Leadership in Healthcare

Why is leadership important? In most businesses, including healthcare, we find over-management occurs. Over-management refers to doing a lot of management tasks rather than leadership tasks. We are over-managed and under-led. Tasks need to be managed, and people need to be led.

Leadership is a learned skill. We think of people as 'born leaders', but that is not true. Leadership is a learned skill and research shows that it is directly connected to outcomes. Good leadership leads to good outcomes. Bad leadership leads to suboptimal outcomes. It's important for us to focus on leadership. 

Management v. Leadership

Manager is a job description. Management is something you do. A manager is someone who supervises or directs others; that could be a line supervisor or even a corporate president. Everyone from lowest level supervisor to highest level president is a manager. Management includes tasks like planning and setting objectives. We refer to 'managing your resources, ' which could be human resources or financial resources. We manage things to achieve objectives and we measure our results. Management is a process.

Leadership is a little different, because a leader is someone who is there to guide and inspire others. It could be guiding their actions. It could be guiding and inspiring their opinions. It's someone who takes the lead in an enterprise or a movement. Leaders have followers and leader is a role as opposed to a job description.

Peter Drucker describes leadership as lifting people's vision to a higher level, raising performance to a higher standard, and building personality beyond its normal limitations. In this definition, leadership is an event as opposed to a task or a job description. Another way of looking at it is that management is "Who is going to do what and when are they going to do it"? Leadership is, "How are we going to do it and why are we doing it?" You can see from these definitions that leadership and management have different connotations. Figure 1 includes a summary of these differences. To be successful, you need to develop both management and leadership.

Figure 1. Management v. leadership summary. 

Traditional Leadership Roles in Healthcare 

In traditional healthcare leadership roles, we have executive leaders. These may be referred to as the C-suite; the chief executive officer, the chief operating officer, and the chief financial officer. Executive leaders may also include vice presidents, assistant vice presidents, and there may be other layers depending on the size of the organization. Executive leadership may also include directors and managers. Examples may be a director of cardiopulmonary services, or a manager of a department.

 

Clinical leadership roles in healthcare include doctors, nurses, therapists, multidisciplinary teams, and others. Ideally, both executive leaders and clinical leaders are important. It would be hard to imagine an organization that could function with strong executive leadership, but a lack of leadership on the clinical side.  And vice versa, an organization does not succeed if you have excellent clinical leaders who don't have support at the executive level. Both types of leadership are crucial in healthcare.

Leadership: Why Do We Need It?

Most organizations do routine employee satisfaction surveys annually or every other year. Happy employees make happy customers and, in our case, that would be happy patients. It is important that our employees are satisfied. Issues impacting employee satisfaction may be salary, benefits, and schedules, which are all management issues.

Most companies or hospitals or departments, however, find that the major issues affecting employee satisfaction are leadership-related failures. Leadership-related failures include things like employees not knowing or understanding the company's vision; poor communication from senior management; and, when employees are not involved in planning and decision-making. These leadership-related failures can all be fixed with effective leadership and it doesn't cost a cent to do that.

Communication Strategies 

Communication is important and employees value transparency. Transparency includes the what, where and how of work.

Three Keys to Transparency: Asynchronous, Scheduled, Multimodal

There are three keys to keep in mind with transparent communication: make it asynchronous, scheduled, and multimodal.

Asynchronous means avoiding communication that only happens at a specific date and time, so it can be accessed anytime. Scheduled refers to the fact that communication is not haphazard; it occurs regularly. Multimodal communication is critical because people learn things in different ways and people receive information in different ways. We want to give employees information in different ways to align with learning needs and preferences. For example, some people might like audible information. They might like you to record something that they can listen to. Some people prefer the visual modality, so they like to read information or watch a video. For effective communication, the message should be available in different formats.

Preplan, Strategize, and Pinpoint

In addition, it's important to plan, strategize and pinpoint what we will communicate on a consistent basis. The frequency may be daily or weekly. I recently worked for an organization that included five hospitals in the system and multiple other organizations, and we instituted a daily huddle at the beginning of each shift. We worked 12-hour shifts so there was a 7:00 AM and a 7:00 PM huddle for the people starting their shifts.

