Dyads in Action

Dyad Management within the Clinical Team

Dyad management, although gaining popularity, isn’t an instant fix for organizational problems. Partnering doesn’t work merely through putting leaders together and asking them to be accountable and responsible. Frequently, as discussed earlier, Dyad partners come from different educational and cultural backgrounds. They may have weaknesses in their interpersonal ability and skills, or management training. When backgrounds are disparate, it’s to be expected that there is opportunity for conflict and disagreement. Elsewhere we discuss possible relationship challenges, but here I am sharing personal experience we have worked through for ourselves and those we supervise with conflict emanating from:

• Gender differences, including patriarchal and matriarchal management approaches to leadership
  
• Cultural differences including historical hierarchies established with physicians as “captain of the ship”
  
• Variation in “blind spots,” those areas of one’s understanding and personality that are clear to others yet hidden from the consciousness mind of an individual
  
• Competency and experience differences

In other chapters, we examine potential conflict areas more in depth. Our experience has taught us that (i) people tend to ignore or be aware of the effect their differences have on relationships and (ii) they seldom take the time to understand and address these. Failure to consistently recognize or deal with conflicts arising from differences in team members will minimize the opportunity to reap great outcomes from Dyad, Triad, or any management team structure. Sometimes, senior leadership can leave conflict resolution to the new partners. Sometimes, because of blind spots that everybody has, they must intervene to assist their Dyad, Triad, or other managers to grow in their team work skills.

Gender Differences

Some key gender differences that we have experienced, and learned from Dyads we supervise, threaten a Dyad team. These are as follows:

• Verbalization versus nonverbalization of thought processes. When two partners have varying expressive and reflective approaches, either can quickly come to the conclusion that the other is either not listening or making decisions without consulting the other.
  
• Thoughtful consideration versus rapid decision making. While these traits are not always gender specific, each can be a catalyst or serious barrier to programmatic success. Not recognizing the default decision process in one’s partner, and in oneself, undermines programmatic timelines and deadlines, or results in unintended consequences when either approach is dominant.
  
• Relationship-based versus program or duty-based interactions. Men and women often vary in these interactions. Women are often concerned with the personal and developmental relationships within the team, while men assuming that relationships are based upon the job or program at hand and that the team and the partnership will naturally rally around this.
  
• Body language. Body language is perhaps one area where women are sensitive and observational, whereas (speaking in wide sweeping terms) men are blind most (if not all) the time. Underestimating this difference, and not asking for transparent feedback when posturing or body language is threatening to others on the team, can cause significant barriers to teamwork.

Cultural Differences

We’ve experienced the need to examine culture as “the way we do our work,” as we’ve grown our clinical Dyads. Clinical leaders from medicine and nursing, as well as from healthcare business specialties, have variable experiences that must be recognized and understood for the team to thrive. They include the following:

• Physician educational process and training, with socialization that results in overreliance upon self. This cultural background is the most difficult for physicians to recognize, understand, and incorporate a conscious questioning and consideration in day-to-day activities. What’s worse, when deadlines or seriousness of tasks are imminent or heightened, their default behavior (self-reliance and tight hierarchical decision making) is enhanced.
  The historical comparison to a captain’s job is indeed mischaracterized by many physicians who take the role of sole leader to heart. They think this means the “skipper” must take on all responsibilities. In truth, the captain is dependent on her team to lead a ship or plane, especially in rough seas or during severe air turbulence. She empowers team members to make appropriate decisions for their roles. Physician education and culture has led to an “I must be the sole team member making decisions” thought process. We have seen clinical examples where this approach has been counterbalanced within a team-based rounding environment, to the benefit of patients. When physicians play true non–healthcare captain roles, the result has been dramatic improvements in outcomes reflecting safe practices, evidence-based interventions, and team-based patient care–related areas.
  In addition, the educational process of a physician emphasizes competition and sole dependency in order to graduate, qualify for medical school, and find the best residency programs. “Team oriented” it is not. This is an area for growth that physicians must embrace in order to be successful as leadership partners.
  
• Professional-level conflict. Highly educated operational managers, nurses, and physicians bring competencies related to their professional training and learnings to the team. If the above team-oriented approach is not honed, these professional differences will often result in decisions made without the complete perspective of the team, thus jeopardizing consensus, joint understanding of the direction in which a project or program may go, or even failure of plans to be implemented.
  
• Hierarchy. Let’s admit it upfront. Healthcare is one of the most hierarchical industries due to historical professional training, CEO business strategies to attract physician volume by fostering the independence of each physician in exchange for his or her business and by the sole reliance and captain of the ship philosophy at the foundation of the physician mindset. Breaking the mold in any of these areas means retraining, dealing with perceptions of diminished importance, and, for many physicians (if aggressively challenged), active resistance to change. Not breaking the mold leads to team dysfunction, passive resistance, and public recognition of the disconnects.

