Five Elements of Leadership

1. Five Elements of Leadership Linda Tavel, MD MBA FAAHPM Program Medical Director Gentiva Hospice

2. Objectives • Describe components of the healthcare continuum • Define 5 different models/metaphors of leadership in healthcare • Articulate the need for balance among multiple styles

3. The World of Healthcare • Complex system • Concept of patient flowing through components • Regulations, methods, goals in each piece can differ • “Whole picture” perspective problematic

4. How Do We Fit In? • Hospice origins: • Promoted by Dr. Cecily Saunders—the patient wanted “something more” • Began in US as volunteer service (not funded) • Regulations started with Medicare funding • The “anti-medicine” • Advent of Palliative Medicine and seeking inclusion • Healthcare Systems are evolving

5. Leadership • Leadership is a process whereby an individual influences a group of individuals to achieve a common goal. • Process • Influence • Groups • Goals Leadership Theory and Practice P. Northouse

6. Leadership Styles • Transactional Leadership • Collaborative Leadership • Outcomes based Leadership • Transformational Leadership • Shared Leadership • Servant Leadership • Among many, many others…….

7. Greek Theory of Matter • Four basic elements (Empedocles, Aristotle) • Fire, Earth, Air, Water • Fifth element in Plato’s writing: ether

8. Models/mindsets/metaphors of Healthcare Leadership

9. Whitewater in Healthcare • Regulatory requirements • Payment issues • Litigation issues • Competition • Shift in control • Shared decision making • Reporting/report cards • The environment

10. Whitewater • Boundary scanning • Your industry • Other components of healthcare • Anticipation/Planning • Flexibility • Survival in whitewater is not a solo sport

11. Whitewater case….Opportunity • A new disease management program (CHF) comes into your community • How are you going to know they are here? • What opportunities do you see? • What impact will they have on your program? • How is boundary scanning going to help?

12. Whitewater case….Need to Change • A new document from Medicare (August 2013) clarifies that the diagnosis: Adult Failure to Thrive will no longer receive payment effective October 2014 • When will you discover this? • Who is watching the regulatory agencies? Other entities’ response to this decision? • When will you decide to act? • Did your organization glean anything else from this document?

13. Strategic air command • Fighter jet • Large piece of machinery with lots of knobs and levers! • You have to understand the machine • Consumes a lot of fuel (resources), so you have to be strategic! • Know your mission! • Know your objectives….. • How do you know where you are? • How do you maintain safety? • How do you continually improve? (why?)

14. Know your mission • How do you maintain safety? • ”Preflight checklist” • Standardized method to ensure all is in order • Guidelines, pathways • Formulary for medication safety • Standardized concentration of infusions • Ventilator withdrawal/procedure checklist • If something is not right, speak up!! • Lives of patients at stake • Livelihood of staff at stake

15. Checklist for Ventilator Withdrawal Hospice Date: _______________________ Patient Name: __________________________ Patient ID#: ____________________ _______ Hospice representative has met with family to discuss goals of care, process. ________ Patient has been evaluated by RN for hospice eligibility and RCP for transport/ventilator strategy _______ Two physicians have reviewed the record for ventilator withdrawal, likelihood of survival to transfer, ability to withdraw ventilator. (One Hospice MD minimum) _______ OOH-DNR signed _______ Power of Attorney/Guardian/Decision maker has been determined. _______ Patient/Family meeting and discussions documented _______ Interdisciplinary Assessment (Chaplain, RCP, SW, RN, MD, other member) _______ Ethics Committee Meeting if decided by IDG (see above.) _______ Psychiatric Evaluation (if applicable) _______ Pharmacy Review/Infusion Pumps/Compounded Drugs _______ IV access (IV site, subcutaneous site, PICC line, other) _______ Assess for regulatory concerns (Adult Protective Services case) _______ State/Federal Legal Statutes reviewed if concerns arise. _______ Informed consent to procedure signed, with documentation of Risks, Benefits, Alternatives, Consequences discussed. ______ Equipment in place prior to patient transfer..

16. Know your mission • Know where you are….. • Dashboard • Information on where your program is • Census, admissions, pharmacy costs, diagnoses, LOS, infection rates, etc. • Simple but essential measures-What’s important? • Not too many measures!

17. Know Your Mission • Debriefing • How did the “flight” go? • Leveled communication (ED to C.N.A) • After one “run”, ongoing, after mission completed • No blaming! Opportunities to improve • Did we meet our objective?

18. Strategy case… • Your organization decides to launch a new program • How do you go about this? • How does this fit your mission? • Metrics for success • Debriefing—who can participate?

19. Firefighting • Dangerous! • Goal of firefighting • Contain damage • Not lose people! • You need: • Good equipment • Good communication • Good training

20. Firefighting • Equipment for hospice/palliative care • Education • Tools to do work • Supply chain--adequate materials to do work • Communication • How do you communicate to staff?How does information about patients travel among the team members? • What is your communication style? • Scripting reports or RN/MD S-B-A-R

21. S-B-A-R • Scripting to improve communication • Situation • Background • Assessment • Request/Recommendation

22. Firefighting • Training • Education • Ongoing review • Concerns: infections, falls,wounds, med errors • Palliative Care principles/new meds, treatments • Strategy (Air Command) • Future state (Whitewater) • Certification • Role playing

23. Firefighting • Running your new program • What equipment, training • Communication as patients flow between teams

24. Earth/Servant Leadership • The servant-leader is servant first….It begins with the natural feeling that one wants to serve, to serve first. The conscious choice brings one to aspire to lead. That person is sharply different from one who is leader first, perhaps because of the need to assuage an unusual power drive or to acquire material possessions…..

