Putting It All Together - Managing Multiple Priorities

1. Putting It All Together -Managing Multiple Priorities Brian J. Zink, MD Professor and Chair, Dept. of Emergency Medicine, Alpert Medical School Lifespan Partners SAEM Business of Academic Emergency Medicine Boot Camp

2. Objectives • Participants will learn how to address and manage multiple priorities in the business and finances of an academic department of emergency medicine in a mission-based manner. • Participants will learn how to assess institutional priorities and align them with departmental priorities to achieve success in the business of emergency medicine. • Participants will review and participate in discussions of case examples of competing or conflicting priorities and solutions to these situations.

3. What Business Are We In? • We are not in the banking business. • We are not a corporation looking to increase shareholder value through enhanced stock price and lower cost of capital ratios. • We are not even ‘just’ a high quality healthcare delivery organization … • We are a part of a complex enterprise dedicated to pushing the margin … a balanced program of education, research and patient care. David Bachrach – Physician Executive Coach, 2008

4. Sound Advice from the Coach The 3 Responsibilities of a Chair • 1. Develop and Communicate the Mission, Vision and Values of the Department • 2. Recruit, Develop and Retain High Quality Faculty Members • 3. Be a Good Steward of Your Resources David Bachrach – Physician Executive Coach, 2006

5. Mission - Possible? We have all heard – “No Margin, No Mission.” But should a departmental mission be based and dependent on progressively increasing amounts of money? If so, how will academic departments survive, much less thrive, when we face cuts to clinical, educational and research funding? If your mission can’t guide you – what will?

6. Mission-Based Budgeting • Introduced about a decade ago for medical education and academic medical centers. • Basic Premises: • ALL components of AMC mission are identified and assigned value and metrics (not just clinical). • Accounts for activity and quality of faculty effort in all areas – clinical, research, education and service. • Financial decisions based on a composite view. Non-revenue generating activities are on equal footing with revenue generating activities. • Mission-Based Budgeting: Removing a Graveyard, Robert T. Watson, MD, and Lynn J. Romrell, PhD Academic Medicine, Management Series: Mission-Based Management, 1999.

7. Beyond Budgeting • Landmark article in 2003 by Jeremy Hope in Harvard Business Review, and subsequent book. • Application in a med school setting – Univ. of Michigan • Elger WR. Managing resources in a better way: a new financial management approach for the University of Michigan Medical School. Academic Medicine 2006; 81(4):301-305 • Basic Premises: • Transparency and openness in governance and operations • Teams set up with high degree of accountability • Create goals with positive reinforcement • Continuous planning with all members of team • Controls and metrics – real time • Most academic EM departments are on a scale where “beyond budgeting” practices can be applied.

8. 12 Beyond Budgeting Principles (2011) www.bbrt.org/beyond-budgeting/bb-principles.html • Governance and transparency • 1. Values - Bind people to a common cause; not a central plan • 2. Governance - Govern through shared values and sound judgement; not detailed rules and regulations • 3. Transparency - Make information open and transparent; don't restrict and control it • Accountable teams • 4. Teams - Organize around a seamless network of accountable teams; not centralized functions • 5. Trust - Trust teams to regulate their performance; don't micro-manage them • 6. Accountability - Base accountability on holistic criteria and peer reviews; not on hierarchical relationships • Goals and rewards • 7. Goals - Encourage teams to set ambitious goals, don't turn goals into fixed contracts • 8. Rewards – Base rewards on relative performance; not on fixed targets • Planning and controls • 9. Planning - Make planning a continuous and inclusive process; not a top-down annual event • 10. Coordination -Coordinate interactions dynamically; not through annual budgets • 11. Resources -Make resources available just-in-time; not just-in-case • 12. Controls - Base controls on fast, frequent feedback; not budget variances

9. Before Budgeting, Before Allocating… • There is the big picture. • Positive organizational change • Abundance Theory • Appreciative Inquiry • Adaptive Enhancement Bandelier National Monument, New Mexico