Multiple Formats

Deliver the same information in multiple formats at the same time. At my previous organization, in addition to delivering information in the huddle, we would deliver those messages in other ways. We'd send an email. We would post it on the board. We did not do a lot of audio-visual communication, but maybe we should have.

Frequent Feedback

Feedback is important in communication. If you have a training, for example, you need to get feedback.  After the training, you give feedback on who completed it, who needs to complete it, and how it is going.

If you are instituting something new on a particular patient care unit, ask for feedback and give feedback frequently.

Employee Retention and Satisfaction

Employee retention and satisfaction is an important part of leadership and management. We know that there's a lot of turnover in healthcare, and that it has increased recently.  Eighty-two percent of hospitals report their nursing turnover rate is 15 to 20% annually. That means if you have 100 nurses on January 1st, by December 31st, only 80 of them will still be there. That's considered a fairly high turnover rate and in many institutions, the turnover rate is even higher. A standard to aim for is turnover of 10% or less.

 

As managers, we need to evaluate turnover to see who left and why they left. Turnover may mean employees are not happy. A good organization will make sure that they get that information from employees when they leave. Sometimes employees may tell us that they didn't have effective leadership and communication and that's why they're leaving. They don't want to work in an organization where they do not feel like they know what is happening. Sometimes there are good reasons for turnover. For example, a small department may have a large number of retirements happening in the same year, which may push the turnover number up. 

How Does Effective Leadership Affect Quality in Healthcare?

Leadership is linked to quality. Leadership affects the quality of patient care and that includes safety. The personality and behavior of leaders may contribute towards quality through the effects they have on the culture of the department.

How does a leader's personality affect safety in high stress environments? Some of this research comes from the airline industry. Research with airline crews found error levels were lowest where the leaders were considered to be warm and friendly and self-confident. There are other studies that have shown that teams produce less errors if they consider their leaders to be intelligent, self-confident, determined, honest, and social.

We have some studies in health service leadership where staff and leaders were asked what makes a good leader. The responses included: 

• More "servant leadership"
• Less "promotional leadership"
• Fostering teamwork and creativity

Some people responded that "more servant leadership" was the quality of a good leader. Servant leadership comes out of the Christian faith model that we exist to serve our followers. Servant leadership is not limited to the Christian faith, and this leadership model is used in healthcare and other industries. It's fairly similar to transformational leadership. Others indicated "less promotional leadership". Promotional leadership means we promote someone into a "leader position" not because they have exhibited great leadership skills, but because they've been with the organization for a certain amount of time and then they are automatically promoted to the next level. Promotional leadership doesn't work very well and employees know that. Lastly, fostering teamwork and creativity is something that makes people think you're a good leader. Fostering teamwork and creativity are examples of actions we can take as leaders to reduce stress, enhance satisfaction, and improve quality, within our organizations. 

Errors in Healthcare 

Healthcare is a stressful environment and we want to give the best possible care in the safest possible manner. We're human and we make mistakes, regardless of the industry we're in. However, in healthcare mistakes can be deadly. What affects quality and safety? When it comes to errors, consider: How errors are reported; when errors are reported; what is the outcome; and, what is the climate/culture in which errors are reported.

Dr. Lucian Leape, a professor at Harvard School of Public Health, testified before Congress on Health Care Quality Improvement. He stated, "The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes." You may be familiar with a case in the national news recently about a nurse who was punished to the greatest extent possible for a medical error. That got a lot of people in healthcare thinking about how it will affect our error reporting. If we punish people for making mistakes, will people be less inclined to report their own errors?

How Are Errors Reported?

Consider how errors are reported. We need a process in place that supports early, easy reporting of errors and also near misses. A near miss is where something didn't go exactly as it should have and although it didn't cause harm to the patient this time, the next time it could. The error reporting system should pick those up, so that we don't continue to do things that might harm the patient. If we make reporting difficult, people are just not going to do it. 

Brigham and Women's Faulkner Hospital, wrote a definition of "Just Culture" as a system of shared accountability, where the organization is accountable. There should be systems in place that are designed for responding to the behaviors of employees in a fair and just manner. Employees, of course, are also accountable. Employees are accountable for the quality of their choices. We all make choices and we have to make good ones. Employees are also responsible for reporting errors and system vulnerabilities. Often, it's up to the frontline leader to kind of foster this environment and that could be you. You could be the team leader, the shift leader, lead therapist, or the department manager and you want to encourage people to bring these errors to the forefront. Most importantly, the culture of your department and hospital needs to support this. The culture is important in order for people to be comfortable bringing errors forward. One of the things we talk about is when are the errors reported?

