Leadership Dyads have been touted as the solution to the challenge of executing complex initiatives in hospitals and health systems. Meaningful physician leadership has been found to be the missing component in some of these implementations. The thinking goes that partnering a strong executive with an engaged physician can overcome physician resistance to such new programs. But not all leadership dyads are created equal.

What Is Dyad Leadership?

As described in a 2015 Advisory Board Article, dyad leadership is “…a partnership where an administrative or nurse leader is paired with a physician leader, bringing together ‘the best of both worlds' of skills and expertise.” According to that report, the use of dyads in health care has become more common over the past decade.

The purported benefits of a leadership dyad include:

• Two leaders with complementary skills can be more effective than any one leader;
• The dyad ensures optimal use of each leader's time and effort; and,
• It improves engagement and reduces stress.

I don't agree with all of these assumptions. Yes, complimentary skills are useful. But there is an equal risk that two leaders attending the same meetings and duplicating their work could result in wasting valuable resources.

Enhanced engagement of physicians seems more likely. But whose stress level is going to be reduced when working on these high priority projects under the usual budgetary constraints and tight deadlines?

Leadership Dyads Would Have Been Useful When…

I can understand how dyads can be beneficial. I've witnessed major initiatives that could have used additional physician leadership at my hospital and others. Some of the more classic examples of projects that met physician resistance and often needed the help of a physician executive included projects such as:

Utilization management.

After DRG payments were instituted by CMS (then called the Health Care Financing Administration, or HCFA) it became clear that UM nurses alone were unable to fully engage physicians. Medical advisors were added to the mix. Many programs did not become truly effective until a high-level physician executive, such as a Vice President for Medical Affairs or Chief Medical Officer, was made administratively responsible for the UM Department.

Clinical documentation programs.

As it became clear that appropriate documentation and coding were essential to ensure that hospitals were reimbursed properly, cajoling physicians to follow documentation requirements produced little results. The next step was to hire medical advisors to intervene with and motivate their colleagues. But at many institutions, until an administrator such as the CMO became involved, medical staffs did not embrace the programs.

Hospitalist programs.

After the initial growth of “organic” hospitalist services (in the sense that they were developed by the physicians themselves), hospital leaders took notice of the increased efficiency and improved outcomes and decided to adopt the model. As they did so, intense resistance by the independent medical staff was often encountered. The hospital administrators then recruited physicians to serve as champions to help educate the medical staff and push the programs through.

Sometimes a “dyad leadership team” of a nursing executive and a respected physician (often the newly appointed medical director) was created to promote the initiative. At many facilities, unless a physician COO or CMO was involved, the hospital-driven programs took off slowly and often remained a financial burden to the organization for years.

Length of stay initiatives.

Like these other programs, effective implementation was often difficult to establish until meaningful executive physician leadership was involved.

Observation units.

This is another important strategic initiative, designed to address requirements imposed by CMS, that was typically met with physician resistance. At our organization, it took a very lengthy planning process involving the CMO and the nursing director to operationalize the unit. It required several concessions to the medical staff, including the ability of the private physicians to manage their patients in the unit, rather than use hospitalists or emergency medicine physicians, which would have been much more efficient.

Lean initiatives.

Pharmacy, emergency department, laboratory and nursing unit Lean Projects can be very difficult to work through without significant physician input and leadership.

Strategic Plans Falter

These and other hospital programs often became strategic initiatives based on presentations at national conferences to senior hospital executives and board members. The executive teams would identify the new initiative that appeared likely to benefit its organization, assign the initiative to one of the team (COO, CNO, VP for Strategic Initiatives, etc.) and flesh out a plan.

Early in the process, resistance by the medical staff would appear. A physician champion would be recruited to help interact with the medical staff. This tactic sometimes reduced the intensity of physician resistance. But the effectiveness of this approach depended on the skills and gravitas of the champion.

In the Advisory Board article, the authors recommend that the partners in this process have the following characteristics:

Physician:

• Sterling clinical credentials
• Excellent relationship and influence skills with physician peers
• Systems thinker

Administrative Leader:

• Management skills: finance, staff, operations
• Clinical credentials
• Persistent, organized and detail oriented
• Relates well to leaders of shared services and relevant functional areas across the organization

There is fairly broad consensus that using the new dyad model (i.e., bringing more physician leaders into the early planning stages) provides for better execution, with less resistance and dysfunction, than when traditional leadership is used.

Still, looking at the above desired skill sets, in my opinion, the experienced physician executive may well have the skills of the administrative leader, but the converse is generally not true.

Two Kinds of Dyads

I fear that healthcare systems are attempting to use the old style of leadership teams, rather than adopt the modern ones described above and in books like Dyad Leadership in Healthcare: When One Plus One is Greater than Two.  My sense is that many hospitals have misconstrued the true nature of effective dyad leadership teams. Simply recruiting a respected physician to help support and promote a new initiative, while still carrying her usual clinical load, is not sufficient.

Another Example

The importance of executive level physician leadership is most evident in the implementation of Electronic Health Records. As it became clear that EHRs would need to be implemented at every health system in the U.S., the common response was to put the onus for implementation on the I.T. Department and engage physician super-users as medical advisors to help communicate and educate physicians. But two realities became obvious as implementations failed:

1. Clinical informatics specialists would be needed (including physician, nursing, pharmacy, etc.);
2. High level physician engagement and leadership would be required, and the growth of Chief Medical Information Officers took off.

Such CMIOs were often partnered with I.T. VPs or Directors to co-manage implementations and lead the informatics, while the nonclinical partner handled the technical issues. Such leadership dyads are generally very effective.

Real Leadership Dyads

Carle Foundation Hospital and Physician Group in Urbana, Illinois has been using leadership dyads extensively. It is an organization that has embraced the model. By several measures, Carle is a very successful organization and has utilized dyads to great effect.

The Studor Group has noted that “Carle has one of the “purest” and most successful dyad models in healthcare today.”

What are the features of the Carle Leadership Dyad model?

• In its model, the physician leader and administrative leader are equal co-managers. For example, at the most senior level, the COO and system CMO work as a team. Part-time super-users, champions and medical advisors do NOT meet this requirement.

• Even their medical directors, assistant medical directors and associate medical directors are at least 50% administrative, leaving less than 50% of their time dedicated to clinical endeavors.

• There is extensive ongoing leadership education and training for its physician managers and executives.

Another critical feature of modern dyads is described in Dyad Leadership in Healthcare: When One Plus One is Greater than Two:

• This type of dyad is often a permanent part of the organizational structure, not a temporary implementation strategy.

In Summary, Don't Kid Yourself

1. Assigning a physician “champion” or “medical advisor” to a help promote and plan a new service line does not meet the definition of the modern Leadership Dyad and will not produce the results obtained by systems such as Mayo and Carle.
2. Using the modern Leadership Dyad model will NOT reduce the need for physician executives; in fact, it will increase the demand.
3. This model will require ongoing education and training of physicians.
4. Therefore, financial resources will be needed to recruit and train more physician leaders. But the result should be faster, more effective implementation of important strategic initiatives and better overall quality of care and patient outcomes.

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Has your organization successfully implemented co-management using leadership dyads?

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