Keywords

FormalPara Chapter Objectives

  • Describe the importance of high-functioning teams in driving quality improvement in healthcare settings.

  • Generate strategies to build and lead effective teams using improvement science tools and organizational tactics.

  • Use principles from psychology of change to create a burning platform to drive change.

FormalPara Vignette 10.1

Over the last few years, the infection control team of a children’s hospital within a larger hospital system was focused on helping teams decrease central line-associated bloodstream infections and catheter-associated urinary tract infections. In this time period, the number of nosocomial C. difficile infections has risen. At a system-level quality meeting, C. difficile rates for the children’s hospital system are presented, showing a rate significantly higher than the benchmark. The pediatric Chief Medical Officer returns from the meeting and charges the quality team to create an action plan and reduce rates as soon as possible.

Opening Question/Problem

Quality improvement opportunities in complex healthcare settings are omnipresent; this chapter describes the importance of creating multidisciplinary teams and leading these teams effectively and efficiently. Intentional thought on creating an effective team with a burning platform will greatly aid in achieving the aim of the initiative.

Introduction

The creation of effective teams is a key element of all organizations, though may be especially important in healthcare settings, given the complexity of healthcare systems. In general, a team is defined as a group working collaboratively and interdependently to achieve a common goal, to which they are all held accountable [1]. In many healthcare organizations, teams are developed using staff with varying knowledge, skills, and experience to help solve complex problems and create pragmatic, innovative solutions. Keeping these teams on track to achieve their aims requires care and purpose. This chapter will review the development of improvement teams, how to make these teams productive, and how to keep the teams strategically aligned with a burning platform.

Vignette 10.2

The Chief Medical Officer of the pediatric hospital has apprised the Chief Quality Officer of the respective hospital about the increased C. difficile rate and the discussion of this at a system-level meeting. Understanding the urgency to fix the issue, she quickly alerts the medical directors of the inpatient units to stop sending tests for C. difficile unnecessarily. The leadership of the Oncology unit expresses some reluctance at the shotgun approach to a problem without systematically assessing the potential myriad contributing factors.

Evolution of Teams for Quality Improvement

Quality improvement initiatives have their roots in teams. The methodologies that constitute improvement science were originally used in the scientific approach to improving the efficiency of manufacturing processes [2]. Key leaders include pioneers such as Frederick Winslow Taylor, W. Edwards Deming, Walter Shewhart, Joseph M. Juran, and Taiichi Ohno who in aggregate developed and perfected ways for organizations, specifically manufacturing, to be more effective and efficient in producing error-free products [2,3,4,5,6,7]. Central to these methodologies was the use of teams to analyze a problem, design tests of change, test solutions, and determine and measure metrics of success.

What Is a Team?

Underlying improvement projects is a well-crafted team who work together to carry out a change process. Members of the team work collaboratively for a shared purpose, with shared responsibility for achieving results. Teams can be used when the problem to be addressed is complex, when learning of the system is a necessary prerequisite, when there is no clear answer to a problem, when innovative ideas are needed, and when cross-collaboration among differing disciplines are necessary. For teams to be successful, they need clear and attainable goals, an appropriately scoped initiative, expertise, and resources from across the organization [1]. An important distinction is between a team and a working group. A working group’s output is a sum of what the individuals in the group attain; in contrast, a team’s performance represents both individual work and collective work that represents the joint contribution of multiple team members [8]. Working groups are used for information sharing, to provide counsel, and to help individuals improve their performance on discrete initiatives. They usually include a clearly defined leader, involve individual work products, and are measured by their influence on others; in contrast, teams focus include multiple leaders in shared leadership roles, have both individual and mutual accountability, develop collective work products, include open-ended discussions and active problem-solving group discussions, and are measured by assessing their collective work products [8] (Key Points Box 10.1).

Key Points Box 10.1

Teams are a group of people who work collaboratively and interdependently towards an aim; the output of a team represents collective work jointly produced by multiple team members.

