Leadership for Great Patient FlowThom Mayer, MD, FACEP, FAAPPresident and CEOBestPractices, Inc800-910-3796Email: tmayer@best-practices.com

Defining the Elements of Flow

1. Cycle Times2. Reduced Variation,

Increased Predictability, and Improved Forecasting

3. Systems Thinking Service Transitions Alignment of Incentives

4. Empowered providers Exceeding Expectations

5. Demand Capacity Management

This isn’t Quantum Physics…

Strategic Optimism

Flow happens…But it doesn’t “just happen!”

At a fundamental level, this is ALL Change All change requires LEADERSHIP.

All meaningful and lasting change is driven by INTRINSIC motivation

Leadership Myth #1

• TRYING TO LEAD PHYSICIANS IS LIKE TRYING TO HERD CATS!

“Without resistance, there is no meaningful change.” Joan Kyes

Leadership is the art of “resistance

management.”

Tom Peters

• Leadership at its best is a discovery process, a mutual discovery process. The best leaders are the best learners. They empower others to pursue journeys of importance to places neither could have initially have imagined.

Uneasy rests the head that wears the crown.

Shakespeare

There is some one Myth for every man, which, if we but knew it, would make us understand all that he did and thought.

Russia is a riddle wrapped in a mystery inside an enigma.

What Winston Really Said…

• I cannot forecast to you what Russia will do. It is a riddle wrapped in a mystery inside an enigma: but perhaps there is a key. That key is Russian national interest.

Leadership Skills #1 and #2

#1 What is the One Myth for this person?

#2 What is in this person or group’s self-interest?

Rule #1 and Rule #2

RULE # 1

Always do the right thing for the patient.

RULE # 2

Do the right thing for the people who take care of the patient

RULE # 3

Never confuse Rule #1 and Rule # 2…

BestPractices’ VisionCreating the FUTURE of Emergency MedicineThrough Our Commitment to-

• The SCIENCE of Clinical Excellence• The ART of Customer Service• The BUSINESS of Execution

What’s the difference between Leadership and Management?

Do the differences REALLY make any difference?

The Wisdom of John Kotter

• Leadership is the development of vision and strategies, the alignment of relevant people behind those strategies, and the empowerment of individuals to make a vision happen, despite obstacles. This is in contrast to management, which involves keeping the current system operating through planning, budgeting, organizing, staffing, controlling and problem-solving.

Leadership Management

• Envisioning• Strategies• Alignment• Empowerment• Direction

setting• Execution

• Planning• Budgeting• Organizing• Staffing• Controlling• Problem

Solving

The Wisdom of John Kotter (Cont’d)

• Leadership works through people and culture. It’s soft and hot. Management works through hierarchy and systems. It’s harder and cooler. The fundamental purpose of management is to keep the current system functioning. The fundamental purpose of leadership is to produce change, especially non-incremental change.

Management deals with WHAT IS, the cold hard realities of our practice.

Leadership deals with WHAT COULD (MUST) BE, with the future we must become

Most companies are over-managed and under-led.

John Kotter

The Wisdom of Warren Bennis

• Managers do things right-Leaders do the right thing.

Steven Covey

Managers are experts at getting the troops to efficiently cut their way through the jungle.

Leaders climb a tree, survey the terrain, and proclaim, “Wrong jungle!”

There is no sense doing well that which we should not be doing at all.

So Which Would You Rather Be…

• A LEADER ?• A MANAGER ?

The Wisdom (?) of Thom Mayer

• If managers do things right and leaders do the right things, ED medical directors must do both-every day of their lives

If that is true, one of our central challenges will always be answering this question-Is this a leadership issue or a management issue?

Management is about coping with complexity-leadership is about coping with change. No one has yet figured out how to manage people into battle-they must be led.

John Kotter

The Case for Flow –Case History #1

• The CEO, with whom you have an excellent relationship, says to you over your monthly lunch:

• “Thom, I’m getting far too many complaints about delays in the ED. It’s just taking too long to see a Doctor. I think we need to look at adding more physician coverage. Here’s an article on a 30 minute guarantee I think we need to develop!”

