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Leadership for Great Patient Flow Thom Mayer, MD, FACEP, FAAP President and CEO BestPractices, Inc 800-910-3796

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Presentation on theme: "Leadership for Great Patient Flow Thom Mayer, MD, FACEP, FAAP President and CEO BestPractices, Inc 800-910-3796"— Presentation transcript:

1 Leadership for Great Patient Flow Thom Mayer, MD, FACEP, FAAP President and CEO BestPractices, Inc 800-910-3796 Email:

2 Defining the Elements of Flow 1. Cycle Times 2.Reduced Variation, Increased Predictability, and Improved Forecasting 3. Systems Thinking Service Transitions Alignment of Incentives 4.Empowered providers Exceeding Expectations 5.Demand Capacity Management

3 This isn’t Quantum Physics…

4 Strategic Optimism

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

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

7 All meaningful and lasting change is driven by INTRINSIC motivation


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

10 Leadership is the art of “resistance management.”

11 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.

12 Uneasy rests the head that wears the crown. Shakespeare

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

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

15 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.

16 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?

17 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…

18 BestPractices’ Vision Creating the FUTURE of Emergency Medicine Through Our Commitment to- The SCIENCE of Clinical Excellence The ART of Customer Service The BUSINESS of Execution

19 What’s the difference between Leadership and Management? Do the differences REALLY make any difference?

20 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.

21 Leadership Management Envisioning Strategies Alignment Empowerment Direction setting Execution Planning Budgeting Organizing Staffing Controlling Problem Solving

22 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.

23 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

24 Most companies are over- managed and under-led. John Kotter

25 The Wisdom of Warren Bennis Managers do things right- Leaders do the right thing.

26 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!”

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

28 So Which Would You Rather Be… A LEADER ? A MANAGER ?

29 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

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

31 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

32 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!”

33 Is this a Leadership Issue or a Management Issue?

34 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?

35 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

36 Is this a Leadership Issue or a Management Issue?

37 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”

38 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.”

39 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…

40 Questions on Leadership and Management?

41 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

42 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

43 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.

44 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

45 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)

46 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


48 Leading Change John Kotter 1. Increase urgency 2. Build the guiding team 3. Get the vision right 4. Communicate for buy-in 5. Empower action 6. Create (invent?) short-term wins 7. Don’t let up 8. Make change stick

49 Change Management Abraham Maslow

50 Change Management Kurt 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

51 Driving & Restraining Forces Case Study #5 You are the Chair of a busy and (previously) highly successful ED You 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!

52 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

53 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

54 All great storytellers know… It’s not just the story you tell, it’s how you tell it!

55 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…”

56 And the world changed…

57 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!”

58 And the world changed…

59 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!”

60 And the world changed…

61 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?

62 “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


64 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.”

65 ER Doc Administrator


67 “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.’ “


69 Negotiation As Change Management The 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)

70 The Leader Under Fire Remove the “I” from the issue. Focus on Substance Define problem areas Define areas of improvement and measuresListen, 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

71 Problem Definition and Resolution Define the problem precisely and concisely State the magnitude of the problem Your perspective? Their perspective? Stakeholder analysis and boundary management Confirming/disconfirming data What tools are needed? Leadership approach Specific goals and strategies/timeline

72 Managing Your Boss Develop and maintain a relationship that Fits both your needs and style Is 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

73 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

74 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

75 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

76 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


78 References - Developing Leadership 1.Augustine, NR: Managing the Crisis You Tried to Prevent. Harvard Business Review. November - December, 1995. 2.Fisher R and Brown S: Getting Together: Building Relationships as We Negotiate. Penguin Books, 1988. 3.Mayer T: Leadership, Management, Stewardship, and Motivation. In: Salluzzo R, Mayer T, Strauss R (Editors) Emergency Department Manager: Principles and Applications. St. Louis, Mosby, 1997. 4.Mayer T: Departmental Integration Strategies. In: Salluzzo R, Mayer T, Strauss R (Editors). Emergency Department Management: Principles and Applications. St. Louis, Mosby, 1997. 5.Mayer T: Managing Professionals in Organizations. In Salluzzo R, Mayer T, Strauss R (Editors). Emergency Department Management: Principles and Applications. St. Louis, Mosby, 1997.

