The Quality Improvement Challenge. Richard J. Banchs

       Leaders are hospital or departmental level leaders who support the project. A leadership position in the organization is not by itself a good selection criterion to become a member of a QI team.

       Some teams may need additional members, such as subject‐matter experts, project facilitators, and consultants.

Selecting the people that you get along with is not the best strategy to create a high‐functioning team. Because we usually get along with like‐minded people, filling a team with the people we get along with will probably result in group thinking. To create an effective team, choose front line professionals who bring the appropriate mix of skills. Choose a good mix of “experts, “doers,” and “schmoozers.” These people have the following attributes:

       Process knowledge. Teams must have at least one person who knows the process.

       Organization. Every team needs members who have the ability to organize and get things done.

       Creativity. Creatives know how to work though problems and find solutions.

       Good interpersonal skills. Effective communicators can explain the team’s message and reach the front line professionals.

      “Thanks, But No Thanks”

      One of the reasons most people hesitate to become part of a QI project is the perception that project activities will increase the workload of an already resource‐stretched front line. In some organizations, QI projects have historically resulted in nothing more than additional work requirements for the front line to negotiate. Be careful when pulling together a group of stakeholders who are already struggling with challenging workloads in order to form your project team. Frontline professionals need to have the appropriate resources and see the value in participating in a QI project. Here are some suggestions to encourage participation in QI projects:

       Critically evaluate the time demands you are placing on those involved. Create as close of a timeline as you can.

       Make sure participating members get the appropriate support from their supervisors. People need time away from clinical responsibilities for project activities. “Improving after five o’clock” is not the best strategy.

       Share realistic estimates of the time required to participate in the project with team members and their supervisors.

       Adhere to strict professional behavior during project‐related interactions, such as adequately preparing for activities, scheduling meetings for the minimum time necessary to complete activities, and clearly communicating accountabilities and deadlines, etc.

       Adopt a flexible approach to the completion of project requirements to accommodate project team members’ needs and conflicts with clinical work.

       Avoid wasting project team members’ time by first acknowledging that there is a cost associated with every project‐related activity. Eliminate non‐value‐added project work; make sure team meetings are efficient and achieve their intended goals (see Chapter 26).

      How Many Team Members Do You Need?

      In general, a QI project team should have four to eight members. A team of this size is better able to work through their “individual, functional, and hierarchical differences toward a common plan and hold themselves jointly accountable for the results” (Katzenbach 1993). When teams are either too small or too big, three things tend to happen:

      1 Group thinking. A team that is too small may run into “group thinking” with lack of diversity in the team’s analytical and creative thinking.

      2 Difficulty managing the team. A team that is too big may run into a number of problems, including scheduling, managing, and decision‐making.

      3 The Ringelmann’s effect. Ringelmann’s famous study — often called the Ringelmann effect — analyzed people alone and in groups as they pulled on a rope. Ringelmann then measured the pull force and found that as he added more and more people to the rope, the total force generated by the group rose, but the average force exerted by each decreased. When teams are very large, team members tend to decrease the intensity of their work because they expect or assume other members will “pull their weight.”

THE TEAM LEADER

      Who Should Lead Your Improvement Team?

      If you are the person who initiated the project, you will most likely be the team leader. However, be aware that the leader of the QI team can be any one in the improvement team. Also, the team leader may or may not be the project leader responsible for the QI project, depending on the healthcare organization, composition of the team, the requirements of the project, and the strengths/ limitations of the project leader. What is important to know is that the effectiveness of a QI team is, in general, a reflection of the team leader’s skill in coaching and supporting the team’s work. The person chosen to be the team leader should meet certain requirements:

       Have a good process knowledge or subject‐matter expertise (a must!).

       Be respected by the front line professionals (staff, nurses, doctors, key stakeholders).

       Have excellent interpersonal, facilitation, and communication skills.

       Have the ability to give helpful and effective feedback, as well as to create and lead an environment of constructive conflict.

       Have good problem‐solving and decision‐making ability.

       Be able to recognize others and celebrate the team’s achievements.

      What Is the Role of the Team Leader

      In general, the team leader sets the project’s strategy and facilitates the team’s progress in meeting milestones and achieving the project objectives. Specifically, the team leader’s role is to

       Provide a framework for the team’s purpose that builds commitment and drives the project.

       Collaborate and help team members clearly delineate their roles and responsibilities.

       Help coordinate the completion of the project work according to the specified time frames.

       Coach the team to accomplish both effective communication and constructive conflict resolution.

      The responsibility of the leader is to establish clarity on the activities and goals that the team must achieve and then give them the tools they need to achieve them. The role of the leader is not to do everything but to facilitate the work of the QI team members. Many leaders feel a great deal of pressure to operate like surgeons (you have a problem, I can take it off of you) rather than a psychiatrist (you have a problem, let me help you figure out a way you can solve the problem) (Heifetz 2002). Having said that, as Larry Bossidy and Ram Charan state in their book Execution. The Discipline of Getting Things Done, a successful leader needs to be “engaged personally and deeply in the substance and sometimes the detail of the execution” (Bossidy 2002).

THE TRUE ROLE OF THE QI TEAM

      All improvement is a change, and acceptance of the need to change comes naturally when the front line is engaged in discovering the reason for poor performance and participating in the co‐creation of innovative solutions. “People support what they help create.” Given the importance of front line engagement in the improvement efforts, the role of the QI team is not to work independently to find solutions and