Leadership, followership, and peak team performance
David R. Williams, MD, CM, and Sandra J. Smith, MA, CHE
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Most health care professionals are very effective at building technical competencies and expertise, but many opportunities to prevent clinical error require them to use non-technical behavioural skills that focus on leadership, followership, and team skills. This opinion paper connects the constructs of leadership, followership, and peak team performance in aviation and space flight with health care teams and organizations.
The challenges confronting health care leaders are growing in parallel with the needs of an aging population and rising economic pressures. Many leaders are focused on achieving broader system goals, such as integration, collaboration, and the creation of value in the delivery of safe, high-quality patient-centred care. Arguably, there has never been a greater need for leaders to help organizations transform into new models of health care delivery, and the increased focus on health care leadership is not surprising. Top
Although leadership is a critical element of system change, the desire for stronger collaboration, coupled with a growing awareness of the importance of interprofessional models of care, emphasizes the need for health care leaders to consider the role of followership in the creation of peak-performing clinical teams. Given the interdependence of leadership and followership in achieving sustainable organizational change, an exciting opportunity arises for leaders to incorporate the concepts of followership into health care.
In complex changing environments, learning organizations are able to adapt to the unpredictable faster than others.1 Garvin and colleagues1 describe the key attributes of learning organizations in which team members continually create, acquire, and transfer knowledge, empowered by leaders who build a supportive environment, develop concrete learning processes, and provide leadership that reinforces learning. For example, applied to safety and quality, a key opportunity to learn from failure is to create an environment of psychological safety that fosters open reporting, active questioning, and frequent sharing of insights and concerns.2 This approach aligns with the creation of an environment where followership thrives. Top
Based on my experiences as a leader and a member of peak-performing teams participating in human spaceflight, my definition of followership is a courageous commitment to contribute and collaborate in an interprofessional team environment. Followership is an active, not passive, process that starts with a personal commitment to bring one’s best to the team environment. Although leaders play a critical role in creating a safe environment for team members to contribute, members still need an element of courage to overcome feelings of vulnerability associated with sharing their ideas.3 Interprofessionalism is changing the power imbalance that currently exists in the hierarchical nature of relations among health care team members, enhancing quality outcomes through effective contributions of all team members. Top
Recently, there has been growing interest in bringing the principles of high reliability organizations into health care. Although the focus has been on achieving sustained quality, reliability, and performance, there are also opportunities to consider the principles of high reliability leadership and how high reliability organizations embrace followership and peak team performance. Humans performing complex tasks will make mistakes. Leaders in such environments can optimize team performance by developing a learning culture that builds followership skills and effective communication skills within teams to reduce the probability and consequence of error.
Human spaceflight takes place in an extremely harsh environment in which time-critical decisions with potential life or death consequences must be made. Once made, a decision cannot be reversed, although the outcome may be modified by subsequent decisions. Similarly, the delivery of health care depends on skilled professionals working together in complex resource-constrained environments using sophisticated technology to care for patients who often have multiple challenging clinical issues. Creating a culture of trust where followership is embraced and team members communicate openly helps achieve high-quality outcomes in situations that are intolerant of error. Although individuals may make mistakes, error trapping occurs at the team level to ensure the mistakes do not affect the desired outcome. Top
