Wednesday, October 31, 2007

Passion and vision

As I travel around the CHRISTUS system, and often when I present to other organizations, two questions that I often receive are: 1) how do you become a visionary, and 2) how do you create passion in an organization?

Although the answers to these questions must be filled with artful thinking rather than scientific approaches, they have been asked so frequently that I recently forced myself to reflect on a more meaningful articulation of the answers to give a better understanding of how you incorporate vision and passion into your professional competencies and therefore into the organization which you lead.

Let’s begin with vision. I think many people believe that visionaries are in some ways sprinkled with angel dust so that the future actually becomes real in their dreams. However, for me, vision must come from people who are embedded in the realities of today, having a clear understanding of how today works, so that their predictions for the future are made with this reality in mind (which hopefully will lend credibility to these predictions).

Footed in this clear understanding of today, a visionary then takes the time to look back and ask the question, “What changed from the past, what caused these changes, and hence, what are the results of these changes that made the present look like it is today?”

This knowledge, then, is helpful in determining the similar causal events that will change today to create a predictable future. An example of “visionary thinking” is my belief that numerous diseases will be cured in the next 10 years, and some new diseases will be introduced. I say this because I have watched tuberculosis, polio and nine types of childhood leukemia--which were prevalent 25 years ago--be cured. The causes for these miraculous events were the focus on understanding the infrastructure of medications and how they worked at the cellular level. This knowledge has been magnified at least a million-fold in these 25 years, which guarantees for me that we will more rapidly eradicate present diseases in the future. I am predicting that more childhood leukemias and adult cancers will be cured, and that Alzheimer’s and Parkinson’s disease may in fact be so well controlled that they can be managed much more easily at home or in outpatient settings.

And yes, there will be some new diseases identified. Why do I believe this? When I look back on my 40 years of travel, I can recall that AIDS was not a recognized as a disease for the first 32 years, and Fifth disease, a viral self-limiting disease in children, was never listed in the pediatric text book which was my bible in med school for child care. Today, however, we are all familiar with the prevalence of AIDS, and studies show that 40 to 60 percent of adults worldwide have laboratory evidence of a past infection of Fifth disease.

So what diseases might be identified in the future? I would definitely expect some in the area of infectious disease, and perhaps several new types of cancer that will appear in the very elderly, as we are seeing people living 100 years or more who will have at least 30 years more exposure to environmental contaminants than previous generations.

In addition to understanding the reality of today and the ability to look back and use the past as a barometer of the future, true visionaries who are creating believable and worthwhile visions also are constantly monitoring environmental, social, political and technological trends based on current data. There are an array of articles and organizations that can provide this information, and a true visionary devotes sufficient time to incorporate the learnings from these trends into their predictive processes.

And at the end of the day, I would also have to admit that if you are comfortable as a visionary, you will take some educated guesses and, occasionally, make a prediction which is less sound (but still possible), with the intent of socking your audience so their ears will always be attentive.

Although we have many futurists and visionaries speaking on the national circuit today, my concern is that many of them are not working in health care or have not worked in health care, and hence their predictions of the future are not based on their clear understanding of today and their ability to look back and use their past experience as a strong predictor of the future. The absence of these two competencies gives me less confidence in the visions that they are seeing.

With regard to passion, I consider it the ability to believe in the vision you have created and sign people up to follow you toward this vision. For me, passionate people who are able to create passion in others are—first and foremost—fully knowledgeable regarding the content of the subject they are delivering. They are able to “connect the dots” between everything they have done in the past, are presently doing and planning to do in the future. They are able to provide believable rationale for what they are doing, and they are able to create soundness in their vision by driving it via the pieces that I outlined above.

Clearly the second competency of creating passion is a passionate style of delivery. And although this will vary from person to person and is best done by delivering charismatic, engaging and rapidly-moving speeches on stage, there are many people who are passionate but are uncomfortable with this type of delivery. The common characteristic of a passionate style is delivering your thoughts in such a way that people truly believe that you mean it and somehow feel the passion exuding from every pore in your body. Consistency of presentation, whether it be the hand-waving type or with quiet style, is a key ingredient, because the one thing that causes people to question passion is inconsistency in leadership performance.

And this leads to the final ingredient: people will only believe that you are passionate if you are credible, which in today’s world means that you “walk the talk”: do what you say you are going to do, do it in the timeline to which you have committed and hold yourself accountable to the goals you have set.

If you are to be a visionary and passionate leader, you must work at developing these competencies, devote the time necessary to studying and dreaming about the future, and people must see a halo of vision and passion over your head when they see you coming.

