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.

[embed_popupally_pro popup_id=”3″]

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

Next Steps

Please add you're thoughts and questions in the Comments. I'll respond to them all.

Don't forget to SHARE this post, SUBSCRIBE Here and complete a SURVEY .

Email me: johnjurica@nonclinical.buzzmybrand.net or leave me a Voice Message.

Thanks for joining me.

Until next time.

The post Not All Leadership Dyads Are Created Equal appeared first on NonClinical Physicians.

I was the newly appointed vice president for medical affairs (VPMA). I had convinced our CEO that is was time to add a formal physician leader to the executive team. It was 1999, and most hospitals of similar size and scope had a full-time VPMA or CMO (chief medical officer).

There were several members of the executive team that had never worked with a physician executive. And that was not the only reason that trust was a bit of a challenge. Each of the executives in the room were focused more on their own division and its performance than on the performance of the executive team as a whole. Adding a physician to the mix added a whole new level of discomfort.

Over time, mostly through gentle encouragement by the CEO and his astute way of pulling all of the team members into the important strategic decisions, we began to work as a team. Part of that working together involved building a high level of trust.

I don't think we fully developed that trust, however, until later in my career. The CEO that hired me moved on to another, bigger challenge. And our COO had taken the reins, first as interim, and then as permanent CEO.

He was very interested in creating a strong, highly functioning team. So we spent time in retreats, and during weekly meetings, discussing and discovering how to develop a more cohesive and effective team. We spent much of that time on developing trust.

I wrote previously about the importance of trust in a team, and how to identify a lack of trust in this post: Six Signs of a Lack of Trust in the C-Suite. The foundation of an effective team that confronts challenges, engages in fierce conversations and gets results, is a culture of trust.

I'm not talking about the kind of trust in which you trust your colleague to do her job, or you trust that your staff will complete their projects. Building trust that I'm referring to is the trust that I can speak my truth and that my colleagues will listen and engage honestly with me.

It is trust that I can be vulnerable in a meeting or in my interactions with co-workers, that I can admit my mistakes and that I can disagree without being criticized. It is trust that politics and game-playing will not be tolerated.

So, why bother developing THAT kind of trust in a team?

Because those are the teams that are really effective. Teams with that kind of trust will express themselves without holding back, and have the kind of conversations that generate great ideas and solutions. Those teams work together to solve organizational problems rather than focus on their silos (divisions or departments). They care less about how they look and more about how successful the whole enterprise becomes.

Who is Responsible for Building Trust in Their Team?

The primary responsibility for fostering an environment in which trust can grow falls to the leader, of course. Some of the mechanisms for effectively building trust can only be done by the leader.

But every member of the team can encourage and promote attitudes and behaviors that promote trust. Members can also participate in being vulnerable within the group, which is one of the hallmarks of a team infused with mutual trust.

Still, the leader must inspire the team to build trust. The leader should talk about the value of trust, vulnerability, and teamwork. He or she should clearly work to limit political agendas and encourge transparency within the executive team. And the leader should acknowledge team members that demonstrate and support trust as an organizational principle.

What Tactics Are Effective for Building Trust?

I think there are at least four major behaviors that must be encouraged and embraced in order to fully develop trust in all members of the team.

1. Encourage Personal Relationships

Some might call this team building. But it is more specific. This component of building a team is dependant on developing personal relationships with others on the team. This does not mean becoming best friends with them, or spending every Saturday at their home.

Each person should develop knowledge of the teammates' families, interests, hobbies and personal backgrounds. This will need to be led by the CEO/team leader and actively supported by the team members. There are specific exercises that can be done to improve this aspect of fostering trust. The following are a few that I have participated in myself.

