Navy Seals, San Antonio Spurs, and Just Culture - Building a - - PDF document

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Navy Seals, San Antonio Spurs, and Just Culture

• Building a Well-Functioning Pharmacy Team

Rob Wills, PharmD, BCPS

• St. Luke’s Boise Medical Center

9/28/2018

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Disclosures

• The presenter has no real or perceived conflicts of interest

related to this presentation

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Learning Objectives

• Identify how team differences and make up can affect goal

attainment and success.

• Recognize successful teams and what factors have led to a

strong team and culture.

• Discuss strategies to develop a just culture.
• Be able to identify opportunities to make your team more

effective.

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The Challenge!

• Divide into 4 person Groups
• Directions

Each group to build the tallest possible structure with using the following items: Note – the marshmallow must be on top! Twenty pieces of uncooked spaghetti One yard of tape One yard of String One standard‐size marshmallow

Sources: BlueSky Personnel Solutions http://www.blueskypersonnel.com/why‐kindergarteners‐consistently‐outperform‐ceos‐on‐this‐challenge/ accessed 8/1/2018

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Image source: hanno.com

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Winner?

• What were the key

differences for the successful team?

• Intelligence?
• Skills?
• Background?
• Communication?
• Clear leader?
• Luck 

Sources: Madaboutscience.com

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Compared different groups

Image source: lycee francais Chicago, jencoinc

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5 10 15 20 25 30 Height (in)

Marshmallow Challenge Winners

Average Business School Students Lawyers Kindergarten CEO's

Sources: Build a tower, build a team, TED Talk. Tom Wujec ‐ YouTube

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Business Students

• Got right to work
• Began talking and thinking

strategically

• Examined materials
• Tossed ideas back and forth
• Asked thoughtful, savvy

questions

• Developed options and

honed their most promising ideas

• Result pursue one strategy

Sources: The Culture Code by Daniel Coyle. Sources: Build a tower, build a team, TED Talk. Tom Wujec ‐ YouTube

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Kindergarten students

• Did not strategize
• Did not analyze or share

experiences

• Did not ask questions or

propose options, or hone ideas

• They barely talked at all

Sources: The Culture Code by Daniel Coyle.

Kindergarten students

Sources: Build a tower, build a team, TED Talk. Tom Wujec ‐ YouTube

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What matters is the interaction

• Individual skills are not what matters
• Business school students
• Appear to be collaborating
• Instead they are engaged in a process psychologists call status

management

• Working to understand the norms
• Who is in charge?
• Is it okay to criticize?
• What are the rules here?
• They spend so much time managing status that they fail to

grasp the essence of the problem

Sources: The Culture Code by Daniel Coyle. Image source: hanno.com

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Kindergartners

• Appear disorganized
• Looking closer
• They are not competing for status
• They stand shoulder to shoulder and work energetically together
• They move quickly, spotting problems and offering help
• They experiment and take risks
• They succeed not because they are smarter but work in a

smarter way

Image source: lycee francais Chicago Sources: The Culture Code by Daniel Coyle.

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NYT I ME S F e b 25th, 2016

What Google L ear ned F r

• m Its

Quest to Build the Per fec t T eam

Source: http://www.nytimes.com/2016/02/28/magazine/what‐google‐ learned‐from‐its‐quest‐to‐build‐the‐perfect‐team.html?_r=0 Image source: www.nytimes.com

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○ Julia Rozovsky ○ Searching for a career ○ Yale Business School – MBA ○ Assigned a study group

○ To foster tight bonds ○ Right of passage for MBA

programs

○ A way for students to practice

working in teams

Sto r y o f Julia

Source: http://www.nytimes.com/2016/02/28/magazine/what‐ google‐learned‐from‐its‐quest‐to‐build‐the‐perfect‐team.html?_r=0 Image source: www.advancedmanagement.net

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○ Every day, between classes and after dinner ○ Her and her 4‐teammates met ○ All smart & curious ○ Gone to similar colleges and worked at similar firms

He r T e am

Source: http://www.nytimes.com/2016/02/28/magazine/what‐ google‐learned‐from‐its‐quest‐to‐build‐the‐perfect‐team.html?_r=0 Image source: www.pilantsbusinessethics.com

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• Constantly felt like she had to

prove herself

• Team dynamics could put her on

edge

• Teammates jockeyed for position

during meetings

• Conflicts over who was in charge
• People spoke louder to gain

authority

• She became afraid to make

mistakes

Source of Stress

Source: http://www.nytimes.com/2016/02/28/magazine/what‐ google‐learned‐from‐its‐quest‐to‐build‐the‐perfect‐team.html?_r=0 Image source: www.pilantsbusinessethics.com

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• Some students were putting

together teams for ‘case study’ competitions

• Participants proposed solutions

to real‐world business problems

• Her New Team
• Different atmosphere
• Creative
• Produces top work
• Connects outside of the group

Julia Started Looking for a new team

Source: http://www.nytimes.com/2016/02/28/magazine/what‐ google‐learned‐from‐its‐quest‐to‐build‐the‐perfect‐team.html?_r=0 Image source: www.123rf.com

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• Google’s People Operations Department
• Invested millions of dollars in trying to learn how to put

together the perfect team.

