Leadership in Health Professions

MY PHILOSOPHY OF LEADERSHIP

            According to Burns (2012), a philosophy of leadership is a working document which continues to grow and change as new skills, knowledge and experience is gained.  This is certainly true as I reflect on how my idea of what constitutes leadership has metamorphosed through the years.  In 1991, writing on the leadership role of the Clinical Nurse Specialist, I stated that “… leaders in nursing … are able to envision future goals for nursing, clients, the organizations in which they work, as well as for whole communities and the world at large” (Turner, 1991).  At the age of 31 years, and just venturing upon my advanced practice role, I believe this was a good start.  Since that time, of course, I have learned and continue to learn, that this is just that; a start; with much more to build onto.

Leadership requires much more than having a vision or goals.  Once must be able to effectively communicate and share that vision with others, so that they too, may see the dream.  Inspirational speaker and author, Stephen Covey, advises, “start with the end in mind”.  As leaders, we must be able to envision what the unit, organization, community, health setting, world, will look like at the end of the project.  But that also, is not enough.  “Vision only becomes powerful if shared with others” (Shanta and Kolanek, 2008).  An effective leader must be able to communicate the vision to those who are expected to take action and implement the vision (Shanta and Kolanek, 2008).  In order to do this, a leader must have not only intellectual ability, but also emotional competence; something we, the DNP cohort, have been reading and studying about recently in our Leadership course.

An important component of emotional intelligence is relationship management: how we relate to subordinates, peers, and colleagues.  A leader must be able not only to speak effectively to relate their vision to others, but also to listen.  Some of the best outcomes of any project or incentive I have experienced is a result of “brainstorming” and listening to various ideas of the team.  Not only does this spur energy and motivation, but also ownership and energy to accomplish the goal.

In developing a philosophy of leadership, Burns (2012), suggests we begin by defining the top three work-related values that motivate us to achieve outcomes for organizational success.  I thought about what these three values are for me.  This also comes not long after participating in the vision and mission meeting with the Dean, Senior Faculty, Assistant Professors and Staff regarding the direction of Emory University.  Many values were discussed, to include those the Emory University Nell Hodgson Woodruff School of Nursing presently embraces: Social justice, excellence.   Are these just words, or are there associated behaviors?

According to Burns (2012), “a philosophy gives leaders an opportunity to learn more about what they truly stand for, how their values support their beliefs, and what actions need to be taken to turn those beliefs into reality.  The first step in formulating a philosophy of leadership, Burns continues, is therefore to identify one’s own three work-related values.  I have thought long and hard about this very question, and combined with my results from having taken the Strengths-Based Leadership Inventory (2007), I have come to identify mine:  1) To treat others as myself, 2) A strong work ethic to include continued learning to improve outcomes and the world at large, and 3) Teamwork.  Treating others as I would wish to be treated incorporates the values of honor, respect, and integrity.  This is congruent with my Strengths-Based Leadership Results (2007), which indicate that I “consider people more important than things” and that “the value [I] place on humankind guides my decision-making.  In having a strong work ethic, I challenge myself and others to achieve and continually grow.  In doing so, I engage others to talk about ideas, concepts, theories; come up with questions and seek to answer them; and challenge our current way of thinking about things.  My work inspires me and in so doing, I hope to inspire others as well.  Through collaboration, I believe that together we can accomplish more than any one of us can alone.  We are more than the sum of our parts.  Together, we can change our world and leave it better than the way it was inherited. It is easy to see how these essential values are woven into my philosophy of leadership: Humanity, Integrity, Challenge, Inspire, Collaboration.  In the words of Max Depree (in Burns, 2012), “The first responsibility of a leader is to define reality; the last is to say ‘Thank You’. In between the two, the leader must become a servant.”

 References

Burns, J. (2012). Defining reality: The importance of articulating a leadership philosophy. OT Practice, 17(20), 19-20.

Covey, S. (1989). The 7 Daily Habits of Highly Effective People. Free Press: Detroit, MI

Shanta, L. L., & Kalanek, C. B. (2008). Perspectives on nursing leadership in regulation. JONA’s Healthcare Law, Ethics & Regulation, 10(4), 106-111.