1. Start by simply spending a few minutes at the beginning of a regular team meeting with each member talking about their personal background. Talk about your family growing up, your hobbies, your interests and your family now. How did you come to work in healthcare?
2. During a retreat or strategic planning meeting, try some exercises to enhance this process. One I liked was this:  Each participant writes down three things about themself that nobody else knows. But one of them is NOT true. Then each person takes a turn describing these three “fun facts” and another participant has to guess which of the three is not true. It works best when participants write things down that seem very out of character, making it more difficult to distinguish the false from the true facts.
3. In subsequent meetings, try this exercise: Have each member in turn tell the group the characteristic that they most appreciate about the member sitting next to them (pick one side!). Then spend a few minutes discussing how the person came to display that characteristic.

2. Promote Individual Commitment to Being Vulnerable

This is where the CEO/team leader really needs to take the lead. He or she must take opportunities to be vulnerable, admit to needing help and soliciting input. In fact, the leader should refuse to provide an opinion on an important strategic issue until all other sides have been heard.

The CEO might ask the COO to present an overview of a new project that is being planned, and then solicit input from everyone before offering his or her thoughts. Also, the CEO might admit that there is no clear answer, that he or she has not led such a project before, and is depending on all of the insight of the team before making a final decision to proceed.

Team members should then offer their opinions and themselves demonstrate their vulnerability. The CEO can then acknowledge when one of the team members is demonstrating vulnerability.

The CEO might also try to “come clean” with examples where he or she failed to follow the commitment to vulnerability and renew the commitment to follow the principles outlined above.

3. Encourage Fierce Conversations and Embrace Collegial Conflict

One sign of trust is the ability to engage in serious, difficult conversations. The leader should promote these conversations, and encourage participation:

“I know these conversations can be difficult. It may sound like some of us are attacking other members of the team. But the only way we're going to explore all aspects of this decision is to hear everyone out. As long as we go into the conversation knowing that we're not here to demean or belittle anyone personally, we can work through all of your perspectives.

“We must have a clear understanding of where each of you stand. I want you to vigorously debate the ideas here, yet remain respectful of those expressing them. Our success depends on hearing everone's opinion, as difficult as that may be.”

Then the leader has to listen carefully, and be sure to intervene if there are any personal attacks. For important discussion like these, everyone should be asked to contribute.

4. Admit mistakes

The leader can start the process by admitting prior mistakes. Let's face it, none of us is perfect. We all fail from time to time. If trust is generated through vulnerability, well, vulnerability is demonstrated through admitting mistakes.

Even the best CEO chooses the wrong strategic initiative, hires the wrong associate, or rushes to judgement on an issue from time to time. When encouraging trust, a statement like the following can be helpful:

“Last year, this team had a healthy discussion about starting a new service line. I know several of you had major concerns about proceeding. When I decided to move forward, you all got on board and supported the project. And I appreciate that.

“In retrospect, it was the wrong decision and we are now going to abandon the project. I take full responsibility for making the decision and I appreciate that everyone worked hard to make it work. I will certainly learn from this and take steps to avoid making this mistake in the future.

“This just demonstrates that I am fallible, and that more than ever, I need the expertise of this entire team when making such an important decision in the future. So, I strongly encourage you to continue to share your opinions with me and the team.”

Final Thoughts

The CEO will create the setting where building trust can be achieved. But all of the team members needs to be willing to expose themselves. They must also be sure to avoid the temptation to hold off-line conversations or engage in political maneuvers rather than open discussions.

If you want to use a tool to assess the level of trust in your team, you can down load the 2 page tool here:

Signs of a Lack of Trust Checklist

For more of my thoughts on healthcare and leadership Subscribe here.

Please help me out by taking a short survey:  Survey Page

And feel free to email me directly at john.jurica.md@gmail.com with any questions about anything.

See you in the next post!

The post 4 Tactics for Building Trust and Inspiring Your Team appeared first on NonClinical Physicians.

When I first joined the executive team at my hospital as its VPMA (vice president for medical affairs), little did I know that conflict would become a welcome part of the job. One of the most challenging aspects was learning to contribute more openly in weekly strategic meetings. I had some exposure to strategic planning meetings as a hospital board member and on various committees in my state medical society.

