High Performance Team – Necessary in a Healthcare setting

Researchers have concluded that teams are capable of outstanding performances and are the primary unit of performance for organizations. However High Performance Teams (HPTs) are a rarity. The paper discusses and analyzes the literature reviews on Definitions, Trust & Confidence, Conflict and Selection Processes linked to HPTs. It is imperative to note that HPTs are needed and are necessary in any healthcare setting as it improves the quality of services1. The authors link the necessity of HPT’s in healthcare facilities.


Introduction
Teams do exist in every organisation; however a High Performance Teams is a group of symbiotic individuals that have repetitive interaction in pursuit of a common purpose [1][2] . HPTs comprise of individuals with unique skills and talents; who appreciate the richness of diversity within the team to co-operate, consult and coordinate tasks effectively and efficiently. "A vast array of research concerning teamwork is conclusive: teams are capable of outstanding performance and are the primary unit of performance for increasing numbers of organisations. Nevertheless, high performance teams (HPTs) are very rare" 3 . Since the 1980s, organisations increasingly initiated, improved and implemented the use of team structures, which are said to have produced significant results 4 . By 1997, Cohen and Bailey found that organisations with a large number of or more than 100 employees used team structures 82 percent of the time. Gradually, more and more organisations started adapting team approaches within their structures as publications infer that teams are assets in helping organisations increase their efficiency, flexibility and productivity 4 . HPTs are not just an assembly of individuals from varied professional backgrounds but are highly capable of capitalising on multiple perspectives for a successful outcome. Shulman 5 discusses the common factor of HPT as having shared development and outcomes including shared ideas, norms, visions, meanings, responsibility, experiences, understanding and effective coordination among group members. In addition, there are numerous fundamental factors that every team necessitates to be successful. These factors include clear purpose, focused goals and objectives, performance feedback and controlled mechanisms, effective communication practices, healthy conflicts, rewards and recognition. Most importantly, 'teamwork' in HPT helps produce synergy and is considered to be one of the most influential attributes for successful teams and organisations (6) It is rather difficult to address every performance criterion and issue; hence this paper specifically focuses on some of the major components of HPTs. It is essential to create HPTs within healthcare settings to combat the biggest challenge of moving towards a safer health system 1 . This will help change the culture from blaming individuals for errors in which errors are treated not as personal failures, but as opportunities to improve the system and prevent harm. Blame, followed by fear occurs in a team when there is a lack of trust; there are continuous back and forth unresolved conflicts and when team members question the intent of their counterparts. Furthermore, errors and near misses are rectified with punishment followed by judgmental behaviors, rather than being perceived as opportunities for learning and recovering solutions. To make matters worse, individuals waste so much time and energy to find fault with their fellow colleagues. The feeling of "everyone for themselves" is given more importance as opposed to "we're all in this together". This is followed by accusations, such as 'finger pointing' on individuals rather than on the behaviors, the systems and processes. Leslie and Nicole Bendaly in their article Improving Healthcare Team Performance (2012) noted that leaders do not actively encourage nor promote the importance of reporting near misses and errors. This is an issue as 'errors' form building blocks to make improvements and craft innovations within the system. They also explained that leaders do not effectively provide constructive and positive feedback to team members on a regular basis 1 . This is another issue that should be given more focus to as constructive feedback encourages better performances and improved behaviors. HPTs are principle-based. This entails that successful high performing teams rely on fundamental principles for their guidance and cohesion, rather than on contract and agreement. HPT members carry out their tasks that are governed by a set of principles, that are closely aligned to their organisation's values and beliefs; instead of explicit 'procedures' or 'service level agreements' 2 . Successful HPTs do not predetermine performance or outcomes; rather they communicate their intent through overarching organisational principles guiding their work ethos and actions. This enables employees to eradicate the feeling of uncertainty or anxiety where in uncertain or unknown situations 7 . Hofstede's cultural dimensions imply that when discussing a project with people from a country whose Uncertainty/Avoidance Index (UAI) scores are relatively low (i.e. United Kingdom, China, New Zealand and India), they are more inclined towards novel events and valuing differences 7 . There are fewer rules, simple structures and they are more concerned with long term strategies rather than what is happening on a daily basis. Our experiences while working in the UAE was evident that Americans expected the details at the end of any project however Emiratis needed comprehensive details at every phase of the project. If this was not complied, the Emiratis would take it as an "Insult", showing Power Distance 7 . It was found that working with Emiratis or Arabs can be quite a challenge for those with different cultural backgrounds as the locals are shy and reserved but also they try to avoid resolving conflicts. This results in an "unhealthy" team dynamic 8 HPTs' successes are guided by those who understand their underlying processes. Executives avoid using top-down approaches in communicating goals, benchmarks, and telling employees what or what not to do. Hanlan 2 says that by simply commissioning orders, teams rarely achieve high performance. HPTs' success is a result of natural processes, whereby the organisational needs are integrated with team creativity and individual desires. These processes are highly dynamic and interactive; this energy is unlikely to be visible to a casual observer. This phenomenon may be explained much better by linking it to the 'Individualism' (IDV) component of cultural dimensions 7 . This scope refers to the strength of the ties people have with one another. This is seen in an organisational context whereby team cohesion is strong; loyalty and respect to other members of the team are highly valued over 'loose' connections. A successful HPT with a low IDV score consists of individuals who work for intrinsic rewards with emphasis on skill development -becoming a master of something-and they value harmony and honesty 7 . If we look around, we discover that different groups are made up of different kinds of people. These individuals have different skill sets, qualifications and expertise. A manager may embrace and transform the group into a high performance team. As a HPT, members share the same values as they are grouped together to decide and achieve on set goals and objectives, and also there is a right balance of creativity within the team 2 . The manager has to mould the team and steer the members in the right direction by transparent communication of set standards for the team. The manager should convey a sense of urgency but also empower members to rely on their skills and responsible behaviours to produce quality results. HPT members will inevitably promote and provide high grade of excellences. Rewards in shape of positive feedback or praises, or even small prizes will help the team to attain their set objectives. Team members are encouraged to have open communication and managers should provide emotional support thus creating a synergetic environment to learn new things and develop healthy team dynamics 9 . Characteristics of High Performance Team Diversity Daly 10 describes that diversity in itself is not accountable for depicting how well a team works together; instead integration -the combination of clear communication, constructive solving of differences and the generation of innovative solutions -is a result of bringing together multiple perspectives within a team for the team's success. Taking it one step further, we may say that effective communication revolves around more listening than talking -where members hear what is intended. This, however can be challenging when interacting with different cultures. Conflict is bound to occur when there are contrasting opinions, mind-sets and ways of practices 11 . Collaborative conflict management (CCM) involves members resolving differences without alienating one another -balancing the anxiousness of their own goals over the goals of others in the team. CCM also embraces constructive and innovative practices, where members build upon the ideas and opinions of others rather than making their own prevail 11 .

