Hospital Management

Managing virtual teams in healthcare systems


Rapid globalisation over the last few decades compels us to modify our managerial skills such that one can optimally lead teams that are spread over large distances and different time zones. This is now commonly referred to as ‘virtual management’. The issues and problems that face virtual teams have been analysed in the non-medical, corporate world for many years [1, 3-5]. However, the problem of virtual management has not received much attention in the medical world. In this article, Dr Arby Khan defines some of the major problems faced by virtual teams in healthcare systems and then provides solutions to those problems using principles gleaned from the non-medical experience in virtual management.

Virtual teams are defined by two classification systems. First, teams are defined based on three dimensions – time, space, and culture. For example, one team could be operating in the same time zone, different spaces (or geographical locations), and within the context of different cultures. This three-dimensional classification leads to six different types of virtual teams – each requiring a specific type of managerial skill[1]. The second classification is based mostly on geographical location and has five different types of virtual teams – only some remote team members, split team, satellite team members, 100% virtual team, and outsourced team[2]. Fortunately, a manager does not need to memorise these complex classifications because there are clear, basic principles easily applicable to all types of virtual teams. Once these basic principles are mastered they can subsequently be easily refined for use within any given type of virtual team.

The distance issue

What then is the major difference between virtual and co-located teams? The distance, of course! This may seem a somewhat trivial hurdle to overcome since we have an array of electronic means of communicating – email, phone, instant messaging, conference calls, to name a few. However, the implications of such distances are far more complex than one might imagine. For example, let’s say that some members of the team are uncertain about the goal to be achieved. If the team is co-located (that is all team members in the same building) then members of the team can easily clarify poorly defined goals and transform an ill-defined project into a realistic one just by being near one another. So, on the same day, team members can communicate in the halls, at lunch, in the parking lot, or simply walk down the hall to another team member’s office. Achieving such clarity by electronic means and across distances may take many days. Thus, communication slows down considerably over distances. Additionally, when you add the other limitations of electronic communication to the equation (for example, how do you really know, without visual cues, that the person at the other end of the phone conference call is actually paying attention), it is clear that a team can quickly fall apart and achieve nothing over significant periods of time[2, 5].

Let us systematically examine some of the problems faced by virtual healthcare teams. As the classification systems described above indicate, there are several different types of virtual teams and discussing each one in detail is beyond the scope of this article. Thus, we will choose one type of virtual team which is common to most multi-site healthcare systems and analyse that in detail. This virtual team is described above in the first classification system as one that operates in the same time zone (defined as less than a 3-hour time zone difference), different space, and same culture. This virtual team is also described in the second classification system as “split team”. Essentially, what is meant is a healthcare system that has many hospitals, all of which are more or less identical, and are scattered across a geographic area large enough that the manager cannot interact with team members in a “face-to-face” manner on a regular basis. This group of hospitals could also be described as a mostly horizontally integrated healthcare system.


The basic problem faced by the manager of such a healthcare system is a significant decrease in many cues and interactions that occur in an otherwise co-located team. As a result, problems, misinterpretations, truancy or errant behaviour, conflicts, and mistakes are more likely to become full-fledged disasters by the time the manager finds out that something is amiss. Thus, the absolutely crucial aspect of virtual management is that the manager needs to enhance communication between team members to such a level that it is as similar as possible to that found in a colocated team. This allows detection of any irregularities as early as possible and before they become unmanageable. How can this be achieved[2]?

Creating the virtual team

It would be useful to be able to choose team members based on their ability to work in virtual teams (see “recommendations” below for details). In most horizontally integrated healthcare systems, however, this is not an option as it is essentially impossible to personally choose the entire management team in every hospital of a healthcare system. Thus, we will not discuss this in any detail. Suffice it to say then, that if possible, team members who have experience in virtual teamwork, all other things being equal, should be added to the already present team members.

Discovering commonalities

With virtual teams, the manager will need to be creative in finding ways to help people find commonalities – and it will take extra time and effort. The manager first has to make the effort to find out more about the team members and then, over time, share this information amongst the team members. This usually occurs spontaneously in co-located teams and may not take that much effort. However, in virtual teams this very important process takes extra effort. Identifying commonalities between people actually makes them like and appreciate each other more than if there were no commonalities. Finding commonalities is a very powerful psychological tool for building an instantaneous initial bond and is described in detail in this reference[6]. A great icebreaker for a virtual team is to ask all members to share something about themselves that other members will not already know.

