Development of Potentially Better Practices for the NeonatalIntensive Care Unit as a Culture of Collaboration:

Communication, Accountability, Respect, and Empowerment

Judy Ohlinger, RN, MSN*; Mark S. Brown, MD, MSPH‡; Sue Laudert, MD§; Sue Swanson, RN, NNP�; andOna Fofah, MD� on Behalf of the CARE Group

ABSTRACT. Objective. The Vermont Oxford Net-work (VON) CARE Group was formed in response to theneed to create organizational cultures supportive ofchange and quality improvement.

Methods. The CARE Group consisted of team mem-bers from 4 participating neonatal intensive care units(NICUs). All CARE Group members chose to work onmultidisciplinary teamwork for the duration of the Neo-natal Intensive Care Quality Improvement CollaborativeYear 2000. A questionnaire was developed by the CAREGroup and administered to the 4 focus group NICUs. Thesurvey focused on 6 domains of the organization: unitcoordination, working in the NICU, leadership, manage-ment of disagreements, authority, and unit culture.Benchmarking visits were completed to supplement theinformation found in the survey and the literature.

Results. Seven potentially better practices (PBPs)were developed on the basis of the surveys, benchmarkvisits, and literature reviews. The PBPs include 1) a clear,shared NICU purpose, goals, and values; 2) effectivecommunication among and between teams and teammembers; 3) leaders lead by example; 4) nurture a collab-orative NICU environment with trust and respect; 5) liveprincipled standards of conduct and standards of excel-lence; 6) nurture competent and committed teams andteam members; and 7) commit to effective and positiveconflict management.

Conclusions. The CARE Group successfully usedquality improvement methods and collaboration to de-lineate principles and practices of multidisciplinaryteamwork. Pediatrics 2003;111:e471–e481. URL: http://www.pediatrics.org/cgi/content/full/111/4/e471; collabo-ration, multidisciplinary teamwork, leadership, culture,collaborative quality improvement, NIC/Q 2000.

ABBREVIATIONS. NICU, neonatal intensive care unit; NIC/Q2000, Neonatal Intensive Care Quality Improvement CollaborativeYear 2000; PBPs, potentially better practices.

KEY POINTS OF ARTICLE• The Organizational Assessment and CARE Group

surveys addressed neonatal intensive care unit(NICU) coordination, leadership, management of

disagreements, satisfaction, authority, and unitculture.

• At benchmark sites, nursing, medical, and alliedhealth professionals supported and demonstratedcollaborative practice.

• The culture of collaboration and teamwork withina unit is not a static “given”; it can be improvedthrough the deliberate application of certain prac-tices.

APPLYING LESSONS LEARNED TO PRACTICE• The CARE Group learned that the essence of team-

work is collaboration, coordination, communica-tion, continuity, and competence (the 5 “Cs”).

• Responsibility for problem solving must be sharedby all professionals because successful quality im-provement is driven by effective multidisciplinaryteamwork.

Culture is the summation and functional ex-pression of the values of an organization—itsdecision-making processes, resource alloca-

tions, division and alignment of power, authority,and influence.1 Culture encompasses the beliefs,norms, attitudes, and assumptions that are learnedover time, shared by the organization’s members,and operate usually at a subconscious level. It isoften described as “the way we do our work here.”

Cultural orientation consists of a blend of group,developmental, rational, and hierarchical elements.1Organizations such as NICUs have varying combi-nations of the elements of these orientations, andusually 1 or 2 predominate. Group elements reflectconcern for employees and patients (customers), em-phasizing teamwork, participation, working rela-tionships, consensus, cohesion, morale, trust, respect,and commitment. Work centers around processesand teams. Leaders are described as coaches, men-tors, facilitators, and team and trust builders. Devel-opmental elements encourage innovation, initiative,autonomy, risk taking, experimentation, flexibility,and adaptation. Leaders are catalysts and cultivatorswho empower, inspire, and promote their peopleand their goals. Success is defined as new products,services, and outcomes. Rational elements are com-petitive, goal-oriented, and efficient but emotionless,formal, and impersonal. The focus is on numbers,winning, and the bottom line. Leaders are assertive,tough, and demanding. Hierarchical elements arestructured, formalized, authoritative, conservative,

