Secondary Logo

Journal Logo



A Business School View of Medical Interprofessional Rounds

Transforming Rounding Groups Into Rounding Teams

Bharwani, Aleem M. MD, MPP; Harris, G. Chad; Southwick, Frederick S. MD

Author Information
doi: 10.1097/ACM.0b013e318271f8da
  • Free


The medical attending, two interns, a resident, two medical students, and a pharmacist stand outside their patient’s door. One intern faces the attending with his back to the other members of the group, and recounts in excessive detail the patient’s long list of symptoms and past medical illnesses. As the attending begins grilling the presenting intern on diagnostic criteria, and beautifully dissects the pathophysiology of the patient’s illness, the medical students consult their pocket manuals. The resident checks his smart phone, and the other intern returns a page. The two-way conversation between the intern and attending is finally completed, and those remaining in the group enter the patient’s room. The floor nurse is nowhere to be found, and the pharmacist is noticeably silent. Is this a highly functional interprofessional team?

Teams are the ideal solution for performing high-complexity tasks that require the interdependence of multiple experts to achieve a collective outcome. A successful team efficiently achieves the goals assigned, and over time team members increase their capacity to work together effectively.1–4 In medicine, successfully managing the hospitalized patient with multiple complex medical problems constitutes a high-complexity task that requires an effective team to efficiently coordinate multiple specialized health care providers to achieve the collective outcome of improving the patient’s well-being.5,6 Teamwork in health care can save lives,7,8 improve the quality of patient care,9–18 reduce errors,19–22 enhance patient flow,23,24 improve communication,25–28 and increase job satisfaction.29,30

Foundations of Our Team Observations

As students in the Harvard Business School, we devoted a semester to studying how business teams should be constructed and launched, and how to manage the complex dynamics of working teams. In the spring of 2010, one-fifth of our class chose to observe interprofessional medical teams and compare their behaviors with the best practices of high-performing business teams, to identify opportunities for improvement. We organized into four groups of three students to independently observe four ward-rounding “teams” (three in the medical intensive care unit [ICU] and one on the general medical service) at a Boston area hospital for two to four hours, and we conducted individual interviews with rounding participants. Our questions and field notes were open-ended. Each team organized their observational data into an analytical paper. We all signed HIPAA agreements, and the study was deemed to be exempt by our IRB.

Despite our diverse work experiences in business, pharmacy, and medicine prior to attending business school, and four sets of independent observations, there was a remarkable consensus across our observational teams regarding our findings. On the basis of the consistency of these observations, as well as our senior author’s (F.S.) experience observing over 50 medical work rounds at four other major hospitals, we believe that what we observed is representative of medical rounding “teams” in many, if not all, medical centers. Here, we draw on those observations to make an argument for team-based practice.

Differentiating Groups From Teams

We found that the health care professionals we observed participating on ward rounds in all instances represented working groups rather than working teams.31 We observed parallel interdependence (individuals working alone and assuming that their work would be coordinated with other health care providers) rather than reciprocal interdependence (individuals working together actively coordinating their care of the patient).1

Reciprocal interdependence can only occur if the appropriate experts are part of the team and if all team members can speak freely, openly, and meaningfully.32 We observed neither of these key conditions. The composition of the rounding groups varied, consistently containing physicians and physicians in training, including one senior physician attending, three to four residents, and one or two medical students, but it only intermittently included bedside nurses in two, and excluded nurses in a third. One ICU rounding group included one nurse throughout their rounds, and two included a pharmacist. In no instance did the rounding groups include a case manager. The number of group members varied from four to nine.

With one exception, the organizational structure was hierarchical, with the senior attending physician possessing the authority. In our interviews, nurses, physician trainees, and pharmacists admitted to feeling psychologically unsafe in expressing their opinions. These attitudes were supported by our observations that nurses rarely spoke, and pharmacists never spoke during rounds. The communication pattern was predominantly one-on-one between the physician trainee presenting the patient’s progress and the attending physician. Because they were not actively included in the rounding discussions, other members of the group frequently performed unrelated tasks and often appeared inattentive. Rounds were usually conducted in the hallways outside the patients’ rooms. Multiple distractions were apparent, including beeping pagers, loud equipment warning sounds, rumbling carts, and members of the group continually coming and going. Excessive noise often interfered with the ability to hear the case discussion.

