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Chapter 6
Dyads as Catalysts for Renewing the Strength of the Leadership Team
Not long ago, we were both invited to attend a 2-day meeting in another state. While it was billed as a retreat for clinicians, attendees included hospital executives and others, such as Human Resources and Finance leaders. There were a number of discussions about the future of healthcare, and the need for stronger partnerships in the future.
On the second day, one of the attendees brought up an issue that had apparently been bothering her for some time. “When I call a doctor at home or in his office, I am not doing it just to waste his time. I either need to get information about his patient or need to give him information. It’s pretty insulting when he either hangs up on me, tells me not to bother him, or actually says very rude things—sometimes these guys don’t call me back when I leave a message that it’s really important for the care of the patient right now. This lack of respect is intolerable, and is not the right thing for quality patient care.” The speaker’s colleagues (from the same specialty) immediately chimed in, telling stories of times when care was compromised by this type of behavior, examples of when they were insulted by physicians, and about how they feel disrespected, and undervalued by members of the medical staff.
When they had completed their litany, three nursing leaders in the front row exclaimed, almost in unison, “You are describing what nurses have dealt with forever.” The speakers looked chagrined, and even more upset. They weren’t nurses. They were all MDs—hospitalists and emergency department physicians, attending this medical staff leadership retreat.
After this meeting, a nurse said, “Well at least they haven’t had a scalpel thrown at them in the OR like I once did.” The other nurses laughed, and some told stories of horrific verbal and physical abuse. Their laughter was the saddest part of the conversation because it indicated an acceptance of what would not be tolerated in any other American industry.
We share this story because it illustrates an issue that Dyad leaders will need to consider as they work toward a transformed healthcare future. While we’ve talked about the various professional cultures and differences that must be addressed as we come together as partners, there are other issues that Dyads cannot ignore as they become leaders for the organization. Behaviors and norms that have been tolerated, even treated with humor, will need to be addressed. Acceptance of a formal leadership position brings with it a responsibility to provide safe, respectful work environments for everyone.
You may be thinking that this is old news. Your organization may already be changing policies so that “poor citizenship” (a euphemism for abusive behavior) is part of the recredentialing process for your medical staff. You may have programs for physicians to help them handle their stress. Some might be labeled “anger management.” If you are a physician, you may think we do not need to talk about this anymore. You may be tired of people always “blaming the doctors for all the dysfunction.”
As the story above indicates, interpersonal issues are still causing problems in our organizations, even among groups many of us think of as one united tribe. (Of course, this is not true, as there are subtribes among a profession that result in perceived superiority or pecking orders. Medicine is no exception, with subtribes based on specialties, and even subspecialties.)
We use the story above as an example of civility problems in healthcare organizations, not as a condemnation of physicians as a whole. For one thing, not all surgeons throw scalpels at nurse, and not all doctors are rude or condescending to physicians of other specialties. In addition, physicians are not the only group with members (actually a minority of members) whose lack of civility makes the workplace unpleasant for others and, as a result, endangers the quality and safety of patient care.
Civility and Workplace Fear
Civility (courtesy, respect, and consideration of others) is not always present among those who work in healthcare. We’ve known experienced nurses who demean and mistreat new graduates (there’s even a common saying among this profession that “nurses eat their young”), departments that denigrate other areas on a regular basis, members of one shift who verbally abuse (or disparage behind their backs) coworkers who work on another shift. We have also experienced rude and unkind managers.
An unspoken, and maybe unconscious, rationale for implementation of Dyad leadership is a hope that co-leaders will increase civility among their two tribes. As mentioned above, all leaders have a responsibility to provide safe, civil workplaces, and not just between their own professional cultures. New Dyads can’t ignore the work environment. They need to actively address intergroup and interprofessional norms. They will have to intervene in relationship problems. In addition, if they do not have education and experience in management, they’ll need to learn about human resources laws so that they do not make errors (while addressing relationship or personal problems) that would place the organization in a compromised legal or regulatory position. If they work in an organization where employees are represented by an organized labor entity, they will have to understand the rules and implications that go with this. (Labor Law and contractual agreements.) While “scientific” professions may think that this work is all “soft,” individual co-leaders may discover that addressing relationship and personal issues is among the hardest things they have ever done.
Some interpersonal relationship issues may seem trivial and easy to solve with a simple “chat” or written policy; others may be obviously more complicated. Experienced leaders know that even some of the “easy stuff” isn’t easy. A single conversation with a colleague or subordinate doesn’t usually solve even straightforward issues. Policies, while important for documenting expected behaviors, don’t guarantee that the behaviors will occur. For example, a physician colleague, new to his leadership role, learned from his Dyad partner that a female nurse had talked with the nursing leader about rude behavior from a male surgeon in which she felt both disempowered and disrespected. The two nurses had discussed their strategy for changing this dynamic. It included the nurse who felt disrespected solving the issue herself. With the nurse executive, she role-played a solution (the nurse had asked for coaching) in which the nurse would approach the surgeon and talk to him about how she perceived, and felt about, his words and actions.
The new physician leader decided he could take care of the problem for the nurse. He cornered his medical colleague in the hallway, told him the nurse was upset about his “boorish” behavior, and asked him to follow the hospital civility policy from now on. Satisfied that he had taken care of the problem, he reported this back to the nurse executive, and was perplexed when she was not happy.
The experienced nurse executive understood what Ryan and Oestreich describe as fear in the workplace (1). Workplace fear includes issues that might not come to mind to everyone, such as fear of being criticized, fear of not being seen as a team player, and fear of disagreements that might lead to damaged relationships. The nurse in this case, was also afraid of being “punished” by the surgeon. She thought he might become even more imperious toward her, or refuse to talk to her, or speak badly about her to others on the team if a third party interfered in their relationship.
In this case, the nurse was right. The surgeon was furious that she had “run to Dad” (the physician leader), embarrassed him, and potentially affected his “citizenship” rating for recredentialing. Their relationship instantly became strained. When the surgeon came to her unit, he insisted on talking to other nurses about the care of his patients, even when those patients were assigned to her care. Now the nurse executive and nurse had a bigger problem. They needed to devise a way to repair the damage.