Spurr, S., Bally, J., & Ferguson, L. (2010). A framework for clinical teaching: A passion-centered philosophy. Nurse Education in Practice, 10(6), 349-354. doi:10.1016/j.nepr.2010.05.002

I originally posted this on the Week 11 page on Thursday, but for some reason it is “awaiting Moderation” so I am reposting here.

Measurability and Sustainability

My DNP project seeks to transform the obstetric triage and admissions process at Ben Taub General Hospital into one that is safe, highly reliable, patient centered, and cost effective. The scope of the project is dependent on the institution, but above all, I hope to change the culture of the obstetric intake area to one of respect, not only for patients and families, but also for residents, nurses, and others.

In order to make any changes sustainable, I must be able to show that the changes benefit the hospital financially, as well as key stakeholders such as patients and staff (Fraser, 2007). I must also engage the leadership of the organization, and align the project with the priorities of the hospital, because sustainable projects have full support of an organizations leadership (Bodenheimer, 2007).

One way to measure the improvement that would include measuring the cost-effectiveness of the project is a balanced score card. Because Ben Taub is a not-for-profit community hospital, the framework would include customers & stakeholders, employee organization capacity, internal business processes, and financial elements, all coming from the strategy of improvement for obstetric triage and admissions (Rohm, H., n.d.).To develop the performance measures, the improvement team can search the literature for evidenced-based performance measures, and select relevant measures for each of the four areas of the balanced scorecard framework (Safdari et al., 2014). In order to prioritize the measures, we can create a Pareto chart, which will help us identify the interventions likely to have the most impact, as well as survey key stakeholders (Fraser, 2007; Safdari et al, 2014).

Ensuring that the project is aligned with the organizations values and mission makes it more likely that the improvement will be adopted (Greenhalgh et al., 2004). The mission of the Harris Heath System, of which Ben Taube General Hospital is a part, is: “We improve our community’s health by delivering high-quality healthcare to Harris County residents and by training the next generation of health professionals” (Harris Health System, n.d.) My DNP project goals easily align with this mission, but emphasizing the alignment could serve to further engage the leadership, which is key to the projects sustainability (Bodenheimer, 2007).

References

Bodenheimer,T. (2007). The science of spread: How innovations in healthcare become the norm. Oakland, California: California Healthcare Foundation. Retrieved from https://classes.emory.edu/webapps/portal/frameset.jsp?tab_group=courses&url=%2Fwebapps%2Fblackboard%2Fcontent%2FcontentWrapper.jsp%3Fcontent_id%3D_2314971_1%26displayName%3DLinked%2BFile%26course_id%3D_92580_1%26navItem%3Dcontent%26attachment%3Dtrue%26href%3Dhttps%253A%252F%252Fclasses.emory.edu%252Fbbcswebdav%252Fpid-2314971-dt-content-rid-2706800_2%252Fxid-2706800_2

Fraser, S. (2007). Undressing the elephant: Why good practice doesn’t spread in healthcare. Raleigh, NC: Lulu.

Greenhalgh, T., Robert, G., MacFarlane, F., Bate, P., & Kyriakidou, O. (2004). Diffusion of innovations in service organizations: Systematice review and recommendations. The Milbank Quarterly, 82(4), 581-629. Retrieved fromhttp://www.jstor.org/stable/4149085

Harris Health System (n.d.) Mission, vision & values. Retrieved fromhttps://www.harrishealth.org/en/about-us/who-we-are/pages/mission-vision-values.aspx

Rohm, H. (n.d.) A balancing act. Perform: Performance Measurement in Action. 2(2), 1-8. Retrieved fromhttp://balancedscorecard.org/Portals/0/PDF/perform.pdf

Safdari, R., Ghazisaeedi, M., Mirzaee, M., Farzi, J., & Goodini, A. (2014). Development of balanced key performance indicators for emergency departments strategic dashboardsfollowing analytic hierarchical process. 33(4), 328-34. doi: 10.1097/HCM.0000000000000033.