Furthermore, the content and organization of the patient presentations varied from physician to physician, and the time devoted to each patient varied from 10 to 45 minutes. Some patients received prolonged attention; for others, clinical progress was only cursorily reviewed. The general ward team also had the physical challenge of caring for patients on six different floors, requiring extra time to walk from floor to floor. After observing these uncoordinated and variable processes, two of our fellow students expressed the opinion that they hoped they would “never have to be hospitalized.”

Evolving From Group to Team

Team setup

On the basis of the lessons learned in our teams class as well as our review of the medical, business, and social science literature, we suggest a number of improvements to interprofessional rounds that have the potential to create the optimal interprofessional teams required to provide the highest-quality care for patients.

First, rounding teams must be truly interprofessional and relatively small in size. The ideal composition of such teams has not been explicitly defined, but it will vary depending on the team’s goals.5 For general medical teams, physicians, nurses, a pharmacist, a case manager, and a social worker have been recommended.29 Intuition may suggest that the larger the team, the more productive it will be. However, as teams get larger there are significant process losses including motivation decrement and coordination difficulties. These process losses reduce productivity, and when teams reach a certain size, the process losses outweigh the incremental increase in resources represented by the addition of a new member.33 In general, for decision-making teams, the ideal number should be 6 to 7, remembering that a 6-member team consists of 15 different pairs and a 7-member team consists of 21.4

Second, successful rounding teams need an effective team launch that fosters fruitful collaborations. During the team launch, expectations for each member of the team should be clearly described, common goals established, and team norms defined,3 including the expectation that all team members should be fully engaged in the rounding conversations, refraining from unrelated activities except in true emergencies.4 The attending should explicitly state that every voice and every perspective on the team is valuable, including nurses, pharmacists, and the case manager.34 Whenever possible, the majority of the team members should join the rounding team within a few days of each other, so that all team members have synchronized expectations, goals, and team norms defined by the team launch. How the team leader sets the stage for a newly formed team is a critical determinant of a team’s future success. Investigations of the airline industry as well as surgical teams reveal that the likelihood of forming a highly functional team is determined within the first few minutes by the initial briefing of the airline captain or the lead surgeon.6,8,35,36 We recognize that many residency and hospitalist programs rotate physicians and nurses at very short intervals; however, administrators should consider how this condition disrupts team dynamics and undermines the benefits of a team launch.

Team communication

Third, to optimize communication, the senior leader of the team should use the Socratic method and serve as the discussion facilitator.4,6 Effective team leaders ask guiding questions and encourage the participation of all team members. They create a zone of safety by flattening hierarchy and encouraging every member of the team to share their ideas.34 Groupthink—everyone agreeing simply to be agreeable37—is avoided, and creative abrasion—open and polite disagreement—is encouraged.38 On completion of the discussion, the effective leader summarizes the conclusions and arbitrates any disagreements. Team members should organize themselves in a full circle that includes the bedside nurse to encourage horizontal communication.4 Communication protocols must be carefully designed for clarity, content, and efficiency and should be consistent throughout the hospital. SBAR (situation, background, assessment, recommendations) has proved to be a highly effective communication tool allowing nurses and physicians to effectively describe unexpected clinical events.39 The problem-based SOAP (Subjective, Objective, Assessment, Plan) presentation can efficiently relay routine daily progress and is also recommended.40 These communication protocols can usually relay the necessary medical information for an individual patient within two to three minutes.40–43 Prespecified time limits should be established for each patient that are based on the complexity and severity of the illness. When possible, the specific time when the team will be at the bedside should be estimated to facilitate participation by the bedside nurse and patient’s family.4

Fourth, the rounding environment should be quiet and free of distractions to ensure meaningful discussions and management decisions. Harsh, noisy environments may impair decision making and increase the likelihood of cognitive errors.44 We suggest designating a two-hour quiet time on the wards, when noise, pages, etc., are minimized. To avoid the potentially distracting hospital corridors, the team may be tempted to meet in a quiet conference room; however, this condition results in the loss of face-to-face time with the bedside nurses, as well as with patients, and has the potential to impair communication.9 On wards with single beds, the team can conduct the majority of their communication at the bedside with the door closed to increase privacy and eliminate hallway distractions.

