All posts by Nate Hagstrom

Chair of Pediatrics at Lehigh Valley Health Network and, Physician Executive for the Children's Hospital at Lehigh Valley Hospital

Pathways to Building and Practicing Resilience

Disappointment, disruption, unfairness, failure, rejection and disease are part of being human.  We build a house of cards in our minds as to what ought to be and are devastated when it falls.  This pattern is one of the first to appear in our cognitive development; it’s also the most important, and certainly the most beautiful.  Given its importance, and the inevitable negative side of this human wonder, we need a recovery mechanism.  It’s called resilience.

Resilience is part of the biological world and it’s truly remarkable.  Cognitive resilience is uniquely human and likely in some respects genetic.  Nurturing inherent resiliency is an important part of being a parent, a grandparent, a teacher and a coach (I’ll add leader as well).  There are different pathways to resiliency, and the effective and timely deployment of a combination of these pathways is the secret.

The pathways are complex and interdependent; they’re physical, cognitive and emotional.  Some are fast, some slow, some require higher levels of cognitive function, and thus can’t be deployed until adolescence and young adulthood.  These pathways work in sequence and ni parallel; they work together like a complex circuit.  Personal experiences, learned behavior and chemical imbalances can interfere with these pathways.  These pathways need to be nurtured and practiced, and developed over time.  There are experts, but most of us always have a pathway or two that could use some strengthening.

The pathways are: self-awareness, tolerance, reframing, hope, self-determination, and action; I call them the Yep, OK, See, Can, Will, Do pathways.  As a pediatric oncologist I’ve seen a lot of disappointment and unfairness, and a lot of resilience.  I’ve seen these pathways in action.  The Yep, is acknowledging that this is bad, and that you’re sad or mad about it.  Feeling negative emotions is natural and human, it’s the depth and breadth we need to minimize to have resilience.  The first lesson we can model and coach is as follows, “It’s ok to feel bad, take a deep breath and try not to stay in that dark place too long.”

OK is sometimes accepting (but that’s hard), but mostly tolerating, or living with it so to speak.  We’ve all seen children do this step very quickly and we’ve all seen them take too long.  Why the difference?  Attachment.  The second lesson, “it is what it is, it happened, it’s in the past, it doesn’t need to take me over, or define who I am.”  You can probably see the developmental progression in that lesson.

See is my favorite; it is so uniquely human and has resulted in so many wonderful things.  It’s intuitive, but must be enabled.  It can be quick, or take a while.  It can be simple or it can be complex.  It can be constructive  or destructive.  Our role as parent, teacher, coach or leader is to enable and empower this pathway, by offering suggestions, modeling the way, or sometimes just telling them what to do.

Can is about hope and optimism.  Some call it a sense of self-efficacy or confidence.  Will is about self-determination and perseverance.  Do is perhaps intuitive, but the faster you can get to it, the better.  In fact, one ought not to seek perfection in the other pathways, or get lost in them at the expense of putting off action.

We ourselves need to have resilience when helping others use these pathways: Yep, controlling emotions is hard, Ok this takes time, I See another way to help, I believe this person Can do this, we Will do this together, let’s Do it.

Relationship-centered interactions

This unique and challenging, relatively sudden disruption to everyday life is an opportunity for us all to realize new ways of seeing life, be more aware of the balance in things, connect with our humanity, and grow as a person.  This includes how we communicate and interact with others.

Relationship-centered care is a frame for looking at how we as professionals approach working with others.  It starts with increasing one’s awareness of where they are as a person physically, mentally, emotionally and spiritually*, and letting that awareness inform hot buttons, biases, personality traits and other factors, which might impact the interaction.  It also allows for one to use self-compassion and be ok with where we are at that moment.  Self-compassion allows for an honest assessment of one’s current state, and allows wiggle room for imperfections.  Compassion for self is a presupposition for having compassion for others.  [*Spirituality simply refers to the way you relate to the world and your purpose in it.]

