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“Getting ‘em to Play Together”

Alexander the Great

Alexander the Great

It takes a lot more than just a quick glance to find anything that Casey Stengel and Alexander the Great had in common. But, alas, they did! In fact, the two were both great advocates for teamwork and understood some very fundamental principles of individual and team skills. They also understood the importance of team function in winning—whether it was epic battles or baseball games.

Alexander the Great obviously had a whole lot more on his agenda than Casey Stengel ever did and played for a lot higher stakes. He conquered an empire that spanned millions of square miles and built more than 20 major cities—all named after him, of course. He was a military genius, possibly one the greatest of all time. Alexander’s soldiers admired him and followed him because of his courage to lead them into battle instead of staying behind. His men saw that Alexander shared in their dangers, not asking them to take risks that he would not take himself. His troops were better trained and better organized than any other army of his day or many centuries to come. Alexander’s teamwork strategy and message was simple, but very profound. As he marched from Macedonia to Africa, India, and Asia he counseled his generals, “Remember, upon the conduct of each depends the fate of all.” And so it is still; upon individuals who practice good teamwork skills rests the outcome of the entire team effort.

Casey Stengel

Casey Stengel

Let’s skip forward about 2,000 years in history and visit Casey Stengel early one spring before the 1954 baseball season. Casey was asked by a local reporter how he would find enough good baseball players to win an unheard of fourth World Series. With his usual downhome common sense he quipped, “Gettin’ good players is easy.  Gettin’ ’em to play together, that’s the hard part.” How true. The best baseball team managers share a common skill with the best generals, CEOs, airline captains, and even surgeons. They all have the ability to get the best efforts out of all their teammates by practicing good teamwork skills. They understand that teamwork multiples the best efforts of individuals. It is the most important bedrock principle of winning World Series games or wars and allowing safe outcomes in aviation and surgery.

Those of us who have adopted the High Reliability Mindset understand this important premise. High reliability theory stresses team training and teamwork as critical high performance skills. Teams are made up of many people and teamwork itself is part of the safety mindset and a teachable skill. High performing teams exhibit a sense of collective efficacy and recognize that they are dependent upon each other. They also believe that, working together, they can solve complex problems by optimizing their resources, engaging in self-correction, and compensating for each other by providing backup behaviors and reallocation functions as necessary. Effective teams recognize potential problems or dangerous circumstances and adjust their strategies accordingly. Good teamwork establishes and maintains group and individual situational awareness—an HRO skill previously described in this blog—and shares information, perceptions, and ideas to keep everyone ahead of the evolving clinical condition.

In all aspects of healthcare, team care has been shown to reduce mortality, morbidity, and length of stay in surgical patients. The safety literature shows that team training improves trauma and ICU team performance and recognition of life-threatening injuries with reduction in death, adverse outcomes, and lengths of stay. Observational studies in the operating room have demonstrated that training clinicians in non-technical and teamwork skills provides important safety nets.

Effective teams are led by effective leaders who play a crucial part in team dynamics. Leaders perform three key functions; they: provide strategic direction of care, monitor the performance of the team, and teach team members by providing instruction. Good leaders and supervisors have the ability to get the best performance from all team members while encouraging each person on the team to share all information. These lessons have been known from the ancient times of Alexander the Great and are still as important today.

The challenge we face as teachers in medical schools and advocates of the High Reliability Mindset is “getting’ ‘em to play together.” Healthcare teams are made up of individuals who are highly skilled and personally motivated. They entered good colleges based on their individual grades and performances in high school, and entrance into competitive medical schools was based on their individual achievements in college. Similarly, competitive residency positions are secured by medical school grades and individual performance. Then they arrive on the wards and we tell them to forget all that individual stuff and be a good team player. As Marvin Weisbord wrote, “Teamwork is the quintessential contradiction of a society grounded in individual achievement.” The answer can be found in teamwork training right from the start of medical school and residency.

We must bring up a new generation of team players. In this way, teamwork will become ingrained in our daily surgical practice to enhance patient safety and surgical outcomes. Phillip I, Alexander the Great’s father, arranged for young Alexander to be tutored by none other than Aristotle. Aristotle no doubt impressed upon the young world-leader-to-be his philosophy that “We are what we repeatedly do; excellence then is not an act, but a habit.” Building into our system a habit of good teamwork will produce excellent outcomes. As winter comes to us, we can remember another of Aristotle’s great quotes, “A snowflake is one of the God’s most fragile creations, but look what they can do when they stick together!”

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  1. robert berry says

    Ken, another great blog – I have begun to share these with my staff and anyone else who has an interest in undestanding the concept of the High Reliability Mindset. It is the fundamental basis for creating an environemnet where people can trust thier best efforts will be rewarded by the best efforts of others. Plus the history is pretty cool (love the Life According to Garp reference a few blogs back).



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