Team dynamics

Fifth, conditions should be established to create bounded, stable teams. Resident and attending rotations should be lengthened for each rounding team to allow sufficient time for trust and an understanding of the strengths and weaknesses of each member to develop—critical conditions for the formation of true teams.3 Rather than the present practice of reconfiguring resident teams every two to four weeks, three to four residents could be designated as teammates for a three- to six-month block and rotate to different wards as a team. To prevent disruption of maturing teams, temporary substitutions of team members should be avoided whenever possible. Time is required for individuals to learn to modify information on the basis of the input of teammates and to make decisions that are truly the culmination of the input from the entire team. Furthermore, to establish stable relationships with the bedside nurses, the medical team’s patients should be housed on a single floor.19 Whenever possible, nurses should care for the same patient on consecutive days to ensure that they remain part of the same interprofessional team. This condition would also allow the nurse to more effectively recruit the patient and patient’s family to become part of the team. We recognize that scheduling necessities and bed availability may compromise these ideal conditions for teamwork. However, caregivers possessing team skills should also be able to work more effectively in short-lived teams.

Finally, we realize that team building is a skill that needs to be taught, and we, along with many health care experts, recommend teamwork exercises to encourage nurses, case managers, pharmacists, and physicians to work together as true teams.5,28,45–47 Scenario-based exercises during which team members are placed in realistic situations commonly encountered on the wards followed by video critiques have proved to be one of the most effective forms of team training.48 Teams also need to be periodically observed and coached by a teamwork expert to ensure optimal function.3,4,48,49 Periodic reflection on the pluses and minuses of each team’s processes needs to become a regular part of each team’s routine. All caregivers should learn and model the modern principles of team design, launching of teams, and management of ongoing team dynamics.

The Power of Teams

The benefits of teamwork are indisputable, and working effectively in teams is a fundamental skill required for 21st-century medicine.50 The business community has embraced working teams for over a decade. Isn’t it time for physicians, nurses, and other caregivers to recognize the power of teams to truly transform the delivery of health care?

Acknowledgments: The authors thank Professor Robin Ely for teaching the “Leading Teams” class at Harvard Business School, as well as the other members of the class who participated in the original observations: Derek Aguirre, Mia Boserup, Maria Carmona, Partha Chakrabarti, Victor Clausen, Elias Goraieb, Creighton Hicks, Fabio Katayama, Wing Province, Karthik Ranganathan, and Brian Shroder.

Funding/Support: None.

Other disclosures: None.

Ethical approval: This study was exempted by the University of Florida IRB #359-2010.