Wednesday, October 24, 2007

Effective Teaming

Although I talked at great length about teaming in my last post, I would like to share some additional thoughts about the qualities of strong teams which I shared with the CHRISTUS Senior Leadership Team as we sat in Chicago waiting to accept our leadership award last week.

It has always been clear to me that teams are grown, rather than born. Consequently, I particularly wish to share with you what I believe has helped to fertilize the growth of our team over the last nine years.

First and foremost, teams must become comfortable with making individual sacrifices for the good of the whole. As we formed CHRISTUS Health and determined that our new location would be in Dallas rather than in Houston or San Antonio (where the two current corporate offices were housed), numerous team members had to make the sacrifice of moving to new geographical areas. For some, the timing was not right because of children’s ages or because they were fully integrated into the communities where they presently lived. In addition, the simultaneous movement of spouses always presents a challenge. But when the decision was made that certain senior team members needed to be in the Dallas office, they voluntarily made the moves and overcame the challenges. In addition, new office space needed to be developed, and because it wasn’t ready immediately when we transitioned to Dallas, we needed to sacrifice and meet in a hotel or other location for an interim period of time. Developing a strong team with a large number of moving parts at the beginning is not always ideal, but yet this was a building block for our strong team’s functioning as we continued our Journey to Excellence.

Secondly, strong teams have to tolerate high anxieties. The original team members were designated as “interim” since they did not know if the new CEO (that is me) would want to continue to support them, nor did they know whether they would want to work for him or her. However, they continued to be very loyal, focused and hard-working as we formed together an outline of what we would need to accomplish in CHRISTUS’ first 60 days. I would like to point out that every member of that original team is still part of the team nine years later.

Third, strong teams need to develop trust—a trust for each other’s judgment, knowledge and commitment to do what we say we are going to do. This trust develops over time and is only enhanced through the years by a team that is strong. Clearly, this may be the hardest competency to develop because we are people with all the characteristics of imperfect human beings. Everything we have done has not turned out perfectly, but our trust in each other is enhanced by debriefing on and learning as much from our failures as our successes.

Next, excellent teams manage transitions well. We have had two COO transitions in the first eight years of our journey, during which I served as the COO for a nine month period in 2000 and a two-and-a-half year period from 2004 to 2006. In August of 2006 we recruited another member of our Senior Leadership Team who fulfills the COO responsibilities. He has transitioned onto our team quickly, becoming a full-fledged member and fully accepted into the organization.

Also, excellent teams are innovative. Once again, our team has demonstrated this in many ways. Some examples of this include our movement into Mexico and our transition of our portfolio to one-third acute, one-third non-acute and one-third international.

Excellent teams must also take risks, and our team’s list of risks would be quite extensive. It would include our willingness to enter international markets as well as our acquisition of the Stehlin Foundation for Cancer Research. Although we were loosely connected with this center before we acquired it (they were located on one of our campuses), we recently became full owners of it, and have, therefore, entered the drug development field. We are taking this risk not because we think it might bring a great financial reward, but because we believe that the Stehlin Foundation has a great possibility of introducing several life-saving drugs for severe cancers that people all over the world now endure. It is important to note that CHRISTUS also took a risk and spent over $20 million in developing the artificial rib for children born with a hemi-thorax in the late 80’s and early 90’s. This apparatus is now FDA-approved and has been touted recently as one of the 20 most significant advances made in the orthopedics in the last 75 years. This serves as just one example of a risk supported by a strong vision which resulted in a life-saving legacy for many people.

Excellent teams also need to know how to “garage sale,” to go through their assets and determine what no longer makes sense for the good of the ministry. Our team has taken this task to heart, and through our eight-and-a-half years, has exited markets and programs, leaving in their places much more innovative ways to provide new and better services in those communities.

Strong teams also plan and manage growth. They are willing to adopt new “children” and assimilate them into their family. We have many new locations and new partnerships which have strengthened the CHRISTUS family through geographical distribution, service expansion and diversity of people.

Resiliency is the next trait that is critical to strong teams. Resilient people remain optimistic during difficult and challenging times, and although they may temporarily find themselves in a valley or on a detour on the journey, they never lose sight of the destination regardless of how high the summit might be. Our Journey to Excellence, although it has be steadily progressing, has had leveling off points where we have gotten stuck in some of our improvement plans, but as a team we have never given up nor lost sight of the end point.

And finally, excellent teams like ours are committed to continuous, life-long learning. We are constantly sharing articles, reviewing journals, pouring over environmental assessments and networking with others to determine the latest trends, technology, etc. As a result, we are developing an innovation institute which will bring together—in a virtual way—all the programs and people necessary to build the future health of care on our successes, one that will serve a greater number of people in a larger number of places, giving them the right care at the right time in the right place.