But this was different. The CEO, COO, CFO and seven or eight VPs met weekly to discuss strategic initiatives and other challenging issues. I was intimidated by the fact that we would be making decisions that affected thousands of employees and patients, residents and clients.

So I was sometimes reluctant to jump into the conversation. The CEO was good about encouraging me to contribute during the meetings. Truthfully, I mostly listened carefully for the first year of meetings, adding little until I began to feel more comfortable with the process.

My reticence was in part due to my introverted nature. I was also a perfectionist and self-conscious about comments I thought might be seen as unwelcome or unhelpful.

It was not until several years later, after the CEO that hired me had moved on, that the new CEO led us through a concerted effort to improve our functioning as a team. We started by working on trust, as I previously discussed in Lack of Trust in the C-Suite. When we felt that trust had improved, the team moved to the second building block of effective teams described by Patrick Lencioni in Five Dysfunctions of a Team: Conflict.

Conflict is Essential in Executive Teams

I could readily understand the need for trust in a team. We needed to work together, and have meaningful conversations.  We needed confidence in one another. But actively inviting conflict to our meetings seemed counter-intuitive.

I had tried  to avoid conflict most of my life. I wanted to please people. I did not want to confront and possibly aggravate them. As a physician, I was trained to de-escalate anger and frustration in patients, not promote it.

But we learned, by reading Lencioni's book and working with an executive coach, that we would need to embrace conflict within the team, in a non-threatening way, in order to fully dissect and address critical decisions.

As Lencioni states: “All great relationships, the ones that last over time, require productive conflict in order to grow.” Note the words “productive conflict”. This must be distinguished from “destructive fighting and interpersonal politics.”

I agree wholeheartedly. Based on the work that we did, our team was much more effective when we had a passionate discussion about a difficult issue. Should we consider proceeding with a major expansion in the face of difficult economic circumstances? Should we develop a new service line that would require significant financial and human resources for several years? I realized that avoiding conflict resulted in poor decisions and often only delayed the inevitable day of reckoning.

We learned that we should not shy away from tackling difficult questions. And, rather than attack a person or their position, we learned to be inquisitive. Because of the time working on trust, we knew we could be open and not be attacked or belittled by our colleagues. And there would be no politicking or back office deals made outside of the meetings.

Ask Probing Questions

During these fierce group conversations, I found that it was best to ask questions, rather than make statements. The point is not to have a debate, but to fully explore an idea using all of the available talents and perspectives of the team. It's important that during these discussions the CEO (or whoever is chairing the meeting) encourages full participation. He or she may need to allow seemingly difficult and uncomfortable confrontations to proceed, while assuring that personal attacks do not go unchallenged.

Let's consider a situation in which the team is deciding whether to open a clinic in a small town 15 minutes east of our town. To do so will mean leasing an office and hiring a new family physician to work there. The VP for Strategic Planning, COO and CEO all believe it is a pretty good opportunity, based on the fact that many of the patients living in that area now tend to utilize a hospital 30 minutes further east.

Poorly Facilitated Conflict

During team discussions, comments like these will not be helpful:

• The last time we tried this, we lost a lot of money and alienated the local physicians.
• We really don't have the funds to devote to a project like this.
• We'll never be able to find a physician for that location.
• This plan seems really poorly thought out.

Promoting Positive Conflict

Constructive comments that might be more helpful include questions like these:

• Do we have any insight into the reaction of the local physicians and/or the community to opening this clinic?
• What does the pro forma look like? What kind of ROI are you projecting? Can you show us the assumptions that went into that projection?
• What does HR say about the ability to recruit a new physician to this site? Have you explored the possibility of moving one of our established physicians to the clinic to work there part-time to get things going?
• Perhaps we could all take your presentation and review it in more detail. Then could we run through a SWOT analysis at our next meeting?

Final Thoughts

I cannot emphasize enough how fear of conflict can impede progress in becoming an effective team. Please let me know your thoughts in the comments.