The next step in relationship-centered care is for one to be open to and as aware as they can to where the other person is currently.  Compassion for them as a person, for the challenges and struggles they bring with them, for their feelings as well as their thoughts.  Compassion is enabled by empathy,  and motivated by concern.  It’s fueled by virtue.  It may not be essential to a relationship or interaction, but it sure helps.

The third step is to see the relationship in the context of your team (or family), the neighborhood (or organization), and the community (or society).  Interactions are relational first, and situational second, and essentially never one or the other.  Certainly in most professional and educational interactions, they are contextual.

I’ve known about relationship-centered care for well over 10 years, and some elements come natural to me, or at least I’m naturally aware of them.  Yet I’m no expert practitioner, and that’s ok.  Each of us has certain genetic and experiential realities that make us imperfectly human.  There are invariably situational smoke screens that can cloud our vision of things.

Be kind to yourself, take a deep breath, be aware, and be positive in your interactions.  We’re all in this together.

 

7 Practices of Successful Organizations by Jeff Pfeffer

In the 1990s, Jeff Pfeffer (Stanford Business School) suggested these 7 “practices” as common themes seen in successful organizations:

  • Employment security
  • Selective hiring of new personnel
  • Self-managed teams and decentralization of decision making as the basic principle of organizational design
  • Comparatively high compensation contingent on organizational performance
  • Extensive training
  • Reduced status distinctions and barriers, including dress, language, office arrangements, and wage differences across levels
  • Extensive sharing of financial and performance information throughout the organization

The first sentence of the conclusion in his 1998 California Business Review article read, “Firms often attempt to implement organizational innovations, such as those described here, piecemeal.”  He went on to say, “Implementing practices in isolation may not have as much effect, however, and, under some circumstances, it could actually be counterproductive.”  He’s suggesting bundled approaches are better.  Sounds complex, and like a lot of work.  Yet, it makes sense: you can hire the right people, provide them with secure employment, pay them well with bonuses tied to organizational performance, be transparent with financial and performance information, and even provide extensive training, but it won’t work unless the work environment and culture fosters self-managed teams and reduces status distinctions.

Within each of these there is a mini-bundle as well.  The implication being, if you don’t execute on the details of these practices, you won’t get the desired effect.  For example here is the bundle for selective hiring of new personnel:

  • Screen for attitude and fit, not for skills that can be readily trained
  • Be clear about the most critical skills, behaviors, attitudes – be as specific as possible
  • Use several rounds of interviews
  • When possible involve senior people
  • Continuously evaluate and improve the recruiting process

So, what is the bundle for self-managed teams and decentralization of decision making as the basic principle of organizational design?  First the structure must lend itself to teams.  In health care, this is often the case given the complex differences across populations of patients, diseases and care settings.  The challenge for larger organizations becomes maintaining that local control while ensuring sharing and implementation of best practices in order to reduce counterproductive variation.  Second, problem solving is encouraged at the local level from idea generating to ideas testing to hardwiring of the best solution(s).  Given the drive for standardization, this local team problem solving can be impeded if standardization is done just for the sake of standardizing.  Larger organizations achieve balance by driving accountability at the level of results, and less at the level of process.  Third, hierarchical control must be minimized and middle management, especially when not part of a team, reduced.  This is hard for many organizations, especially large ones.

Healthcare is at risk because of the significant control IT and finance now have over how teams function.  IT through its tight control of information systems, which are now integral to daily work, and finance by controlling costs and FTEs without local knowledge of the daily work, are forcing teams into boxes that don’t deliver the performance ultimately needed.  Giving too much control to parts of the organization that don’t have expertise in the core product or service of the organization drives short term and self-serving thinking and action.

