Emergency Department Directors Academy – Phase II How to Lead and Inspire a Team May 2011 Building and Leading Teams in the Emergency Department Thom Mayer, MD, FACEP, FAAP Founder and Chairman of the Board BestPractices, Inc 703-356-9201 Email thom@best-practices.com Building, Leading and Inspiring Teams 1 Huddle Up! Winners OWN Teamwork ! 2 Huddle Up! Winners OWN Teamwork ! Teammates or Cowboys ? 3 Our View of Ourselves? A Team? Or (Dys)Functional Silos? 4 Silos Are Not ALL Bad • Training • Practice • New knowledge and skills • Sense of identity • Culture • Familiarity and comfort Leading Teams=Connecting Silos 5 Silos-The Patient’s View Triage Placement Triage and Registration In the ED MD Call for Bed or Discharge Test and Treat Exit ED Disposition Decision to Exit the ED R Room Utili Utilization ti Opportunity for Improvements within each Sub Cycle If You… • Establish silos • Tolerate Silos • Measure by Silos • Punish by Silos • Reward by Silos… Silos 6 You Will Inevitably Get… Leading Teams=Connecting Silos 7 Fill the Gaps with A Team Processes Leading Teams • Leveraging Capacity • “Give me a lever long g enough g and I can move the world.” Archimedes • Strategic Connectivity • My distinctness distinctness--What do I do to the exclusion of or different from others • Others distinctness distinctness--What I don’t but others do • Connectivity/Flow Connectivity/Flow--seeing connections and capability where others may not 8 Silos Are Not ALL Bad • Training • Practice • New knowledge and skills • Sense of identity • Culture • Familiarity and comfort Meta-Leadership is Emergency Medicine • “Meta-leadership p is particularly valuable in circumstances when different organizations and entities must be brought together for common purposes.” 9 Teamwork itself is an End Result • Outcomes have their distinct “impact value” (patients first) • The experience of the process itself “collaborative value” • (Value to the Team) The DNA of Teamwork LEADERSHIP Clinical Quality Service Excellence Patient Safety Flow Risk Reduction Finances Talent Arbitrage 10 How Do We Select Docs? The Problem of the Apostrophe Physicians/Nurses Physician/Nurse Leaders • “My job is to meet my patient’s needs.” d ” • “My job is to meet our patients’ needs.” d ” 11 Stakeholder Analysis Boundary Mgt • Who are the key stakeholders in any given issue? g • What do they view as their stake? • What do you view as their stake? • How can that stakeholder influence the change you are undertaking? • Healthcare is an infinite series of boundaries • Creating a boundaryless organization • Leading the charge in minimizing “boarder patrol” issues • Putting the patient first-ALWAYS !!!! 12 The Wisdom of LBJ If you could do three things to improve your Emergency Department, what would they be… 1. 2. 3. 13 What Do You Want to See More Of? What Do You Want to Less Of? Leadership Skills-As easy as 1, 2, 3 #1 What is the One Myth for this person? #2 What is their intrinsic motivation ? #3 What is in this person or group’s group s selfinterest? 14 The Primary Power of a Healthcare Leader is the O Opportunity t it to t Create C t Teams T of Professionals Empowered to Execute a Clear Vision of Excellence What Makes a Great ER? 1. 2. 3. 4. 5. 15 What Makes a Great ER? • • • • Talent Teamwork Leadership Execution 1) Customer Service 2) Communication 3) Flow 4) Patient Safety Elements of a Team • • • • • • Recruitment Roles Resources Responsibility Retention Review 16 Recruitment • What is the ED’s vision (Why?), mission (What?), strategies and tactics(How?) • Chris Argyris- Espoused Strategy versus Enacted Strategy • Why should a highly-talented young gun want to work here? • Why would anyone want to be led by you? • What will I be like in 3,, 5,, 10 years? y • You say “team,” but do you play team? Roles • • • • • • “Team, team, team” vs. Team Work Zone versus man-to-man defense Empowerment 360 degree feedback Increasing predictability and forecasting Reducing variation 17 Resources • Saying “Excellence!” and providing excrement always fails • If the words and the music don’t match, change either or both • Make it about the patient first • Then, and only then, make it about “The Team” y • Never,, ever make it about you Responsibility • • • • • Fanatic dedication to the patient-Rule #1 Managing Up Who’s got your back? Strongest advocate for all team members Holding people accountable 18 Retention • • • • • • • • Re-recruitment Constantly ongoing Part of the fabric of the organization Burnout vs. Rustout Horizontal vs. Vertical The Role of Mentoring Leave a Legacy P off that Part h llegacy iis a b better place l iin which hi h to work (Rule #1, Rule #2…) Review • • • • • • AAR-After Action Reports Constant attention to making it better for… Patients Ourselves! Why? Why not? 19 The Cold, Hard Reality of EM • I really don’t care how your ED works when you are there. • I care how it works when you’re not there. Lessons From a Truly Great Leader • “It’s not what I know … • it’s what they do on the court that matters. matters ” 20 The Wisdom of Lou Holtz Are Medical Directors Coaches? • Similarities g 1. Mentoring 2. Making it “their” idea 3. Talent development 4 Wins=players 4. Losses=Coach 5. Who wakes at 3 AM? 21 Are Medical Directors Coaches? • Differences j 1. You can’t just tell them what to do 2. Do they “work for you”? 