• For years they have measured every aspect of their

employee’s lives

• From how frequently they eat together
• To building larger networks by rotating dining

companions

• Believed that combining the best people created the best

teams

& Building the Perfect Team

Source: http://www.nytimes.com/2016/02/28/magazine/what‐ google‐learned‐from‐its‐quest‐to‐build‐the‐perfect‐team.html?_r=0 Image source: google.co.th

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• In 2012 Google put

together Project Aristotle

• Goal was to figure out

why some teams succeeded while others stumbled

• Started making

diagrams

Project Aristotle

Source: http://www.nytimes.com/2016/02/28/magazine/what‐ google‐learned‐from‐its‐quest‐to‐build‐the‐perfect‐ team.html?_r=0 Image source: www.nytimes.com

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• Did team’s need to be made up with people of similar

interests, backgrounds, etc.?

• Did the group need to have the same reward system or

values?

• How often did teammates socialize outside the office?
• Did they have the same hobbies?
• Were their educational backgrounds similar?
• Was it better for all teammates to be outgoing or for all
• f them to be shy?

Project Aristotle - Questions

Source: http://www.nytimes.com/2016/02/28/magazine/what‐google‐ learned‐from‐its‐quest‐to‐build‐the‐perfect‐team.html?_r=0 Image source: www.resologics.com

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• Reviewed over 180 teams

within Google

• No combinations seem to align
• r correlate
• 2 teams could have similar

makeup with overlapping members with entirely different outcomes

Project Aristotle’s Results

L e r a b l

• Source: http://www.nytimes.com/2016/02/28/magazine/what‐

google‐learned‐from‐its‐quest‐to‐build‐the‐perfect‐ team.html?_r=0 Image source: www.resologics.com

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• Started looking at Group Norms or

behaviors

• Were there unwritten rules
• Did they have exacting

standards on when to speak

• Some celebrated birthdays,
• thers had informal chit‐chat

prior to the meeting start

Project Aristotle’s Results

Source: http://www.nytimes.com/2016/02/28/magazine/what‐ google‐learned‐from‐its‐quest‐to‐build‐the‐perfect‐ team.html?_r=0 Image source: www.resologics.com

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Good characteristics

• Members spoke in

roughly the same proportion

• If one group or individual

spoke primarily ‐ then the results declined

• High social sensitivity

= Psychological Safety

Source: http://www.nytimes.com/2016/02/28/magazine/what‐ google‐learned‐from‐its‐quest‐to‐build‐the‐perfect‐team.html?_r=0 Image source: the business couch

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• ‘‘shared belief held by

members of a team that the team is safe for interpersonal risk‐taking.’’

• ‘‘a sense of confidence that

the team will not embarrass, reject or punish someone for speaking up,’’

Psychological Safety

Source: http://www.nytimes.com/2016/02/28/magazine/what‐ google‐learned‐from‐its‐quest‐to‐build‐the‐perfect‐ team.html?_r=0 Image source: www.innovationmanagement.se

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Amy Edmondson’s Story

• 1991, first‐year PhD student at Harvard
• Studying organizational behavior
• Specifically looking at Medical Mistakes

Source: Smarter, Faster, Better by Charles Duhigg Image source: hbs.com www.charlesduhigg.com

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Comparing Teams

• Found equally strong teams
• One had fewer errors
• More comfortable reporting errors
• The other
• “if you make a mistake on this unit it is held against you”

Source: Smarter, Faster, Better by Charles Duhig Image source: UofUhealth

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Strong Teams

• Nurses felt more

comfortable reporting

• One important Norm
• Whether people were

punished for missteps

• Influenced if they

were honest after they screw‐up

Source: Smarter, Faster, Better by Charles Duhig Image source: Perelman School of Medicine

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Edmonson’s Research

• Noted a handful of good

norms

• Associated with higher

productivity

• Best Teams
• Leaders encouraged people to

speak up (acknowledged that there will be errors)

• Teammates felt they could

expose their vulnerabilities to

• ne another
• People said they could suggest

ideas without fear of retribution

Source: Smarter, Faster, Better by Charles Duhig Image source: workingnurse.com

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Image source: world economic forum

