Shared Leadership

We believe that the Dyad partners’ goal should be to guide their team to a point where the team can practice shared leadership. As mentioned above, this will probably not be appropriate until the assembly of individuals from different professional cultures has become a team rather than a group. However, early education on shared leadership will help the team develop skills to attain that status. This education is important because we have found a great variety in what people think shared leadership is. It’s also important that team members understand that, regardless of education, status, or position power, this type of team leadership involves informal, plural leadership (where different members lead at different times). In most of the work where Dyads are appropriate for team leadership, the shared leadership model does not replace the need for formal positions, that is, the two individuals who make up the Dyad leadership partnership.

Shared leadership is “a group process.” It is “distributed among the team members and derives from them” (51). It occurs in organizational structures where hierarchy has been flattened (or at least reduced in height). Mature (having established a functional, democratic, respectful, mission-driven, healthy norm–following culture) teams are the only ones that can practice well in this type of model. Shared leadership is a cooperative endeavor—it is not a model of “leaderless groups.” It is an endeavor where different team members lead when they are the best prepared to do so for a specific project—and where individuals take the initiative to do work that they observe is needed for the team’s success (52). Because multidisciplinary healthcare teams consist of highly educated professionals (some of whom have a professional history of autonomy), the team autonomy that comes with shared leadership should appeal to them and enhance their job satisfaction.

The road to shared leadership in our model begins with educated Dyad leaders who understand the stages of team development and are alert to when their own leadership styles should evolve. As teams mature, the leaders can move from more autocratic styles (necessary only when strong professional cultures interfere with the development of teams of “equals”) to more participative styles to shared leadership. (We make it sound like this always occurs, or always occurs in a progressive line. It doesn’t. New team members, changing environments, and other disruptions in team development will call for Dyad leaders, as the formal leaders, to audit team culture and utilize leadership styles depending on situations.)

Even early in team development, leaders will most appropriately act more as facilitators than dictators. They will facilitate the team’s discussion on norms, teamwork, and communication. They may need to step in to discourage monopolization of discussions by stronger personalities and ensure that the quieter people are heard. They give feedback to the group and individuals on their team effectiveness. This is important early on to make sure everyone understand the importance of their own and others’ contributions. Dyad leader use of an autocratic style should be measured and used only when professional cultures over power the group’s intention to build its own culture.

Multiple studies show that leaders who are democratic, participative, and relations oriented are more successful in accelerating the development of a cohesive team. Dyad leaders who can practice this with their teams will speed individual member’s self-confidence, which will help with team bonding. Even when the leaders make final decisions, if their decisions reflect the team’s recommendations, the team performs better (53). When teams evolve into shared leadership, Dyad leaders should not have to intervene (at least not very often) in team politics. Members will enforce their own group norms, by confronting lack of adherence. (That alone should encourage Dyad leaders to pursue shared leadership!)

Even at the performing stage of team development (and even if teams are practicing shared leadership), Dyad leaders cannot slip into laissez-faire leadership. (This is also called inactive leadership because it is descriptive of leaders who avoid their supervisory or management duties.) Dyad leaders have formal organizational leadership positions and the accountabilities that accompany that designation. Leadership roles can be shared, but accountability cannot be delegated. Dyad leaders must pay close attention to the results, or outcomes of what their teams accomplish (even if team members are doing this, too, as we want them to), and take corrective action. They also need to keep in mind that no team is ever permanently fully formed for peak performance forever. The “change out” of even one member can change team dynamics and put the team back into “earlier” stages like forming or storming.

Performing is all about pursuing and accomplishing goals. In Chapter 10, we address the work of Dyad-led teams, which involves change, transformation, and innovation of healthcare organizations.

The Larger Teams

Most of what we have been talking about involves small or co-located teams. These are groups with specific jobs (such as running a clinic or managing a service line) or projects (building a new hospital, implementing a clinical IT system). Members are typically located in the same community. We (Steve and Kathy) have such a team that reports to us at the corporate level of the system (in Denver). While some members of the national clinical services team have solid reporting lines to Steve, and others have solid lines to Kathy, everyone in our clinical services group reports to both through a matrix to one or the other. This isn’t the model everyone will use, but it works well for us.

