The power of associations stems from strength in numbers, with each individual voice contributing to a greater one. Associations are an integral part of growth across all fields. In health care, advances in professional development, medical education, and health advocacy would not be possible without medical associations. In this article, we will provide a conceptual model for high-performing organizations and discuss the fundamental qualities that characterize them. Additionally, we examine evidence-based techniques from business and medicine to be applied for organizations across various fields to promote and maintain these qualities.
RISE OF PROFESSIONAL ASSOCIATIONS
Associations are membership organizations or societies composed of individuals with a common purpose. These groups can be further divided into professional and trade subgroups; professional associations include members within a single profession, whereas trade associations involve members within a particular industry.1
The Royal Society of London is one of the oldest associations in the world that originated in Europe during the Renaissance period following a lecture by Sir Christopher Wren, an astronomer, physicist-mathematician, and one of the greatest architects in British history.2,3 Members were scientists and scholars from different nations, including Sir Isaac Newton, Gottfried Leibniz, Edmund Haley, and Robert Hooke.2 Original research circulated by The Royal Society contributed to the rise of the industrial revolution, embryonic evolution theory, mechanical computation, and planetary gravity. This organization withstood time and international warfare through two key characteristics: shared vision and trust. Members were committed to a shared vision, the advancement of science, and practiced trust, which facilitated respect, understanding, and accountability.
The rise of associations in America began when the first settlers founded professional organizations in the form of “guilds” in the 1600s.4 Early guilds were collections of businessmen and craftsmen who sought financial gain by increasing networking and trade. The number of associations has grown to over 63,000 different organizations encompassing over 1.3 million employees in 2016.1,5,6 Benefits of early guilds were primarily limited to financial gains, whereas modern-day associations provide access to an exclusive community with ample resources and manpower. Compared with early guilds, joining a modern-day professional association provides members with networking, access to professional and financial resources, leadership opportunities, and continuing educational opportunities such as courses and workshops. Additionally, professional associations have expanded the workforce and improved safety through standardized training programs and certifications.7
ASSOCIATIONS IN MEDICINE
Members of professional medical organization can prepare clinical guidelines, further professional development, mentor young leaders, and gain access to cutting-edge clinical research.8,9 For example, the American Medical Association (AMA) is the largest medical association, consisting of over 300,000 physicians nationally. The AMA focuses on improving public health, patient safety, and medical ethics.10 The National Patient Safety Foundation and the Patient Safety and Quality Improvement Act of 2005 were two of AMA’s initiatives to improve quality of care and patient welfare.9 The AMA provided patients and providers with tools to understand how Affordable Care Act will impact health care, including fact sheets, open enrollment information, and answers to common questions.8 It is important to note that the number of dues-paying AMA members has been steadily decreasing from 75% of physicians in the 1950s to only 15% in 2011.11 In recent years, the organization has been experiencing a constant increase in dues-paying physicians, but only up to 2.6% per year.10 Despite these shortcomings, the AMA is the oldest and longest standing medical association and has played a large role in the development of health care. The AMA established the Journal of the American Medical Association (JAMA) Network, a family of journals from 11 specialties and JAMA Network Open, for the advancement of medicine and health care. With an impact factor of 47.7, JAMA is one of the most circulated and highly regarded medical journals worldwide, reaching over 320,000 printed and 1.2 million electronic subscribers.12
Medical associations are further divided by specialty. In the field of plastic surgery, the American Society of Plastic Surgeons (ASPS), established in 1931, consists of over 93% of board-certified plastic surgeons in the United States and over 8,000 plastic surgeons worldwide.13 ASPS aims to promote high standards of training, medical ethics, and research within the field of plastic surgery. The Plastic Surgery Foundation encourages and provides funding for research and innovation in the field of plastic surgery for ASPS members. Furthermore, in 2018, ASPS achieved Accreditation with Commendation, which is a 6-year term award by the Accreditation Council for Continuing Medical Education reserved for the top 18% of all accredited organizations providing continuing medical education.14 Technological advancements by ASPS include the free ASPS member mobile application, Plastic Surgeon Match, and “Ask a Surgeon” forum. ASPS enriches educational and professional development through Education Network, Essentials of Leadership seminars, Residents Council, and Young Plastics Surgeons Forum. Plastic and Reconstructive Surgery (PRS) is a peer-reviewed journal established by the ASPS. PRS is recognized as the top plastic surgery journal in the world, reaching over 13 million users worldwide.15 Plastic Surgery Essentials for Students and PRS Global Open are additional reliable sources of information for students and healthcare providers.
