FIGURE 8-1 Operating room first case late starts. Start time is 07:30. Late starts are those surgeries starting on or after 07:40. Start time is considered time to incision. The intervention began in September 2013.

Summary

Healthcare of the future demands team-based care. At the center of the most effective clinical-based teams are strong, collaborative nursing–physician leaders in a dyad relationship. In order to create healthy nursing–physician partnerships, physician and nursing leaders must join together in a mutually reinforcing professional relationship. They must also create structures that cascade and replicate this relationship and operationalize the model in key management, administrative, departmental, divisional committees, and work teams.

Acknowledgments

We thank Rebecca Shuman, RN, Steve Schneider, MD, Bruce Koefoot, MD, and Donald Kropf, MD, for their leadership in the Operating Room late start time project.

Interview with a Dyad: The CMO and CNO

Cary Ward, MD, has been the CMO for Catholic Health Initiatives St. Elizabeth Regional Medical Center in Lincoln, Nebraska, since 2002. When his first CNO Dyad partner accepted the hospital president role, he interviewed and helped select his new partner. They were hardly strangers. Libby Raetz, RN, was the nursing director for the hospital’s emergency department. Both had previously served on the board of a federally qualified health center. Both had been frontline clinicians in the community, Cary as a primary care physician and then as a hospitalist and Libby as certified emergency nurse. Both were active in their church. Their sons had been in school sports together, and both boys became certified as nursing assistants before college. Cary and Libby were professional and personal acquaintances who never expected to become halves of an official clinical executive leadership team. When Kathy Sanford interviewed them about how they experienced this change in their relationship, they were 3 years into their Dyad roles.

Kathy: Cary and Libby, thanks for taking time out of your busy lives to talk about life as a dyad. Cary, you have more experience at this type of management than Libby. She’s your second CNO partner. You willingly entered into this model for a second time. So, there must have been a positive outcome from your first Dyad relationship. How would you describe that experience?

Cary: It was great. The CNO and CMO roles overlap in so many areas, and by working closely together, we were able to accomplish more than if we’d operated separately.

Kathy: Can you give me an example of what you accomplished together?

Cary: Well, one thing I’m proud of is the Leadership and Safety Rounds we initiated together. When the CMO and CNO go unit to unit, emphasizing ways to keep patients safe while providing high-quality care, it’s obvious to all of the frontline teams that theirs is important work. I think it’s an effective way to model clinical teamwork for the good of those we care for. And, it showed staff that both of us have a sincere interest in their well-being. We kept lists of issues staff members brought up, followed through on addressing those issues, and then reported back to staff about that follow through the next time we were on the unit. By doing this together, physicians, nurses, and other team members saw us as a united front.

Kathy: Was presenting as a united front important?

Cary: Yes, it was—and is, with Libby, too. We’re going through so much change, and there are more challenges than other clinical leaders can cover in a day—or a week, sometimes! When others know we’re working together and when they actually see us together, they’re more comfortable going to either one of us for advice, assistance, or with issues. Because there are two of us available, it’s easier for people to find one of us and things get addressed in a more timely way. That’s better for the organization, the patients, the caregivers—and for us, too.

Kathy: So, with your first dyad partner, and with Libby, you’re comfortable having the CNO address issues for from the medical staff?

Cary: Of course! What’s important is getting the job done. It’s about mutual respect, with no personal professional ego getting the way. We have to work together, include each other in all the clinical components and do what’s right, regardless of whether we’re working with doctors or nurses. In fact, in some cases, Kim (his first dyad partner) was more effective with certain physicians than I was. One surgeon always liked taking his problems to Kim for solutions, if he had a choice.

Libby: And the same holds true for nurses. They see Cary as their leader, too. Sometimes, they take clinical operation problems to him because they see him before they see me, but sometimes some personalities just “click” even if they aren’t in the traditional nurse-to-nurse or doctor-to-doctor chain of command. We’re a team, and either of us can solve problems.

Kathy: So, it sounds like both of Cary’s dyads—Kim and, you, Libby—have been good with Cary!

Cary: Yes, Libby picked up the torch from Kim, and we’ve continued to grow as partners.

Kathy: Libby, what is it that makes Cary such a good dyad partner?

Libby: I believe that a successful dyad partnership is one where you learn from each other. Cary is an incredibly good listener. He is diligent about thanking people for what they do. People can tell that he really cares about them. I’ve watched him and learned from him. Being his dyad partner has made me a better leader.

Cary: Well, that goes both ways. Libby is one of the most positive people I know. She lifts spirits when times are tough. And she tackles tough issues head-on, no matter how unpleasant that can be. She’s creative and has good, novel ideas. I’ve learned from her.