3. Do you really control “playing time”? Who’s controlling X’s and O’s? At a fundamental level,, this is ALL Change Management. All Change Management requires i LEADERSHIP. LEADERSHIP 22 Fundamental Questions for Improvement-Kevin Nolan • What Wh t are we ttrying i tto accomplish? li h? • How will we know that a change is an improvement? • What changes can we make that will result in improvement? Leading Change… Change is an Art… R i t Resistance iis a S Science i 46 23 Leading Change… Change g is an Art… Resistance is a Science… Modulating Resistance is Leadership 47 Addressing Resistance: Four Steps to Remember 1. Bring the resistance to the surface “I’d like to hear your thoughts on this” “Tell me what concerns you about this” 2. Listen and empathize “You’re right that this will mean some inconvenience” “I can understand how that could be a problem for you” “Is there anything else that you see as a problem?” 3. Probe further and explore options p about this and how it will “I want to understand yyour assumptions affect you” “How can this be made to work from your point of view?” 4. Summarize what you have heard “Here’s what I’ve heard you say” Peter Block- Flawless “Let me review what we’ve covered Consulting 48 24 If you could do three things to improve your Emergency Department, what would they be… 1. 2. 3. Create a Compelling Message • Logos-Reason Logos and Logic • Ethos EthosCredibility and Character • Pathos PathosEmotion and the Story of the Patient 25 The Story of Exodus • • • • • • • The Wedge and the Magnet The Parting of the Red Sea The Israelites and the Amalekites The Golden Calf Manna from Heaven The Tale of the Scouts The Land Flowing with Milk and Honey The Eight Stage Change ProcessJohn Kotter 1. Establish a sense of urgency 2. 3. 4. 5. 6. 7. 8. Create the guiding coalition Develop a vision and strategy Communicate the change vision Empower a broad base of people to take action Generate short term wins Consolidate gains and produce even more g change Institutionalize new approaches in the culture John Kotter- Leading Change 52 26 Change Management Abraham Maslow Nothing so needs reforming as other people’s habits. Mark Twain 54 27 Change Management The Change Model-Kurt Lewin 1. Unfreeze (shock a system out of 1 stasis) 2. Transform (make purposeful adjustments) 3. Refreeze (engrain adjustments in system) – Change as a journey, not a destination – Communication is critical 55 Teams-People Doing What I Want • “All I wanted was compliance with my wishes after reasonable discussion.” • The Second World War 28 What Makes a Great ER Nurse? 1. 2. 3. 4. 5. What Makes a Great ER Nurse? • • • • Talent Teamwork Leadership Execution 1) Customer Service 2) Communication 3) Flow PATIENT FIRST ANTICIPATION COVERS YOUR “SIX” NEVER SURPRISED LOVES INNOVATION… 29 What are the Biggest Nursing Issues? What are the biggest Nursing Problems Your ED Faces? • • • • • • • • Nursing Shortage (Vacancy rate) Lack of Experienced Nurses How many actually show up? Language issues Loss of “institutional memory” Lack of accountability Turnover “Pit Bull” Charge Nurse lacking 30 Biggest Problems-Nurses Perspective • • • • • • • Lack of teamwork Lack of collaboration Lack of appreciation Critical reasoning skills underutilized Too much charting Too little experience in new hires Lack of accountability for results TeamWork-Staffing and Service • Your ED is chronically understaffed with nurses, agency nurses are common • Turnover is a huge issue • The latest CS scores are in-good news-the physician scores are up from 57th to 68th %tile • Bad news-the nursing scores have fallen again-to the 15th %tile • “Tough noogies-we’re doing fine!” • “What can we the docs do to help improve scores, morale, l etc” t ” • “Here’s what we’ve done that’s worked well…” 31 Leadership and Nursing • The relationship between ED RN’s and MD’s is the single best benchmark of the health of an ED • The fundamental bond is one of respect • It is a complicated, confusing and compelling phenomenon • Unique in all of healthcare The Fundamental Core of Communication • Rule # 1 1-Always Always start with the patient • Rule #2-Always frame the conversation from the nurses perspective • “I’m really concerned that the boarder issue is going to cost us our best nurses.” • “It isn’t fair to our nurses-who after all are the backbone of the department-to have these kinds of staffing issues.” 