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Connecting with Just Culture

Just Culture: people are encouraged, even rewarded, for providing essentials safety-related information, but clear lines are drawn between human error and at risk or reckless behavior Reporting Culture: people report their errors and near-misses Learning Culture: the willingness and the competence to draw the right conclusions from safety information systems, and the will to implement major reforms when the need is indicated

The Joint Commission. (March 1, 2017). Sentinel Event Alert: Issue 57, The essential role of leadership in developing a safety culture Just Culture Reporting Culture Learning Culture Safety Culture

Source: Danika Severe, SLHS Just Culture, 8/2018

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Individual Behaviors

There are three types of behavior that can lead to a patient safety issue:

• Unintended human error: inadvertent slip, lapse, or mistake
• At‐risk behavior: conscious drift from safe behavior, occurring

when an individual believes that drift doesn’t cause harm

• Reckless behavior: malevolent or willful misconduct; individual

consciously chooses to engage in behavior that has unjustified and substantial risk Each has a different cause so a different response is necessary.

Source: Danika Severe, SLHS Just Culture, 8/2018

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Just Culture Decision Guide

Source: Danika Severe, SLHS Just Culture, 8/2018

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Building Culture

• Daniel Coyle
• Previous books
• Lance Armstrong’s War
• The Secret Race
• Pulls in many concepts

that are featured in other books

• Combines stories and

focus

Sources: The Culture Code by Daniel Coyle. Images from: http://danielcoyle.com/buy‐the‐culture‐code/

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Developing Culture

1.Building Sa fe ty

2.Sha re Vulne ra b ility 3.E sta b lish Purpo se

Sources: The Culture Code by Daniel Coyle. Images from: http://danielcoyle.com/buy‐the‐culture‐code/

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Building Safety

Sources: The Culture Code by Daniel Coyle.

• Its really about Belonging
• Belonging Cues
• Function is to answer the ancient, ever present question
• Are we safe here?
• What’s our future with these people?
• Are there dangers lurking?
• Possess three basic qualities
• 1. Energy – they invest in the exchange
• 2. Individualism – treat the person as unique and valued
• 3. Future Orientation – they signal the relationship will continue

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How to build belonging

• “Wins above expectation”
• The number of times a coach’s team won a game that, measured

by the players skills, they had no business winning

• Most coaches are in line with expectations based on player ability
• Except one – Gregg Popovich
• San Antonio Spurs
• Under Popovich they have won 117 games more than they should

have (more than double the next head coach)

• Selfless play

Sources: The Culture Code by Daniel Coyle. Image Source: The undefeated, Total Retail

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Popovich

• Considered an old‐

school, hard‐core, unapologetic authoritarian

• A steel spined product
• f the Air Force

Academy

• Dyspeptic bulldog
• Possesses a temper

that could be described as “volcanic”

Sources: The Culture Code by Daniel Coyle. Image: Sports Illustrated

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What you see at practice

• Example of attending a

practice following a big loss

• Room was tense
• Popovich walks in and starts

working the room

• Connects with each player
• Touched them on arm, shoulder
• Lopsided grin, laughing
• Eyes were bright, knowing and

active

• Spoke in native languages of

players

He does two things over and over

1. He’ll tell you the truth, with no BS 2. He’ll love you to death

• “you gotta hug’em and

hold’em.”

Sources: The Culture Code by Daniel Coyle. Image: http://fortune.com/2014/06/16/gregg‐popovich‐leadership/

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Making Connections

• Before this Popovich connected in another way – the film room
• Instead of reviewing the previous nights game, highlighting errors and

mistakes

• He played a CNN documentary on the 50th anniversary of the Voting

Rights Act

• Then asked questions, personal, direct, forward…drawing a

connection

Sources: The Culture Code by Daniel Coyle. Image: https://www.si.com/nba/2015/09/29/greg‐popovich‐coaching‐tim‐duncan‐retirement

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Connecting with food

• Popovich is obsessed

with food and wine

• Part owner in an Oregon

wine vineyard

• Food network always on in

his office

• Uses it to build

relationships

• Spurs eat meals together

about as much as they play basketball

• Creates scrap books for

coaches with menus

Sources: The Culture Code by Daniel Coyle. Image: https://terezowens.com/picture‐of‐greg‐popovich‐kahwi‐leanard‐meeting‐in‐san‐diego/