Kathy: It sounds like what is said about another partnership, a good marriage: The best are those in which each partner becomes a better person individually and when the two combine different skills to make a stronger whole. In your case, I hear you both saying each dyad partner becomes a better leader and that your individual personalities and skills complement each other to make a stronger team.

Libby: That’s exactly right.

Kathy: I do have to ask, because you are different individuals, and you come from different professional cultures: Have you had major disagreements or friction over leadership styles or decisions? And, if so, how did you work them out?

Libby: We haven’t really had any major clashes ….

Cary: But, if we ever did, we’d talk it out privately, behind closed doors. Then, once we’d agreed or settled an issue between the two of us, we’d present a united front in public.

Kathy: Back to that united front again!

Libby: It serves us well—there’s none of this triangulation that can cause so much dysfunction in teams—none of that, go to Dad to complain about Mom or vice versa. We once had to counsel and then remove a disruptive colleague from his leadership role. We did it together, and that’s worked out well. Of course, he won’t speak to either of us!

Kathy: The two of you certainly embody partnership. Not everybody has an official partner. How do others, those who aren’t in a formal management role like yours, react to the two of you when you’re both part of a larger team?

Cary: We’ve actually been part of a larger team where there was friction and fairly serious disagreements. We’ve been able to stand together on clinical issues that are important to patients, physicians, and other staff members. We believe we’ve been better able to bring balance to the value equation—where both cost and quality are essential to a successful organization. Clinicians have a stronger voice when physician and nurse leaders stand together.

Libby: I think the additional value we bring to larger teams is our obvious partnership. Just as Cary and I learn from each other, our other team members learn about teamwork by observing us.

Cary: We actually are deliberate about things we do to demonstrate teamwork. We make presentations together the way you and Steve (Kathy’s dyad partner) do. People notice that, just like we noticed the seamless way you present every other power point slide when you present together. It’s a powerful way to point out the effectiveness that can be achieved when nurses and doctors or nurse leaders and physician leaders are united in their passion for outstanding clinical care.

Kathy: Are people besides nurses and physicians noticing this partnership?

Libby: Yes! We present together at our board quality committee. As a result, board members see us as competent clinicians who have our leadership act together. Because we work for a Catholic organization, we’ve met together with the Diocese to discuss clinical issues of interest to the Church, and the clergy see us as a Dyad. Community members call on both of us when ethical issues come up.

Kathy: What are the things you think you’ve accomplished better as a Dyad than you would have as individual clinical leaders?

Libby: We’re especially effective when there are personnel problems in one of both of your areas of responsibility. It’s not easy for leaders to solve interpersonal team issues alone. I think both of us were pretty good at that sort of thing, but we’re even better together. I mentioned how we worked together, first trying to help a clinician change his abusive ways and then removing him from his leadership role when he just couldn’t change. We’ve also tackled the issue of a provider with a substance abuse problem. We’ve worked together to confront issues directly. We’ve referred two medical colleagues to the PULSE program for disruptive physicians. One doctor left our organizations when we intervened.

Cary: It’s too bad that we can’t help everyone change or become better team players, but we can’t have a hospital where bullying is excused or ignored. The staff are appreciative and talk openly about how much better the working environment is because everyone knows that Libby and I stand together to make teamwork collaborative and communication civil.

Libby: We orient new staff together, and one of the points they all appreciate is that we have zero tolerance for disruptive behavior from anyone, regardless of how talented or smart they are—or how much income they generate for the hospital.

Cary: The value in our Dyad isn’t just about personnel issues, though. We are proud of the work we did together on putting together a bundled payment as part of the hospital’s orthopedic initiative. Having both of us at the table ensured that we knew the costs and clinical resources needed to make what some people see as just a financial model work well. Together, we brought knowledge of how to make the operation work.

Libby: We make our safety rounds together, too, so we’re seen as both concerned about quality and safety. All of our team members want to stay focused on doing what’s right for patients, knowing that both their clinical leaders do, too. Well, that helps everyone feel better about continuing the really difficult work of frontline care and still maintain the true caring they all started with.

Cary: Our Safety First Program, based on safety programs from the aviation and nuclear energy industries, is a new way of thinking. No matter how intuitively correct new things are they involve change. Change is tough for everyone—so it’s important that we demonstrate, together, how important this particular program is.

Kathy: Can you give an example of how you made the hospital environment safer?

Cary: Sure. We had an issue with Bariatric patients refusing to allow staff to use the Bariatric lift to move them.

