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
Engagement, Leadership, Patient & Family Satisfaction

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”

 

Engagement

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.

 

Leadership

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

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%.

Care Transformation

Why is transformation so difficult?

Transformation in healthcare needs to occur within a complex dynamic system (i.e. a chaotic mess). Clear communication, shared goals and problem solving are especially challenging in healthcare environments. There are multiple and sometimes conflicting missions. The socialization of healthcare professionals is fragmented and often exists outside the organization and pre-employment. Our organizational structures further strengthen these silos. There are incredibly strong external pressures, constraints and influences from multiple stakeholders (payers, consumers, government agencies, etc.). The core tasks in healthcare often occur locally in complex, dynamic, and ambiguous situations and settings. Patient-driven variability is often a necessity and yet there is a good amount of unnecessary variability. Healthcare is pluralistic. It’s a conglomerate of missions, values, stakeholders, professionals, regulations, processes and practices.

Here are some transformational changes we’ve all been considering with my assessments of where we are:

Team-based care –We’ve been talking about it so much it’s become a cliché, yet we’re not so good at it.  If we actually did it, it would be transformational.

Deeper and expanded competencies – Lot’s of problems get in the way of this, and we’re dreadful at solving problems in healthcare.  This tactic is necessary for reducing costs.  All stakeholders (internal and external) need to get on board.

Explicit goal setting incentivized using internal and external motivators – we think we’re good at this, and we’ve gotten better, but we’ve not transformed how we do this. Why? Because we think we can set goals at the highest level and have them make sense at the local level. Hello? McFly? It doesn’t work.

Local change with targeted centralized support – uh… what we ask for too often is local support for centralized change. Is that you again McFly?

Feedback and redesign with front-line workers and patients at the center of the work. – Who has time for that?  We can do this, but only if we integrate it into our daily workflows and practice.

Use systems, process and team-based thinking. – ugh.  Clinical pathways help change the paradigm and demonstrate the benefit of doing this, but one problem is that professionals don’t know how to do this kind of work without a lot of coaching.

Agile engaging high-performance management systems – Does anyone in healthcare even know what this means?

One last thought…Many of us have been on a journey to point out what we consider to be a cancer in healthcare – variability.  Could variability be the malady of all maladies for healthcare?  Yet variability is often necessary as is cell growth and tissue regeneration; variability at the right time applied to the right patient is the right thing to do.  Also, attacking variability with blunt tools has negative consequences, much like using radiation and cytotoxic chemotherapy to fight cancer.   A better way to frame variability: there is good variability, acceptable variability and bad variability (normal, benign and malignant). We need to address the malignant variabilities with targeted and intelligent tools.

Care Transformation

Transformation: asking the right questions

Transformation starts with asking the right questions. My favorite first question is, “what problem are we trying to solve?” Followed by “why?” If you’re in the service industry and the problem you’re trying to solve is a financial one, that’s not transformational, it’s operational. If the problem isn’t about those you’re serving, then it’s the wrong problem. Loss of focus on true north goals often sends problem solvers down the wrong path; be sure staff define the right problem and stick to it.  And don’t let operational problems get in the way of solving the real big ones.

Common customer oriented problems are cost, convenience and experience. When considering these, it’s important to not forget the most important problem, “Why they’re coming to you or want to come to you in the first place.” – forget that fundamental, and you’ll go out of business.  Perhaps one question for transformation could be, “How can we solve patients’ problems quicker, cheaper and where they are?”

Transformation also starts with realizing what we shouldn’t tolerate, and generating paradigm shifts.  The  patient safety movement is an example of transformation. It started 20 years ago with Dr. Leape using data, and asking the right question, “why are we tolerating this?” We look back now and we can’t believe the things we tolerated. Another example is the patient- and family-centered care approach to delivering care, and designing that delivery. This movement brought about a paradigm shift in how people think about healthcare.

Perhaps another question to ask, “Is what we’re doing and how we’re doing it the best way when you consider the value it brings to the consumer assuming they have to pay every cent of the cost plus a margin?” People are willing to pay a lot to get their cancer cured. They aren’t willing to pay a lot to get a sore throat looked at and cared for.  To think about this try the “miss work” or “miss school” test (e.g. if a family that values their child’s education is willing to take their child out of class to go to the doctor, that service is of value. If it’s not then they will either not go, or they’ll go somewhere after school that is quick and convenient– i.e. CVS minute clinic).

We think patients and families value all healthcare equally, but their behavior suggests they don’t.  We need to provide value starting with thinking a little differently about what value means to those we serve: “if the patient had to pay every cent of the cost of their healthcare, how would we do it differently?”