The medical leader had not wanted to make the problem bigger. Still playing the part of problem solver, he proposed that he would fix things by going back to the surgeon and telling him that “punishing” the nurse by refusing to work with her was not acceptable behavior! He still did not understand the ineffectiveness of this approach. (Over time, he learned, with coaching from his partner, the problem with his instinctual approach). Eventually, the nurse and surgeon worked out their issues, but hard feelings that could have been avoided persisted for some time. This didn’t just affect the two professionals involved; it affected the efficiency of the unit (when the surgeon interrupted other nurses’ work to talk with them about his patients). In addition to understanding the dynamics of interpersonal relationships, the nurse executive’s strategy for helping nurses deal with interpersonal problems themselves was to empower them, by providing them with caring, confrontational skills they could practice with her.
The nurse leader knew that without the ability, skill, and organizational “permission” to talk with other team members as equals (human to human), interpersonal team issues would not be solved. As we move into the highly vaunted (and rightly so) team care of the future, organizations without this cultural norm will not succeed. (In Chapter 8, we delve further into specific challenges of the next era, including safety, and the importance of environments where every single team member must be able to talk directly to every other team member about anything that affects the work environment or care.)
Dyad leaders must manage the environment, understand relationship dynamics, and empower others. While one partner might take the lead in these type of “soft” skill situations, both must understand their importance. We do not mean to imply that only partners new to formal management would make the error attributed to the physician leader above. There are plenty of current leaders who practice paternalism, in which they “take care of everything” because they believe they know what is best for others, don’t believe their team members could handle situations as well as they do, or don’t take the time to coach and help team members develop their own skills.
If current healthcare leaders were all outstanding, we probably would not have the dysfunctional workplaces of today. As Marszaleck-Gaucher and Coffey pointed out in 1990, “for success in the future (healthcare) executives and managers must become more effective leaders” (2). They talked about the need to transform healthcare 25 years ago. So did V. Clayton Sherman, who said, in 1993, that “the denial of management problems by some in the healthcare industry will no longer stand” (3). Sherman’s book was widely acclaimed and read by hospital leaders of that time. They touted his statement that “Passing the test of leadership means staying focused on the destination, not the difficulties and impossibilities of getting there, or the voices saying we shouldn’t take the trip.”
We are taking the trip right now, although it isn’t exactly to the same destination as these leadership authors thought a few decades ago. Transformation is going to happen because of forces outside of the industry (government and private insurance payment reforms). Most know we are no longer an industry of hospitals, but one of healthcare systems. Still, Marszaleck-Gaucher and Coffey’s assertion that management is responsible for the success or failure of the organization is true. So is Sherman’s belief that we cannot deny our problems. We can’t make management and leadership better if we don’t look at how they can be better.
Implementing Evidence-Based Management
During a healthcare model transition (at a time when we are implementing new leadership models, including Dyads,) is a good time to examine how to put better management and leadership in place. Rather than debate what “better” means, we should look to the growing mountain of management research. We should implement, along with Dyads, what Kovner, Fine, and D’Aquila (among others) call “Evidence-Based Management in Healthcare” (4).
The interesting thing about research is that it is often possible to find one or two that supports any argument we want to make. (Kathy jokes that she only chooses to believe clinical or health research that supports the way she wants to live. So, in her world, research that says salt is bad for you is faulty research. Studies that say salt doesn’t have to be limited if you have a normal blood pressure and no health problems, is good research.) Executives can do the same thing with management research. For example, when nursing leaders bring up research that shows a direct link between staffing and patient quality results or mortality, some business leaders find other studies that show no correlation, to counter the nurse’s assertion that more staff is needed.
As executives concerned with patient care outcomes, we are pressuring clinicians to decrease variance of care and utilize evidence-based protocols and practices, even if they can locate a random study that does not support the preponderance of evidence. So, although there may be differences of opinion, we believe leaders should pay attention to the broad findings of research that supports the selection of, education of, and practices of a particular type of leader, as we populate Dyads. We reference many throughout this book.
Findings indicate that to transform our organizations, we need transformational leaders. These are people who motivate others to excel, look to higher purposes, cope better with adversity, create vision, shape values, and help others deal with change. They raise the consciousness of others. They help followers understand their mutual interests in meeting organizational goals. They are optimists. They are able to get others to transcend their self-interest for the good of the group, organization, customers, or country. They are usually charismatic and inspirational. They question assumptions and, because of their own propensity to look at old problems in new ways, they encourage and aid others to innovate.
In addition, those who are able to transform organizations are interested in each of their team members as individual people. They recognize differences, serve as coaches and mentors, and help others to reach their individual potentials. They are superb communicators, and good listeners. They empower others, share power, and are able to put the organization’s goals ahead of their own or their profession’s needs or desires. They recognize their own areas for personal growth and development, are lifelong learners, and have high self-esteem, in spite of acknowledging their imperfections to themselves and others. As Bracey, Rosenbaum, and Sanford said in 1990, they demonstrate care by telling the truth with compassion; look for others’ loving intentions; disagree with others without making them feel wrong; avoid suspiciousness; and recognize the qualities in each individual regardless of cultural differences (5). While both males and females can be transformational, females, as a group, possess a higher proportion of these traits than men do, which is why largely male leadership teams and organization boards should consider adding more females to their teams.
While emerging research is finding that there is more “nature” to what makes a great leader than previously believed, management and leadership skills can be learned, especially when individuals are willing to change beliefs and practices based on past socialization. Mentoring, coaching, and experience are all helpful to develop transformational leaders, but only when new (or experienced) leaders have the humility to know there are many things they don’t know.
Many current leaders, for whatever reason, do not choose to empower others, and do not practice transformational leadership. One thought about why this is true in healthcare is because we have not given managers the education and coaching we are advocating be provided to Dyads. Executive leaders should consider this when evaluating the strengths and weaknesses of their leadership teams. The same techniques used to develop new Dyad leaders would help in the development of individual leaders. In fact, current managers who were originally placed in their positions based on clinical skills, but not given help to develop management abilities, might perceive the resources expended to develop physician leaders as a “fairness and justice” issue. This is particularly true if they suspect that physicians are being educated to replace them in leadership jobs.