This small team has been formalized and has bonded. It has goals and norms, and we have intentionally worked on team building over time with all of the members. Even though travel is extensive for most team members (the company’s geographical spread is from coast to coast in 18 states), we hold weekly team meetings (with some members on the phone). It’s challenging, but doable, to maintain a team culture.

Our larger teams are another story. Steve, as chief medical officer (CMO), has responsibility for the practice of medicine across the system. Kathy, as chief nursing officer (CNO), has accountability for the practice of nursing across the system. Of course, with over 100 facilities (in 18 states), including hospitals, long-term care, outpatient clinics, home health, and a variety of other healthcare facilities, neither can have intimate firsthand knowledge of day to practices by either profession. We are part of a clinical leadership infrastructure that includes our national clinical team, regional nursing and medical executives, and local market clinical leaders. Many of the leaders are paired as Dyads already, and we are planning for more two-people leadership partnerships.

We bring this up because other System Dyad leaders will find themselves in this same situation. What is our responsibility for partnering our two areas of accountability and for team building with teams we do not see regularly (and in many cases, do not even know personally)? Does a Dyad relationship even make sense in such a large arena?

We believe that not only does it make sense to have a formal partnership over the practice of these two professions, but also it is essential to system success in the next era of healthcare. While care is local, national systems are beginning to centralize some functions and standardize others. Because of new technologies, improving data collection (which informs new metrics), and growing evidence about best practices, it is becoming more common for clinical practice to become standardized across a system as well. Nursing and medicine, as well as the other clinical and nonclinical professions, must plan these centralizations and standardizations together. Standardizing clinical practice in national silos is as negligent as managing in silos at a more local level. The dysfunction of silos at the national level will be repeated and duplicated throughout the system, from national, to regional, to local, to clinical working unit level.

For team management to work for system-wide initiatives, the infrastructure of Dyads or other multidisciplinary models must be established at every level of the organization. This can seem mind-boggling, creating more complexity in management. While Dyad partnerships add to leadership executive effectiveness, they can also result in new and different relationships that some Dyad partners aren’t familiar with. One of these is matrix management.

Matrix Management

Matrix management is a leadership model in which individuals (and sometimes teams) have more than one reporting line. Seasoned healthcare managers have probably experienced this type of organized structure, but for Dyad medical staff partners who are just learning about organizational hierarchies, this is another complexity to working in an already complex system. Dyad partners, as individuals, may have matrix reporting relationships with others that their partners do not. In other cases, the Dyad as an entity has a matrix relationship with other groups. (There is no way to simplify healthcare organizational matrix structures as they are lived, but we’ll try to simplify the explanation.)

Matrix leadership in healthcare is based on the need to bring different disciplines together for projects, or ongoing interdependent work. Earlier in this chapter, to simplify the discussion of teams and team building, we allowed readers to assume that the multidisciplinary team reports solely to the Dyad in a “straight line.” Straight line on the organizational chart (also called solid line reporting) is what most of us think of as a traditional hierarchical reporting structure. Managers in this relationship often are the persons employees consider their “main boss” because this manager usually has the final word on hiring, evaluating, and firing employees. Organizations determine what management position has the straight line based on different criteria. These may be function, location, or team.

For example, all nurses in a system might have a straight line (albeit through levels of managers) to the CNO. This is a solid line reporting based on function.

In other cases, in a large system, with multiple work sites, nurses might report straight line to an individual market or facility executive. This is based on geography or a local (or regional) operating model. Finally, at least some nurses may report on a solid line to a leader based on a structure of multidisciplinary teams, not function, or geography. Organizations need to determine what works best for their strategies, and what works best today may not work well next year as strategies evolve. (More on this in Chapter 10.) We expect that reporting structures will be in a state of flux for the foreseeable future (and probably forever).

Managers involved in matrix management, who do not have solid line responsibility to employees, are described as having dotted line relationships. In the examples described above, if the functional leader has the solid line to nurses, geographical leaders (like local CEOs) or team leaders have dotted lines. If the solid line goes to a multidisciplinary team leader, functional and geographical leaders have dotted line relationships with appropriate team members. When large organizations do not select one model (and most do not, for a variety of strategic and tactical reasons), the various reporting relationships can become extremely confusing!

