The Daunting Challenge of Leading Clinical Transformation

Find out what makes successful leaders and review an action plan to strengthen your leadership skills.

The ability to generate and direct clinical transformation is a key attribute for any successful physician leader. As one delves deeper into this topic, it is apparent that there are two overarching perspectives involved in clinical transformation.

First, the term “clinical transformation” should be viewed as a re-engineering of the workforce and care processes at the local level, as well as health care sector transformation at a more global level.

Institutions exist not only in a local micro environment, but also in a macro environment in which the framework of patient care tends to be dictated by government policy, risk and liability, payment methods and the science of medicine.

Therefore, the primary task for a physician leader is to recognize that clinical transformation is a broader and more complex undertaking than just changing institutional policies and procedures.

Second, clinical transformation should be viewed as a leadership issue. What does the term “leading” mean in the context of clinical transformation? In our view, leading a clinical transformation process commands the same leadership attributes as leading a change process, a department or a large institution. It is critical for us to understand what leadership is and how a physician should seek to acquire the necessary skill sets to be a competent leader.

Leaders in health care are under similar economic, regulatory, human resource and cultural stresses that challenge leaders in other industries. Over the past 20 to 25 years, health care has been undergoing structural transformation that is affecting almost every aspect of our industry. This transformation includes, among many other factors: the way the business is run, information technology that supports it, rapid growth in applied technology and biotechnology, regulatory burdens, society’s demand for access, timeliness, patient safety and the changing reimbursement system.

In its landmark 1999 report, To Err is Human the Institute of Medicine noted that “health care is not as safe as it should be.”1 A substantial body of evidence points to medical errors as a leading cause of death and injury. Since the 1999 IOM report, there has been a renewed effort to improve health care delivery, quality, reliability and safety. Progress has been mixed at best and, in many instances, difficult to measure.2

Questions that need to be asked are:

• Why has improvement been so hard to achieve?

• Why is it that so many hospitals and health systems appear to be mediocre in their customer service and patient outcomes?

• Can we just lay the responsibility on direct care providers? Or, should we also look elsewhere?

• Could the present state of our health care system be the product of marginal leadership, among other things? In non-health care sectors failure of senior leadership is without a doubt the number one issue facing companies that are in decline.3 Are we to assume that somehow health care is different?

So if you find your hospital or health system in decline or stagnant, take a close look at your leadership. Ask yourself, “What is the state of our senior leadership system?”

Now, sit back for a moment. Consider your organization and its leaders, physicians, nurses and administrators. Think of critical questions that you might ask about your hospital’s leadership system. During the rest of this article, let us help guide your thinking by suggesting some critical factors that you might want to consider.

Keys to Success

Successful leaders exist within successful leadership systems. However, saying this is just too simple. Putting it another way, organizations are like families. Leo Tolstoy once said, “All happy families resemble one another, each unhappy family is unhappy in its own way.”

Similarly, all successful leadership systems have a great many attributes in common, but failed leadership is much more particular. Leadership is more than making decisions and giving direction in an organization. Leadership is about creating a culture of achievement, a willingness to pursue excellence, and the mental toughness to eliminate the mediocre. This is very difficult to do because within each organization there are competing agendas that have to be balanced. Recall the old, but true adage that an organization’s culture will trump organizational strategy every time.

Leaders, even the successful ones, may from time to time get off track and fail to set the proper direction for their organization. The process of “derailment” occurs slowly, and is the result of a complex set of internal and external circumstances.3 Derailment of any leader consists of five stages.3

1. The first stage consists of the failure of leaders to be self-aware and aware of others in that they lack concern for others and do not see the impact of their behaviors on the leadership team and its ability to function in an aligned fashion.

2. The second stage is characterized by pride and arrogance in which the leader projects himself/herself as the center of the organization’s success.

3. The third stage of a leader’s failure is when the leader misses early warning signs that usually come from persistent feedback about his/her declining performance.

