Team dynamics

Some time after implementation, certain team dynamics gradually began to emerge. As with the perceptions of a team incentive system, both positive and negative events occurred. The former will be discussed first.

4.5.1 Positive team dynamics

After implementation of a team incentive system, positive behaviours between team members began to occur and increase. Team incentives clearly enhanced the teamwork, collaboration, and

interaction between team members and did not provide them with an incentive to sub-optimize their own performance (2, 3, 5, 6). Moreover, team incentives made team members actively reach out to low-performing peers to develop, train, coach, and assist them (4, 6, 8). A family physician from study 6 described how she helped her partner:

I've been on him, but in a nice way, like okay, I ran your list, here's what I did, here's what you could do if you did this, you would get just as much credit as if you had seen 10 patients. (p. 238)

In addition, team incentives sparked more learning from high-performing peers. An internist from study 6 described reaching out to high-performing team members to learn, asking them: "what are you guys doing that's different than I'm doing?" (p. 238). A physician assistant, again from study 6, also described finding a high-performing colleague: "… who's doing really well—you can lean on that person… . I view it as a [way] to improve myself. If I see my numbers aren't as good, for me it's a motivating thing" (p. 238). The enhanced team-working behaviours mentioned above were not obviously affected by adverse incentive effects on morale due to perceived inequity because team working was felt to be dependent on more long-lived influences such as strength of relationships and support within the team (2).

In addition to positive behaviours between team members, there were also team-oriented behaviours by individual team members. After implementation of a team incentive system, team members improved their own performance to avoid hurting their peers' compensation, worked harder on peers' clients, and felt less pressure to shift clients with poor outcomes to peers (6). This was best expressed by a family physician from study 6: "now everyone's looking at my quality, not just if I get a bonus, my quality really impacts my partners' livelihood, so I'd better kick it in gear" (p. 238). An internist added: "I don't wanna be the guy that costs my partners money" (p. 238). In short, positive team-oriented behaviours occurred both between team members and by individual team members. Finally, introducing transparency in peers' performance reinforced team incentive systems and encouraged team members to improve their own performance towards targets (5). This principle applied in particular to certain types of employees and professional groups: "physicians in general tend to be fairly high achievers and want to do well, and [are] used to being somewhat competitive" (a primary care provider from study 5, p. 220).

4.5.2 Negative team dynamics

Implementation of a team incentive system also resulted in several negative team dynamics. Team incentives led to greater overall tension and peer pressure among team members (5, 6). Moreover, team incentives led to free riding of low-performing team members, which subsequently resulted in suspicion, tension, and conflicts between team members (6, 7). A family physician from study 6 stated: "my colleagues who… don't have numbers as good as mine, ride on my coattails because I up the average" (p. 239). An internist in an even more detailed fashion:

… since it's the clinic quality score that determines your pay, if your numbers are higher, you're being punished two ways. Number 1, the clinic average brings you down [and] your pay decreases. Number 2, you bring those who have poor quality numbers up, so they're

being paid more, and they don't have any incentive to improve. This system is benefitting them without doing extra work. (study 6, p. 239)

Study 4 attempted to add some nuance to the negative team dynamic of free riding. In study 4, it was suggested that high-performing employees' concerns about being subject to lower performing employees' performance are removed if high-performing employees organize and cajole other team members to maximize team productivity, and thereby secure a good level of bonus. However, this statement was not clearly acknowledged by the participants, and so the question remains as to what the value of such a statement is. Free-riding problems and team incentive-related problems were typically resolved by watching and carefully controlling peers and by making life difficult for free riders (7). Closely related to the free riding of low-performing team members was the resentment over team members' performance. Team incentives led to resentment over peers' performance and way of working, and frustration over not being able to improve their performance (6). A family physician from study 6 explained:

Physicians… tend to do things a certain way… it's hard to break out of those habits and molds… . You can encourage them and give suggestions, but when push comes to shove, they're in the patient's room with their patient, they do their thing… and it's hard for other people to really influence that to a large extent. (pp. 238-239)

Another frustrated clinician explained:

I cannot change my colleagues' habits at all. It has not happened in the 5 or more years we have been working on quality, so it is not going to happen now. Unless they are losing pay, some are never going to work aggressively on quality. (study 6, p. 239)

In short, there was not only frustration over peers' performance but also over not being able to improve their performance.