Located in an area surrounded largely by private residences and small businesses, Northside Hospital’s mission is committed to the health and wellness of the community as well as becoming a regional leader in select medical specialties.  The values to support this mission, are: Excellence, Compassion, Community, Service, Teamwork, Progress and Innovation.  To align the culture within the organization with these goals, employee volunteerism and community service are promoted by the organization.  Within the hospital units themselves, “we are committed to balancing clinical excellence with safe, high-quality, compassionate care for our patients” (www.northside.com, 2014).  Like most hospitals, Northside actively seeks feedback through patient satisfaction surveys, conduct extensive quality and performance evaluations, and is continuing to grow its campuses as well as branches throughout the metro Atlanta area, demonstrating great financial stability.

To sustain this growth and success as an organization, many internal business processes must also be addressed on an ongoing basis.  One such measure is a patient’s length of stay in the intensive care unit.  Garland and Connors (2013), reported in a recent study that there is up to a 10% increase in mortality when transfer from and ICU to a medical-surgical area is delayed by 9-20 hours.  This lapse in time and the associated poor outcomes must be improved in order for Northside Hospital to remain a regional leader within our community.  Some objectives aimed to achieve this are, entering transfer orders in a timely manner, prioritizing rooms that need to be cleaned, inputting when rooms are ready efficiently, SBAR reporting processes, and multidisciplinary team rounding to improve communications and planning between team members.

Performance measures to track these activities have been developed.  The three most widely used models to rate ICU performance on mortality are the Mortality Probability Model (MPM), the Acute Physiology and Chronic Health Evaluation (APACHE), and the Simplified Acute Physiology Score (SAPS) (Philip R. Lee Institute for Health Policy Studies, 2014).  Recent literature indicates that the choice of model has little impact on hospital performance assessments (Afessa, 2006).

One strategy that was adopted on the unit to that will aid to sustain this initiative is the use of tele tracking; a system adopted by many hospitals in recent years to improve hospital patient flow and optimizing hospital operations.  Through tele tracking, nurses and hospital staff on the unit are able to enter data for a patient transfer in a timely manner.  Patient placement facilitators can also be placed on this tracking system, to assist with the prioritization of rooms to be cleaned.  When ready, Environmental Services is able to input when the rooms are ready for occupancy (Brown and Kros, 2010).  This is only one of several innovative initiatives that can be to connect organizational capacity, efficient business processes, customer value, stakeholder satisfaction, sustainability performance, and market and financial outcomes for Northside Hospital (Rohm and Montgomery, Balanced Scorecard Institute, 2011).

References

Afessa, B. (2006). Benchmark for intensive care unit length of stay: one step forward, several more to go. Critical Care Medicine.  34(10). 2674-2675.

Brown, E.C., Kros, J. (2010). Reducing room turnaround time at a regional hospital. Quality Management in Health Care. 19(1). 90-102

Garland, A., Connors, A.F. (2013). Optimal timing of transfer out of the intensive care unit. American Journal of Critical Care, 22(5), 390-397; doi: 10.4037/ajcc2013973

Philip R. Lee Institute for Health Policy Studies. ICU outcomes (mortality and length of stay) method and data. Retrieved from http://healthpolicy.ucsf.edu/content/icu-outcomes.

Rohm, H., Montgomery, D. (2011). Link sustainability to corporate strategy using the balanced scorecard. Balanced Scorecard Institute. Retreived from www.balancedscorecard.org

The Fuqua Center provides on-site psychiatric services in 16 affordable housing facilities in Atlanta.  Over the years the model shifted from a primarily nurse practitioner (APRN) model to an LCSW care coordination and APRN care model.  The Atlanta Housing Authority and Atlanta Regional Commission Area Agency on Aging are community champions of this work. Thirty housing staffd, behavioral health providers (both public and private) and WellCare (CM0) consistently attend network meetings aimed at pulling together the vast array of healthcare workers needed to address the psychosocial and medical needs of residents and to create a continuum of psych/ mental health services needed to adequately care for an older adult with mental illness (Sandberg et al, 2014). No one organization provides the continuum of psychiatric services needed to support Recovery.  A barrier to evaluating the financial  impact as well as providing an efficient care coordination model  is that there is no one information system platform  (Sandberg, SF et al, 2014; Graetz, I et al, 2014). The desired outcomes are to decrease hospitalizations/ crisis services utilization and improve housing stability (decrease lease violations and evictions). An average of 119 patients are served a year by the model, with greater demand than capacity to adequately serve residents.