Many consider the essence of leadership as the ability to influence others. Leadership training often emphasizes the need to develop and expand a repertoire of leadership styles4 to be effective in a breadth of different situations. Traditional approaches to leadership are associated with a hierarchical model of downward influence in an organization. However, in high reliability organizations, effective leaders understand, empower, and defer to the expertise of team members. Influence in such organizations is multifaceted: it includes the traditional downward influence of leadership as well as the upward influence of active followership and the horizontal influence associated with peer relationships. The concept of leadership–followership continues to evolve as further research is conducted. For example, Vielmetter and Sell5 assert that “leaders and followers are not distinct entities but different relationships in different circumstances.” Top
Successful followership has many attributes, including competency-inspired self-confidence, effective communication skills, respect, a desire to take on challenging tasks and see them succeed through collaboration, as well as a willingness to actively engage with others and to speak up. Yet, there are still many reasons why health care professionals do not speak up or, when they do, they are not heard.6
It can be intimidating for senior team members to express an opinion that differs from that of the CEO. Similarly, staff report that it can be intimidating to speak up to a physician. In a hierarchical leadership model with inherent imbalances of power, it is easy to understand that courage is often needed for followers to speak up. Many leaders understand the importance of engaging and listening to front-line team members and actively solicit input by asking questions and encouraging team members to speak up. However, even when empowered to do so, people find speaking up difficult. Top
At Southlake Regional Health Centre, speaking up has been become one of the corporate values that make up our culture: The Southlake Way. Our culture defines the way we work together as we undertake the mission and vision of the hospital in delivering shockingly excellent experiences to our patients, our people, and our partners. Top
When first implemented, many felt that the new corporate value would immediately empower all team members to speak up, yet we found that many staff either still felt intimidated or felt they wouldn’t be listened to. Our team realized that to truly embrace speaking up as a corporate value, it was critical to teach how to listen up, as well as how to speak up with respect. Both of these skills helped with understanding and acknowledgement of the potential imbalance of power that exists between staff, front-line care providers, and administrative leaders — and, perhaps most important, between patients and providers. Successful communication is a key element of followership and an important learning opportunity for the entire team. Top
Leaders in operational environments frequently say to team members, “If anyone sees anything of concern at any point in time let me know.” It is a statement that I have heard and used repeatedly as a commercial pilot and astronaut; it leverages the power of followership, yet is rarely used in clinical environments. Imagine the potential impact on intraoperative safety if a surgeon were to empower team members to speak up by including that statement at the end of the safety surgical checklist. Imagine the passion and creativity that emerge when leaders defer to the expertise of clinical team members by ensuring they are included in and listened to in meetings. Peak team performance thrives in an environment of trust and open communication through creatively sharing ideas. Top
The challenge of hand hygiene compliance by health care professionals is widely recognized as one of the contributing factors in hospital acquired infections; yet, there is still an opportunity to improve compliance rates. Is this a leadership or followership issue? Are there health care professionals who don’t understand the impact of poor hand hygiene or don’t know appropriate hand cleaning procedures? The responsibility of leaders starts with ensuring appropriate staff training, providing hand hygiene solutions, and measuring compliance. The responsibility of followers is to honour their commitment to use best practices, to ask questions if they are unsure what to do, to speak up to leaders about their concerns, and to be willing to speak up to peers about safety and quality issues.
Positive peer pressure, also known as horizontal organizational influence, is based on a willingness to speak up to a colleague to ensure that best practices are followed. Speaking up for safety should be easy to do in health care; yet, even between peers, it can be a challenge. Learning how to speak up respectfully and how to listen up appreciatively are critical skills for everyone in the organization. Top
In operational settings, such as flying high performance jets, communication of important information can be critical. In a two crew member situation, the workload is divided between the pilot flying “PF” and the pilot not flying or “PNF.” PNF duties included navigation, communication with air traffic control, and monitoring the flight instruments.