Identifying Team Members in an Organization

Teams play such a significant role in driving improvement in organizations that the strategic design and crafting of a team are vital. The team’s inclusion of experts in the process that needs to be changed is a necessary first step (commonly referred to as subject matter experts which can be any level of employee). In fact, studies done at the Hawthorne factory in the mid-twentieth century showed that engaging frontline staff in redesigning a process improved both the efficiency of the process and improved and sustained reliability to the process [4]. Deferring to the expertise of the frontline staff to be able to improve a process with practical context, as opposed to having leaders’ remote to the frontline, was thought to be a contributor to the success. Walter Shewhart, who developed the statistical process control chart, a key tool in improvement science, made a strong case for engagement of frontline staff in improvement activities. He championed the development and deployment of statistical process control charts to be displayed on manufacturing floors to allow frontline staff to identify special cause variation, stop the line, conduct just-in-time analyses, and find and fix issues as they arose [4]. This frontline engagement approach to improving the efficiency of a process was transformative, and its effect persists in improvement science methodologies [9]. A team cannot be assembled without pertinent subject matter experts.

When building a team, understanding how stakeholders view potential improvements is imperative to developing the appropriate team composition. While it may be easier to identify stakeholders who are enthusiastic and will drive change, it may be more challenging to find those who are indifferent or opposed (commonly referred to as contrarians) and engage them in an improvement team. Effective teams are not created with all those individuals that may be the easiest to work with and the most convenient. Indeed, highly effective teams include staunch supporters and similarly strong contrarians.

A stakeholder analysis illustrates the position of each stakeholder with regard to the project, can be used as a tool to understand why they may not be at the level of engagement necessary, and then helps the team determine how much effort should be spent moving that commitment from its current status to that which is necessary to achieve their goals [1]. A representative team composition can be built using the rubric shown in Fig. 10.1. This rubric categorizes stakeholders into four main categories: those with high influence and high interest, high influence and low interest, low influence and high interest, and low influence and low interest. Those with high influence and high interest should be fully incorporated into the team, as they have the resources and passion to drive the project forward. There should be a respectful collaboration with stakeholders of more mixed influence and interest, particularly those who are not initially supportive but offer high potential for cooperation (the team may direct specific efforts to engage these individuals). Those with high influence and more neutral positions may have resources that could be offered to the team and should be informed and engaged. The team that identifies stakeholders who are non-supportive with low potential for cooperation can be prepared to deal with these individuals [1, 10].

Fig. 10.1
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Stakeholder analysis

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An alternate tool that can be used to identify key team members is the SIPOC tool, which maps a process and includes all Suppliers, Inputs, Processes, Outputs, and Customers [Fig. 10.2] [1]. Defining the suppliers and inputs of a process, as well as the customers who will use the outputs of the process, can be helpful in more complex projects to assure all key stakeholders, especially those who are not immediately apparent, are considered [1]. Using this tool to identify hidden team members can prevent the inadvertent exclusion of a member that would potentially be impactful. Identifying key stakeholders late in the game and necessitating a latecomer to “catch up” could possibly derail work already in progress [1, 11]. The SIPOC tool may have the added benefit of starting out the improvement team with a narrow focus on a single process, avoiding the common pitfall of working on a problem that is too broad. In addition to identifying team members, these tools can also aid in identifying other valuable stakeholders who may not be part of day-to-day operations, but may prove to be valuable allies as the team progresses; these other stakeholders should of course be kept abreast of progress on the team and can be used as consultants to the project in an as needed capacity [1] (Key Points Box 10.2).

Fig. 10.2
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SIPOC tool

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Key Points Box 10.2

Developing cross-functional teams for improvement projects requires thoughtful consideration; specific tools such as a SIPOC can help provide structure to designing a team for success.

Considerations Around Designing a Team

While these tools may assure that a team accurately reflects the need of the project, it is also equally important to be mindful of the size of the team. Smaller teams may be more agile, more innovative, and ultimately, more effective. Examples of these teams include many internet start-ups including WhatsApp and Amazon, whose CEO Jeff Bezos coined the “two-pizza rule,” suggesting that any team that could not be fed by two pizzas was too big [12]. Strategies to assure the optimal size of teams include breaking down improvement teams into smaller projects, empowering team members to be the decision-makers, building a trust culture to allow team members to be agile in decision-making, focusing on informal ways of sharing information as opposed to taking formal minutes or creating presentations which can be less efficient, building platforms where team members are actively communicating (collaboration platforms), and effectively using technology to program manage [13].