Creating Trust

Trust and respect is almost always earned, not commanded, and members of a team that trust each other will go far in working together as a team and not just as a group of people working under one manager. The first component of earning trust is to make sure that every member of the team feels valued and appreciated for what they do. Additionally, the manager needs to make sure that all members feel entitled to have an opinion and express it. All opinions need to be heard – of course the manager doesn’t have to agree with every opinion expressed. Speaking openly, however, does not mean members can say whatever they want – there has to be respect for all members. This is especially important because it is much harder to repair rifts in virtual communication. Communicating virtually is quite impersonal and it is easy to feel annoyed at someone just because of one comment. That same comment made face to face, on the other hand, may be totally ignored, or in fact may actually be endearing because team members are able to see that person’s stress – and the otherwise offensive comment is attributed to just that. This is not possible during a phone conference or an email. Thus, it is much easier to make allowances for someone’s abruptness in face-to-face situations and also much easier to misinterpret or take offense to an otherwise benign statement in virtual communication.

Another aspect of building trust is to follow through in a timely fashion on responsibilities – and that goes for the manager as well as the team members. If any team member, and especially the manager, is unreliable or unsupportive, there is erosion of trust and members will not feel comfortable sharing their thoughts and opinions. Additionally, the manager needs to be consistent in messages communicated to team members – inconsistency erodes trust faster than any other transgression. To keep things flowing on time, the manager needs to hold team members responsible for their commitment and their actions. Here again, good relationships, trust, and communication is vital – because you are not going to meet this person in the hallway and be able to politely reiterate that her results are due tomorrow. It will take extra effort and time to make that communication virtually.

Understanding team dynamics

This can be challenging to determine since there are no visual or physical cues in phone conferences or emails. Thus, it is more difficult to determine if one member of the team likes or dislikes another. The team manager is the most influential contributor to team dynamics and positive interactions will ensue if there is a rapport developed (by finding commonalities, building trust, and strengthening relationships) and if there is a high degree of trust amongst virtual team members.

Team member interaction

This is perhaps the most important component of virtual teams. It is vital that the manager ensure there is a lot of communication amongst team members otherwise all the necessary interactions described above will be impossible to achieve. As member interaction is so pivotal to virtual teams, we will look at this in some detail.

When working virtually, it is quite easy to forget you are part of a team – simply because you never really see your team members in person. One can be so focused on their respective task that team meetings – by video or phone – can actually be perceived as a distraction. After a while, it is easy to stop calling in or not answer the phone. One gets invited to fewer and fewer meetings and suddenly one is a non-entity on the team[2]. Now imagine this happening with multiple team members and it is easy to see how a virtual team can become dysfunctional very quickly. Such team members then compel managers and other team members to ask the following questions: if he is not participating in the team, is he completing all his assigned work? If he isn’t interacting, how does he know his work is even valuable? Is he even working on the right task? If the rest of the team is functioning without input from this team member, is he needed at all? Managers of virtual teams should quickly identify such members and bring them back into team interactions by speaking directly and individually with them. Let all team members know that being part of the team is part of the job and is extremely important to the team’s success.


How should the manager communicate? There are various ways – phone, phone conference, video conference, email, Internet, virtual workspaces, online chat, and instant messaging. The manager needs to be very facile with all modes of communication and should determine if his team members are equally comfortable. The method of communication will be specific to the needs of a particular organisation and the team’s project and although the method of communication is important, its regularity is essential. It is useful for managers to insert a personal note to team meetings and to encourage such insertions by other team members. It is conducive to team building to allow and encourage some non-work chatter before and after the meeting. The manager can try to add some fun to the meeting by asking participants about their vacations or what they did during the weekend. Questions like “who had the most interesting weekend?” can generate a nice conversation but such conversation should flow naturally and not appear contrived. It is also possible to have a team lunch – virtually. The team can call into a conference and chat on the phone while eating or having a beverage. However, for such conferences, there needs to be one rule – no talking about work! Some teams even watch movies or TV shows together – virtually[2]. Finally, virtual team days should be organised – these should occur about once every three months if possible. Here, all team members get together in one location in person. These are “fun” days, important in building the communication, the trust, and the basis of personal relationships discussed above. Here also, the cardinal rule applies – no talking about work!

Lastly, just as in co-located teams, sharing best practices is an important component of virtual team interaction and this should be encouraged on a regular basis – depending on the nature of the project of course.

Recommendations for developing virtual teams in horizontally
integrated healthcare systems

Setting the stage for success

- Clearly define the purpose for creating that team. For example: “We need to determine the exact cause or causes of delayed starts in the operating room.” The goal needs to be precise and clear.