Conflict Management

Members of Dyads frequently report to different senior leaders. At the most senior levels of the organization, Dyad chief nursing officer (CNO) and chief medical officer (CMO) often report to the same leader, usually the chief operating officer or the chief executive officer. On the organizational chart, situated below these senior leadership positions are the direct reports from the nursing and physician areas. They are organized along clinical and professional lines. Thus, a chief medical informatics officer (CMIO), although teamed with a chief nursing informatics officer (CNIO), will report to the CMO while her or his Dyad reports to the CNO. Conflicts in any Dyad relationship usually are first surfaced in the direct reporting relationships and not through Dyad to Dyad meetings. Addressing conflict requires either a tight communication between the Dyad supervisors or a strategy of Dyad–Dyad ongoing meetings to ensure that conflicts are managed professionally and personally to the benefit of the organization.

The Dyad team structure brings physician leadership into a more formal operational relationship and has the potential to elevate and enhance nursing leadership into a stronger multidisciplinary clinical presence. It also presents the opportunity for conflict and failure. Recognizing the cultural, gender, and professional differences in Dyad partnerships are the first steps in building a management team for the future of healthcare.

The Clinical Services Dyad Model

Dyad management practice within the clinical services group (CSG) at Catholic Health Initiatives (CHI) developed initially with the CMO and CNO. Our national team consists of members competent in the specialties of nursing research, clinical informatics (including electronic health record implementation and optimization), clinician leadership development, nursing practice, supply chain, pharmacy clinical practice, quality, patient and employee safety, advanced practice nursing, nursing education and evaluation, evidence-based practice, and enterprise information (EI) and data warehousing. Through purposeful extension, Dyad management has become the default style of leadership within CSG, enabling our clinical leaders to approach their responsibilities through multiple perspectives and competencies, augmenting each other’s skills while maximizing their contributions in support of the strategic progress of the organization.

CSG workflows contain complex and matrixed relationships with both national functional departments and local and regional care delivery centers. Although not assigned full accountability, many of the Dyad leaders in CSG hold important influential and advisory positions within strategic planning, finance, operations, mission, service line, and supply chain arenas. Therefore, in addition to our internal CSG Dyads, there are clinical leaders with Dyad accountabilities shared with other national functional departments. Shared here are some examples of both types of leadership pairings.

Within CSG: Our Leadership Development Dyad

Over the past 3 years, CHI has pursued the establishment of structure and process in support of the need for clinical leadership development. As discussed in Chapter 2, many of our physician and nurse leaders, whether in a key clinical (e.g., CMO and CNO) role, or other leaders who support nursing care functions or clinical service lines, lack the comprehensive background, education, and skills to be holistic in their leadership competency. In recognition of this, the first Dyad formally established by the CMO and CNO was a partnership between the vice presidents (VPs) for leadership development (one MD and one RN), who work together to deliver clinical management education. As individuals, they have responsibilities for nursing education and policy, the hospitalist service lines, clinical operational excellence, and other clinical endeavors, but they are perceived as one by the organization within the context of leadership development. The VPs are supported by academic external partners who conduct research and teach at the graduate level. These experts supply core content material, while internal partners from the CHI human resources and mission departments assist in the creation of programs focused on transformational leadership. Content is tailored to include specific areas important to medical directors, hospitalist leaders, service line directors, as well as nursing leaders.

In the transformational leadership programs (TLDP), CNOs are invited along with their local or regional Dyad partner, as CMOs, to begin the process of self-reflection and growth both as individuals and as pairs. Indicative of the success of this program, our most recent group has had the addition of a CEO who requested and joined his CMO and CNO to form a Triad for mutual team development. The course interweaves the Dyad management theme, throughout the year long endeavor, specifically addressing the leadership skills and competencies necessary to be an effective leader. Over a calendar year, the course introduces three areas of foundational leadership. These are expressed as educational objectives.

The individual leadership objectives for TLDP participants are to

• Engage in committing to leadership formation, while also beginning the formation of a strong leadership cohort community
  
• Focus on developing leader self-awareness, self-focus, and self-regulation in the choices made for positively leading others to achieve higher levels of motivation and performance
  
• Learn core leadership framework and concepts, review personal multirater leadership/climate/culture feedback, and revise goals for leadership development based on this information
  
• Continually reinforce the improvement of leadership readiness for advancing a personal development plan, while practicing domains of leadership (on the job with emphasis on application)
  
• Prepare to continue self-development work with peer teams and coaches in the intervening months

The collective leadership objectives of TLDP include the following:

• To provide opportunities to link leadership development to the advancing of the organization’s strategic focus
  
• To examine how to escalate positive leadership styles to others, at the team or unit level
  