From the *Children’s Hospital Medical Center of Akron, Akron, Ohio;‡Presbyterian St Luke’s Medical Center, Denver, Colorado; §Wesley Med-ical Center, Wichita, Kansas; and �Rockford Memorial Hospital Rockford,Rockford, Illinois.Received for publication Aug 13, 2002; accepted Oct 24, 2002.Reprint requests to (J.O.) Children’s Hospital Medical Center of Akron, OnePerkins Sq, Akron, OH 44308. E-mail: johlinger@chmca.orgPEDIATRICS (ISSN 0031 4005). Copyright © 2003 by the American Acad-emy of Pediatrics.

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impersonal, task driven, and prescriptive. Work isconducted according to policies and procedures.Risk taking is discouraged, and security is empha-sized. Leaders are organizers and managers definingsuccess in terms of dependable delivery and out-comes of care or services and low cost.

Without change, there can be no improvement.The fabric of the culture determines the degree towhich any NICU embraces change. The more thatchange is woven into the fabric of the NICU, themore the processes of quality improvement can beimplemented. The cultural orientations that are mostconducive to change and improvement are develop-mental and group.

The principal elements that support change in de-velopmental and group cultures are teamwork andcollaboration—working together in a cooperativeand coordinated way in the interest of a commoncause. The authors of Team-Based Health Care Organi-zations2 concisely described this in their Blueprint forSuccess: A team is a small number of consistentpeople committed to a relevant shared purpose, withcommon performance goals, complementary andoverlapping skills, and a common approach to theirwork. Team members hold themselves mutually ac-countable for the team’s results or outcomes.

At the beginning of the Neonatal Intensive CareQuality Improvement Collaborative Year 2000(NIC/Q 2000) project, a comprehensive survey oforganizational culture was done. For determiningthe distribution of cultural elements, this survey ad-dressed 6 domains of the operation of an NICU: 1)coordination, 2) about your work, 3) leadership, 4)managing disagreements, 5) authority, and 6) unitculture.1,3

The CARE Focus Group, composed of 4 NICUs,was formed because of a joint concern that to pro-duce effective change in NICUs, a supportive orga-nizational culture had to be present. The organiza-tional surveys validated the current cultures of theunits and provided quantified information on howstaff perceived their NICU in the 6 domains. In ad-dition to baseline data on clinical indicators and fi-nancial profiles, survey results were compared in thehope of finding some obvious common theme. Al-though rational and hierarchical elements seemed topredominate in most of the units, no centralizing orcommon theme across units was found.

The CARE Group’s task then was to facilitate themovement of their NICUs toward a culture that sup-ports and values change and quality improvement.The organizational survey provided the initial foun-dation for the work in identifying potentially betterpractices (PBPs) for unit culture, and it gave scientificand process credibility to a topic that is often viewedas nice but not necessary. The first 4 domains of theorganizational survey were used to organize thework. The overall aim was to improve performancein these 4 domains by 25% over baseline for eachparticipating NICU. The group believed that anyoutcome—clinical, operational, or organizational—could be improved if people worked well together asa team. Therefore, the primary focus was on team-work. The name for the focus group, CARE, repre-

sents key elements of teamwork: Communication,Accountability, Respect, and Empowerment.

METHODSEach of the 4 institutions in the CARE Group chose to work on

multidisciplinary teamwork for the duration of the NIC/Q 2000project. At the first meeting, a tentative timeline was establishedfor meeting the goals of the group and the larger collaborative.Between NIC/Q 2000 semiannual meetings, communication oc-curred primarily by conference calls every 2 to 4 weeks. Leader-ship of these calls was rotated among the members. In addition tothe tasks to be completed by each conference call, individualNICU progress was discussed. The CARE Group listerv was theprimary means of exchanging information between calls andmeetings.

DemographicsThe CARE Group included 4 hospitals located in Ohio, Illinois,

Kansas, and Colorado. From the outset, it was agreed that infor-mation would be shared openly, liberally, and respectfully.

