What makes er teams efficient? A multi-level exploration of environmental, team, and member characteristics

WHAT MAKES ER TEAMS EFFICIENT?
AMULTI-LEVELEXPLORATION OF ENVIRONMENTAL, TEAM,AND MEMBER
CHARACTERISTICS
PLEASE DO NOT CIRCULATE OR CITE WITHOUTPERMISSION
Ishani Aggarwal
Brazilian School of Public and Business Administration
Toshio Murase
Roosevelt University
Evelyn Zhang
Carnegie Mellon University
Brandy Aven
Anita Woolley

Emergency Room Teams
• Widely recognized in the patient safety literature that many adverse
events in healthcare originate from flawed teamwork rather than from
a lack of clinical skills (Burtscher, Wacker, Grote, & Manser, 2010; Kohn, Corrigan, &
Donaldson, 2002; Manser, 2009; Risser et al., 1999; Rosen et al., 2008).
• Even highly trained teams vary considerably in their effectiveness and
many teams perform inadequately in such situations (Carbine, Finer, Knodel,
& Rich, 2000; Marsch et al., 2005; Stachowski, Kaplan, & Waller, 2009; Tschan et al., 2006).

• Form of action teams that work in turbulent and uncertain environments,
under extreme time pressure
• Team efficiency is a key indicator of successful performance
• Environments where the importance of coordination, communication,
and knowledge integration for efficient fast action are heightened
because previously relied-upon strategies and routines may no longer
be appropriate (Homan, Buengeler, Eckhoff, van Ginkel, & Voelpel, 2015; Sung & Choi, 2012;
Thomas-Hunt & Phillips, 2003)
Emergency Room Teams

Environmental Factors
• Environmental factors are characteristics of the external environment
in which the organization is embedded, such as industry
characteristics and turbulence, and are likely to have a huge impact
on team outcomes (Cohen & Bailey, 1997).
• Difficult environmental conditions are likely to be one of the major
factors explaining variance in the performance of ER teams since
these teams are tightly linked to the task environment.

Environmental Factors
• Environmental factors in the ER include:
• severity of patient condition
• the number of beds occupied at the time a patient is being treated
• the severity of all the patients in the ER at the time a patient is
admitted

Hypothesis 1
Environmental
difficulty
Team
efficiency
-

Team- and Member-related Factors
• Why do some teams perform better than others in similar
environmental conditions?
• Most models of team performance are based on one of two implicit
assumptions
• all team members perform the same role in a team or
• all of the team roles have the same impact on team performance.
• Yet, the first assumption is typically not true, as teams often possess
differentiated role structures (Belbin, 1993; Mumford, Campion, & Morgeson, 2006;
Mumford, Van Iddekinge, Morgeson, & Campion, 2008)
• Strategic core is defined as the role or roles on a team that
• encounter more of the problems that need to be overcome in the team
• have a greater exposure to the tasks that the team is performing
• are more central to the workflow of the team
• (Humphrey et al., 2009)

Team- and Member-related Factors
• In an ER setting, doctors arguably hold strategically core
roles since they
• oversee the treatment of each patient
• make decisions about the treatment course, and seek outside
counsel if necessary
• provide instructions to the rest of the ER team (such as nurses, ER
technicians, counselors) on the plan of action
• are pivotal to the workflow of an ER

Team factor: Team member experience with
strategically core members
• Teams´ experience in working together as a team reduces patient
procedure time and increases team performance (Reagans, Argote, & Brooks,
2005);
• Improvement in coordination that is a result of working together over time
is one of the main explanatory mechanisms

Team factor: Team member experience with
• Since strategically-core members hold an important role in a team, one
factor that will influence coordination, is the team´s experience in working
with the strategically core members.
• The importance of team experience with strategically core members will
be especially reflected when the environmental difficulty is high.
• i.e. in teams where members have experiential proximity with strategically
core members there will be increased coordination, which will allow for the
teams to be efficient even with increasing environmental difficulty.
• On the other hand, when much time has elapsed from having worked
together with a strategically core member, coordination will hugely suffer,
which will be reflected in decreased team efficiency especially when
environmental difficulty increases

Hypothesis 2
Environmental
difficulty
Team
efficiency
Amount of time elapsed
from working together
with core team members
In teams where less time has elapsed, the relationship between
environmental difficulty and team efficiency will be less negative than in
teams with more elapsed time.

Team-member factor: Cognitive versatility of
• Research has demonstrated that certain member
characteristics (e.g., cognitive ability) exhibit greater influence
on team effectiveness when possessed by strategically core
role holders (Humphrey et al., 2009; Summers, Humphrey, & Ferris, 2012).
• Supports the theory that it matters where these characteristics
reside in the team (Humphrey et al., 2009).