• To explore how to promote an agile learning community that is transparent and innovative
  
• To work through leadership challenges, applying a framework and models that support positive forms of leadership style

The strategic thinking and leadership objectives of the program are as follows:

• To understand the importance of leading strategically as well as how strategic thinking and leadership build on the earlier framework, by focusing on change and cultural transformation
  
• To review feedback reports on strategic thinking styles and use this information to revise participant’s leadership development plan
  
• To apply strategic leadership and thinking to addressing specific leadership challenges
  
• To develop a declaration of interdependence that outlines the way forward for supporting the cohort’s continued interactions among members, as well as with other cohorts (past and future) to advance leadership development in CHI
  
• To celebrate participants’ accomplishments throughout the year

The Dyad partners leading this work have synergistic personalities, professions, and experiences. Their backgrounds include nursing operations, hospital operations, physician practice management, and CMO work, as well as certification in mentoring. Their complementary personalities cap off an exquisite representation of Dyad clinical leadership in healthcare, interwoven with the development of others.

Within CSG: Our Enterprise Intelligence Dyad

EI is another Dyad led responsibility within the CSG. The information enterprise consists of people and structures that lie behind the process of continuous performance management. Utilizing data warehousing, and external and internal sources for data management, EI facilitates the organization’s capture and reporting of data, as well as its performance improvement responses (including change management workflows). This clinical area assumes the responsibility for reflection on the outcomes of such improvement efforts. As our commitment to the “Next Era of Healthy Communities” grows, the need to unite the technical capabilities of data warehousing and reporting with clinical interpretive expertise necessary across the continuum of care is growing as well. The depth of knowledge necessary to oversee operations of the data warehouse aspects is infrequently discovered within clinical specialists. We saw a Dyad opportunity to join these two areas of expertise.

CHI created two VP positions to reflect the growing complexity in information needs. One VP is a physician with clinical informatics training and primary care background, while the other holds the technical competency inherent to the successful operations of a data warehouse. There is an expectation that the two are seen as one unit, demonstrating for the organization the necessity not only for reliable and accessible data but also for the interpretive application of these data to support the efforts of performance improvement.

The EI Dyad management team has managed an external software information vendor change process, which has resulted in enhanced performance and turnaround of data and information, as well as clinical performance reporting at the end user level. Through the exercise of specific competencies and the vendor’s commitment to new processes, the team has automated data exchanges (previously manual processes), coordinated the key data entry personnel for improvement and standardization of the data, and packaged opportunity analysis at the local level. They were careful to include clinical discussions pertinent to any adverse outlier outcomes.

The Dyad in this instance was a superior management structure because competence and skills required for this work were not present in any one background. By forming the partnership, we’ve been able to create an automated, standardized process for data on a monthly basis, complete with clinical interpretation. This facilitates the use of information by end users for improvement activities throughout the organization.

Reaching Beyond the Department: Our Pharmacy Dyad

Pharmacy services in CHI reside in two national functional departments, in addition to the more traditional local leadership at the facility level. Clinical pharmacy and supply chain pharmacy share the mutual responsibility to maximize the supply chain distribution and utilization of drugs, as well as the clinical appropriateness of those drugs across the organization, its service lines, outpatient centers, and physician offices. Two pharmacists share this responsibility, one with skills in the procurement, 340b, and distribution worlds on the supply chain side. The other, a CSG member, is responsible for the clinical application of pharmacy, including generic substitutions, antibiotic deescalation, new drug evaluations, drug utilization evaluations, and technology (IT, smart pumps, etc.). Although job descriptions and responsibilities are quite different, the two work as a team with a united front to the organization in all of their assigned work. Procurement is not separate from use of medications!

Reaching Beyond the Department: Our Clinical and IT Triad

The effects of clinical IT on the future of care delivery and population health are staggering. Not only is healthcare tasked with the implementation of electronic health records but its optimization and upgrading for the clinical teams of pharmacists, nurses, and physicians that use it. The implementation of these records requires a team of personnel including those with clinical and technical IT expertise.

Clinical and IT professionals have a history of being at odds with each other due to varied experiential background. For example, to the IT department, a successful clinical IT implementation has sometimes simply meant putting in the hardware and software. Clinical leaders don’t see an implementation as successful unless clinicians can use it! Such areas as medical and nursing workflow, juxtaposed with the technical needs to standardize and simplify, create conflict issues regardless of how well the team may understand their specific contributions to Dyad or Triad structures. (If men are from Mars and women from Venus, then clinical leaders are from Alpha Centauri and IT leaders are from Vega!) Often supervisory attempts to negate these dynamics have lead to frustration among team members. Relationships between these two groups must be managed actively, which requires hands on attention and time intensity that challenges even the most empathic of our senior leadership group.