A “Sustainability Map” will assist in developing a strategy based score card for a service which can be expected to evolve over time given the rapidly changing healthcare environment in Georgia and at Emory, as one provider among many needed to adequately care for this vulnerable population (Rohm, H & Montgomery, D, 2011) . The strategy told by a map is to improve Organizational Capacity by identifying an information technology (IT) platform which communicates between key providers allowing for measurement of care coordination and desired outcomes.  The ARC/Area Agency on Aging will through braided funding provide care coordination. The identification of an Emory Healthcare champion which provides technical assistance and NP services is critical to sustainability.  The identification/creation of a an IT platform will create Process efficiencies including the ability to measure care coordination according to AHRQ Care Coordination Measures Atlas standards which include information availability, timely information transfer, treatment goals agreed upon by the array of clinicians (partnering agencies) and agreed upon roles of the various clinicians (partnering agencies) (Graetz et al, 2014). With efficiencies will come cost savings for partnering agencies and the ability to be innovative (add to the array of services or increase capacity). The addressing of organizational capacity and internal processes will increase Customer/ patient satisfaction as well as other stakeholders (housing providers) satisfaction.  Care coordination supported by an IT platform will support the Financial objective of reduced costs (e.g., Medicare/ Medicaid expenses, housing expenses related to lease violations/evictions).

References

Graetz, I, Reed, M, Shortell, SM, Rundal, TG, Bellows, J & Hsu, J (2014) The next step towards making use     meaningful, Medical Care 52(12), 1037 – 1041

Rohm, H & Montgomery, D (2011) Link sustainability to corporate strategy using the balance scorecard Balanced Scorecard Institute

Sandberg, SF, Erikson, C, Owen, R, Vickery, KD, Shimotsu, ST, Linzer, M, Garrett, NA, Johnsrud, KA, Soderlund, DM & DeCubellis, J (2014) Hennepin health: a safety-net accountable care organization for the expanded Medicaid population, Health Affairs, 33(11), 1975-1984

I think there is still a lot to be known about dementia and how much medication is too much.  As is pointed out in this website article, the problem of overmedication of elderly people is increasing to almost epidemic proportions.  In addition, the types of medications that may be prescribed, may increase confusion and cognitive abilities in the elderly; steroids  being a good example.

” Overmedicated seniors have been mistakenly diagnosed with depression, dementia, and even Alzheimers Disease” (www.parentgiving.com).  In my own experience, my elderly father moved into Assisted Living as he was beginning to have an increase in falls, was unable to cook for himself, and had trouble managing on his own.  He was very unhappy with this move however, making him feel as if he had lost his independence, helpless, and powerless.  He did not like having to follow the schedule of the facility, although it was a very nice and people did their best to engage him.  He became increasingly frustrated, depressed, and angry.  He was sent out for evaluation.  At the hospital, he was so heavily medicated, that he could no longer raise his head off the pillow, feed himself, and began to slur his words.  He was confused and began to hit at staff.  This resulted in more medication.  When he was released from the hospital, he had to move to a skilled facility, and he was barely arousable.  He could no longer eat or drink.  He was placed on hospice care.  We were told that he had 3-4 days to live.

Of course, not being able to eat or drink, he was also unable to take any medications.  In the days following, rather than passing, he awoke!  He began to swallow, and eat, and drink, and speak, and even walk with assistance.  The system had failed him, however.  He lost a lot of strength during that time.  He will never be able to walk unattended, or leave the skilled facility.

It is ironic that in looking through the evidence-based literature, there is much on this topic from Australia and the UK, but nothing from the United States of America.  In America, it seems, we have the best system to take care of our elderly, and all of the publications focus on how well we are doing.  But that is not really the case.  One only has to look at what real people are posting about their experiences on the website, such as the articles cited above.  My own experience and sharing with others tells me, also, that there is still much work to be done.

Is the nursing home overmedicating your elderly parent?