And don't forget to sign up for regular updates on my sign-up page.

As usual, you can also email me directly at:  john.jurica.md@gmail.com

John

The post Effective Teams Crave Conflict appeared first on NonClinical Physicians.

A primary skill that a new physician executive needs relates to working in teams: to effectively lead teams and to be an able team member. Lack of trust will kill the effectiveness of an executive team. If team members aren't comfortable with expressing their truths, the team will perform poorly.

The definition of trust that we used in our executive team followed the definition given by Peter Lencioni in The Five Dysfunctions of a Team: A Leadership Fable. It basically centered around developing a team in which each member trusted themselves and each other enough to allow for vulnerability. Our team spent over a year working on trust. Our CEO pushed us to create a team that could fully explore difficult issues and utilize the gifts of each team member.

Why Bother?

As Lencioni argues, trust is the foundation upon which an effective team is built. Without trust, deep conversations and confrontation cannot effectively occur. Without meaningful, often difficult, conversations team members will not feel heard and will not commit to organizational goals. Accountability will be shaky and results will not follow.

Signs of a Lack of Trust

There are generally some fairly obvious indications that trust is lacking. Take a moment to reflect on the following scenarios. Do any of them describe the way your team operates?

Here are some of the behaviors to look for:

1. Members of the team have not built personal relationships.

They are not familiar with the personal lives of other members: their backgrounds, where they grew up and attended school, and what their outside interests and hobbies are. It is difficult to build trust when you do not have a personal connection with other team members.

2. The team always seems to be in consensus on decisions.

This is a bit counter-intuitive at first. But members of a team never agree on everything. If there seems to be a culture of consensus, it means that team members are holding back. Highly effective teams can only achieve commitment to a shared goal after a thorough discussion in which participants feel that they have been heard. At that point, commitment may be possible but 100% consensus will almost never occur.

3. The executive team dreads meetings.

Executive meetings are seen as boring and unimportant, because there is little engagement. Attendees are zoning out or checking emails. When our team was functioning at a high level, I looked forward to our weekly strategy meetings. There would be lively conversations, challenges to each other, and strong opinions expressed. I would come prepared, ready to make my case for, or against, a proposed strategic decision. Nobody wants to miss those kinds of meetings.

4. Team members don't regularly challenge each other and the CEO.

With a culture of trust, the participants feel open to challenging each others' assumptions and conclusions. If the meeting room is filled with yes-men (and woman) always agreeing with the CEO's ideas, it is a sure sign of a lack of trust.

5. Lack of discomfort.

In the absence of trust, conversations tend to be superficial. There is an avoidance of the risk of being wrong, or revealing that a mistake has been made. In an environment of trust, intense probing will occur and there will be times when the questioning becomes uncomfortable. There may be “pregnant pauses” during discussion. More empathetic members may feel the urge to come to a colleague's defense. But this discomfort is a normal occurrence in an effective meeting and will dissipate once the discussion proceeds, as long as each participant can openly express themselves without fear of being attacked or belittled.

6. Participants rarely admit their mistakes.

In a team lacking trust, the usual reaction to being called out is to defend your position or blame someone else for your failure. But when vulnerability is encouraged, and team members trust that they will not be criticized or embarrassed, they will admit mistakes, learn from them and move on.

Next Steps

If you recognize 5 or 6 of the above observations in your team meetings, there is a lot of work to be done. Even if only 2 or 3 are true, there is probably weakness in your team that should be addressed.

If you are the leader of the team or the CEO of the organization, then it is up to you to begin to address these issues. I will provide a list of possible actions you can take to build trust in a future post.

Have you witnessed these behaviors in your team? Does the level of trust tend to shift over time? Let me know in the comments section below.

Also, please subscribe to these posts by clicking here: Subscribe. I'd like to send you notices of future posts and get your recommendations on future topics to discuss.

The post Six Signs of Lack of Trust in the C-Suite appeared first on NonClinical Physicians.