4. Stage four occurs when the leader begins to rationalize his or her actions and he/she believes that they are right despite what the data shows.

5. Stage five is when the actual derailment occurs. The leader is notified that he/she has been fired, or simply when the organization starts to fail.

The concept of “Level 5 leadership” was popularized in 2001.4 Level 5 leadership was defined as a leader who builds enduring greatness through a paradoxical blend of personal humility and professional will. In other words, leaders who achieve greatness for their companies do so by not being dictators, but by serving their constituents and stakeholders, a concept sometimes described as servant leadership.5

What is it about successful leaders that unsuccessful leaders do not have? Successful leaders are able to inspire the people they are leading. They are able to do this by first being inspired with a cause. They create an organizational vision and define the direction the company will take. They become servant leaders, essentially sacrificing their own personal needs and desires for the larger goals of the organization.

This has been referred to as “higher-ground leaders” who have an intimate relationship with their inner purpose and the future that inspires them.5 Higher-ground leaders have been characterized using the acronym CASTLE, which denotes six important characteristics:

1. Courage

2. Authenticity

3. Service

4. Truth

5. Love

6. Effectiveness5

So, how can a leader gain the higher ground?

Great leaders move us through their words and deeds — sometimes referred to as primal leaders.6 Primal leaders capture and inspire the workforce using emotional intelligence that allows them to connect to those they are leading at a more visceral level. One can most readily observe EI occurring in sports teams. Strong coaches are able to inspire the team at an emotional or visceral level. But does it occur in health care organizations? Or are health care organizations, by the nature of their work, ill-suited for EI?

Primal leadership traits are noted in this table.6 These categories of traits consist of personal, emotional and organizational traits. As you review these traits, ask yourself these questions: “If I am a leader, have I acquired these traits/skills? If not, how would I proceed to develop them?”

Looking at leadership traits from a different perspective, data were analyzed from 360-degree feedback reports from more than 450 Fortune 500 company executives in order to find out why leaders fail.7 The results from this study noted the 10 most common leadership shortcomings:

1. Lack of energy and enthusiasm: They see new initiatives as a burden.

2. Accept their own mediocre performance: They overstate the difficulty of reaching targets.

3. Lack of clear vision and direction: They believe that their only job is to execute.

4. Have poor judgment: They make decisions that are considered not to be in the best interest of the organization.

5. Don’t collaborate: They avoid peers, act independently, and view other leaders as competitors.

6. Don’t walk the talk: They set standards of behavior or expectations of performance and then violate them.

7. Resist new ideas: They reject suggestions from subordinates and peers.

8. Don’t learn from mistakes: They may make no more mistakes than their peers, but they fail to use setbacks as opportunities for improvement.

9. Lack interpersonal skills: They make sins of commission (abrasive and bullying) and omission (aloof and unavailable).

10. Fail to develop others: They focus on themselves to the exclusion of developing subordinates.

As you can see, strong, visionary and emotionally connected leaders who actively listen to their employees, team-build, communicate effectively and continually try to improve their leadership skills will ultimately be successful and lead their organizations to higher levels of performance. We believe the following action plan will help guide you as you develop your leadership skills.

Action Plan

First and foremost, it is important to try and understand your own personality, what drives you as a person, how you respond to stress, and the way you are viewed by others.

Analyzing your own personality is a must for any leader. We all have strengths and weaknesses. Our communication styles differ and can influence how a leader is perceived. Evaluating oneself through various psychometric testing tools is crucial for any potential leader.

The use of the Myers-Briggs personality inventory is an accepted tool used by many organizations.8 Also, an additional personality inventory test that is sometimes used is the Whole Brain Dominance test.9 The Whole Brain inventory looks at the four quadrants of the brain and links brain dominance and thinking preferences.