A strong team is essential for any organization to reach excellent goals, and I hope my last few posts will give you better insight as to what those competencies are required for those teams and how they might be developed.

Wednesday, October 17, 2007

What Makes an Outstanding Leadership Team?

Last week, CHRISTUS’ Senior Leadership Team was at the Top Leadership Teams in Healthcare conference in Chicago to accept their award as the 2007 Top Leadership Team in Healthcare for large hospitals and health systems from HealthLeaders Media.

The team was recognized for embarking on a steady path to excellence in leadership teamwork since it was created in 1999 and using a commitment to excellence in clinical quality, service quality, financial performance and value to the community as the pillars of an organizational turnaround.

You can read more about the award here.

In a prior post, we reviewed the competencies that health care leaders need to incorporate into their toolboxes in order to be successful during the present times and for at least the immediate future.

These competencies are all developed by fully integrating knowledge and experience, and are often enhanced and grown by having a coach or mentor who can teach--and more importantly--demonstrate them in their activities of daily leadership. However, it is clear that the presence of these competencies in individuals will not necessarily guarantee that the team with whom they work will also share them, and as a result, be efficient and effective.

However, it is my observation that while the competencies for strong leadership teams are identical to the necessary individual competencies, they in fact must be looked at in relationship to team interactions and team building.

This is best understood by looking at several examples. An extremely important competency is always the ability to listen to others and determine the meaning of what you’re hearing. For much of our day’s activities, this could refer to individual listening, but for team building, this means you must be listening to multiple voices simultaneously and analyze what the collective voices are saying. You also must develop the ability to be a good team player, to weigh the rationale behind each voice (particularly if the voices are in disagreement on an issue), and make a determination regarding which rationale is most accurate which will then lead you to support any or all of the part of the voice which it is driving.

So in summary, your listening skills for teaming must go to another level, one which is more complex and more demanding.

Expressing your views based on sound knowledge is also an important competency. For individual conversations, this is often driven by more limited knowledge and can be more quickly influenced by emotional interactions. In a group setting--where you have many more minds that likewise hold knowledge--it is much more necessary to clearly articulate what you know about a subject and to minimize the emotions in the presentations, since this will often cause polarity in a group, which is certainly more detrimental than if one person is dissatisfied with your position for a period of time.

Therefore, my hope is that you will revisit the core competencies that were presented in last week’s blog post and determine--like I did with listening and expressing your views based on knowledge--how the other core competencies may be interpreted and applied in the same way to a team setting.

In addition to these competencies, strong teams must believe that the value of the team interaction is more valuable and creates better decision-making than would occur if the members of the team made the decisions in isolation. Team interaction includes four steps:
1. being open to listening to the views of others
2. expressing your views in a way that creates credibility and clear understanding of what you believe are the facts and what should happen
3. being open to having your mind changed based on what you have heard from others
4. supporting the consensus of the group, not only at the conclusion of the meeting, but particularly when you are leaving the room.

These behaviors are the essence of a strong leadership team.
Strong leadership teams are built of people who exhibit all the core competencies and also have the ability to interact well with other members by adhering to the above four behaviors.

Wednesday, October 10, 2007

Core Competencies for Leaders in Health Care

Just as the practice of medicine has changed significantly over the last decade (an example of which is the use of laparoscopy surgery vs. open incisions), leadership competencies have significantly changed for people who want to create excellent organizations. In fact, in the past, most leadership capabilities have been centered around courses included in a core curriculum in Masters of Health Care programs. However, recently most training organizations and accrediting bodies for health care leadership have come to understand that although these courses provide a foundation for necessary learning, they don’t necessarily create the core competencies that are required for leaders to reach the goals for excellence in their organizations which we have described in prior posts.

This knowledge must be combined with experience to create an integrated approach to developing competencies which we in CHRISTUS Health have clearly defined. Our 23 core competencies are listed below, and were based on what we as a senior team determined were the leadership skills necessary to reach benchmark practices in our four directions to excellence within the next three to five years in all parts of our international system.

Core Competencies
Dealing with ambiguity
Business acumen
Conflict management
Customer focus
Timely decision making
Decision quality
Managing diversity
Ethics and values
Hiring and staffing
Innovation management
Integrity and trust
Learning on the fly
Motivating others
Priority setting
Problem solving
Process Management
Drive for results
Strategic agility
Managing vision and purpose

To understand core competencies in a practical sense, I would use my own medical training as an example. In medical school, based on the traditional medical student curriculum, I was exposed to and learned the basics of anatomy (how the body is put together), physiology (how the body works) and pathology (how the body functions when it is broken). However, in order to become a competent surgeon, I needed to combine this knowledge as the basis for understanding and learning the surgical competencies that were required to perform and have positive outcomes in procedures as simple as a hernia repair and as complex as a whipple procedure for pancreatic cancer.