To understand the similarities and differences among thehealth care delivery environments that might affect cultures,NICU characteristics were compared, such as the number andsources of admissions, the number and varieties of health careproviders and staffing, overall organizational characteristics, andoutcomes. Individual NICU scores were also compared on the 6domains of the organizational survey and the distribution of the 4cultural elements. These comparisons familiarized the memberswith each unit and facilitated the discovery of the roles, if any, thatthese characteristics might play in determining cultural orienta-tion. The 4 NICUs varied considerably (see Table 1).

Internal Process AnalysisThe group began working on the development of an internal

process analysis tool. The purpose of the tool was to assess indetail the state of teamwork within the units and to facilitatecomparison between units. The group developed a questionnairethat focused on the 4 domains of the organizational survey de-scribed above. Each participating institution volunteered to de-velop process questions for 1 domain on the basis of the organi-zational survey results, NICU-specific experiences, and teamworkliterature.

These process questions were then reviewed and revised by theCARE group as a whole. Questions on “coordination” asked aboutcommunication, multidisciplinary input, and consistency in prac-tice. Questions on “your work” asked about role clarity for thestaff, accountability, satisfaction, and empowerment. “Leader-ship” questions asked about role clarity of leaders, supportive-ness, and role enactment. In the section on “managing disagree-ments,” questions addressed interpersonal behaviors and conflictresolution methods.

Staff in each unit completed the questionnaire. The numbers ofstaff members, the numbers of disciplines represented, and thelevels of staff who completed the questionnaire varied. The re-sponses for each NICU were used to establish a baseline descrip-tion of current practice environments, attitudes, and workingrelationships. The survey feedback helped each unit decide onwhich areas of teamwork to focus first.

Lessons learned from this process analysis are summarized inTable 2. The responses made it clear that teamwork was importantto individuals, but surprisingly, most believed that they werealready displaying the attributes of good team members and theproblem was with others who were not. Interestingly, there waslittle faith that conflicts among staff were or could be dealt witheffectively. Furthermore, many respondents held a negative viewof leadership, particularly that an individual’s input was notimportant or valued, and leaders were not sufficiently accessibleto staff. Sincerity, effective communication, and involvement byand with leaders were highly valued. After the internal analysis,the survey questionnaire was reviewed and further revised for usewith benchmark sites.

Literature ReviewThere is a limited though growing literature on multidisci-

plinary teamwork in health care. To ensure that the review was

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inclusive, articles, books, and book chapters were examined, andexpert recommendations, bibliographies, and Internet searcheswere investigated on a variety of aspects of teamwork. Individualsfrom each participating institution summarized and rated eachpiece of material, and these reviews were circulated among theentire CARE Group. Additional members of the group reviewedthose that seemed particularly relevant and useful.

No large, randomized, controlled studies about multidisci-plinary teamwork in health care were found. The majority of theliterature came from business and industry. After the teamworkliterature was evaluated, the material was divided into 2 priority

levels for anyone focusing on teamwork: essential reading (the“A” list) and highly recommended reading (the “A�” list; seeAppendix 1).

From the review, it became apparent that better practices forteamwork had already been discovered and health care outcomescould probably be improved with their application. Furthermore,common themes emerged that seemed fundamental to the devel-opment of potentially better practices. Books of particular noteincluded Gung Ho, The Servant, and Who Moved My Cheese. Al-though not scholarly, all 3 capture the essence of teamwork,leadership, and change. The message conveyed was that worth-while work is key, everyone needs to participate in goal achieve-ment, and interpersonal support needs to be offered and receivedfor teamwork to happen.4 The leaders’ roles are to serve those theylead with respectful and responsible authority, not power.5 Al-though the status quo may be comfortable, change is necessaryand needs to be embraced.6

Benchmarking Site VisitsBased on the results of the organizational survey, the NIC/Q

2000 leadership identified 2 potential benchmark sites for exami-nation of multidisciplinary teamwork in action. To ensure anappropriate fit with the CARE Group’s purposes and for economyof money and time, as much as possible was learned about eachsite before it was visited. CARE Group members interviewedindividuals from these sites, first by telephone, then in person at 1of the semiannual meetings. The revised process analysis tool wassent to each benchmark site for the staff to complete, and theseresponses were reviewed and compared before the site visits.