Professional associations such as The Royal Society of London, AMA, and ASPS have and will continue to facilitate the advancement of medicine, health care, and science through advocacy, health policy, and clinical research. Although the organizations discussed differ in their scope, they share similar core characteristics that ensure their success. Many papers have examined teamwork in the fields of business and health care, but few have delineated the key characteristics of successful high-performing medical organizations. Figure 1 demonstrates a conceptual model that characterizes the qualities of high-performing medical organizations, such as structure, trust, accountability, productive conflict, collective success, and leadership. These fundamental qualities will be discussed further throughout this report, along with an in-depth examination of the techniques used to promote and maintain these qualities.
Structure is the underlying framework of any team or organization and has two components: a mission that members work toward and the actual members themselves. A clear mission enables members to understand the direction and end goal.16,17 International Business Machines is a current leader in both manufacturing and research, operating in over 170 countries.18 Their Process for Quality Management (PQM) method begins with a focused mission to determine the critical success factors that are essential to the project’s survival and completion.19 After its implementation, PQM method reduced costs, improved quality, and raised customer satisfaction.20 The PQM recommends that mission statements are explicit and limited to 3–4 sentences. People of International Business Machines value “dedication to every client’s success, innovation that matters—for our company and for the world, and trust and personal responsibility in all relationships.”21 This statement is simple to understand and remember, establishing an organizational culture that everyone strives to adhere. Members are encouraged to reflect and discuss with each other to ensure understanding and agreement. Identifying a suitable mission is imperative for desirable results while incorrect or unclear missions lead to confusion, unwanted outcomes, and misuse of time, money, and talent.
Moreover, the establishment of a clear mission will facilitate superior results even with minimal supervision.22,23 Netflix is a US-based media company with tremendous growth over the last 2 decades; it began as a rental service and transformed into a streaming platform that is available in almost every country worldwide and consistently produces award-winning TV shows and films.24–26 Netflix requires that each employee read and understand the “Foundational Documents” that contain the company’s philosophy and values, which emphasize “people over process.”23 Specifically, Netflix have “great people working together as a dream team,” leading to a more “flexible, fun, stimulating, creative, collaborative, and successful organization.”27 Employees are trusted to act appropriately and independently on the company’s behalf. The lack of supervision and drive for constant reinforcement enabled employees to broaden their voices, increase responsibility and investment in their work, and enhance overall performance.16 Similarly in health care, in a survey study of over 10,000 nurses across 32 hospitals in England, increased nursing autonomy was associated with better perceptions of quality of care, quicker decision-making, higher job satisfaction, enhanced teamwork, and lower burnout rates.28
Selection of members is another essential aspect of structure and should be based on skill, culture, and diversity (Fig. 2). Skill includes consideration of work experience, current skill level, and skill potential, as no team will begin with all the necessary skills to achieve.29 Culture is the psychological environment shaped by the beliefs, thought processes, and behaviors of group members. In an analysis of culture in over 230 companies and leadership styles and values in 1,300 executives, culture is a powerful differentiator between strong and weak businesses.30 Strong culture drives better outcomes because it fosters employee engagement and motivation. In airline and retail industries, stronger workplace culture has resulted in higher customer satisfaction, leading to recognition awards and company growth.30,31 According to the attraction-selection-attrition model, people are attracted to and remain in teams or work environments with characteristics similar to their own. Although people tend to gravitate toward teams with similar mindsets, teams benefit from variability in demographics. Varying ages, genders, ethnicities, and life experiences in team composition is advantageous.22
Mutual trust permits members to recognize that if another member is pushing them, their intentions are for the betterment of the team.32 Trust abolishes competitive instinct and fixation on upholding individual image of competence and expertise.33,34 Members who practice trust reveal vulnerabilities, admit to issues on performance reviews, and appreciate feedback.32,33,35 Uncertainty and discomfort in revealing weaknesses prevent members from asking each other for help. However, organizational growth is nearly impossible without collaboration; teamwork can even highlight individual capabilities. Employees of organizations that have large amount of trust experience 74% less stress, 40% less burnout, and 50% higher productivity, with 41% exhibiting a greater sense of accomplishment when compared with employees in low-trusting organizations.36
The initial step to demonstrate mutual trust is to simply ask for help.37 Behavioral studies have demonstrated that the rate of getting help from complete strangers was up to 48% higher than expected.38 Help-seekers often underestimate the effort helpers are willing to invest due to the “helper’s high,” an emotional benefit from serving others.37,38 Using in-group reinforcements, positive identification, and follow-up of effect increase the chances of receiving help.33 In-group reinforcements affirm that the helper and help-seeker are on the same team and assure that the helper’s contribution will assist the team. Examples include using words such as “team” or “together,” highlighting shared experiences, or citing common goals or obstacles. Positive identification recognizes the helper for their unique role or attribute, such as a “generous donor,” “dependable helper,” or “reliable teammate.” Following up includes expressing how the helper’s contribution affected the progress of the project.