In one instance, as the aircraft approached the airport on the downwind leg getting ready to land, the PNF called the tower for landing clearance and informed the PF that no flaps were selected, the landing gear was down and locked, and they were cleared to land by saying: “no flaps, three green, cleared to land.” The crew had not discussed a no-flap landing ahead of time and, while safe, the procedure would normally include a briefing about approach and landing speeds. As the PF turned toward the airport on the base leg, the PNF once again called, “No flaps, three green, cleared to land.” With no acknowledgement from the PF and as the turn was made onto the final approach, the PNF repeated the two previous calls. Top
During the debrief after an uneventful no-flap landing, the PF asked the PNF why they had not said that the flaps weren’t down. The PNF pointed out that they had made the call three times, but it was quite evident the PF had not heard the calls. This was a clear team and followership moment. On reflection, the third call by the PNF could have been, “No flaps selected. Do you want to do a no-flap landing? Three green, cleared to land.” Rephrasing the statement in the form of a question that required an answer could have resulted in a discussion and briefing for a no-flap landing. Although there was no mission impact, the debrief learnings included the importance of acknowledging calls between pilots and verifying that information is heard and understood. Top
Effective followership comes from developing a repertoire of communication styles to effectively contribute in a dynamic team environment. In some situations, particularly those that are time critical, a leader must use a directive style of leadership. With relatively inexperienced team members the outcome depends on the expertise of the leader to effectively direct the team. In this situation, followership is based on doing one’s best to do what the leader asks. Top
In highly experienced teams, members also follow the directions of the leader but may choose to speak up if they believe the directions may adversely affect the desired outcome. Respectfully explaining why they are making the recommendation, highly experienced followers can give feedback to the leader on an alternative course of action. If the leader thoughtfully considers the input, with or without further team discussion, and decides to pursue the original decision, it is the followers’ responsibility to accept the leader’s decision and do what they are asked to the best of their ability. Followership can also include speaking up if the situational awareness of the team leader is affected by distractions. In time critical situations, effective team performance is based on communication, trust, and deference to the expertise of the leader and that of the team members. Top
Deference to expertise is one of the characteristics of high reliability organizations. For leaders, it is an opportunity to create a culture of continuous improvement while building the expertise of team members to ensure they are provided every opportunity to develop their personal competencies. Optimum outcomes are typically achieved with highly experienced leaders and team members working together in a manner that effectively uses individual competencies and expertise. Organizations that invest in talent management and building individual and team competencies are creating conditions that favour optimum outcomes. Those that do not may find themselves forming teams that spend a significant amount of time in the “storming” phase7 of team performance before moving on to “norming” and “performing.” Through an ongoing commitment to building expertise, organizations create an environment where teams move rapidly from forming to performing, thereby efficiently achieving peak team performance. Top
Most health care professionals are very effective at building their technical competencies and expertise through continuing medical education and experience. Yet many opportunities to prevent clinical error require non-technical behavioural skills. The application of the human factors is well known in aviation and spaceflight. When applied to health care, it focuses on optimizing human performance through a better understanding of the behaviour of individuals, their interactions with each other, and with their environment.8 Behavioural competencies are as important as technical competencies in achieving high-quality outcomes, reducing error, and optimizing safety in clinical care.
Health care leaders may also consider the importance of developing individual and organizational resilience by building behavioural competencies. The demands associated with working in an ever-changing, complex, resource-constrained environment can have an impact on career satisfaction and lead to burnout.9 Supporting staff when medical error causes an adverse event is critical, as team members often internalize emotional responses with the potential for long-standing consequences. Building resilience is a continuous process; it can be a challenge for health care teams and is, ideally, one of the elements of learning organizations. Top
Positive emotional energy and relentless optimism are important attributes of astronauts participating in long-duration missions. The same attributes are desirable in health care and can be developed within an organizational culture. Individual and team well-being can be enhanced by teaching emotional resilience and optimism through the application of the principles of positive psychology10 to help everyone flourish. Given the inherent challenges in health care, perhaps there is an opportunity for leaders to create a culture where everyone is treated with compassion, empathy, dignity, and respect, where there is a commitment to build behavioural competencies and team skills to ensure quality outcomes and higher levels of staff satisfaction. Top
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8.Human factors in healthcare: a concordat from the National Quality Board. London: National Health Service; 2013. Available: http://tinyurl.com/o45ameq
9.Fralick M, Flegel K. Physician burnout: who will protect us from ourselves? CMAJ 2013;186(10):731.
10.Seligman ME. Flourish: a visionary new understanding of happiness and well-being. Boston: Nicholas Brealey Publishing; 2011. Top
David R. Williams, OC OOnt, MSc, MD CM, FCFP, FRCP, LLD (Hon), DSc (Hon), is a former Canadian astronaut, active commercial Multi-IFR pilot, and currently president and CEO of Southlake Regional Health Centre. He has 14 years of experience as a senior executive in both the aerospace and health care sectors and is interested in human factors and the attributes of high reliability organizations.
Sandra J. Smith, MA, CHE, SHRP/CHRE, is vice-president of Our People and Corporate Services, Southlake Regional Health Centre. With over 20 years of health care experience, she is passionate about leadership and team performance.
Correspondence to: DWilliams@southlakeregional.org
This article has been reviewed by a panel of physician leaders.