Libby: And some nurses who weren’t using the lifts …

Cary: Patients even said they wouldn’t come to our facilities if we insisted on using them, but we changed the hospital policy to require lift use on every patient over a certain weight. Libby and I stood firm on enforcing this policy.

Libby: Staff injuries were reduced …

Cary: And we haven’t lost any patients!

Kathy: Have you had any surprises in this new style of leading? Or big learnings?

Cary: We’ve discovered it’s a good idea to have a meeting before the meeting! Before any major meetings with our team members, we get together and make sure we’re in agreement from the clinical side of things.

Libby: It’s actually come pretty easy to us. We were friends and colleagues before we were Dyad partners, so it may have been easier for us. I really appreciate the leadership classes our organization offers. Dyads are encouraged to attend and learn management skills together. It’s not equally easy for everyone, but we’ve mentored dyad teams who will work with or report to us—and it’s rewarding to see them grow in leadership together.

Cary: It’s been so natural and productive for us that I’ve been shocked when we’ve been part of larger state-wide groups. As a Dyad, Libby and I come together to big clinical tables—and she’s the only nurse there! These groups are trying to tackle big challenges for the future. They’re solving operational problems, and they don’t include important hospital operations experts—the nurse leaders! It’s mind boggling, but they don’t know what they don’t know—we’re working together to help these business and finance leaders see and understand the value of a united nursing and physician leadership. We’re a lot alike, but we’re different, and we bring different skills and knowledge, which makes us a strong leadership team. Hospitals leave nurses out of so many things—I’ve heard leaders say, “Well, we would include them, but they’re intimidated when we bring them to the table. They don’t speak up, so we don’t include them” … Hmm, we don’t have that problem!

Kathy: You are a wonderful example of Dyad leadership! What would you say, individually, is the biggest benefit for you personally, to be part of this pair?

Cary: The best thing about being part of a Dyad is realizing you can’t come up with all the ideas. Hospital management is so complicated. There are so many moving parts. Being a dyad leader with a partner who is bright, someone you respect and can trust to do what’s best for patients and to share new possibilities—well, that’s a blessing.

Libby: Senior leadership can be lonely sometimes. So much has to be kept confidential. It’s wonderful to have a partner you can admire for clinical and leadership skills and who has your back. We can talk openly about anything, bounce ideas back and forth while knowing nothing we say to each other will be repeated outside our private conversation. We can give and get advice, and debate things in private. Plus having a great Dyad partner makes work fun.

Kathy: It seems you two were made to be Dyad partners even though you were brought together by chance.1 Thanks for sharing your story and for choosing to lead.

¹ Interviewer’s note: Cary and Libby continue to serve as clinical Dyad partners in Nebraska. They’ve often marveled at the coincidences that brought both of them to their leadership positions and their formal partnership. They are both active in the community; both sat on the Board of a Federally Qualified Health Center that has been recognized for its outstanding provision of care to vulnerable populations. In Cary’s office, he is proud to display the John F. Finegan Award for Outstanding Practice as a Family Physician. It was named for the Lincoln, MD who started the Lincoln Family Practice Program. It was awarded to him in 2006. Libby knows a bit about the honor that was Cary’s to receive. John Finegan was her father.

A Conversation with Leaders: How Does Dyad Leadership or Shared Leadership Apply in Hospital Medicine?

The idea of working in leadership pairs, and in working in teams to care for patients is growing. The following is a discussion on how teamwork works well in hospital medicine (often referred to as the “Hospital Medicine Service Line”).

In hospital medicine, hospitalists have the opportunity to work in Dyads and teams every day. Depending on the role of the hospitalist, partnerships, and relationships can vary. “Everything we do as hospitalists depends on our ability to function well in teams, to organize teams, to bring people together in teams,” says Thomas Frederickson, MD, SFHM, FACP, MBA, Medical Director, Hospital Medicine, Alegent Creighton Health. He, his Dyad partner, Joe Mangiameli, RN, MSN, and Amanda Trask, MBA, MHA, FACHE, CMPE, one of the national leaders of the Hospital Medicine Service Line, recently took part in a conversation about Dyads and teams. Together they addressed several questions.

How Does the Model of Dyad Leadership Apply Day-to-Day in Hospital Medicine?

In a typical workday, a hospitalist is a potential co-leader of multiple teams. Traditionally, hospitalists have been thought of as “just another physician rounding on patients in the hospital.” Until the recognition of the Dyadic (and larger team) leadership opportunity at the point of care is realized, the physician–clinician team has not been leveraged. While we aren’t talking about formal, organizational chart Dyad partnerships, we believe even temporary, multiple teams benefit from co-leadership. Sometimes this is more than two leaders.