Resources and existing elements of effective management are needed to drive change

Comments on  “Spreading at Scale: A Practical Leadership Model for Change” by Amy Compton-Phillips, M https://catalyst.nejm.org/doi/full/10.1056/CAT.19.1083

In a recent NEJM Catalyst blog Dr. Compton-Phillips described a mental model applied to addressing variation across a large network (PSJ).  The mental model was presented as being new, however, it can be found in many leadership and management publications over the last 50 years.  In fact many don’t need to go further than their own organization to find this model in action.   Vision, Trust, Data, Capacity and Alignment are not only intuitive, but proven and tested elements.  The blog does serve to remind us of these elements telling a story that eloquently illustrates them in action, yet two essential elements are implied but not spoken: resources and effective management.  Both are inferred in figure 4.

Hidden lesson #1 in this post is the requisite need for resources to drive change effectively.  Although resources aren’t directly addressed in the blog, the dependence on them is obvious in the change narrative.  The need for resources makes choosing the right thing on which to focus an important first step; resources are limited and must be used prudently.   Vision can drive prioritization, and it can also inspire people to action.  Inspiration is good fuel for change, especially when resource are limited, yet no amount of inspiration will overcome the error of not providing resources.  The process of prioritization also helps shape the “why” which is key to each of the 5 elements.  The more stakeholders involved in the prioritization the better, but the law of diminishing returns does exist here.

A lack of resources was a root cause of nearly every failed attempt at change I’ve witnessed.  There are multiple examples of why resources are important in the blog.  One example is how PSJ utilized the time of leaders and colleagues from high performing hospitals to assist low performing ones through the formation of work groups; work groups are a significant expense.  Another example is the use of cascading scorecards or dashboards; you can’t collect, use, manage, present, discuss, or analyze data without resources.  In 2007 I was the first to use a scorecard in my organization.  It took me hours to build it and maintain it.  Some of the fields were populated with estimations, or distant surrogate markers, or nothing at all.  It was all done by hand.  Although it served a purpose and did help to drive change, its effectiveness and efficiency was impacted by a lack of resources.

Hidden lesson #2 is that change management is, well, management.  Leadership is a necessary element at every step especially in the beginning.  Yet without local management of people and processes, change initiatives fail.  Existing managers, who already possess effective change management skills and tools, are essential.  One of those tools is an existing strong daily management system. The blog does mention the need for skills, tools and tactics specific to the change effort, and I agree.  Yet, these enablers need to align with the existing daily management system.   For example, if a team doesn’t take the time to frequently huddle around metrics, run by an effective leader and manger, using an already existing cadence embedded in an established management system, a change effort has a high likelihood of failing.  Furthermore, not deliberately leveraging that existing management system to drive engagement around the specific change effort would be unwise.   A daily management system enables alignment.

Alignment requires leadership and management and starts through establishing a shared vision, both of which are mentioned in the blog.   Established values and principles embedded in an existing common management system with built in quality improvement skills and tools assist alignment.  Constantly communicating the “why” and the “what’s in it for me” as mentioned in the blog builds alignment.  The disciplined cadence of a daily management system is a channel for this constant communication.

Because all change is local, and alignment is possible only when local groups stay connected to the larger whole in ways that are mutually beneficial, any change management approach needs to consider how to trust local teams with ample autonomy to solve local barriers to change.  Change is both individual and team based, and both are dependent on local elements of leadership, management, vision, trust, data, and capacity.  Empowering these local environments while driving a common vision through standard work is perhaps the most important deliverable of senior management in any change management initiative.  A strong daily management system allows this to happen with greater ease.

Sensemaking

What is it?

Sensemaking has been defined as the process by which meaning is given to an experience or situation. Literally, it’s when an individual or team makes sense of an event or situation, past or current.  Dr. Weick eloquently described sensemaking as, “a diagnostic process directed at constructing plausible interpretations of ambiguous cues that are sufficient to sustain action.”  Taylor and Van Every described sensemaking as “a way station on the road to a consensually constructed, coordinated system of action.”  In short, sensemaking is a springboard for action, or in the case of a high-reliability team, effective sensemaking is a springboard for effective action.

When does one use sensemaking?

