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

Total Leadership Revisited

Almost 10 years ago I heard an interview on NPR with Stewart Friedman regarding what was then a new book called Total Leadership. At the time I was nearing the end of a long recovery from burnout.  Total Leadership was one of the better books for helping me achieve better balance in my life, and for helping me envision a healthier professional life as a physician leader.

There are two major premises in his book: 1) by integrating your professional, personal, family and community realms, finding common ground and synergy, you can be a total “leader” and achieve better work-life balance, and 2) by being your self, your whole self, and respecting the whole of others, and embracing your creativity, you will find joy and fulfillment in what you do.

Perhaps the best active advice this book provided for me were those that involved reflection.   For example, acting with integrity (being whole) sounds easy, but when you reflect on key crucial moments you may discover that the values you hold dear when calm and collected, can sometimes take a back seat when the heat is on or when things don’t go well.  If you truly value respecting the diverse views of others then you’ll listen even when emotions are high. You don’t have to agree but you’re able to acknowledge and kindly consider their perspective, which by the way takes longer than a few seconds.   Another example is honesty and trustworthiness. Most of us value these, yet, we are often dogmatic about things, which when truly dissected, the facts of which aren’t quite as black and white. In other words we aren’t as dedicated to the truth as we are our attachments to our own biases, our own perspectives.

This last point, reflecting to get closer to the truth of things, is actually a key daily activity for beating burnout. Burnout spirals because our reality is adversely shifted by negative bias.  Be Real, Be Whole, Be Innovative and Be Reflective and you can reduce/prevent burnout.

Being innovative is more about experimenting with new ideas and new ways of doing things than it is about dreaming up the next big idea and thinking it will fix everything (remember be dedicated to the truth). True innovators are doers. Its action on an idea and learning from that action, which takes honest reflection that makes innovation truly energizing (and successful).  And energy is an antidote for burnout (and we all like succeeding).

One of the exercises described in this book is to write a vision of you as a Total Leader in 10 years.  It’s been almost 10 years and as I read what I wrote back then, I realize that I achieved the vision (mostly).  Thank you Stewart Friedman.

Engagement

Stop, Drop and Roll if you’re burning

All this talk about burnout has me… well… burned out. Theories abound and prevalence data is flying about.  Are 54% of physicians burned out, or is it 25%? Is it because we’re worked too hard, or because the “new-trophy-for-everyone” generation is finally being hit with reality?

I can tell you from experience, burnout occurs when there are big things about your work you resent, and the rewards become overshadowed by these key persistent resentments. Working 24/7/365 isn’t the problem, its what you’re not doing because you’re working all the time that is. Its not what we’re doing, it’s what we aren’t that leads to burnout.

Duh? Well… it’s not that simple, and once again it comes back to resentment. Most of us resent what we can’t do because we work so hard, but not all resentments are the same; expectations are the second key contributing factor. If you expected to have a lot of purchasing power because of excellent compensation as a physician only to found out that you really don’t because you chose a lower paying specialty, then you may resent what you do. If you expected to be home by 6 pm most nights only to find out that to finish your charting and phone calls you have to stay until 8pm, you may resent what you do. Know your expectations and be aware of your resentments.

Burnout is best prevented, because fixing it can be hard. Both prevention and cure takes efforts on the part of the individual as well as the “system”. The microsystem (your team/clinic or pod), the mesosystem (the group practice, department or service line), and the macrosystem (hospital or network) all need to participate in the process. But without the individual taking ownership, efforts often fail.

The 4 horsemen of burnout from the HappyMD (https://www.thehappymd.com/blog/bid/290379/Physician-Burnout-The-Four-Horsemen-of-the-Physician-Burnout-Apocalypse) are around every corner and their momentum can be difficult to slow. The Workaholic, the Superhero, the Perfectionist, and the Lone Ranger are wicked creatures. All four have haunted me, possessed me and driven me into the ground (nearly literally). The system can’t exorcise them unless the individual desires it so.

But often the individual who carries the burden won’t let go of it unless others are there to take some of it away.  I survived by lowering my expectations (forget about getting home to see the kids before bed, forget about exercising or having friends, forget about doing those things that bring you joy to your work).  What I didn’t know was that constant stress kills.  My advice to anyone who is approaching burnout or is cooking at a broil: be true to yourself, your family and your patients and stop the 4 horsemen in their tracks, because once you’re toast, scraping off the burnt parts is painful, and what’s left isn’t all that appetizing.  If you’re on one of those horses or all of them, stop, drop and rock and roll on your own terms (and take your family and friends with you).