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Story of the big loss

June 18th, 2013

• Spurs on verge of

winning their 5th NBA championship

• 3 games to 2 lead over

Miami Heat

• Spurs had 94 – 89 lead

with 28.2 seconds

• Odds of victory 66:1

Sources: The Culture Code by Daniel Coyle. Image: https://www.expressnews.com/sports/spurs/article/Spurs‐Archives‐Game‐7‐Finals‐loss‐to‐Miami‐6924469.php

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After the loss – building belonging

Source: https://therivardreport.com/popovich‐brings‐friendship‐respect‐to‐military‐fundraiser/

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Belonging Cues

• Energy: They invest

in the exchange that is occurring

• Individualization:

They treat the person as an individual

• Future orientation:

They signal the relationship will continue

Sources: The Culture Code by Daniel Coyle. Image: https://timedotcom.files.wordpress.com/2018/01/lamarcus‐aldridge‐gregg‐popovich.jpg

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Magical Feedback

• Team of psychologists from Stanford, Yale and Columbia
• One form of teacher feedback boosted student effort and

performance

• Deemed “Magical Feedback”
• I’m giving you these comments because I have very high

expectations and I know that you can reach them.

• 19 words!
• Doesn’t contain how to improve

Source: The Culture Code by Daniel Coyle.

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Question

• How can you help foster Belonging in your department or

institution?

Image source: quibblo.com

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How to design for belonging

• Zappos community in Las Vegas
• Designed to increase the number of interactions

Sources: The Culture Code by Daniel Coyle. Image Source: Las Vegas Weekly, venturebeast.com

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Clusters of High Communication

Sources: The Culture Code by Daniel Coyle. Image Source: Better Projects

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Electronic & In Person

Sources: The Culture Code by Daniel Coyle. Image Source: Rethink the essentials

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Do we need to rethink staffing models?

• Remote
• In satellites
• On the floor

Sources: The Culture Code by Daniel Coyle. Image Source: HBR.com

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Developing Culture

1.Building Sa fe ty

2.Sha re Vulne ra bility

3.E sta b lish Purpo se

Sources: The Culture Code by Daniel Coyle. Images from: http://danielcoyle.com/buy‐the‐culture‐code/

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• July 10, 1989
• United flight 232
• Denver to Chicago
• Captain Al Hayes, 2

years from retirement

• Co‐pilot and engineer

also in cockpit

Share Vulnerability

Sources: The Culture Code by Daniel Coyle Image Source: Maltatoday.com.

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Flight 232

Image source: https://twitter.com/aircrashmayday/status/755329548456173568

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Send him up.

• “The scene to me as

a pilot was unbelievable,”

• “Both the pilots were

in short‐sleeved shirts, the tendons being raised on their forearms, their knuckles were white…”

Source: NPR.org Image source: www.Cbsnews.com “Tell Me What You Want, and I will Help You”

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“Anybody have any ideas?”

• Team spoke in short

bursts

• Notifications
• Open ended
• No hierarchy
• Captain Hayes
• Anybody have any

ideas

• Included some humor

Source: The Culture Code by Daniel Coyle Image source: airodyssey.net

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Its about the Receiver

• We know at some level vulnerability works to establish trust
• Tendency is to think it’s a “touchy‐feely process”
• What its really about is sending a signal that you have a

weakness, that you could use help

• Key
• Its less about the sender than the receiver
• The second person is key
• Do they pick it up and reveal their own weaknesses
• Or do they cover up and pretend they don’t?
• When the signal travels through the group you can see

everyone relax and connect, and start to trust

Source: The Culture Code by Daniel Coyle

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Image source: medium.com

The Vulnerability Loop

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Navy Seals

• Model Organization

for Leadership

• Countless Books
• History of Success
• Starts with Hell Week

Image source: military.com

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Image source: militaryposters.com

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Image sources: navytimes.com and wikimedia

Vulnerability & Interconnection

1. A teammate falters 2. Others sense it, and respond by taking on more pain for the sake of the group 3. Balance is regained

Source: The Culture Code by Daniel Coyle

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• Make Sure the Leader is

Vulnerable First and Often

• Over communicate Expectations
• Deliver the Negative Stuff in

Person

• In Conversation, Resist the

Temptation to Reflexively Add Value

• Aim for Candor, Avoid Brutal

Honesty

• Feedback that is smaller, more

targeted, less personal and less judgmental

Ideas for Action: Shared Vulnerability

Image source: https://www.businessnewsdaily.com/10680‐unmasking‐vulnerabilities‐leadership.html

Source: The Culture Code by Daniel Coyle

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Developing Culture

1.Building Sa fe ty 2.Sha re Vulne ra b ility

3.E stablish Pur pose

Sources: The Culture Code by Daniel Coyle. Images from: http://danielcoyle.com/buy‐the‐culture‐code/

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• 1975 The Credo
• J&J’s one page document
• Leader: James Burke
• ‘We believe our first

responsibility is to doctors, nurses, and patients; to mothers and fathers and all

• thers who use our products

and services. In meeting their needs everything we do must be of high quality…’

Establish a purpose

Source: Johnson & Johnson Sources: The Culture Code by Daniel Coyle.