Clear goals and agendas were established for both visits. Eachvisit began with a dinner meeting on the evening of arrival,followed by a full day in and around the NICU, including multi-disciplinary meetings. Representatives from all disciplines andlayers of the NICU were interviewed, and interactions and rela-tionships among staff members in their ordinary day-to-day workprocesses were observed and evaluated.

Although there were obvious differences between the bench-mark sites, there were striking similarities in the way they con-ducted collaborative practice. Their attitudes, beliefs, and behav-iors were in line with what was found in the literature. At bothsites, the intent to collaborate was clear. Nursing, medical, andallied health professional leaders gave obvious support to thecollaborative process, clearly stated their expectations of partici-

TABLE 1. Comparison of CARE Group NICUs at the Start of the NIC/Q 2000 Project

Unit NICU A NICU B NICU C NICU D

Age of NICU 30 y 27 y 20 y 27 yLevel 3 beds 40 total 36 30 24Level 2 beds 18 30 35Annual admissions 600 780 590 620

�500 g 1% 1% 1% 1%500–1500 g 28% 15% 27% 26%�1500 g 71% 77% 72% 73%% Inborn 74% 75% 77% 0%% Outborn 26% 25% 23% 100%

Full-time FTE 65.5 70 84 71Turnover rate/y 10% 7% 11% 12%Clinical ladders? Yes No No YesCredentialing? Yes No No NoHours/patient day 14.64 12.44 14.43 10.8NNP

Full-time FTE 5 10.5 10.5 8RT

Full-time FTE 4.5 18 22 total 26.3 totalNeonatology

Full-time FTE 6.5 7 8 9In-house Yes Yes Yes YesFellows No No No NoResidents No Yes FP YesMedical students No Yes No Yes

Institution ownershipPublic/private Public Private Private Private

For-profit/not-for-profit Not-for-profit For-profit For-profit Not-for-profitUniversity affiliated No Yes No Yes

FTE indicates full-time equivalent.

TABLE 2. Lessons Learned From Internal Process Analysis

Unit structures are hierarchicalStaff believe that they have little influence in decision making

but recognize the need and have the desire to be moreinvolved

Leadership is perceived as being inaccessible and out of touchIndividually we are willing to change and improve but

collectively we are notIndividuals see their own behavior differently from how others

see itIndividuals believe that they already know how to be good

team players; everyone “just needs to do it”Staff are naı̈ve regarding whole-unit functioning and their

individual roles and contributions to that functioning(deficient in systems thinking)

Respect is higher within disciplines than between disciplinesThere is a lack of trust and respect between “us” and “them”

(staff and management)There is little trust by the staff that conflicts will be resolvedThere is variation in the understanding of the goals of conflict

resolutionDespite an understanding of conflict resolution, people cannot

or will not apply the knowledgeDay-to-day performance issues are perceived as being treated

inconsistentlyBoth monetary and nonmonetary reward and recognition are

importantAll disciplines are willing to participate in conflict resolution

and teamwork training

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pation in collaborative practice, and encouraged creativity. Theleaders at these 2 sites were comfortable with letting go of thecontrol for making decisions and implementing changes resultingfrom those decisions. The staff displayed a “functional” multidis-ciplinary approach to problem identification and problem solvingthat included a sense of personal and professional ownership andpride, responsibility, accountability, respect, and trust.

Although their organizational charts would appear hierarchicalon paper, the leaders of these NICUs made every effort to supportand serve staff. They modeled the attitudes and behaviors ex-pected of staff and saw their role as removing barriers and pro-viding resources for the work of care providers. They exemplifiedthe differences between leadership and management.5 In theseNICUs, the elements of group and developmental cultures weredominant. Lessons learned from the benchmark sites are summa-rized in Table 3.

