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
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A pediatric health care team’s creed.

We’re all part of the same team. 

Our team exists to optimize the health of children.

We work together to avoid preventable harm for every patient, every day in every setting.

We strive to provide care based on best evidence.  

We learn from each other, our patients, and other experts and organizations. 

We continuously improve what we do and how we do it.  

We strive for excellence and celebrate improvement.

We hold ourselves and each other to high standards; we’re accountable to carrying out our mission and achieving our goals.  

We’re transparent and open about how we’re doing and what we need to do better.

We want the best outcomes for all our patients.

The patient and family are part of the health care team.

We treat them with respect, listen to their concerns, honor their goals, readily share information, and show empathy and provide compassion.

They provide expertise about the person at the center of care.

They participate in decision-making, provide most of the care, and monitor and inform progress.

We chose this profession in order to use our talents providing health care to children. We find joy in making a difference in their lives. We find our chosen field dynamic, interesting and rewarding. Our work is hard, challenging, and yet we love what we do.  We all strive every day to provide health care that’s valued by the patients and families, by our teams, by the system at large and the public.  

What are the most important virtues as individuals we need to nurture to be part of a team with this creed? Humility, flexibility, excellence, openness, courage, collaboration, appreciation, gratitude, awareness, commitment to serve others, and a commitment to learn from others.

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Adaptive Challenges – Time for Action

According to Adaptive Leadership theory, there are two types of challenges, technical and adaptive.  Currently we’re facing multiple adaptive challenges in pediatric healthcare.  Complexity, both diagnostic and therapeutic, is increasing.  Expectations, good, bad, and indifferent, of both the consumers and the payers are not only shifting and expanding but increasing in intensity.  Advancements in technology, data analytics, and artificial intelligence are increasingly impacting our business.  Disrupting ways to deliver health care are threatening our current business models.  The economics of health care delivery are evolving into an impossible calculus for these current business models as well.  And most importantly the workforce has irreversibly changed in capacity, context, complement and culture.

Technical challenges can be addressed with known methods and tools.  Adaptive challenges require developing new methods, tools, and systems.  This implies the need for change and innovation while doing the daily work.  Missteps are likely to occur; disruption is inevitable.  PDSAs can be rewarding.  Yet, PDSAs in the middle of an already overwhelming workload, especially if the learning includes what doesn’t work, can be demoralizing and disengaging.  Messiness, failed experiments, change that is hard, and learning new ways of doing things are often unwelcome in the workplace.  Perhaps the biggest challenge is just finding the time to do the work that innovation, experimentation, collaboration, and learning takes.

One risk of not meeting these adaptive challenges is a decline in pediatric health outcomes.  As the larger system evolves out of forces not necessarily aligned with the needs of children, we may see outcomes worsen before they start improving.  Families will opt for convenience unaware of the risks.  New entrants will claim excellence and deliver something else.  Web based services, including AI, will be advertised as a better option, but not be.  I assert there is an urgency to addressing the adaptive challenges facing the pediatric healthcare system.  Addressing adaptive challenges starts with changing how we see things and how we think.  One of those paradigm shifts is looking at how we’re doing through a value perspective.  Value is better outcomes with minimal waste.  Value is deploying resources and getting meaningful, measurable output, and the most important outputs in health care are patient-(& family-) related outcomes.  Process metrics can be good surrogates for outcomes if we measure both, check our assumptions, and connect the dots.

Professional Wellness

Happy? Doctors’ Day

We recently recognized Doctors’ Day, and many well intentioned people greeted their physician friends with, “Happy Doctors’ Day.” Yet, many aren’t happy.  Being a physician has always come with great sacrifice, responsibility, and burden.  There have always been patients who’ve not done as well as expected, and we’ve all made mistakes because we’re human.  Dissecting what has happened in the last 10 years would be like revisiting the cranial nerves in anatomy class, messy and confusing.  I’ve asserted in the past, as have others, that resentment (and in some cases remorse) is a key negative emotion that drives burnout.  The more a person resents the things they’ve done or are doing, the more likely burnout is to occur.  There are 2 buckets of resentment: 1) doing stuff you don’t want to, and 2) not doing stuff you do want to. I’ve always surmised it’s the latter that really matters. 