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• 1975 The Credo
• J&J’s one page document

1. Customers 2. Employees 3. Community 4. Company stockholders

• The word “must” appears 21

times

• He asked for a commitment

to the principles and values of the Credo

Johnson & Johnson Credo

Source: Johnson & Johnson Sources: The Culture Code by Daniel Coyle.

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• Johnson & Johnson
• Acetaminophen (Tylenol)

Scare

• Seven were dead in

Chicago after ingesting cyanide laced acetaminophen (Tylenol)

• J&J went from a provider of

medicine to a provider of poison

• Decision point
• Redirect Blame – protecting

profits?

• Accept responsibility – the

credo?

Sept 30th, 1982

Sources: The Culture Code by Daniel Coyle.

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• Johnson & Johnson
• Acetaminophen (Tylenol)

Scare

• J&J chose to follow the

Credo

• Went from being a

pharmaceutical company to a public safety company

• 100’s of decisions needed

to be made, and made quickly

• Everyone worked together

because everyone followed the same purpose

Establish a purpose

Image source: NPR.org

Sources: The Culture Code by Daniel Coyle.

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• How quickly it improves its

performance of a new skill

• Amy Edmondson
• Tracked 16 Surgical Teams
• Performing a new heart

surgery

• MICS – minimally invasive

cardiac surgery

• Each team took a 3‐day

training course

• Question – which team

would learn the fastest?

Learning Velocity

Image source: medical xpress Sources: The Culture Code by Daniel Coyle.

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Predicting the winner

• Large teaching

hospitals

• Chelsea Hospital
• Worldly prestigious
• Small community

hospitals

• Mountain View

Hospital

• Local team

Sources: The Culture Code by Daniel Coyle.

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• Framing – conceptualizing it as a

learning experience that will help patients

• Roles – teams explicitly told why

their individual and collective roles were important for teams success

• Rehearsal – elaborate dry runs
• Explicit encouragement to speak up

– actively coached through the process

• Active Reflection – between

surgeries

Connected with purpose

Sources: The Culture Code by Daniel Coyle.

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Factors to success

• Factors not

associated with success

• Experience
• Surgeon Status
• Organizational

Support

• Signals may have

differed but all had same vital function

• To flood the

environment with narrative links between what they were doing now and what it meant

Sources: The Culture Code by Daniel Coyle.

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Value of those signals

• Value is not the

information

• Value is in the fact

that they orient the team

• to the task
• to one another

Image source: crazymoneyexpress Sources: The Culture Code by Daniel Coyle.

PULLING IT ALL TOGETHER

Image source: Blue Sky eLearn

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Ideas for Action

• Over communicate

Your Listening

• Head tilted slightly

forward

• Eyes unblinking
• Eyebrows arched and up
• Sounds – stream of

affirmations – yes, uh‐ huh, gotcha

Sources: The Culture Code by Daniel Coyle. Image Source: Music city school counselor

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Ideas for Action: Building Safety

• Embrace the messenger
• Popovich – hug the messenger
• Everyone has a voice
• Overdo “Thank you’s”

Sources: The Culture Code by Daniel Coyle. Image Source: Poundingtherock.com

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Ideas for Action: Building Safety

• Spotlight Your Fallibility Early On –

Especially if you are a leader

• Natural tendency to try and hide our weaknesses

and appear competent

• Use phrases
• Just my two cents
• I could be wrong here
• What am I missing?
• What do you think?

Sources: The Culture Code by Daniel Coyle.

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• Create Safe, Collision‐Rich Space

Ideas for action: Designing Belonging

Sources: The Culture Code by Daniel Coyle. Image source: macworld.com

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• Name and Rank Your Priorities
• Be Ten Times as Clear About

Your Priorities as You Think You Should Be

• Figure Out Where Your Group

Aims for Proficiency and Where It Aims for Creativity

• High repetition, high

feedback training

• Define, reinforce, relentlessly

protect the team’s creative autonomy

• Measure What Matters
• Embrace the Use of

Catchphrases

Ideas for action: Establishing purpose

Sources: The Culture Code by Daniel Coyle.

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Is this a strategy for healthcare?

• How can this be applied to Pharmacy?

Image source: callcentrehelp.com

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What Make s a Suc c e ssful Cultur e?

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Other examples

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Carolina way

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