32 Say What You Want Them to Remember • “I’m Dr Mayer and your Nurse Becky and I are leading a team of people who will be caring for you today.” • “What’s the one thing our team could do to make this an excellent experience for you?” • “If you need anything, let any of our team members know know.” ” Keys to the MD-RN Relationship • Respect, courtesy, and professionalism • Collaboration • Public praise, private problems • Thank them every day • Limited social contact-no physical contact 33 MD • • • • • • • • Autonomous Authoritarian Hierarchical Intense, focused time Ends-driven Technical expertise Linear-deductive “What does this mean?” • Problem Solver RN • • • • • • • • Dependent Collaborative Communications Expanded time Process-driven Interactive-service Circular-Inductive “How do you feel?” • Critical thinking skills ED Leadership Team-Monday Rounds • • • • • • • • Chair Medical Director Pediatric Medical Director Senior Patient Care Director Patient Care Directors Purpose-Where have we been ? Where are we going this week? P bl Problems from f the h weekend k d 34 ED Leadership Team-Department Mtg Senior PCD attends every Department Meeting g Keeps problems small Purpose Information flow with regard to nursing projects Manage “P and Moan” factor Direct communication for f all emergency physician with senior nursing leadership What can we do to make your job easier? ED Leadership Team- ED Ops and PI • • • • • • • • • • Emergency Physicians Nurses L b Lab Imaging Registration Scribes Bed Board Social Services EMS/Helicopter Purpose-Common Huddle for all ED Ops 35 MD-RN Leaders • • • • • • • • Proactive, positive relationship MD as the strongest advocate for nurses F Frequent t meetings ti Supportive relationship Team goals, team results Empowerment, not autonomy Seek and celebrate small victories Celebrate publicly The Huddle • Charge Doc g Nurse • Charge • Nursing Supervisor • Bed Board • Proactive • Positive • Predictable 36 Your Thoughts on Doc-RN? Integrating Administration into the Team • • • • • • • • • • Align strategic incentives. Define success –and its metrics Meet frequently-use time judiciously The power of the carbon copy, email, voice mail Frame questions cautiously Understand the language, philosophy, strategies Inform them of problems prospectively Public praise, private problems B responsive Be i If it’s an ED problem, it’s your problem 37 “There’s a new Sheriff in Town” CMO • Relatively new addition to the leadership team • Deep joy/deep need or tired of clinical practice • Varied backgrounds • Varied training for the position • Friend or Foe? • Beware management by anecdote • Move upstream to his/her sources Negotiation Skills • Negotiation is a fundamental skill of all leaders • The best are highly nuanced • The best know they can often win big by not always winning • Negotiation is not exclusively an innate skill • There are excellent resources available for learning and enhancing negation skills 38 Defining Negotiation • Negotiation is: • an interactive process, • rich in strategy, stratagems, and history, • designed to achieve a desired end • through effective communication • Which builds relationships Negotiation • “an an interactive process” process p 1. Not an event, but a journey 2. Getting them to think it was their idea vs. co-creators 3. You walk in with one idea of what’s going to happen and it changes almost immediately 4. Listening as the key skill 39 Negotiation • “rich rich in strategy, stratagems and hi t history • Know the history of the relationship • Know their personal history • Read history and biography • How H did greatt men and d women negotiate in the past? Negotiation • “designed designed to achieve a desired end” end d” • What does success look like to you? • What does success look like to them? • What are the small successes with which you can begin? • How can you build to the big successes? 40 Negotiation • “through through effective communication • The best negotiators are the best listeners • Questions are better than statements • Slow to anger, quick to forgive • Treat T t attacks tt k as on the th problem, bl nott you Negotiation • “which which builds relationships.” relationships • Most negotiations in healthcare are with stakeholders • Most of the time, you will be dealing with these people again • Positive, Positive proactive proactive, principled • “If you’re throwing dirt, you’re losing ground.” Grandpa Jim 41 Leader =Active Listener • You need to listen… • Can’t you see? • I feel strongly… • Hands to head • Hands to heart • Here’s what I heard…” • I’m beginning to see your vision • So you feel…? • Reason, Logic • Passion, Passion Emotion (?) Getting to Yes 1. Separate the people from the problem. (Hard on problems, bl soft ft on people.) l ) 2. Focus on interests/principles, not on positions 3. Invent options for mutual gain 4. Insist on prospective, objective criteria (How will we judge success?) 