to work together toprovide better care and services for thosethey support. The diversity of theparticipating teams demonstrated that,while team dynamics and make-up can beinfinitely variable, certain key principlesunderpin the evolution of all teams. Anevaluation of the outcomes of the CTPprovided a number of valuable pointers onthe critical elements that help support thisprocess.

✦ Creating time and space for people inthe same team from differentdisciplines and different levels of thehierarchy, to talk to each other andthink about what they do, how they doit and how they could do it better, isessential in enhancing teameffectiveness and improving services.

✦ An action-oriented approach, thatnecessitates working together on realtasks, is central to developing effectiveteams.

✦ Where team membership is reportedas sizeable (over 15), time should bespent considering different ways toconfigure or conceptualise the teams,to enable them to apply the principlesof good team working to their systemsand processes.


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✦ Individuals and teams involved inimplementing change need access tothe necessary power and authoritywithin themselves, their colleagues andtheir seniors in order to bring aboutchange. Personal development, activesupport from managers and theprovision of external support systemsare also required to enable individualsto effectively access this necessarypower and authority.

✦ Facilitators that are experienced andskilled in working with groupprocesses, and are perceived as neutral,are necessary for the exploration ofinter- and intra-team dynamics.

✦ Programmes such as the CTP, whichinvolve implementing change andexploring team dynamics, are neitherstraightforward nor easy. Thosecommissioning, participating in andfacilitating such programmes shouldbe aware of and anticipate this andprovide the necessary supportmechanisms to help people throughthe challenges.

✦ Time is required to allow some of thecomplex processes involved in changeand collaborative working to bethought about, experienced,challenged, owned and implemented.The 10-month duration of CTP wasperceived as a good length of time toenable some of this to happen.

Supporting team development

While the CTP should be taken as anintegrated whole, the programme evaluationhighlighted certain elements which werevery conducive to the overall process of teamchange and development.

✦ From a personal developmentperspective, the opportunity to workwith people from different teams,disciplines, organisations andhierarchical levels within a learningculture that fostered critical thinking,reflection and support was perceived asextremely useful. The process of actionlearning brought these elementstogether and, as an approach, washighly valued.

✦ Increased knowledge about how teamswork, together with the introduction oftools and techniques for translating thetheory of effective team working intopractice, helped team representativesfully involve their team members in theteam development process.

✦ Using patient stories and observationswithin an action-oriented approachand creating the space to reflect, thinkand plan, helped implementimprovements in client care andservice delivery.

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Challenges

The challenges encountered by programmeparticipants included the investmentrequired, in terms of releasing staff fromclinical work; working within pre-existingteam dynamics or those which arose inresponse to exploring collaborative workingand implementing change; and securingsufficient support from managers and teamcolleagues.

4. Outcomes

The most significant finding of this studywas that positive changes took place for theteam representatives, their teams and theservices they provided for clients.

For team representatives, the changesincluded:

✦ a transformed approach to change

✦ improved leadership capabilities

✦ an ability to see the ‘bigger picture’

✦ the acquisition of new knowledge andskills

✦ an improved ability to work withothers

✦ an enhanced sense of an individual’spower and ability to influence change.

For their teams, the changes included:

✦ more proactive and action-oriented

✦ an improved relationship betweenteams and agencies

✦ an increased awareness of the ‘biggerpicture’

✦ increased leadership

✦ increased morale and motivation

✦ increased clarity of individual rolesand the contributions of self and others

✦ increased effectiveness in working withconflict


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✦ more open dialogue and criticalreflection

✦ the increased involvement of all teammembers

✦ changes to team processes andstructures.

For clients and services, the followingdevelopments were identified:

✦ greater client-centred service provision

✦ improvements to the client pathway

✦ improvements to the environment ofcare

✦ greater integration within teams andacross services

✦ improvements in the way teamsorganise service delivery

✦ increased access to a range of services.

The changes achieved through participationin the CTP indicate that the teams developedsome of the necessary capabilities requiredto work effectively with current serviceprovision challenges including:

✦ the provision of integrated carepathways

✦ getting the most from availableexpertise

✦ patient safety

✦ innovation, spread and sustainability

✦ the complexity of working acrossservice and organisational boundaries.