Cognitive Style
• Cognitive Style is a psychological dimension that represents
consistencies in how an individual acquires and processes
information (Ausburn & Ausburn, 1978; Messick, 1984)
• Spatial Visualization
• Object Visualization
• Verbalization
• Only recently explored in the context of teams (Aggarwal & Woolley,
2013)
• Individuals can be high on multiple dimensions: cognitively
versatile (Aggarwal, Molinaro, & Woolley, working paper)

Team-member factor: Cognitive versatility of
• Team cognitive style versatility is associated with
• Improved team coordination
• learning with experience
• reduction in task and process conflict
• Improved team performance in execution and creative tasks
• team viability
Aggarwal, Molinaro, & Woolley, in preparation; Schilpzand, Aggarwal, & Martins, in preparation
• The complex nature of ER tasks and the uncertain environment
• necessitate both depth and breadth of perspectives in order to coordinate
• as well as process information effectively
• complex information needs to be quickly and accurately processed, having cognitively versatile
core members is also likely to aid in handling the information processing demands more
effectively
• While there is a dearth of research on cognitive style versatility, Cannon-Bowers
et al. (1998) found that the benefits of cross training were greatest under high-
workload situations (Ford & Schmidt, 2000).

Hypothesis 3
Environmental
difficulty
Team
efficiency
Cognitive versatility of
core team members
In teams where core team members have cognitive style versatility, the
relationship between environmental difficulty and team efficiency will be
less negative.

Study
• 12-bed Emergency Room unit of a hospital in the US
• Doctors, nurses, nurse practitioners, and nurse assistants
filled out individual measures
• Archival data about over a six-month period
• diagnoses and times at which patients were admitted and left the
hospital
• Employee shift schedules
• 69 employees, who made up 236 teams that treated a
total of 2,203 patients who were admitted for 202 different
diagnoses.

Measures
• Environmental difficulty.
• The frequency with which a diagnosis occurred. The top three quartiles of
occurrence were coded as routine (75% cut-off occurring 58 times or
more), while cases in the bottom quartile were coded as non-routine. E.g.
abdominal pain versus drug overdose
• The number of patients with non-routine diagnosis who were admitted
within 60 minutes before and after each patient was admitted. This 120-
minute time window was used to assess the number of patients still waiting
or being treated when each patient was admitted.
• Teamwork elapsed time-core. The numbers of days passed since the
last time each non-core member on the current team worked with a core
member were calculated and averaged.
• Cognitive versatility- core. OSIVQ (Blazhenkova & Kozhevnikov, 2008) to
capture cognitive styles; a categorical variable capturing the core members’
dominance (or a score at or above 75th percentile of the entire sample for
each cognitive style) in two or more cognitive styles

Measures
• Team Efficiency. Treatment time; amount of time each patient spent
in the ER standardized by the mean time for that particular diagnosis.
• Control Variables
• Familiarity. number of shifts that each member had worked on with
every other member prior to the current shift, and averaged the shift
times across all the members on the shift (Huckman, Staats, & Upton, 2009).
• Shift size. numbers of members on the shift.
• Constraint. total number of patients (both routine and non-routine)
who were admitted within 60 minutes before and after each patient
admitted.
• Routine. As explained previously. Total of 1,411 routine patients and
792 non-routine patients.

Results: Hypothesis 1
Environmental
difficulty
Team
efficiency
-

Treatment Time
Variable Model 1 Model 2 Model 3 Model 4
1
Intercept -.51** -.48** -.48** -.48**
2 Control
Constraint -.08** -.10** -.10** -.10**
Routine -.07** -.07** -.07** -.07**
Shift Size .03 .03 .02 .03
Familiarity -.00 -.00 -.00 -.00
TET-core -.00 -.00 -.00 -.00
TET-noncore .00 .00 .00 .00
CSV-core .01 .01 .01 .01
CSV-noncore -.07 -.09 -.09 -.09
3 H1
ED .04** .04 .06**
4 H2
ED x TET-core .00*
5 H3
ED x CSV-core -.07**

Environmental
difficulty
Team
efficiency
Amount of time elapsed
from working together
with core team members
In teams where less time has elapsed, the relationship between
environmental difficulty and team efficiency will be less negative than in
teams with more elapsed time.

Low TET core (time-elapsed): teams in which less time has elapsed
between non-core members working with core members were less
susceptible to increasing treatment time as environmental difficulty
increases.

Environmental
difficulty
Team
efficiency
Cognitive versatility of
core team members
In teams where core team members demonstrate cognitive style
versatility, the relationship between environmental difficulty and team
efficiency will be less negative.

When teams have core members who are cognitively versatile (High CSV score),
they are less susceptible to increasing treatment time as environmental difficulty
increases that teams whose core members are not cognitively versatile (Low
CSV score)

Conclusions
• When ER teams are able to perform consistently and
robustly even as environmental difficulty increases
• Strategic-core lens: emphasizes that some team members
may play a more critical role than others within a team
• Identify two factors (team-based and team-member based)
that explain why certain teams may perform better than
others as environmental difficulty increases

What makes er teams efficient? A multi-level exploration of environmental, team, and member characteristics

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What makes er teams efficient? A multi-level exploration of environmental, team, and member characteristics