Executives preparing for the next era need strong, educated, committed leaders capable of transformation on their teams. While implementing Dyads or other new models of management, they should evaluate their current leadership team to understand the strengths, weaknesses, and any team gaps. If an honest evaluation of themselves and their organizations reveal a history of preference and promotion of transactional (task oriented) leaders over transformational (relationship oriented) individuals, it is time to balance the team. This can only happen if the executives understand that the value these leaders bring is as great (or even greater today) as that of transactional managers.
If individual growth opportunities are identified, single as well as Dyad leaders should be afforded these. However, as we have mentioned before, some people are simply not capable of learning the leadership or relationship skills needed to lead into the future, as either individual or Dyad leaders. After an assessment of the team, they may need to leave their positions.
Leaders that Might Not Be a Good Fit for the Organization
In particular, we see the following types of leaders as more detrimental than value added to healthcare organizations in a time of transformation:
Authoritarian Leaders. These are managers who exercise position power rather than competence to lead as a way to enforce their will on others. They tend to have poor interpersonal relationships (6). They utilize punishment, or negative evaluations to induce performance (7). They do not do well in unstructured situations (which will be a problem in the chaotic days of change). They are often the same people as the power seekers listed next.
Power Seeking Leaders. These are leaders who seek power for its own sake, and not in order to do good for the organization or others. They are often forceful and argumentative, bossy or domineering. They like highly hierarchal organizations. They want high status, and insist on maintaining the trappings of high status, such as higher (or more prestigious) titles than others. According to research by Mowday (8), these leaders obtain emotional satisfaction from wielding power. In fact, they experience aggressive feelings and physiological reactions, such as the release of catecholamines (associated with emotional experiences), when they demonstrate they are more powerful than others.
Leaders with a great need for power prefer ingratiating followers (9). Ingratiating followers are not people who will point out problems in the leader’s current organization! (This could be harmful to the company’s future because transformation calls for an open culture where problems can be candidly identified and addressed.)
(We need to clarify that we are not against leadership power. All leaders seek and need power. The individuals we are describing here seek it solely for their own aggrandizement, and not for how it can be used in the service of others.)
Machiavellians. These are the leaders who believe that deceit and coercion are legitimate tools if used to meet goals. In other words, in their minds, ends always justify the means. Named for Niccolo Machiavelli, author of The Prince (10), their leadership style is based on being feared, rather than loved. However, recognizing the need to have others trust them, a Machiavellian individual can, and does, mask her character when she perceives it is important to appear moral, humane and sincere! There is actually a test called the Mach Scale to measure how Machiavellian a leader is (11) but we aren’t advocating it be used as part of the leadership team assessment! Over time, Machiavellian personalities and tendencies will become apparent. Given the mission statements, visions, and values espoused by healthcare organizations, it is difficult to believe that any health executive would keep leaders with these propensities on their teams!
Self-Serving Leaders. These are the people in power positions who disregard the rights, values, and feelings of others. They view others are “instruments” to achieve their own goals (12). They tend to be narcissistic, and only want to hear advice that confirms their own opinions. They also tend to hold their subordinates in disdain (13).
Arrogant Leaders. These are the leaders who tend to think they are smarter than everyone else. Because of a self-image of superiority, sometimes honed in a profession that considers itself superior, they overestimate their own ability, and underestimate other people’s ability. They often ignore advice from their team members, which leads to errors that could have been prevented (14,15).
Leaders Lacking Essential Traits. People who lack cognitive reasoning abilities, basic ethics, moral reasoning, integrity, or authenticity are not the right leaders for healthcare. Toxic leaders, who are abusive toward others, violate human rights, mislead others with lies, stifle criticism of themselves, cling to power, scapegoat others, or ignore or promote incompetence (16), should be removed from the management team. If education and support does not help those who lack the courage to lead in times of change, or need help with development of emotional intelligence, they, too, should not be kept in leadership roles.
Some leaders looking at this list of who is not appropriate to lead in an era of transformation might be offended that anyone would think that a healthcare executive would have kept leaders with these traits on his team. Or, they might think they are capable of choosing new (including Dyad) leaders without a list that points out who not to choose! Instead of being offended, we hope you will consider the possibility that there could be problem leaders within your organization, either due to innate traits or lack of education and support. Unless you have the good fortune (and the executive talent, because we know you deserve a large part of the credit) to lead in an organization with top employee engagement, physician engagement, quality, safety, and financial scores, there is a possibility the leadership team needs attention.
A few months ago, a healthcare consulting firm sent us a newsletter with the provocative lead-in, “There’s an 80% chance that your manager isn’t great.” As managers ourselves, we laughed about it, and joked that we know lots of people who aren’t in the “Great 20%” with us. It did get us thinking, though, about the need for greatness in our industry, as we move into the next era. It also reminded us that probably 90% of the people who got that letter believe they are among the top two deciles of great managers, too! Yet, multiple articles and books (and even movies that make the situation into comedies) continue to point out that organizations, including healthcare organizations, often suffer from a disconnect between those who do the work and those in positions to manage (or lead) it.
When we add the disconnection between leaders and frontline providers in healthcare to the divisions between physicians and hospitals, payers and providers, various clinical groups, and parts of the care continuum, it would be easy to say we just can’t fix this. It’s even easier to do what so many do so well: point fingers at everybody else for the problems in our industry. Responsible, mature leaders are not finger pointers. They tend to first look at themselves, and what they can control.
The Arbinger Institute published a book entitled Leadership and Self-Deception in 2002. In it, they point out that self-deception “blinds us to the true cause of problems, and once blind, all the solutions we can think of will actually make matters worse. That’s why self-deception is so central to leadership—because leadership is about making matters better. To the extent we are self-deceived, our leadership is undermined at every turn” (17). We are cheerleaders for healthcare systems, and those who maintain the courage to lead them. That’s why we wrote this book. We think there is some blindness about why and how systems are implementing Dyads and about the cultural and historical issues that will need to be addressed if we are to succeed as true partners in integrated systems. That’s also why we think leaders need to look at the development needs of their current teams and choose wisely who will manage and lead in the next era. During this period, while we are forming new business models, or care models, the development of new management teams can and should spur the idea of assessing the entire leadership team. We will all need people with the right skills in the right jobs for the monumental work needed to change what many of us are able to admit is a dysfunctional environment.