1. Volkema RJ. Problem complexity and the formulation process in planning and design. Behav Sci. 1988;33:292–327
2. Wageman R, Nunes DA, Burruss JA, Hackman JR Senior Leadership Teams.. 2008 Boston, Mass Harvard Business School Press
3. Hackman JR Leading Teams.. 2002 Boston, Mass Harvard Business Press
4. Southwick FS Critically Ill: A 5-Point Plan to Cure Healthcare Delivery.. 2012 Tempe, Ariz No Limits Publishing Group
5. Weaver SJ, Lyons R, DiazGranados D, et al. The anatomy of health care team training and the state of practice: A critical review. Acad Med. 2010;85:1746–1760
6. O’Leary KJ, Sehgal NL, Terrell G, Williams MV. Interdisciplinary teamwork in hospitals: A review and practical recommendations for improvement [published online ahead of print October 31, 2011]. J Hosp Med. doi: 10.1002/jhm.970.
7. Kim MM, Barnato AE, Angus DC, Fleisher LA, Fleisher LF, Kahn JM. The effect of multidisciplinary care teams on intensive care unit mortality. Arch Intern Med. 2010;170:369–376
8. Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical team training program and surgical mortality. JAMA. 2010;304:1693–1700
9. Sutton G. Evaluating multidisciplinary health care teams: Taking the crisis out of CRM. Aust Health Rev. 2009;33:445–452
10. Stone ME Jr, Snetman D, O’Neill A, et al. Daily multidisciplinary rounds to implement the ventilator bundle decreases ventilator-associated pneumonia in trauma patients: But does it affect outcome? Surg Infect (Larchmt). 2011;12:373–378
11. Staveski SL, Avery S, Rosenthal DN, Roth SJ, Wright GE. Implementation of a comprehensive interdisciplinary care coordination of infants and young children on Berlin Heart ventricular assist devices. J Cardiovasc Nurs. 2011;26:231–238
12. Reilly T, Barile D, Reuben S. Role of the pharmacist on a general medicine acute care for the elderly unit. Am J Geriatr Pharmacother. 2012;10:95–100
13. Goodrich J. Supporting hospital staff to provide compassionate care: Do Schwartz Center Rounds work in English hospitals? J R Soc Med. 2012;105:117–122
14. Coons JC, Fera T. Multidisciplinary team for enhancing care for patients with acute myocardial infarction or heart failure. Am J Health Syst Pharm. 2007;64:1274–1278
15. de Mestral C, Iqbal S, Fong N, et al. Impact of a specialized multidisciplinary tracheostomy team on tracheostomy care in critically ill patients. Can J Surg. 2011;54:167–172
16. Dy CJ, Dossous PM, Ton QV, Hollenberg JP, Lorich DG, Lane JM. Does a multidisciplinary team decrease complications in male patients with hip fractures? Clin Orthop Relat Res. 2011;469:1919–1924
17. Ellrodt G, Glasener R, Cadorette B, et al.Multidisciplinary Rounds Team. Multidisciplinary rounds (MDR): An implementation system for sustained improvement in the American Heart Association’s Get With the Guidelines program. Crit Pathw Cardiol. 2007;6:106–116
18. Johnson V, Mangram A, Mitchell C, Lorenzo M, Howard D, Dunn E. Is there a benefit to multidisciplinary rounds in an open trauma intensive care unit regarding ventilator-associated pneumonia? Am Surg. 2009;75:1171–1174
19. O’Leary KJ, Buck R, Fligiel HM, et al. Structured interdisciplinary rounds in a medical teaching unit: Improving patient safety. Arch Intern Med. 2011;171:678–684
20. Leape LL, Cullen DJ, Clapp MD, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA. 1999;282:267–270
21. Blegen MA, Sehgal NL, Alldredge BK, Gearhart S, Auerbach AA, Wachter RM. Improving safety culture on adult medical units through multidisciplinary teamwork and communication interventions: The TOPS project. Qual Saf Health Care. 2010;19:346–350
22. Kucukarslan SN, Peters M, Mlynarek M, Nafziger DA. Pharmacists on rounding teams reduce preventable adverse drug events in hospital general medicine units. Arch Intern Med. 2003;163:2014–2018
23. Dutton RP, Cooper C, Jones A, Leone S, Kramer ME, Scalea TM. Daily multidisciplinary rounds shorten length of stay for trauma patients. J Trauma. 2003;55:913–919
24. Curley C, McEachern JE, Speroff T. A firm trial of interdisciplinary rounds on the inpatient medical wards: An intervention designed using continuous quality improvement. Med Care. 1998;36(8 suppl):AS4–A12