In specialty training, it would be unthinkable for anyone to believe that the curriculum-driven courses that we took in medical school would have been adequate to permit us to practice particularly interventional specialties following graduation. Therefore, for many years, specialty training had to be accrued through a residency program driven by clear evidence that you not only performed an adequate number of procedures, but that the mortality and morbidity levels associated with the procedures you performed were within an acceptable level.

The same principles now hold true for executive and administrative leaders in health care, and therefore not only do our leadership training programs have to embrace the core curriculum, but also the integrated core competencies and teach them to their maximum level in our graduate training programs as well as in our organizational development programs within CHRISTUS health. This is essential, because health care is so complex and is forever changing. A leader in health care today who does not commit to continuous core competency-driven lifelong learning should as quickly as possible transition out of the health care profession.

Wednesday, October 3, 2007

Toxic side effect: Valley Baptist and Evidence-Based Medicine

Recently, a group of physicians in the Emergency Department (ED) of Valley Baptist Hospital in Harlingen, Texas, announced they would resign in December, claiming the hospital administration’s focus on metric results could reduce the doctors’ income and compromise patient care. Specifically, they said the hospital’s goal of reducing emergency room wait times and operating-room turnaround time was putting patient care in jeopardy. Hospital administrators said their goal is to maintain high standards of patient care, and that staff and physicians are expected to adopt the new standards.

Meanwhile, at an emergency meeting, 121 of the hospital’s 136 physicians voted to support the ED doctors’ decision to resign, saying the physicians’ departures served as an example of “poor administrative leadership” by hospital leaders. The doctors said they would ask the hospital’s board of directors to investigate the reasons behind the vote and take action. You can read more about the disagreement here.

Luckily, the two groups were able to reach an agreement last week that will allow the physicians to continue practicing at the hospital for at least the next five years. (You can read more about that here.)

The actions of this medical staff’s vote of no confidence for the administrative team could, on the initial blush, be seen as a vote of non-support for evidence-based medicine. However, anyone in health care would be hard-pressed to state that utilizing procedures and processes in the treatment of patients that is not supported by evidence create better and more sustainable health care outcomes.

So in essence, what is the problem here? Rather than coming to the conclusion that evidence-based medicine is wrong, it is best to reflect on the following missteps, which were probably undertaken when the administration’s otherwise acceptable protocols on evidence-based medicine were introduced into Valley Baptist Hospital.
1. The administrative staff did not reflect adequately on the toxic side effects of these changes, i.e., the expected pushback one gets with the introduction of guidelines—and discuss them openly with the medical staff so that all parties were prepared for the physician’s professional pushback. The importance of determining in advance the toxic side effect of any change was discussed in my post, “The Toxic Side Effects of Change.”
2. The distribution of these guidelines in draft form for vetting by the physicians or at least the medical executive committee of the staff appears to have been lacking. This process would have given the physicians an opportunity to present their acceptable exceptions to these guidelines and provided the administrators with an opportunity to determine where flexibility might have been appropriate in their implementation. Ownership of guidelines based on evidence-based medicine is required by all members of the health care team, but especially by nurses and physicians.
3. It appears that the administrative staff might have ignored one of the best ways to develop ownership of what could be considered controversial guidelines: by implementing them in several pilot areas in the organization, after which administration and physicians could together commit to reviewing the findings of the pilots (the lessons learned), and then make any changes necessary and acceptable before the guidelines are instituted hospital-wide.

As I have stated in prior posts, health care is complex, and making appropriate transitional transformational changes in health care is a mammoth undertaking. But because there is wide variation in the performance and outcomes of health care providers in the U.S., as proven by multiple reports over the last several years, including “To Err is Human” from the Institute of Medicine, the development of practice guidelines based on evidence-based medicine is essential. And because it is my belief that most physicians and nurses want to practice the very best that health care has to offer because of the sacred work we are doing to care for patients and their families, they willingly and quickly want to support and implement evidence-based guidelines. Therefore, I believe that the resistance we have seen specifically in this instance (but we recognize occurs in most organizations when change is fostered), is predominately the result of the process of implementation rather than with the evidence-based guidelines themselves.

Hopefully, the several steps outlined above will make this process better and could provide learning both for Valley Baptist and other organizations that are implementing these necessary changes.