5. The journey toimproved serviceprovision

Integrated care pathways

“I have to say that the programme certainlyacted as a lever, and certainly brought theheads of the services together, which wasgood.”

Many of the teams that took part in the CTPmade improvements to their clinicalnetworks, creating more integrated clientpathways that delivered a raft of serviceimprovements. The teams achieved thisthrough listening to and involving serviceusers and their families and improvingcollaborative working within and acrossteams, largely around shared objectivesetting and procedure and protocoldevelopment.

“Referral processes are more deliberate andplanned – more of a team focus – duplicationreduced. Clearer client pathways.”

Many of the teams enhanced service deliveryby making changes at the key transitionpoints of assessment, admission, referral anddischarge. They also used increased access tothe knowledge and expertise of differentdisciplines. They changed the way theyworked to include critical review andfeedback on performance, and focusedreflection on their work.

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“We’ve developed the rapid response team as adirect result of the programme. Practitionersin the different teams, the intermediate careteam, the community hospital and thecommunity nursing team were saying thatpeople were being admitted to hospitalbecause it wasn’t possible to get a quickenough response in the community...We’vechanged the structures so the team can access and put in place services immediately.”

The largest number of service improvementsreported by teams in the CTP was groupedin the category increased client-centredprovision. These improvements involvedcreating more opportunities to talk andlisten to service users and their families andimproving the quality of information, basedon what service users said they needed andwanted to know.

“We have established a forum for patients andcarers to speak with professionals and ex usersof the service. We get information about theirconcerns through this.”

Getting the most fromavailable expertise

In the world of service networks acrossagencies, multiple providers and patientchoice, it is imperative that members ofhealth and social care teams understand andappreciate the contribution that their roleand the roles of colleagues make to serviceprovision.

“Disciplines are working better together,planning care together and setting goalstogether.”

Increased clarity of one’s own role and thatof others at an individual and team level wasone of the most frequently cited changesidentified by programme participants. Thiswas associated with increased confidence,decreased conflict, reduced duplication andincreased access to a range of services forservice users.

“We are learning how to depend on each otherand appreciate each other’s ideas and skills.”

“There is decreased conflict, we resolve itbetter, we are able to challenge each otherconstructively. Much more open, honest andfrank discussion takes place allowing positiveresults.”

Patient safety

The most frequently reported change inteam functioning was an increase in opendialogue and critical reflection. Thisincluded an increase in challenging andquestioning practice in ‘professional’ ratherthan ‘blaming’ ways, an increase in honestand direct communication betweendisciplines and between different levels inthe hierarchy and a willingness to listen toothers and actually hear what they had tosay.

“Colleagues are now much more able todiscuss case work together in a ‘no blame’ way– this leads to better care.”


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In addition, there was increasedparticipation by junior and non-professionalteam members (who frequently have themost contact with service users) ininfluencing and decision-making. As aresult, teams participating in the CTPdeveloped the characteristics of teams morelikely to prevent and report errors.

Innovation, spread and sustainability

Sponsors at a team level frequently reportedan altered relationship to change. Teamsbecame more proactive, having moreownership of change and being more intouch with their own ability to influence andshape change. The service improvementsimplemented through the programmeprovide further evidence of the teams’ abilityto innovate.

“We feel empowered to make decisions andmove things forward without waiting for it tohappen.”

6. Reactions fromthe sponsors

Improved integration

“To us, this whole intermediate care teamwork is very new and the joining up of socialservices and health was very new, so it wasexcellent in terms of facilitating the work thatwe had already started. In terms of developingthose relationships, networking, andunderstanding better about how patientsmove between each one was very beneficial.Not just roles, I mean we’re talking about – wehad hospital teams, social services teams, andPCT teams. So it’s organisational cultures, it’steam objectives and where they fit within eachof the different organisations.”