79 6.Zaleznik A: Managers and Leaders: Are they different? Harvard Business Review, March - April 1992: 126-135. 7.Kotter JP: What Leaders Really Do. Harvard Business Review; May - June, 1990: 103-111. 8.Farrell JR, Robbins MM: Leadership Competencies for Physicians. Healthcare Forum, July/August 1993. 9.Bennis W: On Becoming a Leader. Reading, Massachusetts, Addison-Wellesley; 1989. 10.Block P: Stewardship: Choosing Service Over Self-Interest. San Francisco, Berrett - Cohler Publishing, 1993.

80 11.Senge PM: The Fifth Discipline: The Art and Practice of the Learning Organization. New York; Doubleday: 1990. 12.Herzberg F: One More Time: How Do You Motivate Employees? Harvard Business Review; September - October 1987. 13. Kohn A: Punished by Rewards: The Trouble With Gold Stars, Incentives Plans, A’s, Praise, and Other Bribes. Boston: Houghton Mifflin, 1993. 14.Kohn A: Why Incentive Plans Cannot Work. Harvard Business Review, September - October 1993.

81 15.Allison EJ, Vawter JW: Strategic Planning and Missions Statements. In Salluzzo R, Mayer T, Strauss R, (Editors). Emergency Department Management: Principles and Applications, St. Louis, Mosby, 1997. 16.Mayer TA: The Role of the Emergency Department Medical Director. In Salluzzo R, Mayer T, Strauss R, (Editors). Emergency Department Management: Principles and Applications, St. Louis, Mosby, 1997. Kotter JP: John P. Kotter on What Leaders Really Do. Harvard Business School Press, Boston, 1999. Kotter JP: A Force for Change: How Leadership Differs from Management. Free Press, New York, 1990.

82 Stewardship Block P: Stewardship: Choosing Service Over Self-interest. Berrett-Koehler. San Francisco, 1993. Frick DM, Spears LC (Editors): On Becoming A Servant Leader: The Private Writings of Robert K. Greenleaf. Jossey-Bass, San Francisco, 1996. Block P: The Answer to How is Yes. Berrit- Koehler, San Francisco, 2002.

83 Change Management Kotter JP: Leading Change, Harvard Business School Press, Boston, 1996. Kotter JP: Leading Change: Why Transformation Efforts Fail. Harvard Business Review, 1995; 73: 59-67. Kotter JP: The Heart of Change, Harvard Business School Press, Boston, 2002. Lewin K: Field Theory and Social Science, Harper and Row, New York, 1951. Lewin K: Group Decision and Social Change. In: Maccoby EE, Newcomb TM, Harthy EL (Eds). Readings in Social Psychology (3rd Ed) Holt, Reinhardt, and Winston, New York, 1958.

84 Boundary Management Hirschhorn L, Gilmore T: The New Boundaries of the Boundaryless Company. Harvard Business Review, 1992; 70: 104-115. Gilmore T, Leadership and Boundary Management. Journal of Applied Behavioral Sciences, 1991; 18: 343-356. Schein EH: How Can Organizations Learn Faster? The Challenge of Entering the Green Room. Sloan Management Review. Winter 1993: 85-92.

85 Negotiation Fisher R, Ury W, Patton B: Getting to Yes: Negotiating Agreement Without Giving In. Pennwooden Books, NY, 1991. Shell GR: Bargaining for an Advantage: Negotiation Strategies for Reasonable People. Viking, New York, 1999. Ury W: Getting Past No: Negotiating Your Way From Confrontation to Cooperation. 1991, New York, Bantam Books. Sebenius JK: Six Habits of Merely Effective Negotiators. Harvard Business Review 2001; 74: 87-95.

86 Teams and Teamwork Katzenbach JR, Smith DK: The Wisdom of Teams: Creating the High Performance Organization. Harvard Business School Press, Boston, 1993. Oncken W, Wass DL: Management Time: Whose Got the Monkey? Harvard Business Review, November-December 1999: 179-186.

87 Leadership Styles Goleman D: Leadership that Gets Results. Harvard Business Review, March-April 2000: 78- 90. Execution Bossidy L, Charan R: Execution: The Discipline of Getting Things Done. Crown Business, New York, 2002. Charan R: Profitable Growth is Everyone’s Business, Crown, NY, 2004.

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