When Are Errors Reported?

We want to encourage staff to report errors early. We want to begin the process of identifying what went wrong as soon as we can.

Are staff encouraged to troubleshoot as they work? Are they looking for accidents waiting to happen? I had a staff therapist come to me when I was a director and he said, "When I enter these patients' rooms and I put an oximeter on their finger, sometimes I get a really bad reading and they're on oxygen. They have the cannula in their nose and I follow their tubing back, and what I find is that the nurses have stuck tubing together without the connectors". He found the tubing was coming apart, because they had up to seven-foot lengths of tubing so they patient could keep their oxygen on while they went to the bathroom. He came to me and he said, "We need to figure this out. This is not working." We assembled a team who found that seven-foot oxygen tubing is pretty much standard. They also make oxygen tubing in longer lengths. If you work in home care, we have 50-foot oxygen tubing that we use for people in their home. We then started stocking the 21-foot length, so that when we had a patient who needed to get further away from their bed with their oxygen on that we could give them a longer tube, instead of sticking things together. In this case, we didn't have a patient who had an adverse outcome, other than a drop in their saturation that we picked up. This therapist was able to troubleshoot this problem and find a solution to it, which may have helped reduce or prevent medical errors in the future.

With medical errors there may be a snowball effect, where little problems become bigger over time. If something is a minor issue we may be tempted to put it on the back burner. However, any little problem that you identify can become a bigger problem over time so it is best to address issues when they are identified. 

Lastly, remember that the leader sets the tone every single day.

What Is the Outcome?

Consider whether solutions and strategies are worked on as a team. The best example of this that I know of is root cause analysis, which we did as part of the Joint Commission process for accreditation. The basic idea is to assemble a team to examine all the possible causes of an error, problem, or near miss and then consider solutions. Again, this is done as a team, with all kinds of people that have some relationship to the error or the potential error.

Consider staff accountability. Staff have to be accountable for the outcome. Management also has to be accountable for the outcome.

Consider how to communicate solutions. Once solutions are developed, how do we ensure that everybody knows what the solution is? That can be a huge undertaking, as it may impact many patients in many areas. A lot of education may be needed.

Positive feedback is essential. We need to keep everyone updated on what we are working on, our ideas of how to solve problems, and how the solutions are working. This is an important part of the outcome.

Leadership Styles

Leadership Style and Stress Level

Stressed staff produce lower quality care and we know that leadership style and ability can affect that stress level. There are many styles of leadership, but the two major leadership styles I will discuss today are transactional and transformational. Transactional leadership is the traditional view where the leader has power and authority over the followers. They use that power to get things done, and to achieve their goals and objectives. The transactions tend to be rewards and punishments. if you do a good job, we reward you. If you don't do a good job, we punish you. In healthcare, we tend to be more oriented toward punishments, and part of that is because it is difficult to find ways to reward employees. A transactional leader focuses on the here and now, and may deal with the problem at hand and what is happening today. Transactional leadership does not really focus on preventing future events, which is important to quality and safety. This style has been in existence for a long time and is still common today. 

Transactional leaders can be more or less active in how they lead. The active transactional leader, through an exchange with subordinates, emphasizes the giving of rewards if subordinates meet agreed-upon performance standards. The less active transactional leader practices avoidance of corrective action (management-by-exception) as long as standards are being met. This is best explained by the old adage, “if it ain’t broke, don’t fix it.”

Transformational leadership is where the leader is charged with identifying a needed change, creating a vision to guide and inspire the change, and executing the change along with committed members of the group. A transformational leader empowers staff and promotes the process of sustaining quality and safety. Transformational leadership is recognized as the best style for eliciting high-quality, safe changes in healthcare.

Four Dimensions of Transformational Leadership

The four dimensions of transformational leadership (Bess & Riggio, 2006) are:

1. Individualized consideration
2. Inspirational motivation
3. Idealized influence
4. Intellectual stimulation

Individualized attention is attending to each of the followers needs like a mentor, a coach, a guide. Inspirational motivation is where you express a vision that inspires and motivates others. Idealized influence is where the leader becomes a role model for their followers. Intellectual stimulation is how leaders take risks, challenge assumptions, and solicit ideas from followers.