Typically, sensemaking is deployed when the situation is, or the event was, unexpected, unusual or ambiguous.  The reflective or post-event retrospective sensemaking is critical to learning.  Sensemaking in the midst of a high-stress, high-risk circumstance, which drives relatively quick and effective action, is critical for a high-performing team to effectively act in an unexpected or complex situation effectively.  This sensemaking is still retrospective, but the real-time nature of it allows for the action to impact that specific circumstance.  Prospective sensemaking isn’t as well defined in the literature, but it speaks to anticipating future events and circumstances for the purposes of framing a mental model and creating understanding in order to proactively prepare.

What makes sensemaking effective?

Effective sensemaking is facilitated when wisdom, originating from practical knowledge of theory and meaningful experience with best practice, is tightly coupled with thoughtful and honest learning of accumulated experiences, as well as sufficient current situational awareness and mindfulness.   Effective sensemaking can be recognized when its there, but its hard to insert when its missing.  It can be nurtured when leaders support training, professional development, provide time for open reflection, and have a plan for recognizing, and retaining senior people.   Yet, individual commitment to excellence over time as experience accumulates is perhaps the most important element.

The more wise the leaders and influencers of a team the more effective the sensmaking of that team.  However, there are attitudinal as well as behavioral elements that influence the quality of the sensemaking.  For example, when reviewing a safety event, if a just culture attitude and approach isn’t taken, the sensemaking will be limited and not balanced.  Another example is during a rapid response or code situation.  If there isn’t a designated leader and clarity among team members as to what their roles are, the sensemaking isn’t organized and therefore is less effective.  Without psychological safety, a team can’t collectively do effective sensemaking, and can’t get better at it over time.  Someone senses that something isn’t right, but doesn’t speak up, and thus doesn’t leverage the team to sensemake and formulate an actionable picture of what’s going on.

We need more dialogue at meetings

A discussion is an exchange of words; a dialogue is an unfolding of new thought.   Dialogue is a conversation where people learn from each other, where there are as many questions asked as there are answers given.  It shapes thinking and creates new ideas.  One flaw in many meetings is the premeditated avoidance of dialogue

Meetings are often designed to avoid conflict by how the participation is structured and the agenda constructed.  If there is conflict the meeting is often facilitated to be a discussion rather than a dialogue.  When conflict is present the discussion  is much like a debate where people assert and defend their positions.  Who “wins” is based on how well arguments were made rather than the merit of the arguments themselves.  Often no one wins because the intent of most meetings is to formulate a plan for the group and coordinate its execution, which requires dialogue.   After a debate many leave the room without any idea what they’re supposed to do next.

Dialogue by definition will have surprises, and often will change minds, shift attitudes and create something new.  Yet, meetings are often designed to avoid surprises.  How would a team improve their meetings over time if a simple outcome measure were the number of minds and opinions changed?

Inquiry is at the essence of dialogue; inquiry that surfaces ideas, perceptions and understandings that weren’t present previously.  How would a team change the structure of their meetings if a simple process measure were the number of questions asked?

Increasing the number of questions requires balancing advocacy with inquiry.  Advocacy is our human default mode at meetings and during conversations (i.e. we defend and assert our opinions, the opinions we walked in with).  It’s nearly impossible to eliminate it.  Yet, if advocacy can be balanced with inquiry then dialogue will emerge.  The more people who have a questioning attitude the more likely that balance will be struck.  This is why whom you hire and the culture you inculcate matter.  If you hire stubborn, opinionated, arrogant know-it-alls, then achieving dialogue will be extremely difficult.  If the culture you foster is one of competition and authority, dialogue will be hard.

When was the last time you had a dialogue about something?  When was the last time you asked clarifying and exploratory questions at a meeting?  When was the last time you changed your mind about something?  If the answer to any of these questions is not in the last 24 hours, then ask yourself, “how open am I to learning from others and seeing things differently?”