25. Earth/Servant Leadership • The difference manifests itself in the care taken by the servant-first to make sure that other people’s highest priority needs are being served. The best test, and difficult to administer is: “Do those served grow as persons? Do they, while being served, become healthier, wiser, freer, more autonomous, more likely themselves to become servants?”Robert Greenleaf, 1970

26. Servant Leadership in Palliative Medicine/Hospice • Geriatrics/Hospice/Palliative Care among most stressful in healthcare • Rest, recharge, recuperation-->retention!!!! • PTO • Skills/Team building • Affirmation and recognition • Nourish your people-->tend (groom) them -->harvest their work

27. Synthesis case • A new pediatric cancer center comes to your community. • There is no pediatric hospice in your community. • Whitewater • Strategic air command • Firefighting • Servant leadership

28. Balance in Healthcare Leadership

29. So……balance in leadership • Success with attending to: • External forces • Strategy • Skills of employees and volunteers • Nurturing your people If we stopped right here, pretty good • BUT…. • Fifth element of leadership!

30. The Fifth Element • Greenleaf: • “What is the effect on the least privileged in society? Will they benefit or at least not be further deprived?” • So the fifth element of leadership Transcends………………

31. Leadership that Transcends

32. Meta-Leadership • Devastating Catastrophe in the land of Silos • Cross-organizational linkages and collaboration • Leadership is a process whereby an individual influences a group of individuals to achieve a common goal.

33. Meta-Leadership • Meta-leadership is an overarching leadership framework for strategically linking the efforts of different organizations or organizational units to “provide guidance, direction, and momentum across organizational lines that develop into a shared course of action and commonality of purpose among people and agencies that are doing what may appear to be very different work.” Leonard J. Marcus, Barry C. Dorn, and Joseph M. Henderson (2006). Meta-Leadership and National Emergency Preparedness: A Model to Build Government Connectivity. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science, Volume 4, Number 2, 128

34. Meta-Leadership • National Preparedness Leadership Initiative • Harvard School of Public Health • Harvard John F. Kennedy School of Public Government • Five Dimensions of Meta-Leadership • The Person of the Meta-Leader • The Situation • Leading within the Silo • Leading Up • Leading Connectivity

35. Meta-Leadership • Calls for flexibility and less scripting • Influence through negotiation • Personal and organizational credibility across boundaries • Creating something new • Sum larger than its parts • Inspiration without authority--Stone Soup ***

36. Meta-Leadership • Inspiration without authority--Stone Soup *** • Dovetailing and developing synergy • Can be used in any cataclysmic change • Disaster • Regulatory changes • Economic shifts

37. Another Consideration • Followers differ by generation and level of engagement • Isolates—completely detached • Bystanders—observe, do not participate • Participants—engaged in some way • Activists—feel strongly, act accordingly • Diehards—go down for the cause. Kellerman, Harvard Business Review 2007

38. Models/mindsets/metaphors of Healthcare Leadership

39. Can the Five Elements Help Us? • Increasing Regulations • Decreasing Reimbursement • Formation of Healthcare Networks • More Competitors • Other agencies scrambling for relevance and funding • Sophisticated healthcare “purchasers” • Report Cards • Economic squeeze on patients and families • Stressors on the larger community within which we operate

40. What do we need as Healthcare Leaders? • Viewing the boundaries and horizons • Developing strategies for success • Equipping our people with good tools, clear communication, and training • Serving our people to enhance their skills • Thinking and reaching outside our own enterprises when occasion arises • Ability to perceive engagement of followers and earn their followership

41. Questions? Thank you! Linda.tavel@gentiva.com

42. Bibliography • Greenleaf Center for Servant-Leadership http://www.greenleaf.org/what-is-servant-leadership/ • Northouse, P. (2004) Leadership Theory and Practice (3rd ed.) Thousand Oaks, CA: Sage Publications. • The Meta-Leaders. Transformational and Transactional Leadership. http://www.themetaleaders.com/leadership.html • Murphey, J. (2005) Flawless Execution. New York: HarperCollins. http://www.afterburnerhealthcare.com/ • Story of Stone Soup http://www.extremelinux.info/stonesoup/stonesoup.html

43. Bibliography • Berwick, D (2004) Escape Fire: Designs for the Future of Health Care. San Francisco: Jossey-Bass. • Miles, S Watkins, M. The Leadership Team: Complementary Strengths or conflicting Agendas? Harvard Business Review 2007; 85 (4): 90-98. • Kellerman, B. What Every Leader Needs to Know About Followers. Harvard Business Review 2007; 85 (12): 84-91. • http://hbr.org/2007/12/what-every-leader-needs-to-know-about-followers/ar/1 • National Healthcare Service Leadership Academy (2013) The Healthcare Leadership Model. https://www.leadershipacademy.nhs.uk/wp-content/uploads/2013/10/NHSLeadership-LeadershipModel-10-Print.pdf

44. Bibliography • National Healthcare Service Leadership Academy (2013) The Healthcare Leadership Model. https://www.leadershipacademy.nhs.uk/wp-content/uploads/2013/10/NHSLeadership-LeadershipModel-10-Print.pdf • Seven Different Leadership Styles for Different Situations http://brandongaille.com/7-different-leadership-styles-for-different-situtations/ • National Preparedness Leadership Initiative. MetaLeadership http://npli.sph.harvard.edu/meta-leadership/ • Five Dimensions of Meta-Leadership http://www.youtube.com/watch?v=eCFIdNAizGM

45. Bibliography • Seven Different Leadership Styles for Different Situations http://brandongaille.com/7-different-leadership-styles-for-different-situtations/ • Inc. Ten Traits of Great Leaders (and Their Followers) http://www.inc.com/kevin-daum/10-traits-of-great-leaders-and-their-followers.html