Navy Seals, San Antonio Spurs, and Just Culture · Source: Smarter, Faster, Better by Charles Duhigg Image source: hbs.com ISHP Fall Conference 2018 Comparing Teams •Found equally

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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

ISHP Fall Conference 2018

Disclosures• The presenter has no real or perceived conflicts of interest related to this presentation


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

• DirectionsEach 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 Solutionshttp://www.blueskypersonnel.com/why‐kindergarteners‐consistently‐outperform‐ceos‐on‐this‐challenge/ accessed 8/1/2018

ISHP Fall Conference 2018Image source: hanno.com


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 francaisChicago, jencoinc


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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


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.


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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


Kindergarten students



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


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 ChicagoSources: The Culture Code by Daniel Coyle.

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NYTIMESFeb 25th, 2016

What GoogleLearned From ItsQuest to Buildthe Perfect Team

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


○ 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

Story of Julia

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


○ 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

Her Team

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


• 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=0Image source: www.123rf.com


• 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=0Image 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=0Image source: www.nytimes.com


• 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

of 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=0Image source: www.resologics.com


• Reviewed over 180 teams within Google

• No combinations seem to align or correlate

• 2 teams could have similar makeup with overlapping members with entirely different outcomes

Project Aristotle’s Results

Lerablo


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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,

others had informal chit‐chat prior to the meeting start

Project Aristotle’s Results



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=0Image source: the business couch


• ‘‘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=0Image 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 DuhiggImage source: hbs.com www.charlesduhigg.com


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


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 DuhigImage 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 one another

• People said they could suggest ideas without fear of retribution

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

ISHP Fall Conference 2018Image source: world economic forum


Connecting with Just CultureJust 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.


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Just Culture Decision Guide



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 Safety2.Share Vulnerability3.Establish Purpose



Building Safety


• 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


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 of 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


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 over1. 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/


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/


Story of the big lossJune 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


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


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.


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


Clusters of High Communication

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


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


Developing Culture




• 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 CoyleImage Source: Maltatoday.com.

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Flight 232

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


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.orgImage source: www.Cbsnews.com

“Tell Me What You Want, and I will Help You”


“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 CoyleImage 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

ISHP Fall Conference 2018Image source: medium.com

The Vulnerability Loop


Navy Seals• Model Organization for Leadership

• Countless Books

• History of Success

• Starts with Hell Week

Image source: military.com

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ISHP Fall Conference 2018Image source: militaryposters.com

ISHP Fall Conference 2018Image sources: navytimes.com and wikimedia

Vulnerability & Interconnection1. 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


• 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.htmlSource: The Culture Code by Daniel Coyle

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Developing Culture




• 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 others who use our products and services. In meeting their needs everything we do must be of high quality…’

Establish a purpose

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


• 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 & JohnsonSources: 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



• 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.orgSources: The Culture Code by Daniel Coyle.


• 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 xpressSources: 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



• 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



Factors to success• Factors notassociated 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


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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: crazymoneyexpressSources: The Culture Code by Daniel Coyle.

PULLING IT ALL TOGETHER

Image source: Blue Sky eLearn


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


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?



• 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



Is this a strategy for healthcare?• How can this be applied to Pharmacy?

Image source: callcentrehelp.com


What Makes a Successful Culture?

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Other examples


Carolina way


Documents

Navy Seals, San Antonio Spurs, and Just Culture · Source: Smarter, Faster, Better by Charles Duhigg Image source: hbs.com ISHP Fall Conference 2018 Comparing Teams •Found equally