One big positive to matrix management is that it is a way to cross over or span boundaries between classic silos and interdisciplinary misunderstandings. It should be more flexible, make teamwork easier, and help individuals gain larger views and perspectives when they have accountabilities to more than one “tribe” (such as their professional tribe and their team tribe). However, it is difficult to put into practice. People who have “more than one boss” can get confused, feel pulled in different directions, and become frustrated with too many priorities. The two supervisors can also become frustrated when they feel they’ve “lost control” over human assets that they can no longer deploy 100% for their goals. Those who have the “dotted line” may need to get work done through influence built on relationships. If they are more comfortable as transactional leaders who feel they need “command and control” power to “get things done,” they will chafe under this model and may actively campaign to get the solid line switched to them!

The result of poorly implemented and defined matrix management can be strife between the managers, confused and overtaxed employees (including middle managers), and conflicting loyalties of team members. Matrix management can also be used to avoid change by professionals who don’t want to “team” with other professionals. Even if the straight line is to a manager outside of the professional silo, those professionals will choose to treat their functional leaders as the Boss. It’s a recipe for triangulation, mentioned earlier in this chapter.

Cutting Through the Complexity to Manage in the Matrix

Dyad partners need to take time to understand what the matrix relationships are in their organization as a whole, and what they are for them as individuals, a Dyad, and team leaders. They need to be able to explain them to team members and to support the leaders with whom they share matrices.

The place to begin is with the Dyad itself. It is likely that some of the shared team has a solid line to one partner, and others have a solid line to the other. In that case, the Dyad team members are automatically part of a matrix, or the Dyad can’t function as co-leaders. During the “norming” stage of team development, this Dyad–as–Matrix needs to be openly discussed with the team. It must be clear to the members that this partnership does not support triangulation and that there are or may be certain specialties that each partner provides for the entire team, regardless of solid line or straight line reporting. In our Dyad, any member who needs leadership help with data or statistics goes first to Steve, because he is a master of business intelligence. Others, regardless of specialty, might approach Kathy on coaching about a particular thorny relationship matter. Of course, any member can seek out either leader, but we don’t take offense (we appreciate it!) when individual leadership skills are utilized by every team member. (In fact, most of the time, team members seek leadership help from each other, not us!)

For Matrix Relations Outside of the Dyad

There is a likelihood that some of the Dyad’s primary team members will have matrix relationships outside of the team. Whether a solid or dotted line, these relationships and all matrix relationships should be defined and documented. Transforming companies are messy, and both leaders and team members must learn “to live in the grey” (where everything is not clearly delineated in black or white), but when it is possible to define solid roles, it should be done. Reducing some of the chaos and confusion makes it easier to deal with the slush that can’t be solidified.

Leaders should not simply tell people they report in a matrix model. The roles of everyone in that matrix should be clearly identified. Job descriptions or policies and procedures can be utilized, but the important things that must be clarified include the following:

• Which leader has the solid line? (and conversely, the “dotted” line)
  
• What do the two lines mean in general?
  
• What do the two lines mean specifically?
  
• How are priorities for the Matrixed employee determined?

Even when roles have been documented, there will probably be conflicts (often over priorities) from time to time. The three (or more) people involved in the Matrix should meet together to talk about the challenges of multiple priorities and together determine the variety of projects in place as well as their order of priority. That’s the best way to avoid triangulation or misunderstandings.

Beyond Dyads

The Dyad as a term, concept, and management model has become part of our organization’s common vocabulary. We use it to describe two leaders in formal, permanent (or as permanent as possible in these days of perpetual change) management roles. We also have begun to refer to temporary partnerships of two colleagues as a Dyad. These are often planned by executives or managers, but sometimes two colleagues will spontaneously become short-term partners in order to accomplish specific objectives or projects. They refer to themselves as Dyads.