A short course on human relations slightly expanded

An old poster some still have on their office wall called “A Short Course in Human Relations”  goes like this:

The SIX most important words:  “I admit I made a mistake”

The FIVE most important words:  “You did a good job”

The FOUR most important words:  “What is your opinion”

The THREE most important words:  “If you please”

The TWO most important words:  “Thank you”

The ONE most important word:  “We”

The LEAST most important word:  “I”

In my searches to find the origin, I came across a blog that told a story from the 1980s.  The author first saw the poster on her boss’ office wall.  The boss noticed she was studying it and said, “You know that’s not the whole course.  There is also the SEVEN most important words, ‘I don’t know, but I’ll find out.’  Now you know the complete course.”

What keeps people from saying these phrases and practicing their intent?   Perhaps they aren’t telling themselves the EIGHT most important words: “I have the courage to say these words.”

Now you know the complete revised course.  Here it is again:

The EIGHT most important words:  “I have the courage to say these words.”

The SEVEN most important words:  “I don’t know, but I’ll find out.”

The SIX most important words:  “I admit I made a mistake”

The FIVE most important words:  “You did a good job”

The FOUR most important words:  “What is your opinion”

The THREE most important words:  “If you please”

The TWO most important words:  “Thank you”

The ONE most important word:  “We”

The LEAST most important word:  “I”

 

Back to basics for bashing burnout

I recently created 2 documents outlining expectations for physicians: one addressed professionalism and the other productivity.  The intent was to articulate what is needed as a baseline from each physician, and point out the importance of discretionary (extra) effort for us to be successful.  Acknowledging and thanking those who go above and beyond on a regular basis was essential to this exercise.

The activity was undertaken because of complaints from a number of colleagues about low productivity and poor professionalism among a few; this small minority was threatening the joy and pride in work of those many who go above and beyond.  Although obvious but not always front of mind is the connection of professionalism and productivity to burnout – the more individuals in the workforce underperforming in either, or both, the higher turnover, the lower overall engagement, and the more likely burnout will occur.  The underperforming few can drag the hardworking majority down.

As leaders we know clarifying expectations is important.  It sets the bar, and it also provides the opportunity for us to remind those pushing themselves way beyond the bar to cut back and strike a healthier balance.

Expectations need to be clear before people can be held accountable, self-reflect and resolve to improve where appropriate, whether it be on one’s balance, commitment or focus.  The under performing who feel burned out despite doing the minimum need to improve efficiency and cut out activities that aren’t aligned with what is needed (i.e. essentialism).

The explanation of professionalism I drafted centered on the following principles:

Respect for the voice and value of others – listen to learn and understand; value others contributions.

Kindness – speak with humility and respect, not dogmatism or for the purpose of demoralizing another.

Focus on the mission and core functions of the team; avoid drama, avoid drawing attention to oneself unnecessarily.

Professionalism – balanced and non-judgmental communication; courage balanced with consideration

The explanation of productivity centered on the following:

Time– >50 hours a week on average outside of night call is almost always needed – professionals who need to work less than this may need to go part-time.

RVUs– a starting place for reflecting on efficiency and contribution – it’s not a 4-letter word, but it is an imperfect measure, and needs to be taken in context.  Yet its needed because it’s too easy (and very human) to be biased about how hard one works.

Discretionary effort for certain committees, projects (e.g. quality improvement) and activities (e.g. teaching) is a must for us to be successful.  Yet one must feel that this work is meaningful and making a difference.

Triaging– invariably individuals and teams need to prioritize their activities, schedules, patient care, phone calls, who and what they teach, etc.  We can’t do it all.

Still a work in progress, yet it does drive a good dialogue.

 

Is Servant as Physician and Leader a Dead Concept?

Servant leadership: I’m concerned it’s dead.  It’s been suffering a deep malignancy for years, and it seems to be reaching the terminal phase.  The profession of medicine is dying along with it, because of the indivisible link between the two.  What happened?  Greed? Arrogance? Apathy? A decline in responsibility and ownership?