Chapter Summary
The selection of those who will lead healthcare transformation is vital to thriving in the next era. As systems designate and select Dyad partners, executives can consult management research as a guide to evidence-based leadership practice. In addition, implementation of new management models can facilitate assessment of current leader strengths and skill gaps that should be addressed to strengthen the organization’s team.
Dyads in Action
Expanding Roles of Dyad Leadership in Healthcare
In March 2012, CEO Doug Hawthorne announced the creation of a Dyad leadership structure within Texas Health Resources (THR). The chief operating officer and a chief clinical officer would be responsible to Mr. Hawthorne for the entire clinical operations of the newly designed organization. “This Dyad leadership model has been adopted by other leading healthcare systems and has proven to be an effective structure for aligning operational and clinical sides of large, complex health organizations. So we are transforming our organization from being a hospital-centered system to become a well-connected and coordinated system of health service that strives to help people be healthy and well in addition to expertly treating disease” he said (18).
Texas Health Resources is not alone in adopting a Dyad configuration. Many health systems are migrating to this management model, either at the highest level of the organization or within the management structure of care coordination, service lines, vertical integrated delivery networks, or clinically integrated networks. Physician and clinical leadership roles are exponentially expanding in response to the organization’s needs for clinical quality improvement, efficiencies of care, improved patient satisfaction, and enhanced performance across the continuum of care.
Before detailing Dyad management models in the above areas, it is important to characterize the actual qualities and operational responsibilities of Dyad managers. At THR, a physician manager and an operational leader are equal partners. An article in Physician Executive Journal of the American College of Physician Executives (ACPE) points out the importance of establishing clear accountabilities, qualities, and overlapping responsibilities in these new positions to bring clarity to the Dyad’s roles.
According to the authors, Zismer and Brueggerman, physician and operational Dyad leaders share responsibility for
- the mission
- the vision
- the values
- the stated clinical, patient service and business goals
- the strategic plan and goals
- the performance scorecard or dashboard
- the culture.
The physician co-manager’s role is primarily in
- quality of the clinical professionals and their work
- provider behaviors
- provider production
- clinical innovation
- compliance
- patient care standards
- clinical pathway and model management
- relations with referring physicians and provider “leverage”
The administrative co-manager has the responsibility for
- operations
- revenue cycle
- operations expense management
- capital planning
- staffing models
- performance reporting
- supply chain and support services (19)
Dyad management teams with clear and concise roles and shared responsibilities will perform the best across the new continuum of care business models. It is not important to share or divide the same responsibilities outlined above, but it is important to clarify specific expectations of all the distinct and shared roles.
The proliferation of Dyads in healthcare has occurred without a clear understanding of how to account for each role and its overall contribution to the outcomes of an organization. This lack of resolution in roles and responsibilities, within an environment of cultural and experiential diversity, is a recipe for the creation of conflict.
Let’s examine a couple of idealized representations of Service Line and Care Management Dyad roles and responsibilities as well as opportunities for conflict these could engender.
National Service Lines: A Cardiovascular Example
A national cardiovascular service line (CVSL) within a complex multifacility system is composed of Dyad leadership for the national structure as well as local operational and clinical Dyads at the local facilities. The national objective is to knit disparate and varied groups of local Dyad managers and physicians into a nationally focused, cohesive structure.
Skills necessary at the national leadership level include clinical knowledge, operational knowledge (including an understanding of supply chain, throughput, and Lean techniques), growth and development, and (perhaps most importantly) group and relational dynamics experience. There is a necessity for clear roles and processes, as well as an understanding of the cultural connections of each Dyad partner.
The clinical knowledge necessary to lead a CVSL is enormous, often overwhelming the physician leader’s ability to manage competently across all aspects of diagnostic, chronic, interventional, electrical, and surgical cardiovascular care. A high degree of competency and training in interventional cardiology alone does not fully prepare a leader in the clinical realm. That’s why the acquired skills of delegation, selection of local physician leaders to fill in competency gaps, and empowerment of other experts to make decisions is necessary to gain success. Relationship building with other physicians is required to create a team collaborative environment for the tackling of difficult tasks. Tasks may include widely variant activities such as pricing on single stent vendors, clinical outcome measurements, performance improvement in below median outcome measures, and the persuasion of one’s colleagues to attempt a different care approach for the good of the patients and organization. Different physicians from among the service line leaders may exhibit skill (and interest) in specific areas or responsibilities.
Medical practitioners able to lead teams must be sought and developed through mentorship programs. This often necessitates the replacement of leaders with others who have the prerequisite skills and self-reflection ability necessary to manage with excellence. Leaders must understand their blind spots, including natural tendencies to over control and not delegate or share decision making.
Operational responsibilities within a service line may come in direct conflict with clinical imperatives. Examples of where operational and clinical objectives may collide include length of stay management initiatives, nurse staffing ratios, growth strategies, and supply or pharmaceutical utilization evaluation and improvements. Shared Dyad goals and vision for the Service Line provide a foundation upon which these natural conflicts may be adjudicated.
For example, a physician leader may insist there is a clinical need for utilizing a certain drug regimen for the benefit of patients. Her operational partner, looking at the variation in the usage of such a medication (in addition to the multimillion dollar spending on the drug), sees usage and cost as being the driving determinant of whether it should be allowed as part of the service line formulary. Both perspectives need to be considered by the leaders, who decide together on the inclusion or exclusion of this regimen. The physician brings clinical evidence to the discussion, while the operations partner provides a comprehensive business analysis approach.
Within the CHI Cardiovascular Service Line (CVSL), such a conflict arose over the use of the drug bivalirudin, used with an interventional stent procedure to prevent blockage of the stent. Bivalirudin reduces incidents of severe hemorrhage when compared to other (less safe) drugs. Even though Bivalirudin use is supported by the literature, national data revealed there was a sixfold difference in the usage of this drug across 12 cardiac programs within the organization.