Over and beyond choosing the right constituents for and the size of the team, other considerations in creating effective teams include understanding how members of these teams will work together. There is science behind the concept of which elements make teams more effective at their work, including problem-solving. While the functional role of team members is important, the psychological role that a team member plays may be equally important [14]. Teamwork is dependent on elements such as affective states, behavioral processes, and cognitive states of teams, much of which is influenced by the personality types of individual team members [14]. When teams are being created, it is imperative to craft a well-balanced mix of team member personalities including those team members who are results-oriented, relationship-focused, process and rule followers, innovative and disruptive thinkers, and pragmatic [15]. A mix of personality types allows for effective teamwork that translates inputs (expertise, capabilities, knowledge) into outputs (process changes, products). The diversity of a team cannot be understated; it is well demonstrated that diverse groups in terms of race, ethnicity, and gender are more rigorous in problem-solving [16] (Key Points Box 10.3).

How teams work together is integral to how they will function. Increasingly, it is becoming apparent that effective teams have several key components: mutual trust among team members rooted in emotionally intelligent behaviors, a clear group identity, and a belief that the team is more effective working together compared to working alone. Central to this is the idea is the concept that self-awareness and regulation of emotions translate into the group setting; teams should work on setting standards for behaviors that help foster trust, group identity, and a feeling of group efficacy [17].

Key Points Box 10.3

Designing a team should take into account key stakeholders, level of engagement, skillset, and personality types of individual team members; teams should be the right size to be able to work together and have mutual trust that the team will be more effective working together compared to team members alone.

Roles and Responsibilities for Team Members

Once stakeholders are identified, role delineation is imperative. The core team is comprised of several important team roles (which should be delineated on the project charter): team member, team leader, coach, and senior sponsor.

Team members contribute to the overall success of the team by sharing their knowledge and experience during team meetings and participating in implementing changes. As previously discussed, it is imperative to include members of the clinical team, particularly the frontline staff or those in the know of current work processes, who will be able to give context to key drivers to achieve an aim within a clinical setting. These members include physicians, nurses, and other clinical staff. Sometimes, these individuals may be seen as informal leaders in their work environments and may have key relationships that allow them to operate as key influencers to promote change. Teams should include subject matter experts to give content expertise and provide deep knowledge in the area for improvement. Many teams can and should include patients and/or family members on their improvement teams. Inclusion of the patient voice lends credence to the improvement project and assures that the changes are patient-centered (Fig. 10.3).

Fig. 10.3
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Roles and responsibilities for improvement projects [1]. Reprinted with permission from Scholtes et al. [1]

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Even with team members whose members have formal authority within an organization, effective teams need a clearly defined leader who runs the day-to-day operations, leads meetings, and may become a liaison to clinical and executive leadership. Often times, the team leader is not the team member with the highest title or most power in the organization. The team leader serves as the communication link between the team and the rest of the organization. It is the leader’s responsibility to maintain the data related to the project, as well as supervise preparation of reports and presentations; the team leader is the public and organizational face of the team and is accountable [1]. Returning to the C. difficile reduction vignette, a physician in the hematology-oncology unit who is enthusiastic and results-oriented may be a clear leader for the project.

If the team is an improvement team, there may be an improvement coach (referred by many different titles in different organizations). The coach is someone experienced in quality improvement who can bring in improvement science as needed; of course, it is unreasonable for them to teach quality improvement principles to a team. Oftentimes, in improvement work, the team leader may also fill the role of coach, depending on their background and skillset. An effective coach should advise how to best apply improvement science methodology to the problem, demonstrate appropriate data collection and analysis techniques to ensure accurate interpretation of results, and then encourage decisions be made based on the evidence gathered [1]. In the previous C. difficile example, the Chief Quality Officer, or perhaps a project manager or data analyst within the hospital’s quality division, would fill this role.

Lastly, an executive sponsor is oftentimes necessary, especially when there may be challenges in carrying out specific interventions, a significant change needs to occur outside the limits of the team’s authority, or considerable resources may be needed. The executive sponsor is a leader in the organization who serves to lift barriers by providing resources or influencing change and will ensure alignment of the project’s aim with the organizational goals, thereby increasing the likelihood of success [1]. In the case vignette for this chapter, the C. difficile reduction initiative, the Chief Medical Officer is the logical executive sponsor. Memorializing both the aim of a project and key team members in a project charter or other formal document solidifies team roles and responsibilities as well as communicates to senior leadership the scope of an improvement project; some organizations take the additional step of having the executive sponsor sign this formal document as a team charter [18] (Key Points Box 10.4).