25. Vazirani S, Hays RD, Shapiro MF, Cowan M. Effect of a multidisciplinary intervention on communication and collaboration among physicians and nurses. Am J Crit Care. 2005;14:71–77
26. Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C. Improving communication in the ICU using daily goals. J Crit Care. 2003;18:71–75
27. Halm MA, Gagner S, Goering M, Sabo J, Smith M, Zaccagnini M. Interdisciplinary rounds: Impact on patients, families, and staff. Clin Nurse Spec. 2003;17:133–142
28. Sehgal NL, Fox M, Vidyarthi AR, et al.Triad for Optimal Patient Safety Project. A multidisciplinary teamwork training program: The Triad for Optimal Patient Safety (TOPS) experience. J Gen Intern Med. 2008;23:2053–2057
29. O’Leary KJ, Haviley C, Slade ME, Shah HM, Lee J, Williams MV. Improving teamwork: Impact of structured interdisciplinary rounds on a hospitalist unit. J Hosp Med. 2011;6:88–93
30. Dodek PM, Raboud J. Explicit approach to rounds in an ICU improves communication and satisfaction of providers. Intensive Care Med. 2003;29:1584–1588
31. Arrow H, McGrath J, Berdahl J Small Groups as Complex Systems. 2000 Thousand Oaks, Calif Sage
32. Lafasto FMJ, Larson C When Teams Work Best: 6,000 Team Members and Leaders Tell What It Takes to Succeed.. 2001 New York, NY Sage Publications
33. Steiner ID Group process and productivity. 1972 New York, NY Academic Press
34. Nembhard IM, Edmonson AC. Making it safe: The effects of leader inclusiveness and professional status on psychological safety and improvement efforts in health care teams. J. Org Behav. 2006;27:941–966
35. Ginnett RWiener E, Kanki B, Helmreich R. Crew as group: The formation and their leadership. Cockpit Resource Management. 1993 Orlando, Fla Academic Press
36. Ginnett RCHackman JR. Airline cockpit crews. Groups That Work (and Those That Don’t). 1990 San Francisco, Calif Jossey-Bass:427–448
37. Smith KK, Berg DN. A paradoxical conception of group dynamics. Hum Relat. 1987;40:633–657
38. Leonard DLeonard D. Creative abrasion. When Sparks Fly: Igniting Creativity in Groups. 1999 Boston, Mass Harvard Business School Publishing
39. Vardaman JM, Cornell P, Gondo MB, Amis JM, Townsend-Gervis M, Thetford C. Beyond communication: The role of standardized protocols in a changing health care environment. Health Care Manage Rev. 2012;37:88–97
40. Ilan R, LeBaron CD, Christianson MK, Heyland DK, Day A, Cohen MD. Handover patterns: An observational study of critical care physicians. BMC Health Serv Res. 2012;12:11
41. University of Florida Academic Health Center. . . Gatorounds: Applying Championship Athletic Principles to Healthcare. Accessed August 11, 2012
42. . Institute for Healthcare Improvement Web site. Accessed August 16, 2012
43. Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. . TeamSTEPPS: National Implementation. Accessed August 11, 2012
44. Donchin Y, Seagull FJ. The hostile environment of the intensive care unit. Curr Opin Crit Care. 2002;8:316–320
45. Interprofessional Education Collaborative. . Core Competencies for Interprofessional Collaborative Practice: Report of an Expert Panel. Accessed August 8, 2012
46. Chakraborti C, Boonyasai RT, Wright SM, Kern DE. A systematic review of teamwork training interventions in medical student and resident education. J Gen Intern Med. 2008;23:846–853
47. Magrane D, Khan O, Pigeon Y, Leadley J, Grigsby RK. Learning about teams by participating in teams. Acad Med. 2010;85:1303–1311
48. Salas E, DiazGranados D, Weaver SJ, King H. Does team training work? Principles for health care. Acad Emerg Med. 2008;15:1002–1009
49. Neily J, Mills PD, Lee P, et al. Medical team training and coaching in the Veterans Health Administration; assessment and impact on the first 32 facilities in the programme. Qual Saf Health Care. 2010;19:360–364
50. Kohn LT, Corrigan J, Donaldson MSInstitute of Medicine (U.S.). Committee on Quality of Health Care in America.To Err Is Human: Building a Safer Health System. 2000 Washington, DC National Academy Press
© 2012 Association of American Medical Colleges