Does the Triple Aim depend on leaders who demonstrate a commitment to the larger mission, have “soft skills,” and obvious integrity? The answers seem to be obvious: yes, yes, and yes.
My friend Michael Soman, the retired president of the Medical Group of the old Group Health in Seattle would agree that it does, as he did recently when he responded to a section in one of my weekly “Healthcare Musings” letter on the subject of is whether or not “truth is dead.”
Nice issue, my dear friend.
Wanted to share with you (I may have done so previously) something triggered for me by your discussion of “truth”.
We have learned that historically, perceptions of dishonesty are one of the most difficult (or even impossible) character traits a leader can overcome. I always shared with leaders with whom I was blessed to work that fact, along with a practical definition of honesty for them to consider:
Honesty on behalf of the leader can be looked at by followers through 4 questions:
Do you do what you say you are going to do? (i.e., are you reliable?)
Do you tell the truth? (what many people call “honesty”)
Are you capable of doing what you say you will do? (i.e., I can’t dunk on Labron even if I want to!)
Are you beneficent? (i.e., holding other’s interest at a very high level)
This seemed to be a helpful way of looking at honesty, so I pass it on to you!
Be well, my friend, and don’t even TRY to apply this definition to the current President of the United States!
michael
As usual, Michael was crisp and to the point with humor. Michael knows leadership. While I was leading Atrius Health and Harvard Vanguard I visited Michael at Group Health several times for ideas and inspiration and Michael brought his leadership team to Boston to visit us. We connected at GPIN and other meetings to discuss leadership and its stresses, and shared best books with one another. Finally, we both retired at almost the same time!
Michael’s note is a good introduction to the important issue of healthcare leadership at this moment in our history. The imperative of reevaluating how we develop leadership was underlined in a recent “perspectives” article in the New England Journal of Medicine by Lerman and Jameson from the Perelman School of Medicine at the University of Pennsylvania. The article simply entitled “Leadership Development in Medicine” is an excellent description of the first three steps of a Lean approach to problem solving.
The paper begins with a “reason for action” that is succinct:
Health care in the United States suffers from a persistent and worsening disconnect between the capacity of the physician-leadership workforce and the needs of our expanding and increasingly complex health systems. Closing this gap will require leadership skills that are not acquired during traditional medical training.
The practice of medicine is evolving rapidly. New health care technologies and precision therapies are shaping medical decision making and patient care. A diverse group of commercial and government payers are continuously changing approaches to the approval of clinical services, quality oversight, and payment. Health systems are implementing electronic health records, quality-improvement programs, multispecialty clinical service lines, and programs to improve population health. In light of the rising costs of care and shrinking margins, payer and provider systems are consolidating to improve efficiency.
The authors note that our world much more complex than it was when many of our current leaders were trained. While the complexity that leaders must manage has increased quickly our response to change the way we train leaders has been slow. I wonder if the slowness is in part an expression of the two different worlds of the academic medical center and practice in the community. The authors note that even leaders in academic medical centers are unprepared for the pace of the times.
Michael and I came along at a different time and at a different pace. There was much to learn about business and leadership, but there was plenty of time for learning through doing and we were fortunate to work in organizations where there were plenty of “big brothers and big sisters” who had the time and the desire to help us develop. Our worlds were more internally focused and there was much less external pressure from changing regulatory agencies or the demands of payers. In summary the authors “current state” is:
This transformation has occurred within a short period, and the pace of change is unlikely to slow. Our profession has been somewhat complacent in the face of these disruptive forces and hasn’t prioritized cultivation of leadership skills such as communication, team building, collaboration, and deliberative decision making that will position the next generation of physician leaders to succeed in this rapidly changing environment…
…Health care represents 18% of the U.S. economy, and there are nearly 6000 hospitals and more than 1 million physicians in the United States. Depending on their roles, physician leaders of departments, quality-improvement programs, clinical service lines, practice groups, information technology teams, and other units may manage budgets similar to those of medium-sized businesses and work in organizations that are often among the largest employers in their community. Although training in finance, business planning, and personnel management is central to the professional development of health system executives, these topics are not generally emphasized in the training of physician leaders.
A decade ago we recognized these issues at Atrius Health and invested heavily in creating an internal “Leadership Academy.” The work was conceptualized and led by Zeev Neuwirth who is now at Carolinas HealthCare System which has recently renamed itself as Atrium Health. [That is close! Atrium v. Atrius] Every six months we selected 30 of our best young leaders chosen from our physician leaders, medical managers, and nursing and advanced practice health professionals and started them on an eighteen month journey of intense training in all of the business skills they would need as well as the “soft skills” that are so critical in the leading and development of the professionals who are the “knowledge workers” of healthcare. The program required an unusual commitment from the individuals since the training was not all done during normal working hours. Many evenings and weekends were added to the work of fully employed professionals.