Key Points Box 10.4

Teams are made up of several important key roles including, for example: team members, team leader, team coach, and senior or executive sponsor.

Vignette 10.3

Rethinking her initial shotgun approach, the Chief Quality Officer assembles a team to develop an improvement project to decrease nosocomial C. difficile rates. She invites the head of the antimicrobial stewardship team, the director of infection control, a quality improvement consultant, and the data analyst for quality to a meeting. They ask the Chief Medical Officer to be the executive sponsor. They review the current state and develop an aim and key drivers. In a kickoff planning meeting, the quality improvement consultant suggests the team produce a SIPOC tool to help identify additional team members. They identify a lab technician and an antimicrobial stewardship champion as additional members and, after stakeholder analysis, recognize they currently have minimal interest or engagement with this issue. They plan to have the Chief Medical Officer socialize the project to each of them and develop a communication plan to increase their interest in the project. Later, during walk-rounds, the Chief Quality Officer meets a passionate nurse who she witnesses peer coaching a surgical fellow on proper infection control practices. The Chief Quality Officer approaches the nurse to ask her perspective on the biggest safety issues involving nosocomial C. difficile, and she eagerly voices her suggestions and concerns.

Running Effective Meetings

Running effective meetings is a crucial skill in improvement activities and one of the many important responsibilities of the team leader; indeed an entire chapter can be written on just this topic of teamwork. Time spent in meetings has to be of value; if meetings are ineffective, in addition to the time wasted in a meeting, engagement and goodwill in working on the team can dissipate quickly. A careful assessment and purposeful leadership in meetings are integral, therefore, in both running effective meetings and assuring the team achieves its aims.

Preparation for a meeting is vital in assuring that the meeting is a success. A first and important step is to establish clear goals for a meeting. Given the time that a meeting takes and the intrusion into day-to-day work, a deliberate approach to agenda creation can dramatically improve both the efficiency of a meeting and the engagement of team members [19]. A key element in laying the groundwork for a meeting is to elicit input from team members on what topics need discussion in a larger forum; involving team members in agenda creation has the added benefit of improving engagement and attention during the meeting. Agenda items should be pertinent to the entire team; they should represent issues that involve a coordinated, interdependent response. One recommendation is to list agenda items as questions to focus participants’ discussion to answer specific questions. In addition, each agenda item should have a purpose – to share information, solicit input for a decision, or to collaborate to make a decision; clarity around this can aid team members in effectively participating. Team leaders should consider that it may be more efficient to share information through alternate routes rather than use meeting time. Distributing the agenda ahead of the meeting and being prescriptive regarding what people should prepare will ensure that the time spent together is most efficient. Assuring that each agenda item has a specific time allotted to it as well as a facilitator identified ensures that team members understand their specific role in a meeting [19]. In addition to timing specific agenda items, considerations should be made around duration of the meeting; meetings that are 30 or 45 minutes and not stacked back-to-back (in succession) may give team members the ability to tackle other business in between meetings and allow meetings to start on time which in and of itself will increase efficiency of the team [20, 21].

The team leader must lay the groundwork for collaboration for the team, especially in interdisciplinary teams. It is imperative for improvement teams to understand the global aim for improvement efforts, at each step of the way. Using the initial minutes of a meeting to re-establish the aims of a specific project and the rationale for the meeting may be a strategy to prime team members for the meeting. While it may be repetitive, understanding and confirming the “why” of the project develops team bonds and underscores the rationale to spend time on the initiative. For example, in healthcare environments, teams that include patient/family stories or safety stories help set the tone for the meeting and tie team members to the mission of both the improvement effort and the organization.

Facilitation of meetings is an important role of the team leader. Starting with introductions may help promote collaboration and respectful communication, especially in teams where traditional hierarchies may impact the way team members interact with each other. To assure that all members are treated respectfully and those who are not considered formal leaders feel empowered to speak, simple icebreakers or other tools to promote collaboration may be important. Informal chitchat may help to break the ice and pull a team together – leaving time at the beginning of a meeting to promote socialization has been shown to promote team work [22]. Team leaders are responsible for facilitating the discussion during a meeting. Generally speaking, leaders of meetings should take an inquisitive approach – asking questions, probing for answers, modeling active listening, and drawing out reluctant participants. To assure all ideas are brought forth, one consideration is to allow for individuals to respond to specific questions via web-polling or by writing down ideas before sharing as a group [20]. An example of this is “brain writing” which instructs team members to individually reflect and write down ideas before sharing [1]. Other strategies to keep meetings efficient include controlling the size of the meeting so that there is robust discussion and yet everyone feels engaged, corralling the conversation so that it is pertinent and does not go off-tangent as well as preventing a few from monopolizing the conversation [23].