Engagement, Population & Public Health

Driving organizational success in children’s healthcare

In 1998 Jeffrey Pfeffer published an article in California Management Review describing what he sees as the seven practices of a successful organization. Comparing these practices to your typical health care organization today portends a crisis (some say the crisis has arrived).   Here is the list (with sarcastic commentary included for comedic effect – because if we didn’t laugh…) :

Employment security – apparently the data suggests that when employees fear for their jobs, they under perform – who knew?

Selective Hiring – the larger the applicant pool the better your workforce…mmmm – pediatric professionals weren’t in abundance as of … yesterday. Choosing employees to your organizational culture and the unique needs of your teams… is currently a luxury.

Self-managed teams and decentralization as basic elements of organizational design – uh – I’m not sure Dr Pfeffer realizes this… but it’s hard to empower practices and units in health care to actually manage their own performance – it takes time, training, dedicated people and robust real time data management – not to mention team meetings and engagement of front-line staff in analysis, action plan formulation, testing ideas, and managing sustained change. It’s easier to just tell them what to do, even if it’s wrong.

High compensation contingent on organizational performance – define performance, define high.   Is it ok to do high compensation no matter what? That would be great, because then we wouldn’t have to change anything.

Extensive training – Doesn’t everyone come into the health care workforce already trained?  Can’t they train themselves?

Reduction of status differences – we might actually be improving on this one in health care, but I’m not sure it’s having the impact we had hoped for.  Instead of collaborating we created more silos. Professionals who do shift work can’t make it to meeting where having reduced status differences allow for free exchange of perspectives and ideas.  Physician burnout has increased, because more and more tends to be dumped on them in this new order of everyone is equal and no one should do menial work, except the person who is ultimately responsible (oh, right, that difference still exists).

Sharing of financial and performance information throughout the organization– we have been tying to get better at this, but it’s …well… complicated.

So, what is the secret sauce for changing our organizational practices?  Sarcasm aside, let me put on my sunshine hat (yes, I actually have one). Accountable care will create the forces needed to shift health care into the realm of organizational success.  Fee for brief units or services of care has created a system of volume rather than value with regulatory and tort systems that drive fear rather than rationale thinking.

Working in teams, driving local continuous improvement, and driving true waste out of our processes, using the data management and sharing necessary to do so, with the staff training and professional development required, which will attract people to health care where professional joy is a given, will get us to the seven practices, and will create a care system that patients and families find value in and the workforce is proud of.

Leadership

Versatility and Balance

It helps to be focused on a few priority goals and values. It’s nice to be able to describe your mission, vision and strategy in a quick elevator speech.   For a leader to have a few outstanding character traits and to be clear for what they stand are good as well. Yet, to be successful these must be balanced with the study and grasp of diverse and complex hard and soft data and the possession of environmental, organizational, and emotional intelligence.

Balance is key.   Flexibility and versatility are essential in today’s leadership environment.   The capacity for renewal and reinvention are increasingly important as well. I’ve become convinced that one reason humility and will are level 5 leadership traits is because they are necessary for achieving balance and versatility. And they are needed if one is going to leverage renewal and reinvention to stay relevant.

Kaplan and Kaiser articulated this concept of versatile leadership in a 2003 MIT Sloan Management Review article. They framed it as forceful leadership balanced with enabling leadership, and strategic leadership balanced with operational leadership. Awareness of these types and their vices and virtues can help a leader in today’s world of rapid change, generational differences, and unprecedented ambiguity.

 

kaplan-and-kaiser

Confidence is important, yet better if it comes from knowing which style to lean on, rather than always leaning on the style the leader knows best. Courage is required to take the risks of switching back and forth. And, of course, leaders must work on developing their competence in all 4 styles. Humility assists the leader in recognizing the need to shift to a different style, and the need to work on developing skills in those less used styles. Will assists the leader in overcoming the inevitable bumps that come from shifting.

For executive leaders, it is often helpful to verbalize to direct reports and others from which leadership perspective you are operating in a given situation and why. Versatility is essential, yet it can have its downsides. One of those pifalls is creating confusion regarding the roles and expectations of others on the team. Are we being strategic or operational? Forceful or enabling? Am I to be using the same style?

Knowing where to start and where to shift can be challenging. Wisdom derived from experience and thoughtful reflection aids this. Wisdom complements humility and will, and may in fact be the difference between the nimble versatile leader and the awkward novice.