Improvements for clients and service delivery

“There has been a lot of simple stuff that cameout of it, but the funny thing is that when youwork every day in an environment youobviously get de-sensitised to the everydayproblems that you see, or that you don’t seeprobably. And just taking time out, just toreflect on a day’s work, and looking at diariesand that sort of the thing, makes you realizehow simple some of the problems are to solve.”

Improvements to client care

“I think for me there were probably two veryclear messages. One was around the impact it

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had had on patient care, and the fact thatthose that participated, because they had donethe patient stories and the observations, veryclearly had become far more patient focusedand quality focused. Almost to the extentwhere they saw themselves as delivering aservice to a customer. It was almost thatrecognition that they had a responsibility toact on things that were not right.”

Improvements in achieving targets

“During the life of the programme we haveshifted the number of people we see on a day-care basis from 37 per cent to 62 per cent. Thiswas championed by one of the consultantsurgeons.”

Adapting to change

“The team is very much more able to copewith different demands and I don’t think thereis any doubt that a lot of it has had to do withthe Clinical Teams Programme, in terms ofgetting the team working much bettertogether, accepting that you have to havetargets and addressing them and thenworking out ways of how to meet thosetargets. So there’s a much greater flexibility. IfI’d given those targets to them, say, 12 monthsago I think we’d have had a much more of akind of a ‘no way’ response, whereas now it’s a‘can do’ approach.”

Working differently

“There is much more tolerance, respect andunderstanding between the different teammembers and of their colleagues from otheragencies. Now you might find a nurseexplaining to another nurse why socialservices couldn’t do something, whereas in thepast, they wouldn’t have known that – orcertainly wouldn’t have expressed it.”


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7. Implications forpeople, teams andorganisations

Improved integration

The CTP is, in essence, a change programme.Through the processes of the programme,teams examine their way of working and the focus of their work. As a result, theydecide they want to do some thingsdifferently. Effecting this change can be bothdisruptive and difficult and some teamsinitially experienced a decrease infunctionality as they disassembled oldpatterns and ways of working andestablished new ones.

All the participating sponsors were able toidentify tangible benefits for individual teammembers, the teams themselves and forservice users, while 91 per cent confirmedthey had seen organisational benefits too.

Less directive and more challenging thanmany had anticipated, all sponsorsconfirmed that the skills based, client-centred approach of the programmegenerated extremely positive outcomes. Mostof all, CTP helped people to look at thingsdifferently, enabled them to challengeestablished practice and thinking, andaddress highly complex issues.

“I think it was beneficial for all of the staff tobe thinking a different way. I think it wasbeneficial from the point of view that it

recognised individuals. It valued people andtheir opinions. Very much so, even thoughthey were challenged.”

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8. Further readingBorrill C and West M (2002) Team workingand effectiveness in health care: findings fromthe health care team effectiveness project,Birmingham: Aston Centre for HealthService Organisation Research.

Department of Health (1993) A Vision for theFuture, London: NHS ManagementExecutive.

Department of Health (2000) The NHS PlanDOH 2000, London: DH.

Department of Health (2001) Shifting theBalance of Power within the NHS: SecuringDelivery, London: DH.

Department of Health (2003) Building on theBest: Choice, Responsiveness and Equity in theNHS, London: DH.

Department of Health (2004) NHSImprovement Plan: Putting People at theHeart of Public Services, London: DH.

Department of Health (2005a)Commissioning a patient-led NHS, London:DH.

Department of Health (2005b) Creating apatient – led NHS: Delivering the NHSImprovement Plan, London: DH.

Department of Health (2006) Our health, ourcare, our say: a new direction for communityservices, London: DH.

Healthcare Commission (2005) NHSnational staff survey 2004: Summary of keyfindings, London: Healthcare Commission.

Marquardt M (2004) Optimizing the power ofaction learning solving problems and buildingleaders in real time, Palo Alto, California:Davies-Black.

Published by the Royal College of Nursing 20 Cavendish SquareLondon W1G 0RN

020 7409 3333

The RCN represents nurses and nursing,promotes excellence in practiceand shapes health policies.

Publication code (003 067)ISBN 1-904114-34-2

October 2006Review date October 2007

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