A new term has begun circulating in our corporate office: triads. Small teams of three have also begun to work together. Most commonly these trios have consisted of two clinicians (from different professions) and a finance colleague. In addition, some of our system’s hospitals refer to their hospital president, CMO, and CNO as a Triad. (It gets really confusing when these three add their CFO to the mix. Then, they call themselves a Triad Plus One—probably because “Quadrad” is just too strange on the tongue.) We think that more than two leaders is a leadership team (and doesn’t need another designation). Our major concern at Catholic Health Initiatives (CHI) (and for this book) is with the two formal leaders who are hired to work together to transform our organizations through shared management and the reduction of silos. We think this model is what is needed right now for the next era of healthcare. We also know that management and leadership will continue to evolve, and models not yet conceived may be best for the next era +1! Shared leadership is rich with possibility, and we’re looking forward to seeing what comes next.

Chapter Summary

Dyads don’t work alone as a twosome. They have larger work families, or teams. Teams with two formal managers have the same team formation challenges as other groups brought together to meet organizational goals. They have an additional complication because there are two leaders, but being led by a Dyad is advantageous as well. When individual managers have learned to share leadership with each other, they can more easily transfer the skills of that partnership to support the evolution of shared leadership among the entire team. Team building is important for the development of both teamwork and team member leadership skills.

Dyads in Action

One Community Organization’s Applications of the Dyad Model

Good Samaritan Hospital (GSH) opened in Kearney, Nebraska, in 1924, sponsored by the Sisters of St. Francis. In 1996, GSH became part of CHI, a system originally formed by consolidation and transfer of sponsorship from three Catholic healthcare organizations. GSH currently has 256 staffed beds on two campuses. These include the main acute care hospital and the behavioral health program located at the northwest campus. As an American College of Surgeons verified level 2 trauma center, comprehensive services are provided to support the regional healthcare needs of a large referral area (350,000 people in the primary, secondary, and tertiary services areas of Nebraska and Kansas). Services provided include acute care services: neurosurgery, cardiovascular (including open heart), neonatal intensive care services, critical care, cancer care, rehabilitation, and behavioral health services, as well as air and ground transportation services, 911 services for the city, and skilled nursing care. Kearney has been a single hospital community since 1951, with GSH providing the only acute care hospital services to the area.

In 2009, this situation was changing. As a result, GSH was facing hospital competition for the first time in decades. There were problems between local medical staff members and the organization. Hospital administration needed to take a hard look at what was needed for the community, Kearney’s clinicians, and our patients. Among other actions, it was determined that learning to manage together could help us prepare for the next era of healthcare and improve partnerships. The following four stories explain how we started on the journey to Dyad (and Triad!) leadership as a methodology for learning to lead together.

Dyad Partnership to Support a Physician and Hospital Business Relationship

The concept of “parallel play” comes from the discipline of developmental psychology. We think it’s applicable in healthcare because of historical relationships between hospitals, physicians, and other clinical providers. The concept refers (in psychology) to the developmental stage in children where they are “absorbed in their own activity, and usually play beside rather than with one another” (54). This is a stage that precedes the more complex stage called cooperative play. When we were writing this manuscript, this idea was loosely applied to how we have evolved from historical silos to a physician and hospital administration partnership. We believe Dyad partnerships will lead us to the cooperative collaborations needed in the future.

GSH began exploring new ways to work with physicians as true partners in the operations and delivery of care in 2009. As a result, we developed a co-management business relationship in which key physicians and hospital leaders aligned to partner in the leadership of surgical services. A physician and hospital administrator Dyad relationship was formed between the two of us—Larry Bragg, MD, and Carol Wahl, RN, Vice President of Patient Care Services.

At that time, there were approximately 126 physicians on staff. Local physicians had traditionally embraced the independent medical practitioner model. There were employed physicians in a few surgical specialties (neurosurgery, cardiovascular, and endoscopy), behavioral, and the emergency department. However, the majority of physicians in the community were associated with one of three large private physician multispecialty practices.

During the summer of 2009, rumors surfaced about a plan to build a second hospital in Kearney, which would be physician owned. As more information became available, it appeared that the rumors were true and that areas of physician concern had prompted this intention. These were

• A perception by physicians that their decision-making impact had deteriorated to responsibilities for credentialing and peer review. Physicians perceived that they had little say about hospital operations that impacted their practices, including capital equipment purchases. They voiced frustration that strategic decisions that impacted their work environment were made at higher levels of the organization, without physician input.
  