Collaborative Climate and Trust
Working effectively together takes place in three ways that are structural features, which includes clear identified roles, responsibilities and accountabilities as well as clear and open communication and an issue of climate, depicting the feelings of collaboration and commonly the feelings of trust 12 Researchers suggested that trust is probably one of the most important factors in constructing HPTs. Trust is a combination of honesty, openness, consistency and respect, which are essential for teams to stay 'problem-focused'. When trust in built within a team environment, tremendous stress can be alleviated off the team [12][13] . Most of the time it creates higher energy and focused concentration, as well as the ability to work on meaningful problems and solutions. This then creates and crafts a deeper level of interaction and a level of expression between members 14 .

Structure & Performance
Teams can function effectively under extraordinary structures or a few flourish under minimal structures. Depending on the purpose of the team, structures are built to achieve a particular performance objective -a formation that does not confuse the efforts with the results -and a simplified structure that makes sense to team members 12 . Four essential factors critical to team structures are clear roles and responsibilities; an effective communication system; monitoring individual performance and providing positive feedback and fact-based judgement 12 .

Conflict Management
HPTs' success is often a reflection of the team's ability to combine talent in a creative and coordinated fashion. Central to this is the use of conflict; which is a catalyst for creativity but also establishes a platform for open exchange of ideas, objective assessment of alternatives and the rigorous constructing of perspectives 15 . This, in turn produces beneficial conflicts in which creative ideas, innovations and solutions are crafted. In a team with multifaceted perspectives, conflicts are inevitable, however not all conflicts are bad. Healthy or positive conflicts are beneficial to HPTs as members become conflict competent. Conflict competence is the ability to develop and utilise cognitive, emotional and behavioural skills that enhance productive outcomes of conflict while reducing the likelihood of escalation or harm 16 . At the same time, the varying perspectives in a multifaceted team may give rise to destructive conflict 17 . Such interactions may produce anger and alienation, which can lead to individual dissatisfaction and resentment within teams. Conflict and diversity in interdisciplinary HPTs are said to be 'natural' and mostly unavoidable 17 . The natural tendency is to perceive conflict as a threat, however, for team decision-making, conflict is rather appropriate and necessary 17 . The analysis of varying perspectives enables one to distinguish the practical from personal problems and identifies the hidden stresses -conflict emerges to become a medium for growth 18 . Conflict does not just reflect the divergent perspectives of team members but, more importantly, their interactions with the organisation, its system and also its clients 19 . Its importance can easily be outweighed by destructiveness if it is not handled and managed skilfully. If managed appropriately, the growth of conflict allows for teams to draw inferences on its roles with people, systems, providers and institutions: High performance teams create 'functional diversity'; wherein members' seek information about each other, enough to enhance unity and demonstrate their own expertise and proficiencies within a team 20 . If a problem presents itself within this team, members can resolve the conflict constructively as they have knowledge about the behaviour and personality of other members in the team. This helps in quickly putting differences aside and generating ways to move ahead with a challenging task. Key points for avoiding unhealthy conflicts within a high performance team are: • Embrace Diversity -to improve on creativity & innovation regardless of differences in values and belief systems 11 .
• Patience -to allow for differing perspectives and quality decision-making 15 .
• Professionalism v Personal Problems -as members are working towards a common goal, HPT members set aside differences to pursue the task at hand 20 • Interchangeable Leadership -leadership is not the responsibility of one member but the focus of every member in their roles and of their tasks 21 .
• Development of Robust Techniques -a) compromise -to find a fair solution between disagreeing parties; b) collaboration -encourage open discussion for conflict resolution and be open about the damage the conflict is causing; and c) accommodation -encouraging one of the conflicting parties to "give in for the sake of giving in" if conflict is seriously jeopardising team productivity and is harmful to the organisation 22 . Healthy conflict enables discussion of inefficiencies within a team, promotes pre-discussion disagreements, which stimulates the quality of making decisions; side stepping to go back to basics and brainstorm; explore new strategies, inspire and implement approacheswhich contributes to team development and better team performances 23 .