One example of co-leadership in the day-to-day routine of the hospitalists is when a hospitalist, nurse leader, and care management leader meet regularly with the patient and/or family to evaluate the patient’s care plan. When this relationship is formalized into a care team, with the patient as the center of focus and member of the team, the patient’s plan of care can be realized in a more timely manner. There is more complete information, input, and feedback from various clinicians. This relationship is often referred to as multidisciplinary rounds. In our case, we see it as sharing leadership.

Every team member has a voice in planning and delivering care. Reliance on the specific expertise of each care provider leads to better collaboration and allows all aspects of the patient’s care plan to be considered.

How Does this Apply in Hospital Medicine Medical Practice Management?

As the industry of hospital medicine continues to mature, more and more value is placed on the team relationship between a hospital medicine physician leader and an administrative operational partner. The recognition of hospital medicine as a formalized medical practice has led to a strengthening of the physician leader and operational leader relationship.

By pairing a hospitalist leader with an operational leader, while matching the right personalities and unique talents, the leadership team is able to influence positive change and ensure success of the collective. It is not that any one person has more or less knowledge to offer, rather it’s the power of the team that makes for greater strength and knowledge. One real-life example of this Dyad relationship is our leadership partnership at Alegent Creighton Health in Omaha, NE.

Joe Mangiameli, RN, MSN, is the Director for Hospital Medicine Services at Alegent Creighton Health. He is the administrative leader of the Hospital Medicine Service Line Dyad. He says, “As a Dyad, we try to leverage our expertise and relationships in the organization. We each bring different experiences to the table that complement the other’s skills.”

Tom Frederickson, MD (the physician leader of the Dyad), says, “First, it has to be a relationship. We have to understand each other. In everything we do in the program, we try to think strategically. It helps to have different backgrounds, expertise, relationships, experiences, and points of view.”

Dr. Frederickson also indicated that “another real, practical aspect of our effectiveness is the ability to divide and conquer. We strategize about what needs to be done, appraise each other on our progress, and advise on directional changes to be made. One example of this is around process improvement. We had an opportunity to improve the revenue cycle by changing how we captured the physician charges. As a physician, I was able to explain to our physicians why it was important to do this and then provide education for the change. My administrative partner, Joe Mangiameli, was able to focus on other administrative aspects and work with other departments to ensure implementation of the changes. Our different strengths and responsibilities meshed together to get the job done. We helped each other out and moved more quickly through the project than if one of us had to lead it alone.”

Both partners agree that their leadership Dyad, which is similar to a strong ambulatory practice management leadership design, encourages practice strategic planning, analytics, clinical collaboration, and application of practice leadership principles in a hospitalist practice environment.

How Do Dyad Leadership Principles Apply in the Hospital Administrator Relationship with Hospitalists?

Hospital medicine leaders also have team relationships with the hospital C-suite. Since all hospitalist efforts and decisions affect the quality outcomes of patient care, there is a need to create dyad relationships with hospital medicine leaders and hospital leaders. We must bring the clinical and business side together for the success of the organization. And, of course, since hospitalists work closely with nursing, there is a natural partnership that needs to be nurtured and cemented with the CNO.

In both small and large complex healthcare organizations, creating formalized Dyadic relationships and ensuring frequent communication leads to a higher degree of collaboration, cooperation, respect, and trust. Both parties, hospital executive leaders and hospital medicine leaders, need to recognize the opportunity to cultivate a partnership relationship to ensure a full understanding of shared goals and pathways for the achievement better outcomes for our patients and organizations.

How Does this Empower Hospitalists to Influence the Industry?

Hospitals are some of the highest cost venues in healthcare. And, since hospitalists fully focus on hospital care, this group of providers has the opportunity to significantly impact the cost of care for a population. In the next era of healthcare, ensuring the most appropriate use of acute care is a key to managing the costs. By enlisting the interests and input of hospitalists, healthcare organizations can achieve improved care in a population management scenario. Leveraging the dyad relationships enables hospitalists and organizations to shape the future of healthcare.

Working with multiple subject matter experts with complementary strengths on a common platform enhances not only the quality of the outcome but the timeliness as well. Patient care can improve, implementable plans for change can be stronger, the timeline for completion of a project can be improved, and more cost-effective operations can result. In addition, we can transform the hospital culture to be focused on quality, safety, and service to our patients. The results of leading together will be beneficial to them, their families, our caregivers, and our organizations.

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