Mutual trust is essential for safe and effective patient care.39–41 To build trust, teams that work together are encouraged to train together to promote understanding of roles.39,42–44 In plastic surgery, simulator training has been shown to be a cost-effective tool to increase knowledge and technical competency.44–48 Multiple studies across different surgical disciplines have demonstrated that team simulations prevent errors, decrease surgical mortality, and improve patient safety.40,41,49
Mutual trust cultivates interesting meetings filled with free flow of ideas, open communication, and productive conflict. Productive conflicts are unfiltered, passionate discussions about current team issues and solutions to overcome them.32,34 In theory, teams possess collective intelligence and are driven by experiences, information, and talent that each member can contribute.50 However, in practice, teams habitually fixate on shared, rather than unique knowledge. Even in situations where team members are explicitly told to share all the information, members will still withhold pertinent information because of existing habits, information overload, or inattentiveness.50
Productive conflict can prevent groupthink. Groupthink refers to when a group makes poor decisions owing to their desire to reach a consensus quickly to avoid conflict.32,50 These groups safeguard artificial harmony and prohibit individual creativity, leading to informational signal and reputational pressure error.51 Informational signal error occurs when a team member receives faulty information from another member, whereas reputational pressure error happens when a member is hesitant to state his/her honest opinion in fear of penalty. Both of these errors are amplified by the leader and cascade down the chain of command, ultimately leading to poor decisions.51 Unfiltered discussion and open communication promotes productive conflict and limits groupthink. Creating anonymous polls dissolves fear of penalty or need to protect reputation. Another method is to provide each member with sufficient time to develop his/her ideas and protected time to share. Assigning roles for different tasks promotes discussion through increased ownership as each member will have different information to add. The leader of the group can endorse open communication by remaining silent during early phases of the discussion and show interest through listening. This prevents unintentional bias as members are not swayed by the leader’s ideas.
In health care, surgical teams that share information less frequently at the beginning of the case or during patient handover double the risk of surgical complications compared with teams that share information frequently.52 Methods to improve communication in health care include thinking aloud, checklists, and structured handover tools. Verbalizing given information and the decision-making process facilitate input and understanding by other members.39 The establishment of World Health Organization’s surgical safety checklist has significantly reduced patient morbidity and mortality.53 This is attributed to the fact that all staff involved are present in one place and time to share pertinent patient information, the treatment plan, and any special concerns. Effective handovers are essential for continuous and safe patient care; multiple studies have demonstrated that residents feel that handovers are poor.54–56 Highly rated handovers are those with complete assessments, relay of pertinent information, and less time required to seek out any missing information.57 Structured handover tools that outline important information improved handover quality.54,58
High-performing organizations consist of members who hold both themselves and other members accountable.32,59 Active avoidance of interpersonal discomfort limits this process. Accountability leads to productivity, establishes respect, and urges poor performers to improve to meet the team’s standards.60
Methods to increasing both individual and mutual accountability include detailed tasks, if-then planning, and progress updates. Tasks should be explicitly outlined with what needs to be done, by whom, and by when. If-then planning technique uses our neurological wiring to build contingency plans.60,61 When a certain cue or situation “x” arises, task “y” will be performed. If-then planners are more likely to meet deadlines and practice timely preventative care, including exercising and taking medications as scheduled. Teams that incorporate if-then statements are more efficient, complete tasks in a timelier manner, and are 300% more likely to reach their goals.60 Progress updates range from quick 15-minute communication huddles to regular meetings to weekly emails. Communication huddles improve interdepartmental teamwork and provide 24-hour updates, anticipate adverse events, review resolved issues, and discuss solutions to new problems.62 The huddle framework begins with identifying participants and the leader, setting time and frequency, and