In this era, use of devices such as cell phones and laptops may interrupt and impede free flow of conversation and decrease members’ attentiveness to the project. The team leader should be encouraged to set ground rules regarding using devices. Perhaps the onus on controlling wandering attention falls to the team leader to run a tight, focused, meeting; indeed, the value of the meeting should compel attention and hopefully prevent drifting attention. Furthermore, limiting membership in team meetings to core people can decrease device use and inattention [24].

However well planned a meeting is, if the meeting does not conclude with a clear action plan, many of the gains from the meeting may be lost. One helpful strategy is concluding a meeting 5–10 minutes before the end of the allotted time to do a recap and confirm an action plan and assigned responsibilities. Assigning roles as explicitly as possible with specific tasks and due dates and then sending out a structured meeting summary to memorialize the discussions into a document serves to commit the team to the action promised [22] (Key Points Box 10.5).

Key Points Box 10.5

To run an effective meeting, team leaders should prepare purposefully, set team norms for behavior, and facilitate to promote collaboration, especially in diverse teams.

Vignette 10.4

The Chief Quality Officer calls a kickoff meeting for a new C. difficile reduction team. In addition to the members from the previous meeting, she invites the nurse who she met on the hematology-oncology unit to provide clinical expertise, a fellow and physician who practice on the unit, a representative from housekeeping, the medical director of the unit, and a pediatric resident. She designated a quality consultant and data specialist for her team. She asks the physician and nurse to co-lead the team with the support from the quality consultant and coaching from the Chief Quality Officer. They develop the scope of the project and sign a charter, cosigned by the Chief Medical Officer who serves as the executive sponsor.

The team started with introductions, and the clinical leaders shared the problem and shared a patient story about an adolescent boy with cancer who was close to discharge when he developed nosocomial C. difficile, which prolonged his hospitalization, and he had to miss his senior prom. The team leaders use an inquisitive approach to stimulate discussion around ideas for key drivers and ultimately focus on working on lab stewardship as well as improving housekeeping effectiveness as early PDSA cycles. Despite hesitation of some staff to initially speak up due to one of the physicians monopolizing the conversation, the team leaders have enthusiastically requested input from all team members. Over time, nosocomial C. difficile rates dropped by half by changing multiple processes: cleaning of rooms, nursing documentation of stools, algorithms for testing, infection control practices, and overall antibiotic utilization. After going 30 days without an infection, the team walks the units to congratulate the frontline on this milestone.

Creating a Burning Platform

Multidisciplinary teams may need assistance from leaders to develop true cohesion. Creating a sense of urgency behind the desired changes serves to unify team members and make it easier to attain buy-in from stakeholders. The burning platform metaphor is based on a true event and has been used for many years to illustrate a high level of urgency leading to change [25]. In July of 1988, a catastrophic explosion occurred on the Piper Alpha oil-drilling platform in the North Sea off the coast of Scotland, where over 200 crew members were employed. A superintendent, 1 of only 63 men to survive, recounted the decision he faced shortly after the explosion: jump approximately 15 stories off the platform into extremely frigid ocean waters or remain on the burning platform. Though he knew jumping into the cold water was extremely risky and would likely lead to his death were he not to be rescued quickly, he believed staying on the platform would lead to certain death. He chose to make a frightening and potentially fatal decision because he believed the status quo, or resisting the change, was too costly. We can see similar sentiments during our implementation of process improvements: major changes can be frightening and risky to some; executing these changes often requires true determination to act [25]. While a structured approach to creating a team is important, it may only go so far; leading change is as much about understanding the culture of an organization as it is about the psychology of the people that make it up. In healthcare organizations, similar to other larger organizations that use cross-functional teams, it is imperative to understand strategies to manage diverse teams from different backgrounds [26].

All too often, improvement leaders will encounter resistance during the course of their project, stemming from concerns with loss of control, fear of the unknown, increased workload, and a lack of confidence that their current skills will translate to success with a new process [27]. Effective quality improvement efforts must have strategies to negotiate this resistance, built on psychology of change principles. The Institute for Healthcare Improvement developed a Psychology of Change Framework which describes activating people’s agency through unleashing intrinsic motivation, co-designing people-driven change, co-producing via an authentic relationship, distributing power, and adapting in action [28] (Fig. 10.4).