Within this milieu are the CMIO, the CNIO, and the IT VP for clinical IT strategy. Rather than two partners, we have found that three are needed for clinical IT work. Triad model leadership is inherently more complicated than Dyad management, so relationship building must serve as a cornerstone for programmatic success. Three strong leaders from technical areas (IT and clinical IT), which are largely transactional in nature, must develop their relationship skills, both for themselves and their teams, in order to work together. Their leaders (the national CMO, CNO, and chief information officer), realizing this, have coached all three and provided team building opportunities.

Leading the Cardiovascular Service Line Together

There is an old saying that “two heads are better than one.” Is that what they meant when we were told that we were going to work as a “Dyad?” Or could it have meant that we were going to be more like Siamese twins, effectively joined together but ineffectively functioning as we were pulling in opposite directions? This Dyad leadership model was certainly going to be both new and challenging.

We were an “arranged marriage” brought together through the parental wisdom of the CHI corporate office. On the units, we were kindred spirits; a doctor and a nurse accustomed to working on behalf of the patients. In the C-suite, we were potential adversaries; an administrator and a clinician, each a passionate advocate on behalf of our constituents. How would this fit? What were we supposed to do? Only time would tell ….

Nearly 3 months later, the wisdom of this decision has become clear. Our sum is clearly greater that our parts and we have effectively moved forward, in lock step, toward the common goal of birthing a national cardiovascular service line. The design and oversight of an enterprise of this size and complexity requires a skill set that neither of us possessed. Collectively, however, we have been able to draw upon our relative strengths and advance the mission of the service line.

With a common vision of the future state, our disparate skills have come together to effectively paint a picture, without any gaps and colored in a way that neither could produce alone. Balancing goals and strategy, policy and guidelines, and wants and needs, we collectively move the enterprise forward. The success of the dyad model rests in the recognition that our job is like a see-saw. Sometimes one partner does the heavy lifting, at other times it’s the other—but on average, our work load and contributions are equal and well balanced.

Communication

Like any marriage, the key to the success of this one is effective communication. We meet every day and at multiple times. We travel together. We speak with one voice. In our interactions with staff and with our market-based organizations (MBOs), we are consistent and united in our approach and response. There are no back channels of communication that can subvert the role and effectiveness of our dyad model.

In projecting our unanimity, we have also created an internal structure that reinforces it. We have a weekly staff meeting with equal participation of both Dyad members. Our MBO meetings are similarly performed in unison and designed to project our solidarity. The success of our dyad, while based in effective communication, is secured by the mutual respect for each other.

Dyad Roles: Who Does What?

The day-to-day work falls into place based on our skill sets and strengths. As leadership partners, our areas of focus complement one another. Project management, the performance scorecard, business operations, budgeting, and human resource functions are typically managed by the administrative dyad leader. Matters pertaining to clinical practice, innovation and research, physician relationships, leadership, and mentoring are key areas managed by the physician dyad leader. Working with our team, we set the strategic direction for the service line. Together, we address matters of clinical quality, care process redesign, and efficiency. Working with the MBO leaders, we serve as a liaison with the various corporate departments to ensure our growth toward common goals.

Our First Team Meeting; The Dyad Team in Action

Prior to our first on-site meeting with one of our MBOs, we planned our approach. This was to be our first meeting with them as a dyad; our coming out as a complete team. Together, we developed an agenda that balanced our goals and objectives of the visit with the needs of the local team. While we were excited about our first meeting, our anxiety levels were high. We did not want to fail.

We began our day with a one-on-one session with the local cardiovascular dyad team. This initial meeting was to be more than a simple meet and greet—it was a time for us to begin developing the relationship that would carry us forward. That evening, we met with the larger physician team to learn more about their priorities and goals. We were counting on the amalgamation of our administrative and clinical skills to foster a sense of credibility and serve as the foundation for our work on behalf of MBO and the national enterprise. As the day unfolded, we had many opportunities to learn more about the local program, make introductions, and share experiences. Our mutual confidence and connection grew by the hour. It was rewarding to see the market physicians connect, on common ground, with the physician dyad leader. They readily shared their experiences and perspectives on a variety of topics. In a similar way, the administrative dyad leader addressed the business aspects of the service line, relating to the obvious challenges, potential rewards, and need to alter our approach to healthcare.

As our first meeting came to an end, it was apparent that the formation of a dyad team was a true asset—both for the national service line as well as for the local administrators and physicians.

With a foot in each world, we are bridging the needs of both groups. There is a sense of acceptance and common understanding and a sense of optimism that this novel model of management will not only succeed in advancing the mission, vision, and values of the service line, it will set the stage for the creation of new relationships and roles that will transcend the traditional operation of cardiovascular practice. The service line dyad is a well-thought-out marriage that will undoubtedly bear fruit for many years to come.