The teamwork that was observed at these sites included amultidisciplinary approach to problem solving in the NICU, withownership and pride by everyone, shared responsibility, effectivecommunication without previous assumptions, and mutual re-spect. These visits confirmed the view that successful qualityimprovement is driven by effective multidisciplinary teamwork.The importance of leaders as role models of teamwork attitudesand behaviors and their service in barrier removal and changefacilitation toward goal achievement was apparent. Collaborativeprinciples and practices were observed in action and were con-firmed as both invaluable and achievable.

RESULTSFrom the outset of the project, the primary task

was to derive PBPs for multidisciplinary teamwork.These practices were synthesized from a combina-tion of the internal process analysis, the literaturereview, and the benchmark site visits.

The aim of the list of PBPs was to be concise andminimally redundant and to customize this list for aNICU environment. It was realized early that allPBPs for an effective and functional NICU teamworkculture were inextricably intertwined. It was difficultto identify any single practice that stood out or stoodalone. All were supported and underpinned by 1 ormore of the other practices. From all of the above

processes and lessons, the PBPs were condensed to 7(Table 4).

Clear, Shared Purpose, Goals, and ValuesCommon purpose, goals, and values, specifically

articulated, provide a unifying effect to the directionand commitment of team members. The purposeaddresses, “What are we here to do together?” Thegoals are the milestones in pursuit of the purpose.Values describe how the team members are expectedto behave on a day-to-day basis, how the team willtravel together.

Effective Communication Among and Between Teamsand Team Members

There are 2 types of communication critical toteam success: organizational and interpersonal. Thissuccess depends on how well team members com-municate not only among themselves but also toanyone else who is likely to be affected by or inter-ested in their activities.

Organizational communication necessitates theuse of multiple methods of communicating the sameinformation. Information should be shared openlyand often, including agendas, meeting minutes, cal-endars, and financial and clinical performance data.This links individual and unit-based activities to thebig picture and how each member contributes to theoverall functioning of the unit.

Interpersonal communication needs to be viewedas a 2-way process. Attentive “listening for under-standing” is especially important and is not a skillthat many people typically possess. All team mem-bers should encourage balanced participation in alldiscussions.

Lead by Example: “Walk the Talk”Leaders’ primary responsibility is to facilitate

whatever it takes for others to do their jobs effec-tively using resources both within and outside thedepartment. They need to be seen as accessible andactively advocating for the NICU.

Effective leaders encourage decision making thatis visible and participative. They trust team memberswith meaningful levels of responsibility and providethem with the autonomy necessary to achieve pur-poses and goals. Leaders manage the principles ofeffective teamwork and let these principles managethe teams. They do this by modeling the attitudesand behaviors desired of the rest of the staff. Theyalso do this by identifying and addressing skill,knowledge, performance, and attitude deficits orproblems fairly, impartially, and consistently at alllevels.

Leaders strive to develop leadership skills in oth-ers, thereby creating more leaders. Their goal is tomove team members from dependence on leaders toindependence and eventually to interdependence, asystems model. To accomplish this, they use leader-ship styles that are appropriate to the developmentallevels of individuals and groups moving betweendirecting, coaching, supporting, and delegating,rather than command-and-control.7 By being open tonew ideas and information themselves, they influ-

TABLE 3. Lessons Learned from Benchmark Site Visits

Collaboration comes first and weaves the fabric of all NICUactivities

Teamwork is collaboration, coordination, communication,continuity, and competence (the 5 “Cs”)

Responsibility for problem solving must be sharedSuccessful quality improvement is driven by effective

multidisciplinary teamworkA healthy, respectful environment of ownership and pride is

pervasive and contagiousLeadership is key—it sets the tone for everythingAddress conflict, do not avoid itThe NICU is a community—take the time to build trusting,

respectful relationshipsMake no assumptions

TABLE 4. Summary List of PBPs

Clear, shared purpose, goals, and valuesEffective communication among and between teams and team

membersLead by example: “walk the talk”Nurture a collaborative environment with trust and respectLive principled standards of conduct and standards of

excellenceNurture competent and committed teams and team membersCommit to conflict management

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ence movement away from the status quo, valuingand supporting the energy and talents of team mem-bers to try new things without fear of rejection orretribution. This fosters members’ personal interestand commitment to the outcomes that lead to greaterlikelihood of successful achievement.

