title: Effective Leadership of Surgical Teams: A Mixed Methods Study of Surgeon Behaviors and Functions.
abstract: BACKGROUND
  The importance of effective team leadership for achieving surgical excellence is widely accepted, but we understand less about the behaviors that achieve this goal. We studied cardiac surgical teams to identify leadership behaviors that best support surgical teamwork.
  
  
  METHODS
  We observed, surveyed, and interviewed cardiac surgical teams, including 7 surgeons and 116 team members, from September 2013 to April 2015. We documented 1,926 surgeon/team member interactions during 22 cases, coded them by behavior type and valence (ie, positive/negative/neutral), and characterized them by leadership function (conductor, elucidator, delegator, engagement facilitator, tone setter, being human, and safe space maker) to create a novel framework of surgical leadership derived from direct observation. We surveyed nonsurgeon team members about their perceptions of individual surgeon's leadership effectiveness on a 7-point Likert scale and correlated survey measures with individual surgeon profiles created by calculating percentage of behavior types, leader functions, and valence.
  
  
  RESULTS
  Surgeon leadership was rated by nonsurgeons from 4.2 to 6.2 (mean, 5.4). Among the 33 types of behaviors observed, most interactions constituted elucidating (24%) and tone setting (20%). Overall, 66% of interactions (range, 43%-84%) were positive and 11% (range, 1%-45%) were negative. The percentage of positive and negative behaviors correlated strongly (r = 0.85 for positive and r = 0.75 for negative, p < 0.05) with nonsurgeon evaluations of leadership. Facilitating engagement related most positively (r = 0.80; p = 0.03), and negative forms of elucidating, ie, criticism, related most negatively (r = -0.81; p = 0.03).
  
  
  CONCLUSIONS
  We identified 7 surgeon leadership functions and related behaviors that impact perceptions of leadership. These observations suggest actionable opportunities to improve team leadership behavior.
authors.affiliation: Department of Health Research and Policy, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.
authors.forename: Juliana L
authors.initials: JL
authors.lastname: Stone
authors.affiliation: Department of Health Research and Policy, Harvard T. H. Chan School of Public Health, Boston, Massachusetts; Cambridge Centre for Health Services Research, University of Cambridge, Cambridge, United Kingdom.
authors.forename: Emma-Louise
authors.initials: EL
authors.lastname: Aveling
authors.affiliation: Department of Health Research and Policy, Harvard T. H. Chan School of Public Health, Boston, Massachusetts; Health Care Management Department, The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Molly
authors.initials: M
authors.lastname: Frean
authors.affiliation: Department of Health Research and Policy, Harvard T. H. Chan School of Public Health, Boston, Massachusetts; Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts.
authors.forename: Morgan C
authors.initials: MC
authors.lastname: Shields
authors.affiliation: Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts.
authors.forename: Cameron
authors.initials: C
authors.lastname: Wright
authors.affiliation: Negotiation, Organizations & Markets, Harvard Business School, Boston, Massachusetts.
authors.forename: Francesca
authors.initials: F
authors.lastname: Gino
authors.affiliation: Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts.
authors.forename: Thoralf M
authors.initials: TM
authors.lastname: Sundt
authors.affiliation: Department of Health Research and Policy, Harvard T. H. Chan School of Public Health, Boston, Massachusetts; Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts. Electronic address: ssinger@hsph.harvard.edu.
authors.forename: Sara J
authors.initials: SJ
authors.lastname: Singer
mesh_terms: D006801:Humans; D007857:Leadership; D010348:Patient Care Team / Q000458:organization & administration*; D012189:Retrospective Studies; D066231:Surgeons / Q000458:organization & administration / Q000523:psychology*; D011795:Surveys and Questionnaires; D013903:Thoracic Surgery; D000078329:Workforce