A local physician leader was designated by the national physician leader to do a literature search and come up with the best recommendation for the drug’s use. As a result, a three-tier approach to the drug was developed for the service line. It stratified low-, medium-, and high-risk patients with clear and concise recommendations for the use of the drug in each category, optimally steering the CVSL to a 50% or $4 million reduction in utilization. Management of variation and cost resided in the operational partner while the clinical solution lay within the expertise of local and national physician leadership. Building upon principles of mutual clinical respect, encouraged by frequent face-to-face meetings and relationships, “simple” operational variations were solved by the clinical representatives.
A cautionary note must be raised even with the success demonstrated above. In the creation of Dyad partnerships, and the incorporation of physicians into a greater clinical responsibility, there are tendencies to create an expectation that service lines be “physician led.” This would literally imply the replacement of operational leaders with physicians. Physicians in most markets are woefully unprepared for this, not for a lack of clinical expertise, but because of a paucity of managerial skills as well as organizational perspectives important to balance the management model. Put rather simply, it is rare to find a “Renaissance” physician who has both the clinical and management experience to become an effective sole leader. This “physician-led” mantra may unfortunately lead physicians to an unrealistic conclusion that they already possess ability to fully lead alone. While “Renaissance” physician leaders are becoming more common, the number of positions requiring physician expertise as we prepare for the future outnumber these leaders. For the foreseeable future, an operational manager should round out the Dyad.
In response to gaps in physician capabilities, many clinical leaders including doctors, nurses, and pharmacists obtain higher management degrees such as MBA, MHA, or their equivalents. While helpful in navigating the operational and financial milieu of the complicated healthcare environment, these degrees do not automatically elevate clinicians to a level of operational competency to lead. (This is equally true for the newly graduated MBA entering healthcare for his first year of work.)
Care Management Dyad Partners
As the complexity of inpatient, outpatient, home, ambulatory, and skilled nursing environments becomes interwoven into the structures for managing population health, Dyad partnerships are surfacing in the areas of care management. Numerous professions are embarking into Dyad leadership relationships. They include the following:
- Physicians and nurses (home health and skilled nursing home management)
- Social workers and care managers in acute and postacute patient management settings
- Physicians and social workers in at-risk population management organizations
- Traditional inpatient and home/outpatient health coaches
Each of these professions brings an expertise and cultural competence to the Dyad partnership.
One of the emerging models is shared leadership between social workers and physicians. Many of these Dyads have been created because of the necessity to oversee the care of complex patient populations in either dual eligible or high-risk Medicare populations who require social work intervention. These populations certainly have complex medical problems, but their needs for solutions to access, compliance, and mental health require social work expertise. The social work role of coordinating community services, food and transportation, along with comorbid mental health treatment may play an even more influential role in establishing a stable medical scenario for individuals than the services of health coaches traditionally located within a medical home.
These Dyad relationships have yielded better patient care plans through personal interventions created by nonphysician professionals. In some of the more successful models (CareMore Medicare Advantage Plans, for example), physician medical models supplement a core of social and other needs met by a cadre of nonphysicians.
Hospital Leadership Models
A physician as a chief executive officer in a hospital is no longer a rare occurrence. Physicians as chief medical officers paired in a Dyad model with either an operations or nursing leader is an emerging a predominant model. Physicians as chief medical officers paired in a Dyad model with either an operations or nursing leader is an emerging model. To declare this, a mature model, however, is a bit presumptuous. Historical and cultural influences make this pairing among the most challenging, for reasons well detailed in other chapters.
Dyad partnerships in healthcare within service lines, continuum of care models, full-risk care delivery models, and clinically integrated models are quietly joining other leadership models. Careful attention to the outcomes necessary for success, clear delineation of roles and accountability, and comprehensive understanding of the strengths of each Dyad partner’s background and experience will make these new Dyad partnerships flourish well into the future.
Dyad Clinical Leadership in the Ambulatory World: Managing the Physician Enterprise Together
In early 1999, Dr. Richard Oken was appointed as president and board chairperson for a large independent practice association (IPA) comprised of 600 physicians, > 90,000 covered lives in commercial and Medicare Advantage business lines in a capitated business model in Northern California. Later that year, Mr. James Slaggert was hired as the chief executive officer of the Company. This is the first person story of how these two, who had never previously met or worked together, formed a highly effective Dyad management team—the strength of which can be measured by their business success in this 12-year relationship.
The Early Days: In Our Own Words
When we began this journey, the IPA was facing several large problems including financial challenges, business defection by physicians, reimbursement pressures from health plans, and widespread physician dissatisfaction, primarily due to payment inequities among physicians. The company had a balance sheet showing negative $10M equity with impaired cash flow. Payor contracts required immediate renegotiation and member physician trust in leadership needed to be restored.
At the outset, we agreed to admit the serious nature of our economic condition, meet with our creditors and terminate inequitable contracts that were in place from the previous business model. We also released all consultants so that our Dyad would personally direct the company. We planned to build a reliable information system via partnership and explain to our physician shareholders the options of business as usual versus total restructuring of the company.
Fortunately, the physician board of directors and other key physician leaders of the IPA were fully supportive of embarking upon a turnaround to restore the company to financial stability. Without this underpinning of broader support, turnaround efforts would have failed.
Assembling the Team
An executive leadership Dyad will not be successful without a talented management team and we were no exception. Key members of our team were the director of contracting, who could renegotiate payer contracts (subsequently this person was promoted to chief operating officer), the medical director who would promote quality of care linked to effective use of resources, and a director of Medicare services to coordinate all aspects of this critical line of business. With a small team, it was important to have trust and collaboration, values supported by both of us as Dyad leaders. We were fortunate to have a cohesive management team who stayed together loyally for several years.
In addition to the management team reporting to Mr. Slaggert, an executive committee of board officers was reestablished by Dr. Oken. This committee met monthly under delegated authority from the board of directors. Meetings were chaired by Dr. Oken and attended by the management team to promote collaboration between the governing board and management.