Nurture a Collaborative Environment With Trust andRespect

A collaborative climate refers to the extent towhich members communicate openly, disclose prob-lems, share information, help each other overcomeobstacles, and discover ways of succeeding. It isteamwork. Collaboration flourishes in a climate oftrust, allowing team members to stay problem fo-cused, not personality focused, and promotes effi-cient and effective communication and coordination.Trust is produced in a climate that includes 4 ele-ments: honesty, openness, consistency, and respect.

Live Principled Standards of Conduct and Standards ofExcellence

Standards define a team’s acceptable level of per-formance, but every standard is eventually definedby individual performance. The establishment of andadherence to high personal and team standards havea direct influence on the quality and value of perfor-mance and outcomes. Standards cannot be dictated.Group process and consensus should determinethem.

Nurture Competent and Committed Teams and TeamMembers

There are 7 identified core competencies that facil-itate effective and efficient teamwork. Team mem-bers should be aware of these and work towardachieving them. In brief, these core competencies are1) intellectual ability to arrive at objective and fact-based judgments after obtaining and comparing rel-evant information; 2) results orientation, the abilityto work toward outcomes and to finish what is start-ed; 3) interpersonal skills that demonstrate the abilityto relate to the needs, wants, and feelings of others

by conveying interest and respect and offering assis-tance; 4) ability to manage time and priorities for selfand others, handling multiple activities, meetingdeadlines, and planning and organizing skills; 5)team orientation, the ability to work collaborativelywithin a complex structure, making team goals ahigher priority than any personal objective; 6) inter-dependent maturity whereby individuals act respon-sibly, respectfully, openly, and honestly in their deal-ings with all people and situations; and 7) presence,the ability to demonstrate high standards of personalexcellence in ways that contribute positively to teamexcellence and success.

Commit to Conflict ManagementIn any team that is really working toward its goals,

there are bound to be conflicts. The assumption thatconflict is always negative needs to be reconsidered.Unmanaged conflict can sabotage team progress, re-sulting in a tangled web of tensions and disagree-ments that are difficult to unravel. There are con-structive ways of managing conflict so that peopleare able to express and work through their differ-ences without the risk or necessity of damaging oneanother. A successful team is one in which leadersand members all make the commitment to and takeresponsibility for managing conflict.

DISCUSSIONThe CARE Group was diverse in many ways and

worked from the premise that to achieve effectiveand enduring quality improvement, health care pro-viders must have the desire and ability to seek andembrace change, work collaboratively, and incorpo-rate the 4 key habits described by Horbar and Plsek.Throughout their work, this premise did not change.A change of culture can lead to a culture of change.

Successful teamwork and a collaborative NICUculture require a clear purpose shared by the entirehealth care team. This purpose supports the pyramidof team basics whereby individual and team skills,accountability, and commitment lead to personalgrowth, collective work products, and performance

Fig 1. The intertwined relationships of the PBPs(adapted from Katzenbach and Smith8).

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results (Fig 1).8 It represents the essence of whypeople do their work, encompasses their values, andhelps guide decision making and conflict manage-ment. Leadership has to believe in and model theingredients of teamwork to instill the values andbehaviors of teamwork in others.2 For teamwork tobe successful, all members of the team need to iden-tify with and participate in the change process andits evaluation. The role of leadership is to set theexpectations and boundaries within which the team-work occurs and to facilitate the team’s efforts.5There needs to be accountability for the work beingdone through all levels of the team. The substancethat holds the teams together is communication atall levels and in both vertical and horizontal di-rections.9–11 Communication is key to everyone’sinvolvement and commitment, facilitating goalachievement and resolving conflict.