There are behaviors that we would commonly see in a transformational leader. Transformational leaders: articulate a vision; set a positive example; communicate high performance expectations; show sensitivity to individual followers’ needs; encourage a team attitude; and provide intellectual stimulation.

Research shows that groups led by transformational leaders show higher levels of performance than groups led by other types of leaders. Transformational leaders' high expectations give their subordinates the self-confidence to persist in the face of setbacks, often resulting in exceptional performance. Things do not always go smoothly, and transformational leaders give their subordinates self-confidence to manage bumps in the road. Transformational leaders develop exceptional performance in their followers.

Other Leadership Styles

Other leadership styles include: Servant leadership; Mindful leadership, focused on mindfulness; Laissez-faire leadership, or hands off leadership; Authoritarian leadership, which is similar to transactional leadership; Participative leadership, which is similar to transformational where people are participating; and Delegative, which delegates things to other people in our group. There are other leadership styles; this is not an exhaustive list.

Transactional Tasks and Transformational Leaders

Sometimes it's hard to function as a transformational leader in healthcare because some healthcare functions are inherently transactional. Centralized performance monitoring, clinical auditing, re-accreditation, and central error reporting are examples of transactional tasks. The more centralized the functions in an organization, the harder it is for a leader to give their staff discretion and allow the kind of participation that is needed for transformational leadership. The key is trying to find balance.

How does the leader translate centralized, regulatory messaging to their staff? Remember that the leader shapes the culture of the department. If the Joint Commission is coming for re-accreditation, there will be a lot of transactional tasks for the department. The leader could delegate or we could get our team together and talk about how to accomplish the tasks. What is our vision? What are some things that we think that we could do better than we're doing? We can move into a transformational mode, but it can be difficult. Developing

Developing Personal Leadership Skills

Management tasks can be learned. Look at how many types of management degree programs exist. Many colleges will have 10 or 12 different management degrees that they offer. Can we also develop leaders - can leadership be learned?  Yes. leadership can be learned and there are leadership skills that we can develop. Enhancing leadership skills positively affects the culture of a department or organization. When we improve the culture, we improve the quality and safety.

Personal leadership skills include active listening, managing conflict, decision-making, and strategic thinking. Those are personal skills a leader can develop. We also have skills that fall under the staff development category. Leaders should develop their staff, by empowering their followers and building teams. In order to develop these skills in employees, leaders must have them as well.

Active Listening

Active listening refers to making a conscious effort to hear. It means not just hearing the words that another person is saying, but trying to understand the whole message. It is not as easy as it sounds. Tips for active listening are included in Figure 2.

Figure 2. Active listening tips.

 

How do you pay attention when you are really listening to someone who is telling you a story? You make eye contact with them to show them you are focusing on them and what they're saying. You observe their body language, because their body language may give you a different message than their words. You remove any distractions by muting your phone and turning off the television. Your body language should be open so that they know that you are willing to receive what they're saying. You want to give them encouraging comments that indicate you are very interested in what they have to say. You want to provide feedback, such as reflective statements. An example is, "Do I understand you correctly? This is what I'm hearing - can you clarify if this is what you are saying?"  In addition, you want to defer judgment by listening to the whole story without interruption. And finally, respond appropriately. Once you've heard the story, be candid in your response. Your response could be, "Thank you so much for telling me all of this. Here's what I'm going to do next". Sometimes you have to defer the result, because you need more information or have to talk to others, but you can still be candid in your response.

Managing Conflict

Managing conflict is not something that most leaders look forward to doing. It's difficult but important. Sometimes the best solutions to problems come out of constructive conflict resolution. When we have people who are on opposite sides of the fence and we put our heads together to solve a problem, the solution may be better than what either group may have come up with otherwise. Conflict can increase understanding of others' viewpoints. It can build trust. It can strengthen workplace relationships. It's important that we manage conflict constructively.  As a leader, dealing with conflicts among co-workers, between supervisors and employees, and even between employees and customers can have a significant impact on a department’s success. Tips for managing conflicts are shown in Figure 3.

Figure 3. Tips for managing conflicts.