In some cases we may need to be explicit about the value.  For example if a family takes their child to the doctor primarily to get vaccines, what would happen if they were to become solely responsible for the cost?   They would start going to CVS to get them.  Just walk in, get the shot and leave whenever at a cheap cost, no doctor involved (and by the way stop at the do-it-yourself height and weight station on your way out). Yet, there is value in going to and paying for the doctor visit that may not be entirely understood.

Management

What kind of hours should we ask our professionals to work?

When I hired the first advanced practitioner in my management career, she worked 5 days a week in our sickle cell center. Most days she worked 9-10 hours; occasionally more than that and sometimes less than that. After about a year, things got busier and her hours per day increased to 10-11. She began to get burned out. It wasn’t just the additional hour, it was what she was giving up (time with family, time to get personal things done, sleep). In addition despite putting in the extra time, she didn’t feel as if she was getting everything done. She left after being with us only 2 years. She was good at what she did and losing her hurt us terribly.

When I hired our 2nd advanced practitioner around the same time for our cancer center, she asked to work four 10-hour days. The operations director of the practices (a nurse by training – who had been in management for over 20 years) was against it. She told me that professionals ought to work 9-10 hours a day, 5 days a week, which is 45-50 hours, and to do that working 4 days a week, she’ll need to work 12-hour days, and she won’t do it, and the clinic is only open for 10 hours. The director said. “this is just a way to make the same amount of money working less, and she won’t be here everyday and someone else will need to do her duties that 5th day, which usually doesn’t work.”  The advanced practitioner worked with me for over 10 years, only leaving when I left.  She averaged 11-12 hours a day, and there were days she didn’t leave until I did, which was after 9pm most nights. The operations director was wrong. There were adjustments we needed to make to the practitioners workflows (she spent the last few hours of the day documenting, calling families with labs, handling refills and writing orders for the next day).

There are several morals to this story:

  • Yes, professionals need to work 45-50 hours a week, if they aren’t they are costing the system too much. Why should one professional be allowed a 40-hour week when the majority who are doing a good job work 10-20% more than that.
  • If professionals work 50-60 hours a week, burnout is a risk. That extra 5-10 hours is golden, and its not the work that’s burning them out, its what they’re giving up that’s killing them. And if they feel like they aren’t keeping up despite working extra, then they will surely burnout.
  • Working 4 days a week reduces burnout, but it doesn’t have to reduce productivity.
  • 20 years in management doesn’t mean you always know what you’re doing. To be wise requires managing your biases, thinking outside the box, and being open to the ideas of others just as much as having knowledge and experience.
Engagement, Leadership

The art of dialogue: an indispensable leadership skill

I became a physician “leader” frankly because staff asked me to change things or they would quit.   It started 17 years ago.  I was an informal “leader”, becoming increasingly formal over the next 5 years.  It was a rough road for many reasons, but my lack of skills, knowledge, awareness, maturity, preparedness, good mentoring, and sleep were at the top of the list.

Because I was so bad, I was given the gift of a professional coach, which was helpful with guiding my self-learning and reflecting. Thankfully, I was able to improve on some of my deficiencies; the one that I had to work on the most, both because of my ineptitude and the importance of it, was having discussions and dialogues with people.

I’m still learning and practicing dialogue. I wish it were easier, but its not. The biggest problem is that it takes time, which we don’t have a lot of. The second biggest problem is that we’re human, and have learned some unfortunate human habits. The biggest of these habits is a tendency to be defensive, to take things personally and to hold onto ideas and memories with too much dogma, blinding ideology, and just plain old-fashioned emotion. This internal milieu interferes with listening, learning, and most importantly thinking. We’ve all seen how egos and lack of humility (hubris) can derail good conversations, but that’s only part of the story. The other big problem we humans have is judging (criticus).   We judge, judge, judge.  Dialogue can be derailed by hubris and criticus. Being aware of these barriers is the first step, doing our best to abate them, without beating each other up about them, is the second.

Suppressing our hubris and criticus is important when having a dialogue, but without respect, appreciation, a desire to learn, and time, it still won’t happen. Stepping outside ourselves, our attachments and our preoccupations isn’t easy, but necessary.  Try asking yourself: do I really know everything that needs to be known? Is my view truly the only possible viewpoint that has merit? Have I thought of all the possibilities? Am I showing how much I care about the people in the room? What else might we face in the future that makes how we accomplish this conversation as important as what the conversation is about?