The use of an executive coach is another tool that you should consider. Coaching and mentoring, particularly early in your career can save you a lot of difficulty as you gain leadership experience. A leadership coach should be experienced in coaching and mentoring, preferably not in the same industry sector and able to maintain client confidentiality. Our preference is to use a licensed psychologist with coaching credentials.

Role modeling is another tool that should be considered. Select three or four outstanding leaders in your community, either within or outside health care and learn from them. Interview them and study their behaviors and learn how they manage difficult issues. Volunteer to participate in as many committees and administrative functions in your organization as possible. In each circumstance study the participants and role model only those individuals who exhibit behaviors that demonstrate service to their team, commitment to the task at hand, honesty, integrity and good judgment.

As a leader, you are expected to be facile with a number of business skills, such as knowledge of finance and accounting, process management, health care law, ethics, strategic planning, etc. These skill sets can be acquired through formal management degrees such as MBA or MHA or other certification processes offered by various organizations.

Practice written and oral communication. In order to lead individuals to your vision you must be able to communicate effectively through a variety of media. Be open to having your writing style analyzed. Practice writing each day on any topic. A good idea is to write articles for a journal or online outlet of your choice. Becoming a well-published expert goes a long way toward developing your leadership credibility. Videotape yourself speaking and have your executive coach review and critique your style.

Be aware of your body language. Taking a course in body language or reading a book on it will help you avoid giving the wrong signals to others and at the same time help give you the advantage at meetings or negotiations. Part of presenting yourself is how you look and dress. Successful leaders understand the importance of presenting a successful image. Always be personable and present an image of optimism.

Honesty and integrity in all activities and interactions is a primary hallmark of a successful leader. Say what you are going to do and do what you say. Walk the talk, be aware that you are on stage at all times.

Be visible to your constituents. Leaders that hide in their offices miss the multiple opportunities to influence, lead, and create the necessary human networks that drive business success.10

Transformation

Now, let us turn our attention to the second half of the phrase “leading clinical transformation.” What does the term transformation really mean? It means to change processes or activities, using technology accelerators that significantly improve the delivery of care, the quality of care, and ultimately, the patient’s experience. In the context of patient care, it would imply providing better care at a lower cost and driving organizational performance more efficiently and safely.

More specifically, the Institute for Health Improvement suggested that in order to achieve the value proposition in health care delivery, four things need to be accomplished.11

1. Deliver all indicated services at the right time.

2. Avoid services that are not helpful to the patient or are not cost effective.

3. Avoid safety hazards and errors that harm patients and employees.

4. Respect patients’ unique needs and preferences.

Clearly these are the goals of everyone who works in health care today, yet our view is that the health care industry has not achieved these goals universally.

In 2012, the Commonwealth Fund, using the concept of the medical home, proposed a model for transforming primary care and this may ultimately provide the framework for the entire health care industry, by incorporating these key change concepts:12

1. Engage the leadership system into making the necessary changes, including redirecting the culture of the organization to support the needed transformation.

2. Develop a quality improvement strategy that identifies opportunities for improvement that uses rapid cycle change methods.

3. Link more effectively patients to their providers to facilitate continuity of care.

4. Create an environment of team-based care ensuring adequate cross-training of staff to better deal with absences and turnover.

5. Use decision support technology to systematically plan care and ensure that care is based on the evidence in the literature.

6. Create the necessary changes in the culture that will include patients in the decision making process.

7. Ensure that patients have access to their care team and their own clinical information.

8. Provide for effective transitions of care.

Where do you start with such a daunting challenge of clinically transforming your organization? The reality is that to transform health care into a 21st century system requires a comprehensive approach. A 2005, article suggested a roadmap for clinical transformation that might help you going forward.13

• Commit to a strategic process, not a project. Leadership of any organization should recognize that undertaking clinical transformation is a strategic initiative and not a project. Management, the board of directors, physicians and nurses must have a shared vision, goals and the necessary resources, along with a long-time horizon, in order for this to be successful.