The first tip to managing conflicts is to stay neutral. Don't jump to conclusions. Don't decide that you already know what the answer to this conflict is before you've heard what the people have to say. You're the judge and you're going to not jump to conclusions until you have heard all the evidence. Acknowledge the problem; do not minimize the problem. Even if you do not think it is a big problem, that is not okay for you to say. You do not want to tell people in conflict that they are making a mountain out of a molehill and it is not a big deal. Focus on the problem, not the people. Difficult employees are not the problem, even if you know Joe and Mary are not agreeing on something and there have been other issues in the past where Mary did not agree with people. Seek common ground rather than think of Mary as a "difficult employee". Find any areas of agreement (there is usually more than one) between the two parties, or the two segments of your department who are in conflict. Be patient. You need to listen, listen, and listen more. Use those active listening skills that we just talked about. Listen, then act. Be decisive. If you have all of this information and you do not do anything with it, that tells people that you are completely ineffective.

Decision Making

All of us are confronted with decisions every day. Some are minor and others are potentially life-changing, difficult, and challenging. Considerations for sound decision-making are listed in Figure 4.

Figure 4. Considerations for sound decision making.

When making decisions, keep in mind that are no guarantees. We work with the best information we have. An example in respiratory therapy is extubation. How do we know it is time to take the tube out? We gather information by looking at the patient, test results, x-rays, and other evidence to make that decision. However, there is no guarantee and a certain percentage of patients who we extubate will need to have the tube put back in. 

When making decisions, look for opportunities. Look at the past and present, and use each success and failure as education. For example, if we have a lot of patients who are failing extubation, we examine why they failed. We review the information we had to see if we missed something or if there was another test we could do. Keep in mind that hindsight is not always 20/20. Healthcare changes very quickly, and what happened in the past may not be as relevant today. I remember my first management job in a hospital setting. We wore buttons that said "Because we've always done it that way" inside a circle with a red slash through it. They were reminders that we were never allowed to use the fact that we've always done things a certain way as justification.

When making decisions do not let fear get in your way. Fear of failure is the biggest obstacle to any endeavor. If you are constantly afraid that you're going to make the wrong decision, then you basically will not make any decisions. Not making a decision is a decision in itself, and not an effective one.

Don't second guess yourself. It doesn't inspire confidence. If you've made a decision and then the next day, you say I'm not really sure. Maybe, that's not such a good idea. Maybe, we should think about it again. The people that follow you will not have any confidence in your decision. 

Strategic Thinking

Strategic thinking is a broader and more innovative way of thinking about the overall goals of your job, team, and organization. It is oriented to the long term, with a systemic and holistic view of the environment.

The three keys to strategic thinking are vision, strategy, and execution. Vision refers to a clear picture of the desired result or goal. Strategy is mapping a plan to get you from where you are to where you want to be. There are some good tools that you can find and use to map out your strategy. Execution refers to the discipline and courage to see it through. Strategic thinking is a process that can be used for the smallest or largest of change projects.

Developing Leaders Within a Department

 

Developing leaders within a department has both practical benefits and “feel good” benefits. John C. Maxwell is a writer on topics related to management and leadership, and he said, “The one who influences others to follow is only a leader with certain limitations. The one who influences others to lead others is a leader without limitations.” 

The idea here is that you are a better leader if you develop other leaders. Practically, it is less expensive to develop our own homegrown leaders within our departments than to hire people from the outside. Developing our own internal leaders also provides succession planning so that there is continuity in the organization when the leader leaves, moves into another role, or retires. That supports organizational stability and growth, which are important. Developing internal leaders may increase job satisfaction, increase buy-in from staff, and reduce turnover. Staff may be more interested in sharing responsibilities and working with us, which makes everyone feel good and makes your job easier. This is not the same thing as promoting someone from position A to position B with a new job title and new job salary without developing them in any way. 

Empowering Followers 

Developing internal leaders is about empowering people. To empower followers, focus on these areas: communication, reward and recognize, support, problem-solving, and suggestions.

Promote open communication and transparency. Always provide context. When we give someone a message, they know what it means and what it is about. Defining roles is also key to communication. What is your role? What is their role? What is someone else's role? Be very clear on that.

Reward and recognize self-improvement. If an employee has gone out and done something on their own, reward and recognize that. Encourage safe failure. Allow people to work on projects and if it does not turn out as planned, they know they will not be punished for that. They will be rewarded for getting involved and trying. Encourage your staff to get engaged and involved.