Key physicians were selected to chair subcommittees of Finance, Credentialing, Quality & Utilization Management, and Medicare Services that reported to the board. Dr. Oken, Mr. Slaggert, or a senior management executive was placed on each committee.
This ability to have governance and management on the same page strategically, while keeping a clear distinction of roles to avoid micromanagement of day-to-day operations by the board, was another critical support system to allow our Dyad to be successful.
Values, Styles, and Personalities
If we could point to two items that fueled our Dyad, it would be shared values and complementary personal styles. The values of honesty, integrity, open and forthright communication, and transparency served us well.
We communicated often with our physician members as well as hospital and health system strategic partners. Physician communication vehicles included frequent, written correspondence distributed across the physician membership, quarterly “Town Hall” meetings, quarterly primary care physician meetings, and regularly scheduled meetings with strategic partners. As a tightly connected Dyad leadership team, most written communications to our physicians were coauthored. We focused on one-page documents to be concise and gain maximum attention. We were also cognizant of the need to be honest and “tell it like it is,” sharing both good news and bad. This open and transparent communication helped build trust and credibility with our board and member physicians, which was essential in resolving conflict.
We found that one-page communication vehicles were the most effective to correspond with our physicians, so we implemented this executive summary format widely. We also utilized face-to-face meetings with key constituents at their request or as needs emerged. These small group meetings, typically attended by both of us, were a key step in establishing trust between administration and our physicians.
Dr. Oken insisted that our performance was evaluated annually by the Board of Directors. Each year it was pointed out that a strength of our leadership Dyad was our complementary styles and personalities. Dr. Oken, a bit brash and fiery, was a very good match for Mr. Slaggert’s more reserved and introverted style. These differences allowed us to function very well as a team when different situations benefitted from one, or a combination, of these styles. As we grew to know each other well (over 12 years of working together), we were able to recognize and use our contrasting styles to move our organization forward.
Trust in Each Other
In short order, we developed a high level of trust and respect for each other. This was a critical element of successfully working together through a time of organizational uncertainty and turbulence. It was the basis for our ability to be on the same page strategically. It also allowed us to present a cohesive, unified position to both internal and external stakeholders and partners. Not that we were perfect (see “STUMBLES” in a few paragraphs), but we did focus on communicating clearly and often with each other. We wanted to ensure we were consistent in how we worked collaboratively with our Board of Directors, and how we viewed and implemented strategy, physician relationships, and operational direction.
As our mutual trust increased, and the Company’s financial results improved, we shared the efforts and resulting progress through open and frank discussions with the Board on a monthly basis. Similarly, we presented financial and organizational results to our IPA member physicians on a quarterly basis. These forums, where we presented information as a team, helped continue to foster an environment of open communication. This helped tremendously in times of conflict.
Over time we learned each other’s strengths and weaknesses. We were fortunate, especially not having worked together previously, to have balanced strengths and weaknesses that we were aware of, shared openly with each other and used to the benefit of our Dyad team leadership of the organization. For example, while Mr. Slaggert was building relationships with physicians in a new community, Dr. Oken was an established, credible physician with 30 years in the community. When Dr. Oken could be emotional, Mr. Slaggert could be calm and measured.
Even with these differences, we were both clearly focused on the success of the organization. This was evident to our physician partners as we worked together to dig out of our financial hole and stabilize the company for the benefit of our physicians and the patients we served.
Fostering Diversity
Six years into our journey we were working well with our Board. With their direction, we began to actively recruit diverse physicians into positions of leadership for the IPA. Potential new physician leaders were identified by the then-current Board members based on exhibited leadership skills and potential age, gender, and ethnic diversity as well as business relationship strengths with the IPA.
Once potential physician leaders were ascertained, we each went out to meet individually with them in order to gauge their interest level in working with the IPA in a leadership capacity (either on the governing board or as a committee member). Due to the credibility we had earned with our member physicians and our reputation for being like-minded and presenting a consistent view for the direction of the company linked to strong support of the board of directors, we were able to individually communicate a consistent message that was viewed and heard by our physicians. They viewed us as two leaders in a partnership, speaking as one voice in support of the organization. This allowed us to efficiently and effectively gather feedback for our governing board, which used this information to add new energy and diversity to our physician leadership team.
Although we were not successful with all of our recommendations for new leaders, the end result was a board steeped in diversity in every regard: age, gender, race, ethnicity, and practice specialty.
Stumbles
As in any relationship, we did make mistakes. The challenge with a Dyad is to jointly admit responsibility, not blame each other or hold grudges, but to appropriately fix the problem together and move on.
One striking example of a mistake we made was inconsistent messaging to our board of directors on a critical hiring recommendation of a medical director. We had two excellent final candidates, one internal and one external. The internal candidate was one of our highly regarded local physicians who had gradually moved from clinical practice to administrative roles. He was very well respected by our board and other leaders but lacked hands-on IPA medical director experience. The external candidate was an MD/MBA with a high level of progressive medical director experience, but unknown to our physician community beyond the interview process.
At the Board meeting where we were to make a final hiring recommendation, we were reminded that great communication must never be ignored or assumed. Unfortunately, we each assumed that we were in agreement on which candidate to jointly recommend to the board. This resulted in a split recommendation from the Dyad team on which candidate to hire. The board was confused, to put it mildly, as this was the first time we had not made a unified recommendation to them. We were asked to come back quickly with a joint hiring recommendation.
As we dissected this experience to learn, we realized that our mistake was simple and straightforward as well as fully avoidable. A critical communication step was missed, as we never confirmed our hiring choices with each other in advance of our board meeting. Rather, we each incorrectly assumed we were in agreement with the other.
This was a painful but valuable experience midway through our 12-year tenure. It caused us to redouble our communications with each other especially on recommendations to the board and committees. Lack of unified direction from Dyad partners is a sign of a dysfunctional team and we were not dysfunctional.
Conflict Resolution as a Team
As can be imagined, especially when faced with a $10M balance sheet deficit, our main conflicts with physicians in the IPA centered around finances and physician reimbursement. This was exacerbated by an inadequate financial support infrastructure, which led to conflicting data for negotiations between the IPA and member physicians. Added to this were real and perceived payment inequities among our physicians. This was a recipe for contentious and passionate negotiations.