• Declare and support a senior executive champion. This is a critical step because moving the direction of clinical transformation down into the hierarchy of the organization will only guarantee failure. The organization must maintain strategic alignment and focus which can only be accomplished by assigning this process and accountability to a senior leader.

• Openly debate the critical decisions and then make the decisions. This activity should be assigned only to high level decision-makers in the organization, including physicians, and should be monitored on regular basis. Since clinical transformation potentially is a very long process, adjustments in organizational strategy, budget and technology may have to occur over time.

• Ensure adequate resource allocation for people and time. This is a difficult task since organizational budgets tend to get focused on infrastructure, supplies and personnel costs and the “soft” costs of development, learning and experimentation tend to be underfunded.

• Embrace process redesign. Adopting some process change methodology like Six Sigma or PDCA into the daily activities of the organization and ensure that these activities are supported by adequate communications, funding and decision-making.

• Define your metrics. Without the use of prospectively designed metrics, understanding and agreeing as to the progress of the transformation process will be difficult, at best.

• Use national standards, guidelines and evidence-based practices, if they exist. The use of standards will provide some assurance that the best practices available will be employed throughout the organization.

• Operations must drive the initiative with support from information technology. Since clinical transformation extends across the entire organization, across all specialties and departments, horizontally and vertically, the process must be managed and directed by the operations function of the organization where there is adequate accountability, leadership and staff support.

Leading clinical transformation is undoubtedly a complex and, at times, daunting task. Yet, steadfast commitment to learning, self-assessment and personal development can equip physician leaders for great success in this arena. Just as clinical transformation cannot be achieved overnight, physician leaders should approach this endeavor with long-term commitment and patience.

Eugene Fibuch, MD, CPE, CHCQM, FACPE, FABQAURP, was professor emeritus at the School of Medicine and co-director of the physician leadership program at the Henry W. Bloch School of Management at the University of Missouri in Kansas City.

Arif Ahmed, BDS, PhD, MSPH, is an associate professor of health administration in the Henry W. Bloch School of Management, and co-director of the physician leadership program, at the University of Missouri in Kansas City.

REFERENCES

1. Kohn LT, Corrigan JM, and Donaldson MS (eds): To Err is Human. Institute of Medicine. 1999. National Academy Press, Washington, D.C.

2. Wachter, R. M. (2010). Patient safety at 10: Unmistakable progress, troubling gaps. Health Affairs, 29, 165-173.

3. Kabcenell K, Nolan TW, Martin LA, Gill Y. The Pursuing Perfection Initiative: Lessons on Transforming Health Care. 2010. White paper. IHI. Pp. 1-31.

4. Wagner EH, Coleman K, Reid RJ, Phillips K, and Sugarman JR. Guiding transformation: How medical practices can become patient-centered medical homes. 2012. Commonwealth Fund, publication no. 1582.

5. Nolan K, Schall MW, Erb F, Nolan T. Using a framework for spread: The case of patient access in the Veterans Health Administration. 2005. Journal of Quality and Patient Safety, Vol. 31 (6), pp.339-347.

6. Irwin, T: De-Railed. 2009. Thomas Nelson, Inc, Nashville Tennessee.

7. Collins J: Good to Great. HarperCollins Publishers. 2001. New York, N.Y.

8. Secretan L: Inspire: What Great Leaders Do. 2004. John Wiley and Sons, New Jersey

9. Goleman D, Boyatzis R, and McKee A. 2002. Primal Leadership. Harvard Business School Press, Boston Massachusetts.

10. Zenger J, and Folkman J: Ten fatal flaws that derail leaders. 2009. Harvard Business Review, June.

11. The Myers & Brigg Foundation. myersbriggs.org

12. Herrmann N. The Whole Brain Business Book. 1996. McGraw-Hill, New York.

13. Peters T, Austin N. A Passion for Excellence. 1985. Random House, New York,