Fig. 10.4
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The IHI Psychology of Change Framework [28]. Reprinted from www.IHI.org with permission of the Institute for Healthcare Improvement (IHI), ©2019

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Unleashing intrinsic motivation involves enabling team members to use reasons that are personally motivating by themselves in order to drive change, not being forced to carry out an improvement in which they have no interest [28]. Crafting a powerful narrative behind the team’s purpose and goals, or offering time for members to share personal stories, can unite team members and launch improvement efforts [29]. Incorporating concepts from motivational task design can help access people’s intrinsic motivations, which is generally more sustainable than extrinsic motivation, such as earning monetary rewards or avoiding punishment [30]. Psychologists have shown that intrinsic motivators include the experience of meaningfulness (the task is important), the feeling of ultimate responsibility (the outcome is dependent on the team member’s performance), and visible results (allowing the team member to get real-time feedback on their performance) [30].

Co-designing people-driven change speaks to the idea that the team consists of the people that it is most likely to affect – building a team with the right key stakeholders including frontline participants avoids the consultant model, whereby improvement teams swoop in and swoop out after the project is completed [30]. Using the SIPOC tool can be key to ensuring change is truly people-driven by identifying and including all stakeholders to develop initial improvement ideas together.

Co-production in authentic relationships is about fostering respectful and responsible team dynamics, avoiding hierarchies and promoting dialogue even regarding contentious issues [28]. This concept values different perspectives and promotes an environment where everyone feels safe sharing their opinion. One of the key tools in building these relationships is the one-to-one meeting, in which leaders focus on asking open-ended questions, intently listening to the responses, and ending with a strategic exchange of resources and a clear commitment to the next steps [31].

Distribution of power allows for a team to work collaboratively on a level playing field, avoiding any natural work-related hierarchies from drifting into the improvement work. Leaders should be aware of their own implicit and explicit biases and how these may lead to power imbalances within the team [28]. Ideally, improvement teams should adopt a distributed leadership structure, where responsibilities are shared among several smaller groups which may be divided based on task or location [31]. Sharing power and holding team members accountable for tasks in a positive way is motivational, relaying an urgency to act which is crucial to improvement work [32].

And finally, adaption in action – actions that motivate teams to move forward, even when actions may lead to failure. Inherent in the PDSA cycle is the ability to learn from prior actions, particularly failures, and adapt the test of change for further improvement. Making this continuous learning visible to team members can be reassuring that their efforts are integral to the advancement of the improvement process, strengthening their continued participation [33] (Key Points Box 10.6).

Key Points Box 10.6

Strategies to create a burning platform include understanding people’s psychological nature and interests in working with a team to drive improvement.

Resources

Editors’ Comments

We challenge readers to show us any quality improvement project done by a single individual. Quality improvement is done with teams, by teams, and for teams. This chapter is at the core of quality improvement. The improvement team may not be apparent (usually working behind the scenes), but without it – nothing substantive will occur. However, success is not an accident. Building and leading teams can be taught and needs to be learned and appreciated. This chapter serves as a primer for the reader to understand the value of teams, how to construct teams, and how to work within teams.

A significant learning from this chapter is the need to have role delineations for teams; without team members understanding the role they are going to play, a team will not function at the optimum level. The authors expound upon this point and help the reader understand the different roles and the intrinsic value in each and how they contribute to the overall success of the initiative.

Teams need meetings to be productive. The bane of many administrators’ time is meetings. The authors give wonderful examples and strategies on how to make meetings effective (e.g., a distinct period at the end of each meeting to summarize the meeting, discuss action items, and assign responsibilities).

The authors end where any quality improvement initiative should begin, the burning platform. If the leader, or even the team, cannot articulate the burning platform and the imperative for action, then others will not follow, and the quality improvement initiative will not have a foundation to start its work.

Often times, improvement scientists perseverate on the data and necessary improvement charts yet forget about the teams, how to run meetings, how to create a burning platform, etc. – it is these factors that probably lend the biggest part to the success of a quality improvement initiative. One can find many platitudes regarding teams, the Editors strongly believe that the success of a quality improvement initiative is directly correlated to its focus on creating the right team and platform.