Commitment
Unified commitment -an amazing component of HPTs -is the focus on clear and worthwhile goals and relinquishing the self (or ego) for the greater purposes of the team 12 . HPTs are not only committed to organisational goals, but more importantly, they are committed to one another. High performing individuals within HPTs outshine their work relationship and begin to truly, care for each other, where the attitude becomes, "if one of us fails, we all fail" 9 .

Attitude
HPTs cultivate a set of attitudes that sustain, enhance the energy, interest and overall experiences that are needed within a team. HPTs avoid trivial problems that are focused on the team; rather they generate enthusiasm, energy, respect and results -which are critical factors for effective and productive team performance 21 . In essence, conflict needs to be viewed as part and parcel of HPT, and it could be unhealthy if a team tries to avoid conflicts 8 .

Team Selection and Development
Team selection is an important process that helps identify members with specific qualities and skills for a specific role 2 .

Selection Process
There are four major criteria that determine the inclusion of members within a High Performance Team. These attributes are: member's qualification -designed to identify the best and most suitable individual from the pool of candidates; peer selection -allow members to voice their opinions in selecting who they prefer to be part of their team (to avoid favouritism); personality test -tools such as Talent Dynamics of Myers Briggs (MBTI) tests to explore in which roles a member is most likely to find their flow; and performance improvement -wherein members are selected based on their credibility, years of experiences and effective interpersonal skills to drive productivity, ensure progress and efficient performances. Qualities of HPTs' members are (but are not limited to) skills, experience, talent for innovation; personality, character, commitment, capabilities and enterprising nature for team's development 3 .

Team Development
While some members claim that HPTs are where one finds them, not where one wishes they were 9 , there are various ways to help facilitate team development and performance. In adapting Kotter's 8-step leadership change model, critical practices that may lead to high performance areas follows 24 : 1) Establishing urgency and a sense of directionrecognising that the more urgent and the clearer the expectations, the higher the probability of reaching high performance. 2) Teams must select individuals based on specified skills for the task and skill potential.
3) Getting the right vision -creating a vision that can be conveyed in a matter of minutes is going to move people into action much more effectively than detailed analyses ever will. 4) Communication -keeping communication channels open and simple. Clear rules of behaviour must be agreed upon. 5) Empowering the team -mini goals and victories must be provided to help the team establish sense of early confidence. 6) Create short-term wins -provides feedback about the validity of organisation's vision and strategies; provide members who are working hard and efficiently with recognition and encouragement; build faith in change project and take power away from cynics. 7) Implementing and sustaining change -to create structures and situations that empower people to take risks and deal with problems without fear of reprisal. Removing structural obstacles is also important: giving people enough leeway to innovate and solve those intractable problems. 8) On-going proceeds -Change does not stop here. New ways of working must continue successfully for some time before the culture truly changes. Culture cannot change until new ways of operating are implemented. Finally teams need a plethora of positive feedback, recognition and rewards for their diligent work and efforts 24 .

Conclusion
To conclude, there are many organisations with great strategies in developing HPTs but how many of those great strategies are actually executed? This paper focuses on the make-up and structure of teams, but more importantly, members are recognized as valued assets of an organisation including healthcare settings and environments. Team have the capability to increase organisational performance, but also to heighten team members' satisfaction by helping members to become more valuable in the process. This value improves task efficiency and over time, we are bound to see high-level improvements in team effectiveness. On the path of developing tremendous outcomes as a result of effective HPTs in organisations, the ultimate benefit is shaped in the form of individual human development. It is through the process of collective progression and excellence that individuals become more than 'the sum of their counterparts' and learn to work together in harmony, towards goals that provide significant meaning, not only for the organisations that house them, but also, more importantly, for the individuals that sacrifices for them. It is imperative that managerial bodies understand these characteristics of High Performance Teams discussed in this paper. In this era of competitive marketplace, it is essential to harness the power of teams that promote advanced performance at the individual, team and organisational levels for short-and long-term organisational successes.