Overmedication and Seniors/Problem of Overmedication

Article was accessed through Kaiser Health News at  http://online.wsj.com/articles/a-lesson-from-my-great-aunt-1414708082?KEYWORDS=health+law

From Ellis Island to Ebola: Is Sacrificing a bit of comfort for public health such a great indignity? WSJ October 31, 2014 6:33pm posted

Opinion article by Peggy Noonan

This article, as the title indicates, makes a case for placing all healthcare workers under 21 day quarantine who have cared for a person with Ebola.  The author cites policy since immigration through Ellis Island of monitoring persons at high risk of contracting infectious disease; however, the case is made that policy should be overzealous, and not necessarily science based, in order to eliminate all risk of further exposing members of the public.  The Federal government is faulted for not communicating a policy which supports placing all healthcare workers who have cared for a person with Ebola under 21 day quarantine.

I believe this article and many other articles have pointed to unclear and untimely direction being provided regarding the care of healthcare workers.   This unclear communication reflects poorly on the US Centers for Disease Control (CDC). There have been numerous spokespersons and experts consulted regarding Ebola and an “Ebola Czar” has been appointed but it remains unclear who the “leadership team” is who has the authority and responsibility to of communicating guidelines for healthcare workers.  Lencioni (2014) stresses the importance of a cohesive leadership team in order to have a healthy organization.  Three characteristics of a healthy organization, as described by Lencioni, and appear to missing are

* Defining the leadership team: It is important that the team be small, collectively responsible with a common, well defined objective (Lencioni, p.26). From all appearances, there is not a well defined leadership team with the responsibility of providing guidelines for healthcare workers

*Building Trust: The leadership team must demonstrate vulnerability-based trust, trust amongst the team members which allows members to be transparent, ask for assistance and are complimentary of each others expertise and defer to members of their teams expertise (Lencioni, p. 27).

*And finally, and most pertinent, I believe in this particular case is that the team demonstrate the ability to “Master Conflict.”  Lencioni clearly states “conflict without trust, however, is politics, an attempt to manipulate others in order to win an argument regardless of the truth.” (Lencioni, p.38) I fear that the lack of clear guidelines regarding quarantines, has been lost in politics which results from the lack of vulnerability- based trust among a cohesive leadership team which has the responsibility to communicate clearly guidelines for protecting healthcare workers who as a group  are responsible for protecting the public.

Reference

Lencioni, P., (2012) The advantage: why organizational health trumps everything else in business. San Francisco, California: Jossey-Bass

Remarks by Deputy Secretary Sloan Gibson (Veterans Affairs):

http://www.va.gov/opa/speeches/2014/07_22_2014.asp

This article is an example of a failing health system within the United States.  The VA has recently experienced leadership and organizational challenges which has unfortunately resulted in negative outcomes for patients as well as employees of the VA.  It is my opinion that Deputy Secretary Sloan Gibson outlines clear improvement initiatives in this document and exemplifies qualities of a strong leader.

• Transparency: A key concept for improving quality.  The organization demonstrates transparency in outlying faults in business processes and leadership.
• System Improvement:  The VA recognized the need to improve system processes which are ultimately heavily influenced by leadership and top executives.  Structural changes within leadership were implemented by the Deputy including reallocation of resources and halts to financial incentives for executives.
• Employee Opinion: Gaining data and feedback from frontline employees is crucial in implementing changes within an organization.  Personal interviews among these workers were conducted by the Deputy.   The Deputy also placed an emphasis on valuing and embracing employee opinions rather than penalization for workers who express their perspectives related to work environment issues.

http://politi.co/1n9zCjA VA Whistleblowers to Detail Retribution

According the whistleblowers interviewed for this article, the VA had a pervasive culture of punishing anyone who raised questions about safety, quality, or fulfilling the core values of the VA (French, 2014). The VA’s website states that the core values – integrity, commitment, advocacy, respect and excellence (I CARE) – define the culture of the organization and how it cares for veterans. However, when some employees attempted to make changes that improved the care of veterans, or exposed problems that jeopardized the safety of veterans, they were demoted, sidelined, fired, or sued. In reality, the stated values of the VA culture and the actual values of the VA culture were not aligned, and this misalignment is a serious impediment to organizational health. “The importance of values in creating clarity and enabling a company to become healthy cannot be overstated” (Lencioni, 2012, p. 91).