There was a huge benefit to the weaving of the didactic program with the normal work of the “students.” The skills being taught and the connections being developed across a large multi sited organization yielded immediate benefits. What was being learned and the collaboration on the academic exercises were immediately applied in a way that could never have occurred if “learners” had been sent out of the organization for learning and then returned to try to influence a rigid status quo. Over my tenure as CEO several hundred internal leaders developed skills that were available immediately to help us create programs that enhanced quality and patient satisfaction, create affiliations, increase productivity, improve work life balance, and reduce costs. The Leadership Academy created relationships and imparted skills that moved us toward the Triple Aim. As our Lean transformation progressed we had leaders who knew the importance of leadership that focused on coaching, mentoring, and supporting others through meaningful relationships grounded in a mission.
Michael’s four points about honesty and leadership are foundational to the effectiveness of “relational contracts.” Professor Rebecca Henderson at Harvard Business School and others have discussed and stressed the importance of trust in relational contracts and the importance of relational contracts to successful organizational transformation using the tools of continuous improvement. Healthcare at every level is about trust between multiple parties whether they be patients and providers, providers working together or organizations working together to create business advantages that will translate into community benefit.
If there is anything that our current political environment should teach us, it is that leadership without trust rarely accomplishes anything unless it is coupled with force and intimidation. There are “top down” healthcare organizations where success seems to be possible through pressure and abuse. I never could have worked in such an environment.
The authors of the NEJM paper stress the importance of beginning leadership training in medical school and I agree, but they extend their suggestion of a “better state” to something much like the Leadership Academy at Atrius.
Leadership development should begin during medical school, and potential leaders can be nurtured at each stage of professional advancement. We suggest that health systems focus on three key strategies for promoting the effective development of physician leaders.
First, such systems could build a diverse pipeline of future physician leaders from within the organization. This approach would expand the pool of potential leaders, allow emerging leaders to take on progressively increasing responsibility, and ensure that leadership strategies are aligned with the organization’s culture and priorities. Health systems could start by identifying potential leaders and engaging them in task forces, committees, retreats, and formal training programs. Each of these activities requires dedicated time and institutional support for leadership development.
Providing frequent, structured feedback to emerging leaders offers opportunities for ongoing assessment of leadership potential, mentoring, and succession planning. Whenever possible, goals, metrics, and incentives should be transparent and quantitative. Developing talent from within — a foundational approach in other industries — can reduce the time required for recruitment, transition, and integration…Second, health systems could implement a deliberate process for rigorously mining talent pools, whether internal or external. The most promising leaders are those who not only have experience and a compelling vision but also exemplify the core values of the institution and can engage and inspire others to rally around a shared vision.
It is gratifying to to read how close their suggestions of what would be better mirror our experience. They go on to stress that leadership should be a priority. I would add that a huge challenge is that organizations avoid leadership investment if they feel financially stressed. Sometimes they make leadership development the first casualty of budget driven reductions in response to external financial pressure. Jim Collins describes the painful slide to oblivion that many organizations follow in his book How the Mighty Fail. I do not think medical systems, hospitals, or medical practices are immune from the disorder that Collins describes. The author of the HBR review that you can find by clicking on the link sums up Collins’ findings on how organizations fail as:
He [Collins] settles for describing the typical path to ignominy in five phases …
- Hubris born of success
- Undisciplined pursuit of more
- Denial of risk and peril
- Grasping for salvation
- Capitulation to irrelevance or death
Listening to Michael we can see that the lack of honesty or trustworthiness in management is at play in each of these steps. An organization that is not focused on leadership development is at least at stage 3 and those who had leadership programs and have reduced or eliminated them for cost reasons are lost causes and are at step 4 or 5 in the process. They are well on the way to giving up autonomy to the mercy of another organization as their only rational option to total failure. One can hope that the newer larger combined organization will recognize truth and honesty as core principles. There is nothing that is more essential in a new affiliation than trust girded by honesty and commitment to mission.
The authors of the NEJM article ended by saying:
In any high-performing organization, leaders have a disproportionate influence on organizational culture and performance.
And to that I would add Michael’s comment:
We have learned that historically, perceptions of dishonesty are one of the most difficult (or even impossible) character traits a leader can overcome.
