What makes teams effective? (2) Achieving the Piranha Club state

Back in the mid-1990s, when I was working in the Center for Clinical Effectiveness at the Henry Ford Health System, I had the privilege and joy of being part of a team of smart, creative, passionate people working to transform health care.  The team included a core staff and an extended collection of collaborators from various clinical and administrative departments within Henry Ford and the Health Alliance Plan.  The extended team also included collaborators from outside the institution, including the American Group Practice Association (now called the American Medical Group Association) and other physician organizations around the country that shared the vision of population management, quality and outcomes measurement, evidence-based medicine, and patient-centeredness — the same concepts that are at the heart of the current wave of health care transformation efforts.

The thing that I found so refreshing and stimulating about working with that team was the intensity of the intellectual discourse.  Everyone passionately debated everything, but nobody’s feelings seemed to get hurt too badly.  The ideas that survived tended to be good ones.  One of the members of that team was Yoel Robens-Paradise, a young project manager.  He captured the essence of this debate society culture in a satirical poem that he wrote in December of 1994.


Based on this poem, we coined the term “Piranha Club” to describe the rare but excellent state of a team where “everyone is fiesty, but no one is mean.”  I’ve been actively working to achieve the Piranha Club state in all the teams in which I have been a part ever since, including research teams, information technology development teams, clinical program design teams, consulting teams, and business leadership teams.  Sometimes I succeed.  Sometimes, not so much.

I am convinced that the secret to achieving the Piranha Club state is to have every single member of the team have two things.  First, each team member must start by having the confidence to know that they belong there. They can’t be worrying that other people might be questioning their competence or their integrity.  The slightest crack in this confidence will lead that team member to be defensive.  They will interpret negative feedback not as a critique of their idea, but rather as an attack on them personally.  If one person gets defensive, it can spread to the rest of the team like a bad cold.  To achieve this level of confidence and drive out defensiveness, members of successful Piranha Club teams offer each other constant reinforcement, showing respect, commenting on positive things.  Non-defensive, confident team members become skilled in the art of holding their ideas out in front of themselves, rather than keeping them in their chest.  They place their ideas on the meeting table, treating them as inanimate objects, rather than parts of their own identities.

The second requirement to achieving the Piranha Club state is for every single member of the team to be skilled in offering criticism in a constructive, “loving” way. This can reduce the chance that the critique will be received with defensiveness.   The right choice of language can go a long way in this regard.  In a Piranha Club, the team members say “this design has problem A” rather than “you are wrong.”  Rather than framing a question in black and white terms, they describe a spectrum framed in such a way as to make it easy for everyone to agree that both extremes are undesirable, and that the debate is merely fine tuning.  They go out of their way to mix negative feedback with some positive feedback.  And, most importantly, they use humor.  Almost every Piranha Club team has the habit of cracking jokes.  In the tradition of the court jester who can tell the King what the King needs to hear without getting thrown into the dungeon, Piranha Club teams naturally use satire, silliness and humor to lighten up and sweeten up negative feedback that can otherwise be too heavy and bitter.  In fact, Yoel’s poem is an example of how the original Piranha Club even joked about itself.

More recently, when I was at Blue Cross Blue Shield of Michigan, I tried to promote this Piranha Club state by giving out Piranha Club coffee mugs.

Mugs given to members of Piranha Club

These were awarded to members of the epidemiology, biostatistics, medical informatics and clinical program design teams.  To earn a Piranha Club mug, a team member must have demonstrated that they were able to take an intellectual beating with grace, or that they were able to rip someone else’s ideas to shreds in a loving way.  Every time a mug was awarded, there was an opportunity to explain the Piranha Club concept to newcomers and to reinforce the concept to people who heard it many times before.  I was truly amazed at how important a $6 coffee mug was to people.  In some strange way, it seemed as if some of the team members were eager to make a presentation, and eager to have others criticize their work, so they could show how bravely and graciously they could receive the criticism to earn the mug and to become an official member.  It became almost a right of passage.

And, for some reason, coffee just seems to taste better in a Piranha Club mug.

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What makes teams effective? (1) Not being too role-focused

I am a big fan of people in the fields of “usability” and “human factors.” These are engineering disciplines which have been applied to software engineering, more broadly to information technology and even more broadly to organizational effectiveness. Usability and human factors people focus on considering the mental and physical characteristics of users when designing systems. They make systems more intuitive and less tiring. Within this field, I am particularly fond of an organization called User Interface Engineering (UIE).  They are a software usability consultancy that works on specific software and web application design projects. They also do seminars, training, and publications. Back in about 2003, I took the entire Reward Health Sciences team, all four of us at the time, on a 3 day field trip to Boston to attend a UIE seminar. It was great. We used crayons, construction paper and scissors to construct prototypes of software user interfaces and used them for quick usability testing and redesign sessions. They emphasize a light, iterative approach. In a three hour period, we would go through 5 iterations of design and testing. The fifth iteration was substantially different than the first, clearly reinforcing the importance of not falling in love with your first design and seeking frequent input from users.

Ever since I attended that seminar, UIE has been sending me e-mails with short articles about usability. This morning, I read their most recent article, entitled “Who is on the User Interface Team?”  They studied user interface design teams that were highly successful and compared them to those that were struggling to see if they could find characteristics that predicted success.  The answer?  Successful teams focused less on their individual roles, and conceptualized more people as being part of the team.