- What skills are needed to achieve these goals? Do we need a statistician? An anaesthesiologist? A surgeon? An administrator? Do we need somebody who has free time to roam around the operating room to determine what is really going on? Does this person need to be somebody from outside the operating room team so that there is no conflict of interest? These needed skills will in large part determine the composition of the team (below).
- Choose your virtual team. People with the above required skills need to be identified. It is crucial to look inside and outside your organisation for ideal team members. Virtual team members generally need to be highly self-disciplined and motivated. People who need a great deal of supervision are not suitable. Try to find people who actually have an interest in what you are trying to achieve. Clearly, an endocrinologist will have little interest or incentive to create a more efficient operating room – a busy surgeon, on the other hand, who has to stay late because of inefficiencies will be quite motivated to identify the root causes of delayed starts. However, it is a double edged sword – the surgeon might not see himself as the cause of delays. Thus others who are more objective will need to be included in the team.

Fostering team identity

- Hold a launch meeting. It is very important that members of your virtual team get together for a face-to-face meeting right from the start – even if it is the only time they meet face-to-face. Devote one or two days to this meeting – for it is important that team members get acquainted at a personal level. Create small groups and assign them to discuss certain aspects of the task at hand. Then rotate the groups so that eventually, everybody has a chance to be with every other member of the entire team. This creates a sense of identity, of belonging to a team. It creates group cohesion.

- Establish communication protocols. It is not as important to decide which mode of communication to use as it is to create protocols to communicate as frequently as possible. Remember, we are trying to replicate the interactions, verbal cues, physical cues, etc, that are an essential part of communication in a co-located team. Additionally, at these virtual meetings, and especially when all team members are at the virtual meeting (phone, video conference, etc) it is important for the manager to reiterate the team’s goals and how achieving that goal fits into the larger strategic direction of the organisation (if the manager is unable to do this then it is possible that senior management has not clarified the strategic goals clearly – a relatively frequent occurrence). Everybody should agree on standards and protocols for communicating – who will receive what communication and when, who will be copied on what, how frequently team members should check email, voice mail, etc, and how quickly are responses expected. It may seem trivial to have to set all this up, but it is not. Team members can very quickly become less and less available until they are seldom heard from – this cannot be allowed by the virtual manager. Documenting expectations and processes is very important. One of the best tools available for this is Microsoft Office Project. This can clearly state, for all team members, who is responsible for doing what, when it is due, and what the interdependencies are for each member’s task. Thus, everybody can see, for example, that the deadline is 20 days from now, and team member B’s task, while taking only five days, cannot be started until team member A has finished his task. So, if team member A’s task takes 14 days, then there is clear pressure on team member A to finish his task – because all those who have access to the Office Project file are monitoring the project. All managers need to be facile with MS Office Project or some similar project management software. It unifies the team while at the same time providing all team members with crucial information about what everybody else is doing and how their work is dependent on their team members’ work and vice versa.

Keeping team members aligned through communication

Project Management Software. Once again project management software, such as MS Office Project, is ideal for keeping all team members informed and aligned. The importance of this alignment cannot be emphasised enough. Documenting expectations, keeping everybody informed, creating a work plan, monitoring the work plan, updating the work plan – all these crucial aspects of leading a virtual team can be accomplished by project management software. It should be used by all managers serious about managing efficiently.

Using coaching to enhance team performance

- Maintain excellent communication with team members. Some team members may not be able to work with others, or may not know how to use presentation software, or may not know how to create a balance sheet. This is similar to issues that arise with co-located teams, however it is more difficult to address these issues with virtual teams. First, the manager may not find out that there is a problem until it is too late. This can be prevented by creating the communication protocols and personal relationships described above. Subsequently, this very communication will then help solve the problem as well.

Leveraging technology effectively

Assess time, money and resources
- Determine each team member’s access to technology
- Assess technology compatibility
- Assess ability of members to use the necessary technology. If the manager deems it necessary to use MS Office Project or some similar project management software then it is necessary to make sure that all team members are taught how to use it


Henry Ford opined that “coming together is a beginning; keeping together is a process; working together is success”. Whereas this quote could be used in any human relationship, it has special significance for virtual teams. The main disadvantage of virtual teams is that lack of co-location, absence of visual and physical cues in team interaction, and the inability to walk down the hallway to speak with a team member or run into them at lunch, leads to serious delays in detecting problems. Thus, the key to making virtual teams successful is to establish the method and, more importantly, the frequency of communication in such a way that the manager is able to detect problems as early as he would in a co-located team. This leads to effective virtual teams that complete meaningful tasks on time, within budget, and with a sense of satisfaction that comes with the camaraderie of working with a group of likeminded and hardworking people.


 Date of upload: 15th Nov 2011


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