establishing the type of information to be shared and follow-up procedures (Fig. 3). The Joint Commission recommends that teams huddle for at least 6 months before anticipating results. Institutions that practice communication huddles saw quicker solutions to real-time problems, increased interdepartmental communication and trust, and improved quality care for patients.63 Regular team meetings facilitate face-to-face discussion and can generate rapport, which increases understanding, trust, and accountability. The implementation of a service improvement program that encourages regular team meetings in a geriatric rehabilitation center for 12 months resulted in reduction in staff absences and major patient safety incidents.63 Within our own research team at the Michigan Comprehensive Hand Center for Innovation Research (M-CHOIR), each member sends a weekly update to rest of the team regarding the progress of current projects. These emails promote transparency, maintain open communication, and facilitate understanding among laboratory members.
Collective success is woven into the culture of an organization; this occurs when members prioritize the team’s needs over the individual’s. In teams that promote collective success, members are better oriented and more outcome-driven.32 The outcome-driven cycle consists of three parts, including recognition, plan, and reward (Fig. 4). Progress is driven by “recognition” of both past team accomplishments and areas that need improvement. “Plan” consists of establishing a clear mission, goals, and subgoals. “Reward” is influenced by individual intrinsic and extrinsic factors. Intrinsic motivators include job satisfaction, self-gratification, or sense of meaning whereas extrinsic motivators include recognition, positive feedback, or monetary value.22 Understanding this cycle allows leaders to retain achievement-oriented members, minimalize individualistic behavior, and reinforce actions for the betterment of the team. During the Great Recession of 2008, DTE Energy (DTE) recognized that employees were underperforming based on their engagement and investment to work. To combat this, the company focused on connecting people to a new purpose: “We serve with our energy, the lifeblood of communities and the engine of progress.” This plan began with a video demonstrating how power generated by workers at every level impacted homes, businesses, and hospitals across the nation. The reward of seeing the meaning behind their work empowered employees to keep improving; DTE stock price tripled from 2008 to 2017.64
Emphasis on team results, public announcements, and visual aids endorse a collective success culture. Highlight team results by focusing on how a member’s contribution brought the team 1 step closer to accomplishing the goal. Public announcements of individual accomplishments can boost morale and facilitate recognition. Visual aids using a bulletin, display, or task board to exhibit the team’s current position and provide continuous guidance for members. In healthcare settings, the priority of the team is to optimize patient care.65 Although members must take perspectives of others into account; each member should ultimately perform tasks that are aligned with the team’s priorities rather than individual ones.39,66
Strong leaders make definite decisions, optimize desirable results, and lead through example. Leaders who are decisive, even if they are wrong, are 12 times more likely to be described as strong Chief Executive Officers.67 Bad decisions are better than no decisions; indecisiveness slows down teams through bottlenecking, often resulting in ambiguity, frustration, and overcautious members. Successful leaders can hone into the underlying motivation and understand the needs of others. This skill permits leaders to design and execute strategies targeted at suitable outcomes. One of the most important qualities in leaders of high-performing team or organization is their ability to lead through example.32,68 These leaders establish structure, assemble the right members, display vulnerability, encourage positive debate, hold themselves and others accountable, and highlight the success of the team rather than their own.
The framework, composition, and discipline of teams have dramatically changed from a simple collection of members and will continue to transform with time. Modern-day teams span across different departments, professions, and locations. Completion of a project requires a compilation of various skills, including design, funding, strategic planning, mechanics, and marketing.22 Achievements by associations such as the Royal Society of London, AMA, and ASPS were not accomplished by one single member, but rather through the compilation of joint resources, knowledge, and effort. Associations are essential for continued progress; through our literature search, we found that the qualities described above are essential to building a successful high-performing organization.
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