In the case of today’s physician, many feel like they aren’t getting to those important things they want to do because of things they’re required to do, which they feel don’t add value.  Spending time with family and friends, attending to human responsibilities outside of work, and having a hobby or two are among the things many aren’t getting to do. Yet, I think there is more to the story.  The value physicians are getting out of their core work has lessened, creating an imbalance hard to overcome. Endless work that never seems to get done without joy is a bad combination.  

For some it might be a financial issue, meaning their purchasing power isn’t what they expected, and yet they feel like they’re working harder than expected.  Fair enough, but I know plenty of 2 doctor families who have more money than 99% of the population and burnout still occurs. Perhaps for some there is a expectation that there be more outward recognition for their work from those in charge or even from their own team members. I’ve learned as a leader, that just like compensation, the impact of saying thank you, is fleeting. I don’t buy that these two things, financial and recognition, are major sources of burnout.

Perhaps more importantly, the joy of working with and helping patients and their families has diminished. The reasons for this are complex and likely vary from physician to physician.  This lack of appreciation appears in multiple forms such as less than stellar patient satisfaction scores, patient complaints sometimes expressed in social media, misplaced anger and blame directed at the physician, a sense of entitlement, a cultural hubris of “well, I know… everything, everywhere all at once.”  Or just a lessening of smiles and thank you in general.  It’s not easy sacrificing so much and thinking no one appreciates your efforts.

The workplace has changed as well. Relationships are important to physicians, and work place relationships have been strained. Respect from health care colleagues for what physicians do and the burdens they carry has diminished. There are many systems issues that need to be fixed and although there are some changes happening, they’re small.

Although this won’t help, I still say, “Thank you.” Thank you to all physicians for choosing to take on the sacrifices, the responsibilities, the burdens of being a physician.  Thank you for devoting your professional lives to helping people.  Thank you for being caring and compassionate despite all the challenges and non-value added tasks.  For those who provide health care to children, the children are why we do this, and the difference you’re making in their lives is immeasurable, priceless as they say, and far above anything else.  Thank you!

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Servant Leadership: Part 1

Leadership matters.  It is both a rebarbative essential and a winsome desire.  What makes an effective leader matters; yet, what matters may shift with the situation, the culture of the social environment, and the demographics and perceptions of the followers.

What kind of leadership will work today and in the future?  What kind of leadership will you embrace and embody?  If leadership is a calculus, then it stands to reason that style and methods may need to shift over time, even over a single day, perhaps in the same meeting.

A style increasingly referenced, and yet frequently misunderstood, is servant leadership.  Simply put, a servant leader is one who serves others first, who is selfless, not to a fault, but to an end that is not their own.  A servant leader may have common visible attributes: kindness, humility, a strong sense of balanced responsibility, but not all are universal.  Some historical military leaders were  servant leaders, but kindness and humility not always outwardly present.  However, a strong sense of balanced responsibility is a common thread even in the military.

A balanced sense of responsibility can be found throughout military history in both myth and true accounts.  It is most commonly expressed as a leader feeling responsible for victory, or successful defense against invaders, while protecting the lives of civilians and soldiers, and minimizing damage to civilian and military infrastructure.  It often includes thinking ahead to the next battle while considering the capacity and capabilities of the people and the collective company or battalion they constitute.

How does a leader achieve the right balance?  First, by recognizing the need to surround themselves with a balanced group of advisors and lieutenants, to listen to what the people have to say, and to check their assumptions and biases.  Second, by crafting their communications with balanced perspective and recognition for the various receiving constituents and their unique perspectives and roles.  And third, by making decisions that clearly and outwardly maintain integrity of the balance for which they’ve chosen to be responsible.   In other words, by being dedicated to the truth, simultaneously honest and visionary, and committed to the people and their purpose.

Taking the path of servant leader isn’t essential to achieving a proper balance in every possible situation, but I would argue it is the one path that works consistently in every situation in a balanced way with integrity and sustainability.  Our founding fathers had faults and made mistakes.  They had moments of bias, self-centeredness and breaks in integrity and humility.  Yet, many of them embraced servant leadership.  George Washington, John Adams, and yes even Thomas Jefferson were servant leaders.  Abraham Lincoln’s secret to success was embracing servant leadership.  He is by far the best historical example, which is why most of the historical books in my library are about him.  Read a book about A. Lincoln if you want to learn more about servant leadership.

Leadership

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.

Leadership

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.

 

Management

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.

Management

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.

Quality & Safety

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.

Engagement

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?”