As we approached physician compensation negotiations where we knew conflict was unavoidable, we took several steps as a leadership team. First, we presented our negotiation strategy and parameters to the board for their support. We also kept them fully apprised as negotiations proceeded. Then, as a Dyad team, we spoke with one voice of common purpose in negotiating sessions and jointly attended all critical meetings. This allowed us to work toward building relationships of trust, which we wanted to maintain when negotiations were concluded.
Of the several difficult negotiations with our member physicians, two were particularly contentious and required the use of an independent mediator. We are highlighting these here, as Case 1 and Case 2. Both of these negotiations were with single-specialty physician groups who were sole source providers of their clinical specialty in the community. In addition to working in partnership as a Dyad through the negotiations/mediation, we included individual board members on our team to promote balanced discussions and problem solving.
Case 1
When our finance staff performed a comparative analysis of specialty physician compensation, one specialty was revealed to be paid higher than their peer group. This caused internal payment inequities in the IPA as well as dissatisfaction among the peer group due to lack of reimbursement parity. With the support of the board, we proposed to lower the compensation for these physicians to reach internal equity and fairness. As expected, the higher paid physicians were less than pleased and viewed this as a hostile action from the IPA board and leadership. Their initial reaction was to send their 90-day notice of contract termination to the IPA.
After a series of nonproductive and highly charged negotiation sessions, no common ground was established. A mediator was brought into assist, but still no solution was to be found. Ultimately, the physicians stopped treating our patients with 36-hour notice. This immediately escalated the situation from a contract negotiation to a patient care issue and caused the hospital’s medical staff leadership body and ultimately, their governing board to become involved. We finally reached agreement on contractual terms, and patient care was restored without incident. The Dyad lesson we learned was that by working in tandem, both with our board and during negotiations and mediation, we were able to land at a reasonable conclusion and kept this valued group of clinicians in the IPA. Additionally, both we, as the Dyad leaders, and the board of directors gained additional trust and respect with the broader physician membership of the IPA for addressing this significant and divisive situation.
Case 2
In a second situation, we also had tense negotiations with a sole-source, single-specialty physician group that proceeded to mediation. In this case, we experienced a much different and positive process and outcome.
This group of physicians was being paid less, on a relative basis, than their peer group. There was agreement between the Board and management to raise their compensation. The complicating factor was an assertion by the physicians that they had been systematically underpaid by the IPA for several years and therefore, demanded restitution. This negotiation occurred approximately 1 year into our Dyad partnership. Given the previously mentioned balance sheet deficit and cash flow issues, we were unable to provide the requested additional payment. As we proceeded through negotiations and mediation, hostilities lessened, cooperation improved, and a mutually acceptable solution was reached. As a bonus to concluding negotiations amicably and developing mutual trust among all involved, several of the formerly disaffected physicians assumed IPA committee leadership positions and one was elected to the board of directors.
This is one of our best practical demonstrations of working as a Dyad, so that 1 + 1 > 2.
Summary and Lessons Learned
During over 12 years of partnership, we lead a team effort to restore the IPA to financial strength and established trust as well as a cohesive culture among our physicians. The final chapter for us was when we successfully negotiated an affiliation with a larger IPA in the region. The Company had improved finances to reflect a multimillion dollar balance sheet surplus at the time of the affiliation, allowing a substantial distribution back to physician shareholders at the conclusion of the new partnership.
We want to share our major Dyad lessons learned. These include the following:
- Trust in each other. If there is disagreement on an issue, sort it out in private and provide a consistent and unified position to all stakeholders.
- Establish and promote an environment of honesty, integrity, and transparency and be willing to accept constructive criticism.
- Communicate often and clearly with all stakeholders. This is particularly important in times of change and potential conflict.
- Expand the team. A Dyad can be an essential leadership structure but management talent and governance support are critical.
- 1 + 1 = more than 2. Bringing together our complementary styles, coupled with a physician/nonphysician partnership was very credible and powerful.
We would be remiss to overlook one intangible—friendship. Over the 12 years of respectfully working toward a common purpose and unified vision, a strong friendship emerged. This helped us to communicate openly, laugh frequently, and have work/life balance. Our friendship continues to this day.
The Quality and Safety Leader as Natural Dyads
Successful Dyad relationships have to be closely aligned with an organization’s core values and the attributes associated with each value. Often in the workplace, we are asked if, or we state, “I like this person.” Sure, there are occasions when we work on projects and develop friendships with those team members who might have similar interests or hobbies. Although, we believe when we are asked whether we “like” a coworker or Dyad partner, the question is really “do we respect and trust him, is she sensitive to others, does he put forth his best effort, and does she do what she says she will do?” A successful Dyad relationship is predicated on these values and attributes.
In many organizations, quality and risk functions are operated in separate silos. Regardless of reporting relationships, we believe that quality and risk management working together will reduce the health risks of our employees and improve patient safety. We have experienced individual safety improvement projects that are conducted separately. These sometimes fail to address issues that are common to both disciplines, which squanders efforts and may not address all the risks. In our Dyad, as leaders from two different functional divisions at a national system level, we have come to focus and collaborate on developing a system wide culture of safety without regard to individual or favorite programs. These essential elements of the Dyad partnership include a commitment to safety, visibility, transparency, and continuous improvement. We know that is doesn’t matter where or who we report to. It matters that we work hand in hand as a partnership sharing goals.
There is always work to do and that will never stop! We believe in monitoring and measuring outcomes of everything we do so that we can show progress toward meeting current goals and set new goals that will take us into a safer, higher quality next era of healthcare.
In September of 2009, First Initiatives’ Insurance, Ltd. (FIIL) Board (a company owned by CHI) approved an update in the company’s strategic plan to include a “Quality and Safety” strategy. The strategy included the following objectives:
- To develop risk metrics: Assist in the evaluation of clinical performance throughout the system through the development of risk metrics with CHI’s operational groups.