Is this a Leadership Issue or a Management Issue?

Management Leadership

• What do the data say?

• What is the key piece of data with regard to Doc delays?

• Do you routinely monitor that information?

• What are the component elements of ED delay?

• Input-Throughput-Output

• Faced with the data, what do they mean?

• Should the focus be on gimmicks or substance?

• What will be the impact on the ED staff of an intrinsically imposed guarantee?

• If a change is made, how do I motivate the staff behind this change?

The Case for Flow-Case #2

• At your monthly meeting of the emergency physicians, one of your docs says, “Every morning at 9 AM, we have 3-5 patients present at triage, but they don’t get into the rooms until 10-10:30. Just send them back!”

• In other words. “Direct to Room !” or Triage ByPass

Is this a Leadership Issue or a Management Issue?

Leadership Management• What’s the source of

resistance?• Boundary management• Stakeholder analysis• Vision• Rewarding teams

• What do the data say?• Information flow• Why not? Data vs Why?• What does JCAHO say?• What is the VOC?• “Bed turns” and

“patient velocity”

Case History #3

• “Thom, I just got an interesting call from one of your competitors. I usually don’t take those calls, but this one talked his way past Becky. They claim to have the highest pay rates in all of emergency medicine, which allows them to recruit the best emergency physicians in the business. I know you’ve told me you have a couple of openings on your staff. I’ve heard some of your Docs complaining they haven’t had a raise. Maybe you should take a look at their model.”

What Do the Data Tell Us?

• The collection and monitoring of data are a management function Are their docs better paid?

• The interpretation and envisioning of data are a leadership function Does high pay = Good Docs?

• Each of these functions must be integrated in order to answer this massive issue intelligently Patient velocity, patient satisfaction, patient safety, risk reduction…

Questions on Leadership and Management?

Fundamental Test for Flow

• “You can accomplish anything in life, provided that you don’t mind who gets the credit.”

• “I wonder how far Moses would have gotten in the desert if he had taken a poll.”

• “The only new thing in life is the history you don’t know.”

Harry S Truman

Bill Russell-Invisibility

• The most powerful test of a leader is how influential they are when they are NOT there.

• The power of invisibility is the most neglected concept in leadership

• To do so, the message must be VERY powerful and masterfully presented

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.

Case History #4

• Your ED group is a democratic, open-books, ‘We few, we happy few, we band of brothers.’ You believe this is the only real practice model for EM.

• However, your CEO has insisted on a performance clause in your contract tied to customer satisfaction scores.

• Despite an aggressive CS focus, two of your eight partners have basement-dwelling scores-and they are getting worse

• Is this a leadership issue or a management issue?

• Which skills will be most important in resolving this problem?

• Do you have the “right people on the bus?”

• Are they in the right seats?• What are the brutal facts? (The

Stockdale Paradox)

Defining Success

• Don’t let life be a surprise to you

• Winning is never enough• The Wisdom of Rabbi Zusya• Churchill’s advice-begin with

the end in mind

Leading ChangeJohn Kotter

1. Increase urgency2. Build the guiding team3. Get the vision right4. Communicate for buy-in5. Empower action6. Create (invent?) short-term

wins7. Don’t let up8. Make change stick

Change ManagementAbraham Maslow

Change ManagementKurt Lewin

• Driving Forces versus Restraining Forces

• Why? Vs Why Not?• Thrust versus Gravity• Thrust must exceed gravity for motion

to occur• Driving forces must exceed

restraining forces for change to occur• HOWEVER, THE KEY IS IN REDUCING

RESTRAINING FORCES NOT IN INCREASING DRIVING FORCES

Driving & Restraining Forces

Case Study #5You are the Chair of a busy and (previously) highly

successful EDYou have a new Nurse Manager, who was brought

in by the equally new CNE (and you couldn’t even spell CNE!)

They have a meeting saying they want more autonomy and a far more collaborative practice

The CEO says good nurses are hard to find-humor them!