So, be focused and use sound bites, stand up for your values and principles, be visionary and relational, yet not too much. Be careful not to slight the detail work of change management, performance improvement, and plan execution, yet not at the expense of ignoring the changing environmental forces and keeping an eye on the big picture. Don’t forget the importance of opening up dialogue and listening to others, and when needed be a forceful leader, communicating with clarity, and reframing and renewing in inspiring ways.

 

 

Leadership

Narcissism: what keeps a high-achiever from being a great leader

With the awareness of saying something stupid comes learning and even at times insight. This awareness doesn’t erase one’s stupidity, but it may make one smarter for the future. I was recently talking with a friend about physician leaders and out leaked an incorrect generalizing comment. I suggested that physicians who tend to be self-centric in their view if not narcissistic aren’t good leaders. What I meant to say was that a lack of broad perspective is a barrier to being an effective leader, however, it may not be a barrier to positive contributions to organizational learning and problem-solving, not to mention being a good physician.  Dogmatic views and attachment to narrow perspectives can interfere with good leadership in complex, diverse and uncertain environments. However, in certain situations those qualities can be helpful. Not being a good listener is a problem if your leading a diverse group through complex issues, but good listeners (aka good leaders) like people who will speak up, and that’s were physicians, even those who are somewhat self-serving can contribute facts, ideas and insights.

As I tried to recover from my stupidity, a thought popped into my head. Could narcissistic physician leaders start to lose their effectiveness the more broadly their leadership asks them to think and function? What if they contribute quite well until they get to the executive leadership level? In 2012 Justin Menkes wrote a short article for the Harvard Business Review entitled: “Narcissism: the difference between high achievers and leaders.” He suggested that high achievers who are also narcissists can do very well to a point, however, at the executive level they can sink your company. The narcissism just gets in the way.

In 2000 and 2004 in the Harvard Business Review, Michael MacCoby published “Narcissistic leaders: the incredible pros, the inevitable cons” where he suggested that narcissistic leaders do have the advantage in certain situations, specifically where there is chaos or opportunity for innovation. Implied but not specifically stated in his article is that you have to be really good at what you’re doing (e.g Bill Gates, Jack Welch, etc.). Healthcare may be going through a lot of change, and some would claim chaos, but at the heart of providing health care is the patient, a person who doesn’t need chaos or change, they need high-reliability. Narcissism won’t get you that at the micro- or macro-system levels. Even beyond health care delivery, narcissism is potentially dangerous in healthcare. Just consider the case of Theranos and Elizabeth Holmes. Narcissism, even if you think you’re doing a good and just thing, gets in the way.

 

Management

Is Health Care a Business?

I haven’t entered a blog in over 4 months, primarily because I’ve been held hostage by a financial crisis.  We were successful in reversing the crisis, but not without some “damage”.  The biggest damage I’m learning has been staff morale.

In the last several months I’ve heard several front-line staff tell me that health care has become too much like a business with too much focus on RVUs and money.  Some have “attacked” me personally for being too focused on the business aspects.  Financial strength is critical for long-term success (i.e. staying in business), and action is necessary when it’s eroding.  And it’s not about the money, its about preserving the organization, the service it provides to the communities, and the people who provide the service.

This message was lost somewhere along the way.  I do admit that communication is hard and as hard as I tried to frame things in a balanced manner, the complete message didn’t always get across. The root of this seems to be the cascading of the message – the ability of middle and front-line managers to communicate the message as intended: “We need everyone to think about where and how we can be more productive and where and how we can be more efficient recognizing that not all areas will have the same focus or countermeasures,” becomes “We need to see more patients or we’re all going to lose our jobs!”  Hope is an important part of any message in a crisis and hope doesn’t appear to cascade.

Let’s make no mistake about it…health care is a business and it is the responsibility of management to keep it in business. Front-line people need to recognize that reality. However, management needs to face the reality that staff are emotionally attached to what they do, how they do it, and attached to their own personal finances whether they want to admit or not.   They are running a business at home, but don’t want to see their organization run like a business.

Celebrating early successes, thanking people, pointing out where we are excelling, and providing reminders that what we do is important to our patients and families…isn’t enough. Paying people the same amount and giving them a raise at the end of the year despite the huge challenges in making that happen isn’t appreciated nor is it enough. So, what is a leader to do?

Deming in his writings and speeches gave us a clue – the key processes and results of a business need to be constantly scrutinized for improvement and the improvement efforts need to include everyone.  So, when the crisis hits, everyone is already on the same page. These key processes and results rarely change – they are constant – regardless of any crisis.  Metrics of efficiency, which often include financial markers, are now included in the critical processes and results of healthcare.  If you’re in healthcare, expect to hear more and more about the importance of finances along side patient safety and the care experience.