- To provide safety education: Develop education modules for employees about patient, occupational and environmental safety.
- To ensure data integration: Strengthen relationships with the system’s clinical services, business intelligence and Finance groups through integration of existing data sources.
- To spread clinical best practices: In collaboration with clinical services group, identify and disseminate evidence-based practices, as determined by our loss experience and clinical outcomes.
As a result of this strategic direction, the Risk and Insurance Management Group changed its focus from a claims- and insurance-driven company to a loss prevention and safety-focused organization. We were to establish a risk management operations team that would focus on (outcome based vs. process based) results, more collaboration with other CHI Groups, and a formal partnership with Clinical Services Group on one of CHI’s Clinical Excellence Objectives known as “SafetyFirst.”
Clinical Services and the Risk and Insurance Management Groups had worked together on a previously successful patient safety initiative entitled “CHI Perinatal Care Collaborative-Because One Is to Many.” This was after the 2005, IHI release of the “Idealized Design of Perinatal Care” White Paper, which included characteristics of high reliability perinatal units. Our system’s collaborative goal was structured as one of CHI’s quality and patient safety strategic priorities. The intent was to eliminate preventable birth injuries by December of 2008 through empowerment of perinatal staff as we moved toward behaviors and processes designed to create a safe environment. The key theme was to create the safest environment possible by reducing avoidable complications.
The collaborative was sponsored by the Clinical Services Group and Risk and Insurance Management Group. It functioned through national web conferences, other formal communications, and resource sharing. These mechanisms offered several advantages to the hospitals throughout CHI, such as leveraging and spreading implementation of the work, access to peer expertise, creating accountability and commitment, and establishing a formal network and shared vision for reaching the objective.
We experienced success with the perinatal work as a result of the clinical division and the risk operation working hand-in-hand as Dyads. Both departments have credibility when it comes to information and resources around quality, loss prevention, and safety. CHI reduced the occurrence of birth injuries from a baseline of 4.85 per 1000 live births in FY05 to 2.06 per 1000 live births in FY08. Other groups became involved with the work, including knowledge transfer, nursing, and national clinical competency. The combined efforts created a successful team collaboration. We learned from this project that individuals from Clinical and Risk were good team leaders when they worked in a partnership that could reach many stakeholders within CHI to accomplish safety-related objectives.
As a result, when we embarked on our SafetyFirst program (CHI’s Culture of Safety initiatives and movement to a high reliability organization [HRO]), we decided to formalize this model with a designated Dyad to lead the work. (One leader came from the Quality function of CHI’s Clinical Services group. The other is a risk leader from the Risk and Insurance Management Group.)
SafetyFirst is a multiyear, system-wide implementation of highly reliable and safe practices that are monitored and measured by metrics focused on reducing serious harm to patients and reducing work-related injuries to our employees. Group Sponsors of this work are executives from clinical, legal, and risk management. The business partners designated to make up the leadership team responsible for planning and implementing change are the formal Dyad. The partners are Jeanie Mamula, VP, Quality Improvement, and Randy Wick, VP, Risk Management Operations.
How We Were Separate (Silos) and Then We Weren’t (Dyad)
Jeanie: We had known each other for several years but weren’t close, as our jobs did not totally interact and we met only occasionally at operations team meetings. We really began our partnership in 2009 when both of us were promoted from director to VP positions. Our jobs changed. We discovered that in some ways, they overlapped and we felt that we could help each other a great deal by working together. Some people think that risk and quality are separate functions. We believe that the two are synergistic and really are functioning ineffectively when not working together.
Randy: At the very beginning of the SafetyFirst program, we both recognized that neither of us had been involved in a body of work so large and significant for the organization. We were proposing a business plan that stated we were going to further develop and maintain a “culture of Safety” within CHI that would change perspectives and behaviors of all leaders and staff. That’s pretty momentous stuff.
It quickly became apparent we had very similar beliefs and attitudes about the operational aspects of CHI. We had both been long-time employees working in different geographic locations and disciplines. I knew that Jeanie knew certain aspects of the company that I did not, and she felt the same about my knowledge. Because each of us was willing to share and be open and honest with the other, we were able to quickly agree on how we should approach things in order to get them done in the most efficient and effective manner.
As with many colleagues, Jeanie and I share common strengths in our respective areas of expertise, experience and skill sets. We recognized that one of us had certain skill sets and knowledge the other didn’t, and vice versa. In order to be successful with the work, we acknowledged this and agreed to take turns the leading aspects of the work when individual skills would increase the chances of success. We also agreed to give unwavering support to each other. Our strengths are as different as our personalities, levels of patience, ability to use computers and software, organization and planning abilities, and technical or clinical expertise. As a result, we developed a style I think of as “pick up your partner/Dyad when you can.” We also consider who has the time and resources and is best equipped to handle an issue or question. From the beginning, Jeanie and I have complemented each other and shared the work equally. That makes a great recipe for a successful Dyad relationship.
Historically, there has been shifting of focus and attention for the medical/legal, risk, quality, and regulatory arenas. This shift of priorities between one area and another has contributed to the creation of silos, whereby one discipline may be viewed as more important at any given time. In other words, people sometimes believe that, “my work is important than yours.”
For example, the medical liability insurance crisis in the 1980s focused on needed tort reform, claims, and litigation in healthcare. This increased the perceived importance of risk functions. Rather than assigning status, we believe we have a common bond regardless of which area is getting the most attention at any one time. Our goal is to provide the best possible care to all of our patients without causing them harm. When we do this by working together, it will ultimately benefit everyone. As we say in risk management and legal, “the best loss prevention is high quality care.” This mantra has enabled and facilitated the Dyad relationship between risk and quality.
Why We Knew We Had to Be Partners
Randy: To be successful in our SafetyFirst work, and to demonstrate shared objectives to all clinicians and staff working in clinical settings, we have a written goal that is everyone’s number one priority:
“Safety has to be the top priority at all levels of the organization. It has to be recognized as doing the right thing that is also good for our business. The message has to be delivered as one by various disciplines and groups, not just quality and safety. The more employees who ‘get’ this message, the better our opportunity for making positive changes in how we do things.”
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