42 The Role of the BATNA • • • • • Best Alternative To a Negotiated Agreement What are you left with if negotiations break down ? The BATNA • Spend some time on it, know it, write it down • Keep it to yourself (lots of power in timing) • The greater your BATNA, the greater your power • Like all power, the strength is in not using it (until the time is right) • However, if they know you can walk away, yyour power p increases • The Trip Wire (above the BATNA) • Boost/grow your BATNA • Know their BATNA 43 BATNA Versus Best Agreement • Best Negotiated Agreement Negotiate! • BATNA • Best Negotiated Agreement Don’t negotiate! • BATNA 44 The ED Leader and the Medical Staff • • • • • Align strategic incentives p and appreciation pp Mutual respect Round on admitted patients Round in the MD lounge Focused, succinct clinical summaries • Obtain discharge summaries on ALL admitted patients • Inform leaders prospectively on inflammatory lesions Integrating the Medical Staff on the ED Team • They don’t want to hear from us.. • Our job is to keep the unwashed masses away from them • Proactive understanding of rules, courtesy, communication • Parity of titles • Focused, succinct summaries • Clear statement of what you want them to do 45 Leadership and the Medical Staff • Meet with the leaders regularly • Make them a part of the ED team • Offer Off concrete, t succinct i t solutions l ti to t problems • Beowulf-go below the surface of the lakeWhat are they really saying? • Take the sail out of their wind • Meet on their turf • Protect P t t your fl flank-use k th cc the • Focus, focus, focus… • Surprise them • Adversaries often become the best allies Team Work –EBM and Protocols • Participating in the development of clinical guidelines which cross departmental lines is an excellent e cellent tool to foster and de develop elop teamwork • Focus on the evidence • Focus on stakeholder and boundary management • Include the nurses 46 What Makes You an Expert on Crisis? Rule # 1 of Crisis Leadership • First, state clearly that you do not know all the facts • Second, state the facts that you do know • Get it right • Get it quick • Get it out • Get G t it over • Crises get worse with age, not better 47 “Old sayings are good sayings.” Basque Proverb “If you can meet with triumph and disaster And treat those two imposters just the same… If you can keep your head when all about you are losing theirs And blaming it on you Wisdom from Casey Stengel • “I don’t have any experience with that• and it’s all bad! bad!” 48 The Press-Be Prepared • “Does anyone have any questions for my answers?” Henry Kissinger Crisis Management Messages • If you don’t do it right-and quickly… • Someone else will do it for you! • And they are usually wrong… 49 Managing the “Sound Bite” • Prepare • What the sound bite is you want to get across ? • Discuss this with the crisis management team-they will know what they want said • It’s up to you to know how to tell the story • If you act in charge, you are in charge ! • Multiple reporters-multiple variations on the same sound bite Dealing with the Press-The Ultimate Test of Sense-Making • If it weren’t weren t highly unusual, unusual ambiguous and dynamic, it wouldn’t be a crisis • You will regret it, either way… • More of a chance to be proactive • 100% chance to correct misinformation • Do it right or someone else will do it for you • They’ll get important parts wrong, do not have your best interests at heart, will make the own “sense,” which will not make sense 50 Despite the elegance of the plans, one must occasionally look at the results. The Leader Under Fire • Remove the “I” from the issue. • Focus on Substance Define problem areas Define areas of improvement and measures Listen, don’t defend after listening, restate the issue • Set priorities, action plans, time frames • Use resources (including consultants) • Arrange follow-up mechanisms and timelines • Document improvement on a daily basis • Approach this with ferocity, equanimity, class 51 Of all the will toward the ideal in mankind only a small part can manifest itself in public action. All the rest of this force must be content with small and obscure deeds. The sum of these, however, is a thousand times stronger than the acts of those who receive wide public recognition. The latter, compared to the former, are like the foam on the waves of a deep ocean ocean. Albert Schweitzer, MD Out of my Life and Thought 52 THANK YOU! References 106 53 References Berwick D. A primer on leading the improvement of systems. BMJ 1996; 312: 619 622 619-622. 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