Of course, you also want to support them. Support staff independence, which is empowerment. They need to be able to make some judgments om their own. Appreciate the efforts that your staff and at the same time require accountability. Staff have to be accountable for what they do.

Problem-solving with your followers can help to empower them. Problem-solving or improvement is not the same as complaining. As a leader, we try and see through complaining to determine the problem, and then engage in problem-solving and improvement with our followers. 

To empower followers and support them with problem-solving, we provide suggestions. We ask questions such as: 

• Can you clearly define the problem/challenge/obstacle?
• Does this problem affect only you or others in the department/organization?
• What are all possible causes?
• What are all possible solutions?
• What do you think is the best solution?
• What is your willingness to be involved in the solution?

 

Define the issue clearly. Find out who it affects because then we can all work together on a solution. Determining causes and solutions is similar to root cause analysis that we discussed earlier. Sometimes people will bring us a problem, and they want us to fix it. However, to empower followers, they should also be involved in the solution.

Building Teams

Building teams is probably the most important skill of a leader. If you're going to be a successful leader, you have to have teams that can work together and help you out. Chain and Link Theory refers to the fact that a chain is only as strong as its weakest link. if you are a good leader, but do not have a strong team, then the chain is not strong because those links are going to break.

 

We need to make sure that our teams are well developed. Who does the majority of work in the department? Who are natural leaders? What happens when you are not there? One of the most rewarding things for me as a leader has been knowing that I have a great team on nights and weekends when I am not there. You want to know that when you leave the building, things are in good hands. You are not going to be getting calls when you are not working because nobody knows what to do. Develop teams that function just as well when you are not there as when you are there.

Successful teams have good leaders. so choose good people. Successful teams play to win and make other team members more successful. Successful teams also keep improving and aim to always be doing better and better. The key is great leadership at the top. Essential to this process is understanding what motivates others and creating a culture of success. 

Building a successful team starts with the hiring process. Hire people that are open and coachable, who want to improve themselves. Ensure you know what the job requires so that when you hire someone and put them on a team, they understand the expectations. Know your staff, what their motivations are, and what rewards them. Those are important features of team building. 

Take Home Thoughts

Good leaders make good quality, safe patient care, which is what our profession is all about. I would like to leave you with some quotes on leadership to reflect upon.

Jane Goodall: "What you do makes a difference and you have to decide what kind of difference you want to make." That's true for all of us, regardless of what position we're in.

Sam Walton: "Outstanding leaders go out of their way to boost the self-esteem of their personnel. If people believe in themselves, it's amazing what they can accomplish." 

Robin Benincasa: "You don't inspire people by showing them how amazing you are. You inspire them by showing them how amazing they are."

John Quincy Adams: "If your actions inspire others to dream more, learn more, do more, and become more, you are a leader."

Mario Batali: "One of the most important leadership lessons is realizing you are not the most important or the most intelligent person in the room at all times." Check your ego at the door. 

Joel A. Barker: "Vision without action is merely a dream. Action without vision just passes the time. Vision with action can change the world." 

And my last take-home thought is this:  "You manage things. You lead people." 

 

Questions and Answers 

One of your slides indicates that 82% of hospitals report that their nursing turnover rate is about 15 to 20% annually. That's a pretty high number. What are your thoughts on that?

It is a high number. We all know that there's a lot of turnover in the nursing profession and those numbers may be increasing. It is a bad financial decision to take actions that drive turnover because turnover is expensive. It is expensive to recruit and train new employees to replace those that leave. It is important to find out why people are leaving. Employees often cite a lack of effective leadership and poor communication as reasons for quitting. Sometimes we do not make an effort to interview people who leave; they simply complete an exit form. We should focus more on finding out why people are leaving, and the person doing the exit interview should not be the person's manager. Most employees will not tell their manager, "I"m leaving because you are a poor leader." The human resources department or upper-level leadership is responsible for finding out why people leave and how they can take steps to do things differently and retain employees. It is not just a financial issue. New employees do not have as much on-the-job knowledge as seasoned employees and may place a burden on existing staff. Also, positions may go unfilled for a while, burdening existing staff. Managing turnover and increasing retention is an important part of leadership.

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