Driving and Restraining Forces-Docs and Nurses Clashing

• Driving Forces Communication Rudeness Stress Delays Sniping at ED

• Restraining Forces Lack of

teamwork 2 cultures Alignment of

incentives Communication

skills

TeamWork

• Two words which combine to make a far more powerful single concept

• The single best measure of the health and success of your emergency department is the relationship between the doctors and nurses

All great storytellers know…

It’s not just the story you tell, it’s how you tell it!

Abraham Lincoln

• Did not say… “These dead soldiers inspire us..”

• But he did say… “…that from these honored dead we

take increased devotion to that cause for which they gave the last full measure of devotion…”

And the world changed…

Winston Churchill

• Did not say “We shall fight in on the coastal

perimeters, we shall fight at the airports, we shall fight in the constabularies…”

• But he did say “We shall fight on the beaches, we

shall fight on the landing grounds, we shall fight in the fields and in the streets, we shall fight in the hills-we shall never surrender!”

And the world changed…

Martin Luther King

• Did not say… “ I have a negotiating strategy that

will accomplish affirmative action…”

• But he did say… “ I have a dream that one day our

children will be judged not by the color of their skin but by the content of their character-I have a dream!”

And the world changed…

What’s the Point?

• Your language and your behavior and the story you tell …

Changes the World!

How can there be any doubt about that?

“How can anyone doubt that a small group of dedicated people can change the world? Indeed, it is the only thing that ever has.”

Margaret Mead

Case Study

• You have been the very successful Medical Director of your ED for 10 years

• The CEO, who is a “good old boy” and a trusted friend, just got fired

• The new CEO is data-driven, not relationship driven and says to the medical staff, “There’s a new Sheriff in town.”

ER Doc Administrator

STRATEGIC OPTIMISM

“We were just talking about the bed situation and all of us kind of looked at each other and said, ‘I’ll bet Thom can figure this out.’ “

Negotiation As Change ManagementThe Story of Exodus

• The Wedge and the Magnet• The Parting of the Red Sea (Leading

by personal example)• The Israelites and the Amalekites

(The importance of alignment)• The Golden Calf ( The importance of

vigilance and teamwork)• Manna from heaven (Romanticizing

loss)• The Report of the Scouts (Personal

transformation)

The Leader Under Fire

• Remove the “I” from the issue.• Focus on Substance

Define problem areasDefine 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

time-lines• Document improvement on a daily

basis• Approach this with ferocity,

equanimity, class

Problem Definition and Resolution

• Define the problem precisely and concisely

• State the magnitude of the problemYour perspective?Their perspective?

• Stakeholder analysis and boundary management

• Confirming/disconfirming data• What tools are needed?• Leadership approach• Specific goals and

strategies/timeline

Managing Your Boss

• Develop and maintain a relationship that

Fits both your needs and styleIs characterized by

mutual expectations Keeps the Boss informed Is based on dependability and honesty

Selectively uses your Boss’ time and resources

Balances the razor-thin line of change

What to Expect

• Maslow’s Hierarchy of Needs (physiologic to self-actualization

• Expect them to act in their own self-interest

• Expect them to treat you as a “hospital-based physician”

• Expect them not to have courage-Bismarck’s wisdom

• Expect them to see the ED as an immensely confusing place (Corollary-do the Virgil maneuver)

• Expect them to hold you accountable for a system over which you have little or no control or authority

Aphorisms

• Find your deep joy• It’s not about power-it’s about

results• People can only be so happy for

you-and that’s not very happy• Relying on the cavalry is risky• Nothing is always a good thing to

say-and often a good thing to do• Patience-then the bold move

Aphorisms

• When you’re ready to talk, they’re not ready to listen.

• Don’t go looking for No-No can always find you-Look for Yes

• Invest in people-good people can always fix the process

• Gratitude is rare-appeal to self-interest

• Actively foster a reputation for discretion-listen always and actively-speak rarely

• Step to their side• Be kind, be kind, be always kind

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.

Albert Schweitzer, MD Out of my Life and Thought

THANK YOU!

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