It can be speculated that an effective strategy forimplementation of the PBPs listed here would be tocapture an opportunity to champion 1 of the prac-tices. The intertwined nature of all of the principlesand practices should produce subsequent opportu-nities to implement others. Although the PBPs mayseem obvious, implementing them is very likely todiffer from one NICU to the next, and it is oftendifficult to find measures of cultural change as in-terim or endpoints for PDSA change cycles. Further-more, although significant improvements can bemade in clinical outcomes, in the presence of lesssupportive cultures of change, such improvementsare likely to be difficult to implement and sustain.Collaborative teams, representing predominantlygroup and developmental elements, are more capa-ble of producing quality improvement results thatare enduring.

It was clear throughout the processes of comingto understand collaborative work and team build-ing that leadership is vitally important to a cultureof change. Leaders need to support those on the“front lines” by defining boundaries and expecta-tions and removing barriers to permit them to per-form their work well. Problem identification andideas for problem solution ideally should occur onthe front lines. Change needs to be sought, sup-

ported, implemented, and evaluated by those on thefront lines. Everyone needs and deserves to knowwhat is going on in their unit to work effectively.Therefore, truly effective communication is vital.

The CARE Group’s work with NICU culture hasbeen primarily qualitative. The principles presentedhere need to be evaluated as PBPs. The way to im-plement them is individualized and presents a sig-nificant challenge. The threat throughout such a pro-cess is loss of objectivity. The time to see results isprolonged. It is difficult to uncover and change deep-seated attitudes, beliefs, and histories of poor work-ing relationships. Therefore, the achievement of acollaborative NICU practice culture is not an eventbut rather a process.

ACKNOWLEDGMENTSCore members of the CARE Group: Heather Adams, Mark S.

Brown, Paula Delmore, Kathy Duritza, Ona Fofah, Laurie Fortune,Kris Grayem, Cindy Harmon, Patricia Ittman, Anand Kantak,Nancy Leahy-Jacklow, Sue Laudert, Judy Ohlinger, Laura Riss-man, Connie Rusk, Evelyn Samples, Monica Smith, Sue Swanson,Terese Tangye, Diane Tindall, and Bill Velbeck.

REFERENCES1. Baker GR, King H, MacDonald JL, Horbar JD. Using organizational

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2. Manion J, Lorimer W, Leander WJ. Team-Based Health Care Organizations:Blueprint for Success. Gaithersburg, MD: Aspen Publishers; 1996

3. Horbar JD, Plsek PE, Leahy K. NIC/Q 2000: establishing habits forimprovement in neonatal intensive care units. Pediatrics. 2003;111(suppl):e397–e410

4. Blanchard KH, Bowles S. Gung Ho! New York, NY: William Morrow &Co; 1997

5. Hunter JC. The Servant: A Simple Story About the True Essence of Leader-ship. Roseville, CA: Prima Publishing; 1998

6. Johnson S. Who Moved My Cheese. New York, NY: GP Putnam’s Sons;1998

7. Blanchard KH, Carlos JP, Randolph, A. The 3 Keys to Empowerment. SanFrancisco, CA: Berrett-Koehler Publishers; 1999

8. Katzenbach JR, Smith DK. The Wisdom of Teams: Creating the High-Performance Organization. Boston, MA: Harvard Business School Press;1993

9. Scholtes PR, Joiner BL, Streibel BJ. The Team Handbook. 2nd ed. Madison,WI: Oriel Inc; 1996

10. Chang RY. Success Through Teamwork. San Francisco, CA: Jossey-BassPfeiffer; 1994

11. Senge PM, Kleiner A, Roberts C, Ross R, Smith BJ. The Fifth DisciplineFieldbook: Strategies and Tools for Building a Learning Organization. NewYork, NY: Doubleday; 1994

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2003;111;e471Pediatrics Judy Ohlinger, Mark S. Brown, Sue Laudert, Sue Swanson and Ona Fofah

Empowermentas a Culture of Collaboration: Communication, Accountability, Respect, and

Development of Potentially Better Practices for the Neonatal Intensive Care Unit

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Empowermentas a Culture of Collaboration: Communication, Accountability, Respect, and

Development of Potentially Better Practices for the Neonatal Intensive Care Unit

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