Key financial metrics and other metrics of efficiency are results, outcomes, that if not constantly improved will put you out of “business”, out of “mission”.

 

 

 

Management

What Managers Do

Outcomes aren’t “managed”, processes and behaviors are.  Outcomes are consequences, which we analyze for the purpose of informing system design and driving behavior.  Thus, if management is to drive processes and behaviors, its stand to reason that knowledge about how they’re performing would be critical. Yet, we often don’t collect these data, and if we do, we struggle to understand what they’re telling us.

Furthermore, managers would be masters at systems design and improvement, and skilled at influencing behavior. Yet, managers are best at creating schedules, tracking budgets, coordinating resources, and analyzing outcomes.  And we’re great at getting performance evaluations done by the deadline (notice I didn’t say how great we are at performance evaluations).

So, do we have this all wrong? What are the barriers to getting it right?  Lack of time? If so, why do we lack time?  –  We all know the answer to that one: we spend so much time on the other stuff.

Senior managers often ask: “What are your results?” and “What are you doing to improve them?”  Therefore, that’s where we focus.  Instead they might want to ask: “What are your critical processes and vital behaviors?” and “What are you doing to improve them, and how are you doing with that?”

I’ve talked about care experience survey results before, which are sampled outcomes, lag by about a month, and are reported monthly, which further adds to the lagging.  In other words, they’re outcomes – and it’s behaviors and processes on which we ought to focus day-to-day.

To manage these two things, we first identify, define, measure and analyze them.  Then can we manage and improve them. And in doing this we perform cause analysis, solve problems (breakdown barriers) and execute change.   – And the big one: influence behavior.

I’ve found that getting people to see things differently, and think about things differently as well as creatively, is often an important step. Human biases are multiple and strong. In my opinion changing paradigms is critical for changing behavior.  When one is creative they are essentially building new paradigms.

Deming was correct when he made the psychology of people a pillar of quality improvement, along with systems thinking, knowledge processing (learning), and variation analysis.  Good managers know the psychology of people and use it to influence behaviors.

 

 

Management

Does a healthcare macrosystem need mesosytems?

What it needs is great microsystems (units and practices).  What I’ve observed is that mesosystems are often workarounds. They are created when the macrosystem fails to or can’t support the development of microsystems (units and practices) in such a way that they are high functioning, effective learning, and capably connecting units.  Mesosytems take many shapes [separate business entities or divisions, service lines, discipline silos (e.g. nursing services and medical staff), middle managers, committees, work groups, etc.].  Special effort needs to be taken to not create too much waste when putting a mesosystem in place.

How the mesosystem is set up and structured is important. Many children’s hospitals within a hospital are set up as a mesosystem. It make sense, because the business of children’s hospitals is different from the business of adult health care units. However, the children’s hospital needs to be big enough to warrant the investment of its mesosytem.  Supporting functions that become mesosytems are also typically not lean and create significant waste.  The best example of this in health care organizations is the separation of nursing services and medical staff into large mesosystems.  It often creates waste.  This isn’t to say that creating connections among disciplines isn’t helpful, but it needs to be done in a way that limits waste and maximizes the functioning of the microsystem.

The question for every health care organization ought to be: what does it take to have high-functioning, effective learning, capably connecting units or microsystems?  At the microsystem level is where the output and performance of the organization matters the most.  The manager(s) and leader(s) of those units need to be effective at managing processes and leading people.   They need to be good at connecting with the leaders and managers of other units, and they need to be good at managing up to their bosses. They need ready access to and processes that effectively connect them to support systems (e.g. HR, Finance, IT, facilities, etc.). They also need to connect well with other units or microsystems where they share patients and critical interdependencies. And finally they need to be well connected to the macrosystem leadership. Achieving this isn’t easy, but creating a complex set of mesosystem workarounds isn’t the leanest approach.  So, it needs to be deployed carefully, and in some cases not deployed.

Good managers and leaders of microsystems are capable of driving continuous improvement and adaptation through team learning and robust quality improvement. Learning takes transparency, a just culture, and coordinated teamwork. Processes have to be mapped out, visible and constantly scrutinized through daily management.   Robust quality improvement processes and tools need to be in place with skills and knowledge of quality improvement integrated throughout the team. The ideal would be to embed these attributes into the microsystem, not leave them up to a mesosystem to do them.  Support services are just that.  They are there to help the microsystem and are embedded in the microsystem as much as possible.