• A values-based culture is strengthened by leaders who demonstrate application of the values in large a small ways everyway (Daft, 2012). Members of the organization learn the values of the organization by watching the leaders, and not by being told what the values are (Daft, 2012). In an organization with a constructive culture, leaders value whistle-blowers and react swiftly to correct problems for the benefit of the organization, instead of focusing on the harm to a specific department that exposing problems may cause (Daft, 2012). Unfortunately, in the examples cited in this article, employees at all levels valued personal convenience over serving the needs of veterans (French, 2014).
• Core values already exist and do not change over time (Lencioni, 2012). Aspirational values are values that an organization wants to develop (Lencioni, 2012). It is common for organizations to confuse core values and aspirational values (Lencioni, 2012). According to employees interviewed in this article, I would conclude that the VA labeled its aspirational values as core values (French, 2014). Therefore, there was no clarity for employees, which is vital to organizational health (Lencioni, 2012).
• Rolland states that whistle blowing happens in healthcare organizations that place loyalty to the organization above loyalty to the patients (2008). In the Politico article, the general reaction to safety concerns voiced by whistleblowers is to protect the VA and the status quo, at the expense of the patients (French, 2014).  It is the leaders’ responsibility to communicate the ethics and values of the organization, and to be responsive when problems are reported through internal channels (Rolland, 2009).

A well-known example of the ailing organizational health of the VA is the scandal related to wait times for veterans to get appointments. In some instances, schedulers were pressured to falsify wait times for appointments, and many veterans waited months for urgent appointments. (Oppel & Goodnough, 2014). The repercussions of that scandal and the harm in caused to the VA and to veterans continues to make news.

References

Daft, R. (2012). Chapter 10: Organizational culture and ethical values. Organization Theory and Design. Cengage Learning. London. 390-429.

French, L. (2014) VA whistleblowers to detail retribution.  Politico.  Retrieved from http://politi.co/1n9zCjA

Lencioni, P. (2012). The Advantage: Why Organizational Health Trumps Everything Else in Business, Jossey-Bass: A Wiley Imprint. San Francisco, CA.

Oppel, R. A., & Goodnough, A. (2014). Doctor shortage is cited in delays at VA hospitals. The New York Times. Retrieved from http://www.nytimes.com/2014/05/30/us/doctor-shortages-cited-in-va-hospital-waits.html

Rolland, P. (2009). Whistle blowing in healthcare: an organizational failure in ethics and leadership. Internet Journal Of Law, Healthcare And Ethics, 6(1), 11.). Retrieved from http://ispub.com/IJLHE/6/1/9204#

U.S. Department of Veterans Affairs. (n.d.) Mission, Vision, Core Values & Goals. Retrieved from http://www.va.gov/about_va/mission.asp

Congratulations to everyone for a engaging and spirited (get the play on words?) book club about Leadership Conversations by Berson and Stieglitz. Based on my rubric and your peer feedback everyone was 100% successful! I would expect no less from each of you.

As you move forward through your career, and leadership journey hold onto this book. Its a keeper for sure and a great reference manual. My favorite quotation: “Leaders are made, they are not born. They are made by hard effort, which is the price all of us must pay to achieve any goal that is worthwhile.”

Berson.A., Stieglitz, R. (2013). Leadership Conversations (p.127). San Francisco: Jossey-Bass.

I don’t seem to be able to post a comment on Olga’s post (although I could comment on Alex’s and Eve’s!), so I am going to do this as a new post.

This is what I would have said about Olga, if time permitted today:

Based on her profile, Olga is values driven, intuitive about people, a hard worker with high standards, and has a drive to learn and know more. She is not a micro-manager, and will not get bogged down with facts and data, but she will insist on a quality product.  She does not like conflict.

I believe Olga will meet with each team member and get a sense of their strengths and how they might fit together. She will then divide them into small groups of people who can work together well, each with a task. The small groups will report back to her and to the team as a whole. In the meantime, Olga will put in long hours researching best practice for combatting C difficile, and will provide this information to the teams. She will welcome feedback, listen and connect with team members, but will cut short any bickering or conflict by redirecting team members. Her values, sense of purpose, and drive will inspire the team, and her hard work and insistence on excellence will get results.

Am I close, Olga?