When the unsuccessful teams were asked “who is on your team?” they responded “We have two information architects, an interaction designer, and a user researcher.” When successful teams were asked the same question, they responded “Our team handles the interaction design, information architecture, and user research for the product.” And, the successful teams were more likely to include end users, project sponsors and other stakeholders as part of the team.

I feel strongly that this research finding applies to many types of business and clinical teams.  For example, effective primary care teams don’t start off focusing on which team member has an MD, and which is a nurse, aide or clerk.   All brains are turned on.  All are invited to have ideas on all subjects.  Of course, the knowledge, skills and talents that each team member brings to the team may be very different.  That will naturally drive different people to be more influential on different aspects of the design, analysis or management problem that the team is trying to solve.  But, in my experience, the most effective teams let those differences play out naturally.  They don’t spend energy enforcing them based on titles, degrees, certifications or other such distinctions that serve as barriers to inclusiveness in the intellectual effort of the team.

This fundamental driver of team effectiveness is one of the things that sometimes gives smaller organizations an advantage over larger ones.  In smaller organizations, the “all hands on deck” principle comes naturally.  But in larger organizations, the advantage of being able to afford specialized team members can too easily turn into a disadvantage when locked down role descriptions inhibit the shared intellectual effort that makes teams successful. Fortunately, this can be overcome by cultivating a culture that celebrates decentralized creativity and that promotes inclusiveness across traditional role boundaries.  To be successful, ACOs and other types of health care organizations should actively promote a culture that is intellectually inclusive and avoid focusing too much on specialized roles.

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We don’t need more data. We need better story-telling.

This morning, I read a blog post from someone in the “business intelligence” industry complaining that, after years of innovation, “BI” is not really having the envisioned effects.   The author wondered whether it was because BI, like most other business applications, are not “fun.”  The author suggested that BI applications should consider borrowing from fun social applications with features like “friends” and “like.”

I share the author’s disappointment in how little visible impact we’ve achieved, at least in the health care industry, from years of investment in “business intelligence,” “management information systems,” “data warehouses,” “data mining,” “dashboards,” “report cards” and other systems intended to put more data and reports at our fingertips.

But, I don’t share the view that social networking features are the missing ingredient.  Rather, I think the key to making analytics more engaging and useful is to focus on telling interesting, truthful, actionable stories, backed up by data. People are natural story-tellers and naturally enjoy listening to other people’s stories, particularly if they have an interesting “line” — a beginning that sets the scene, a challenging problem or crisis, and some resolution. The problem with “BI” (and the other data-at-fingertips technologies) is that they are devoid of story line.

When I have had the opportunity to work with young analysts, this is the most important concept that I try to get across.  Fresh out of grad school, the young analysts who have an IT background tend to start with a view that computers can do everything.  They just need to put the power of computers and data in the hands of the “people.”   The young analysts coming out of training in statistics, epidemiology, economics and other research disciplines tend to start with a world view that advanced mathematical methods can do everything.  In developing such young analysts, “job one” is getting them to appreciate the importance of story-telling.  To be effective in changing the world, they have to learn to change minds.  To change minds, they have to keep the attention of their audience — not with outlandish, shocking conclusions or colorful “eye candy” graphics — but with an interesting plot-line that makes their audience eager to see how the story ends.  Once they learn how to tell a story, they can apply that knowledge to the telling of actionable stories, where the ending is a call to action.

The first step in effective story-telling is to develop a good outline. This is a lesson that we all learned from our high school English teachers (or, whatever was your first language!).  Back in the 1990’s, I worked with Dr. Bruce McCarthy at the Henry Ford Health System.  He used to talk about the “logic train” and we would compose our abstract presentations by putting our slides in a line on the floor.  We would joke around by doing a little “chug chug” dance along the line of slides to see if there was a good high level flow to the story.  I repeated this exercise with my 7-year old daughter in the kitchen last month when she was preparing a class speech.  She loved the chug chug dance.  I challenge you to try it out at your next meeting with analysts.

After the outline is clarified, the second step in effective story-telling is to design each slide to clearly and simply communicate its message. This requires focus on the visual design.  In my opinion, a good designer avoids clutter, demanding that every bit of “ink” has a purpose, other than just decoration.  Effective communication takes advantage of the conventions of graphical language unless there is a good reason to violate convention.  For example, if you are telling a story about change over time, people generally expect time to be on a horizontal axis moving from left to right.  They generally assume “up” means “more.”  They expect an arrow to convey sequence or the direction of flow.  They expect thicker lines, bigger fonts, and bolder colors to indicate importance.  Experienced designers of quantitative visuals know that a particular format may work well or not at all depending on the data itself, making it difficult to design an unchanging report that will be consistently effective over time when applied to different data.

This brings me to the most important conclusion.   Despite the huge attention that has been paid to the need for more data and more sophisticated analytic software, the rate-limiting step in our efforts to bring the health care field into the knowledge age is neither data nor technology.  Except for the most mundane monitoring purposes, useful analytics cannot be completely automated.  Effective analytics requires effective analysts.

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