• The trend toward employment of non–hospital-based physicians alarmed medical staff members because of the potential that their practices would be impacted. Physician recruitment decisions were being made without local practitioner input regarding community need for various specialties. There was concern that physician revenues would be affected.
  
• Healthcare trends that focused on reducing costs were causing reduced revenues along with increased expenses in physician offices. Some doctors felt that by owning their own hospital, they could gain a new personal source of revenue.

GSH was experiencing similar areas of concern. Decreasing reimbursement made it clear we needed to maintain market share, reduce costs, and improve quality outcomes. It was also apparent that in order to thrive in the new healthcare environment, we needed to consider new approaches. CHI, as a large healthcare system, was aware of these increasing challenges and provided leadership in the quest to improve quality and reduce costs.

Clearly, we were all (the national company, the hospital, and the medical staff) headed on a journey where a common vision and goals, aligned incentives, trust, and collaboration are essential for moving forward. GSH began looking for potential opportunities to work with physicians in a different way. We wanted a new model to increase physician and hospital engagement.

Assisted by experienced facilitators, key hospital administrators met with specialty groups of physicians: surgery, cardiology, primary care, and family practice. Various concepts of co-management were presented and explored by the different groups. The sole group of physicians, who decided they wanted to examine the potential of these concepts further, was the multispecialty surgical group. They agreed with the hospital that alternative models of management should be investigated.

The surgical group expressed that a new hospital could result in a significant impact to the broader community of central Nebraska by actually causing reduced availability of services. They believed that the programs and services needed to support a comprehensive trauma program could be at risk when some specialty surgeons no longer practiced at GSH. In addition, they feared that access to capital for purchase of technology required to care for complex patients could be reduced when two hospitals shared the care of patients in such a small market.

Previously, surgeons, anesthesiologists, and the hospital had successfully collaborated on the establishment of a free standing outpatient surgery center. Because of this history, the group felt there was potential for a partnership where all had aligned vision and goals. The group was committed to improve surgery services, thereby improving access and care outcomes and reducing inefficiencies that contributed to higher costs of surgical care.

After careful consideration of the advantages and disadvantages of various partnership models, the physicians and hospital administrators decided to pursue a clinical service line co-management agreement (CMA). Both groups saw this as a proven model, a path with a predictable implementation plan, and a compatibility of integration with current operations. However, they also knew there was a high level of complexity in this relationship because the partnership involved the services of an entire surgical department instead of a narrow specialty service line. There was some physician skepticism about the sincerity of the hospital to fundamentally change how surgical services were managed. These feelings were mitigated when the physician and hospital team, facilitated by the physician and administrator team of Larry Bragg and Carol Wahl, openly discussed specific responsibilities of physicians and the hospital. There was dialogue about decision-making authority, which was committed to a binding agreement. A summary of the key components of our CMA is listed in Display 9-9. Our work plan for implementing this agreement is identified in Display 9-10.

Display 9-9 Summary of the Clinical Service Line Co-management Agreement (CMA) Components

• Purpose of CMA: improve the quality of the service line and reduce overall cost of healthcare to the community.
  
• Physician specialists provide the hospital with a high level of management services in a specific clinical service line.
  
• Payment to physicians include: base fee calculated on fair market valuation of time spent in providing management services, which included a performance bonus based on achievement of specific performance objectives
  
• Primarily a service agreement

Display 9-10 Summary of CMA Implementation Work Plan

1.  Complete CMA letter of intent (LOI) and term sheet with interested physicians

2.  Select physicians who will be offered opportunity to participate in LOI

3.  Engage valuator acceptable to hospital

4.  Determine base fee under CMA and performance parameters (before and after LOI)

5.  Determine performance bonus methodology

6.  Physicians form Limited Liability Company (LLC) with members (owners) who intend to sign binding CMA

7.  Draft CMA

8.  Obtain written valuation

9.  Obtain signatures of all parties

10.  Identify initial members of the joint operating committee (JOC)

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1. Developing a Dyad
2. Learning Dyad Skills
3. What Do You Believe?
4. What We Say Today May Not Be True Tomorrow

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