Engagement

Great teams start with members who are there to serve

I recently attended a conference of health care administrators and executives and one of the topics was developing high-performance teams. I was asked to sit on a panel and give a brief presentation on the subject. I’m not entirely sure why I was standing up there, but I assumed it was to give a physician’s perspective. I struggled with where to start and where to end; the capacity and capability for physicians to be part of effective teams is variable.  Some physicians are great at it most of the time and some aren’t some times and other not most of the time, and the reasons range from lack of skill to lack of sleep.

The other 2 panel members had great insights and advice: 1) Teams are critical to success now and in the future given the rapid changing landscape of healthcare, 2) Teams need to be interdisciplinary, 3) Clinical teams benefit when there is a physician co-leader, and 4) Common ground is reached when making the patient the focus of the goals of the team. They gave examples of successful teams in their organizations: the key elements were clear purpose and goals, senior leadership support and involvement, openness, and transparency. I decided to focus on the key attributes of successful teams, which boiled down to 1) collective leadership, 2) strong culture, 3)  inspiring purpose and 4) focused discipline.

I also discussed the importance of the attributes of each member of the team.  A great team member has 1) commitment to the task, 2) openness to discuss crucial and sensitive topics, 3) humility for listening and learning, 4) ability to maintain group optimism and enthusiasm, and 5) skills for acknowledging the dogmatic, then help them be better team members. These attributes were taken from the literature on teamwork and #5 seemed especially pertinent to physicians. Physicians tend to be dogmatic. And dogmatism can squash a team, especially in today’s rapidly changing environment and evolving workforce of generation Xers and Yers.  The message is that good teams have individuals who can acknowledge dogmatism  in a constructive way and help that person contribute.

There is a passage in Managing the Unexpected by Karl Weick and Kathleen Sutcliffe that speaks to how individuals on teams create a culture that drives team effectiveness: “Expertise resides in the heed with which people view their inputs as contributions rather than as solitary acts, represent the system within which their contributions and those of others interlock to produce outcomes, and subordinate their contributions to the well-being of the system, constantly mindful of what that system needs to remain productive and resilient.” [Managing the Unexpected p. 78]  When physicians are on teams, it’s usually because they bring critical expertise. Physicians are great team members when their actions and words serve the best interest of the organization, its people and the patients and communities they serve.

Leadership

Communicating: some wise advice from Lao Tzu

For a leader one of the toughest challenges is communicating. Getting right the what and the how, the who and the when and even the where isn’t easy.  In certain situations, there is no perfect way.  Sometimes it’s not just what is said or how it’s said, but who is saying it that matters the most.   Effective communication starts with the speaker, the leader: their credibility and the level of trust the team or organization has in the leader.

Over the years I’ve worked hard at improving the effectiveness of my communication. With patients and families I’m effective most of the time, but there is always room to improve – the approach to communicating needs to be tailored to the individual, as well as the situation and circumstances – and that’s hard to get right every time.   Even within one episode of communication, the approach needs to be fluid.  This takes emotional intelligence and practice.

Lao Tau has some advice for communicators.  Lao Tau said, “He who knows does not speak.” He also said, “Practice doing ‘not doing’.” These two tenets of Daoism need to be front of mind when a leader is communicating.  He is telling us to listen – do more listening than speaking.

One can gain many lessons about communicating from Daoism. Daoism encourages one to consider that the whole is real and the divisive is perceptual.  A single idea or opinion cannot be good or bad, because that would place judgment, which is a comparative and perceptual approach not a synergistic or uniting one. To throw out an idea would threaten the balance of the whole.  Lao Tzu said, “Long and short complement each other.” Meaning you can’t have long unless you have short.  In communicating, one would do well to remember that nothing is really new, or better, or old or bad, it simply is, and whatever it is complements and colors the conversation, making it more whole, more real.  To do this takes listening.

Nevertheless speaking must be done. It’s what people expect from leaders. My first goal when I speak is to drive common values and principles, to align thinking and actions, and to motivate effort towards a shared vision.  In other words: be inspiring.  My second goal is to be a sensemaker.

It is the job of the leader to bring order to the whole in order to influence the group to reach their shared vision. This is called sensemaking. A leader must do it well and communicate it well to be a good leader. Lao Tzu said, “What is a wise man’s job, but to make another wise.” A leader’s job is to create wisdom for all. Great communicating requires a humanistic approach, which results in an increase in collective wisdom.