One possibility is that it was never alive to begin with, but merely an illusion.  I can’t name one doctor or leader I’ve met or been mentored by over the past 25 years I would like to be like.  There are those who have attributes I admire, and those who have attributes that I share, but none who I aspire to be.  Thus, I can only conclude that servant as physician and leader has always been and remains a rare anomaly.

Another possibility is that there is no energy or time to acquire the knowledge and skills or for the reflective listening needed to expand the awareness required to be a servant as leader and physician.  The lack of time has many contributing factors: the increasing complexity of practicing medicine, the immense breadth and depth of knowledge required, and the increasing amount of time required for EHR documentation, insurance-related administrative tasks, and various regulatory and licensing requirements.  A more positive reason for the lack of time is the shift to valuing wellness and balance if not synergy in one’s life, as well as the importance of being present with one’s family if you’ve decided to raise children.  Thus, some things had to go and among them were taking the time to learn the skills and behaviors to be a servant physician leader, and executing them on a regular basis.

A common root cause of both possibilities may be the lack of value individuals and society as a whole give to the concept of servant leadership or servant as physician.  Today there are conflicting priorities. One is forced to choose, often choosing with a natural self-centered bias.

Physicians often complain about RVUs, work hours and compensation; many want to make more money then complain about the focus on RVUs, which is how physicians get reimbursed.  Almost universally money eventually wins in this generative tension. What happens is that the physicians drive (perhaps unknowingly in some cases) an increasingly more efficient system designed to optimize revenue.  The resulting culture is: if a physician isn’t going to get paid for doing it, they won’t do it as much, or as well, or even at all.  Servant leadership often takes time and energy that has no RVUs attached to it.

I don’t have a cure, and it may already be dead.  I fear this lonely dream of servant as physician and leader will forever be securely stuck in the corners of my imagination.

Strategy is about both the what and the how

When we put together our strategic plan for the children’s hospital four years ago we used a modification of the triple aim as a frame, expanding it to the quadruple aim a year or so later. Super Health for all children was established as our primary purpose and passion, Super Care was affirmed as a presupposition of being in the business of providing health care to children, and a Super Supportive Care Experience being what makes a children’s hospital different, would be what we would need to make us different from any local or regional competitors.  A year later we added the essential element of engagement of our colleagues, as well as the patients, families and communities we serve.  For our colleagues we felt that feeling joy and pride in their work was important.  We identified the 2 most important things as reliability in providing care and engagement of all those supporting, delivering and experiencing that care.

In our efforts to fully realize a children’s hospital we focused equally on what we would do and how we would do it.  For example, we chose as a frame for how we would achieve engagement and a super care experience child- and family-centered care and decided we would need a child-friendly environment and family support systems.  When it came to achieving reliability and super care we chose high-reliability principles and robust continuous quality improvement methods for the how .  We borrowed from the theories and philosophies of Deming and Covey, and the methods of Lean management.  We focused on how we would achieve our desired results more so on a daily basis than what those results were.   The best example of this is measuring safety behaviors and practices daily, while paying attention to the outcomes of hospital acquired conditions (e.g. days since last event) weekly.

We developed a set of high-level guiding principles: transparency, collaboration, alignment, ownership for excellence and fiscal responsibility (aka efficiency).  After reliability and engagement, efficiency has become an essential management focus today, and yet to not pay attention to how that is achieved is to lose out on reliability and engagement.

Our strategic plan has been very successful, reaching most of our goals and milestones, and on time.  Our secret sauce comes down to disciplined improvement, relentless alignment and empowering accountability.  For a best practice conceptual frame for management we’ve used the Shingo model.

Our strategic measure of success, as well as our means to justify and secure what it would take to realize a children’s hospital, has been growth, including inpatient and outpatient, subspecialties and primary care.  We’ve realized growth through increasing our capacity through recruitment of more clinicians as well as improving the efficiency of our key processes, all along keeping front of mind that if we didn’t stick to our mantra of super care and a super supportive care experience, we wouldn’t gain the needed respect and awareness from the public.  Our growth has been consistent year to year and has exceeded our target of 10%.