William Isaacs in his famous 1999 book Dialogue and the Art of Thinking Together describes 4 steps we can take when participating in dialogue: Listening, Respecting, Suspending and Voicing. Out of these 4, suspending is often the hardest (aside from leaving voicing until the end). Edgar Schein has talked about “accessing your ignorance” as a means to start the suspending process. To access one’s ignorance, one must pause, embrace humility and suspend judgment. This practice naturally leads to the advice that one ought to ask questions first, then voice their opinion second; seek to understand before being understood.  Questions are most effective when coming from a place of ignorance.

Dialogue is about reducing our collective ignorance.  It doesn’t make it completely go away, but we’re better prepared to face our challenges nonetheless, and face them together.

Uncategorized

A Loop for Getting Somewhere

We’re faced with what seems to be impossible challenges: doing more, doing better, and doing it all with less, while at the same time promoting professional joy, facilitating engagement, and ensuring legal and regulatory compliance. On top of that, the expectations of the families and communities we serve too often goes beyond what we can meet.   And dare I say, the expectations of our front-line colleagues has followed suit in some cases.

There’s a team leadership loop I’ve observed when teams are at their best.  I call it the MLSA loop: mindfulness, learning, sensemaking, and action.   The learning and action steps are the easiest for people to understand (but often the hardest for teams to do). Whereas mindfulness and sensemaking are hardest to understand, but the best teams seem to do it naturally.

Sensemaking is facilitated when there is sufficient wisdom present, which comes from practical knowledge of theory and best practice, and accumulation of thoughtfully and honestly reflected experiences.   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.

Mindfulness is facilitated when high-reliability attributes are present along with humility and acceptance. Humility is necessary to create the right environment of openness and collective presence. Acceptance is necessary in order to eliminate the negative emotions that can derail a team.  Acceptance also helps drive the needed amount of focus a team needs to stay on the correct rail.

Collective presence refers to the combinations of team alertness and calmness, and  team diversity and respect, which allow for optimal flow of information and ideas.

Applying this loop to the broader context of today’s healthcare environment could aid leaders as they struggle with the seemingly impossible challenges they face. There is hope and solace for the beleaguered leader in this model of how effective teams face complex, high-risk, and high-emotion situations.

Achieving mindfulness before we begin to learn ensures we are open, thoughtful, and broad minded. Learning before we make sense of things, ensures that we frame things in a helpful, focused and positive way, which will drive optimal and flexible action. More importantly perhaps, is that mindfulness enhances our ability to assert a positive and confident outlook, and meet the challenges with confidence, calm, and the positive outlook and impenetrable will others need from us to stay on track.

Be mindful my friend.

Leadership

THE SUCCESSFUL LEADER’S GENOME EXPLORED

Over 10 years ago (and probably long before that) a paradigm of leadership different from the top-down approach started to surface: as highly educated and skilled people increasingly constitute the workforce , leaders must learn to lead leaders, not just followers.  As much as I’ve been a slow learner, it appears I’m not alone.  It wasn’t until this month’s Harvard Business Review that I discovered one root cause: most senior leaders, including board members, actually don’t appear to encourage, incentivize or even model the right kind of leadership needed today, and they don’t hire it.

Described in What Great CEOs Do Differently by the CEO Genome Project (HBR May/June 2017) are 4 behaviors of the most successful CEOs: 1) deciding with speed and conviction, 2) engaging for impact, 3) adapting proactively, and 4) delivering reliably.   In other words: set a course and believe in it, inspire and engage others, continuously learn, improve and renew, and deliver results consistently.

The article doesn’t really describe the genome, but rather gene expression.  They do mention in passing a few “genes” such as, “…while boards often gravitate to charismatic extroverts, introverts are more likely to exceed expectations…”

Mistakes boards make are because they focus on the downstream impact of gene expression.  Nearly all successful CEOs in this study had made rather significant mistakes in the past. Yet, boards and others who choose leaders shy away from anyone who’s made a large mistake.   High confidence improves the likelihood of a person being hired, but makes no difference in whether they’re successful or not (an example of focusing on the wrong gene expression).

There are a few more genes that others have pointed out that are supported by the CEO Genome project: 1) focusing on something bigger than themselves, and sacrificing themselves to that vision, 2) humility, and 3) …you guessed it… the ability to lead leaders, although this may not be the gene, just the expression.

The ability to inspire people who are leaders, especially those with a suboptimal leadership gene expression profile, eludes many of us.  Is it emotional intelligence?  No, a lot of good leaders have that.  I think it’s more fundamental than that.   I think its mindfulness or openness.  Mindfulness allows one to achieve a certain level of awareness, acceptance, humble inquiry, honest reflection, and caring with a sense of service.  It used to be called taking the higher road, calling it mindfulness begins to describe how to get there.