10. Moving Toward a Fundamental State of Leadership Self Focused Internally Closed Externally Open Other Focused Internally Directed Results Centered Externally Directed Comfort Centered From: Quinn, RE. Building the bridge as you walk on it. Jossey-Bass, 2004

11. Four Questions as You Craft Your Vision Adapted from: Cameron KS: University of Michigan Business School, 2006

12. Appreciative Inquiry • A new paradigm for organizational development. • Pioneered in 1980’s by David Cooperrider at Case Western Reserve University. • Derived from experiences and observations at the Cleveland Clinic – physician leadership success. • Has been utilized with positive results by many businesses, organizations, the Navy, etc. to reshape the perspectives and approach of leaders and workers.

13. What is Appreciative Inquiry? “It is the discovery for the best in people, their organizations, and the relevant world around them. It is an art and practice of asking the unconditional positive questions that strengthen a system’s capacity to apprehend, anticipate and heighten positive potential. Instead of negation, criticism and spiraling diagnosis, there is discovery, dream, design and destiny. It works from accounts of the “positive change core”. AI links the energy of the positive core directly to any change agenda and changes never thought possible are suddenly and democratically mobilized.” David Cooperrider, PhD., 2008

14. What is Appreciative Inquiry? • Appreciative Inquiry is a collaborative and highly participative, system-wide approach to seeking,identifying, and enhancingthe “life-giving forces” that are present when a system is performing optimally in human, economic, and organizational terms. “AI is the ability (a kind of intelligence) to perceive the positive inherent generative potential in the present.” – David Cooperrider From: Don Schutt, Ph.D., NCC, LPC, MCDP; Univ. of Wisconsin; A Strength-Based Approach to Career Development Using Appreciative Inquiry

15. Discovery “What gives life?” (The best of what is) Appreciating Dream “What might be?” (What is the world calling for) Envisioning Results Destiny “How to empower, learn, and adjust/improvise?” Sustaining Affirmative Topic Choice Design “What should be--the ideal?” Co-constructing Appreciative Inquiry: The “4-D” Cycle From: Cooperrider, DL, Whitney D, Stavros, JM. Appreciative Inquiry Handbook. Crown Custom Publishing, Inc 2008.

16. A Non-Traditional Approach • The abundance culture and philosophy. • A core of “positive energizers” who are free to do their work. • Investing in our People: • “Human relationships and leadership are more important than ever before. The speed and sophistication of technology and information have made human capital the key competitive advantage for most organizations.”Kim Cameron

17. The Power of Positive People • The 5:1 positive rule for high performance teams. • Unless marriage partnerships, families, or work teams have a ratio of 5 positive comments to every 1 negative comment, the quality of the relationship deteriorates. • Try this out at home!

18. Positive Energizers • Positive energizers tend to enhance the work of others. People who interact with or are connected to energizers also perform better. • High performing firms have three times as many positive energizing networks as low performing firms.

19. Positive Performers in the Work Place • Externally focused, advocates. • Solution-finders, well-connected with good networks. • Willing to take on challenges in an innovative way. Adaptable. • All of these are core characteristics of … EMERGENCY PHYSICIANS

20. High Performance Teams(source: Losada & Heaphy, 2003)

21. Approaches to Organizational Improvement Approach #1 What problems are we encountering? What are the major obstacles to success? How can we close the gap between our problems and effective solutions? Approach #2 What is working here? What is the best we have ever done? What are our peak experiences? How can we close the gap between our highest aspirations and sustainable achievements?

22. Comparing Approaches to Improvement PROBLEM SOLVING Problem Identification: Identify problems or needs Cause Analysis: Analyze symptoms & root causes Identify Solutions: Generate alternative that address problems Action planning: Design interventions that address or solve problems BASIC ASSUMPTION: Our job is to overcome major problems. APPRECIATIVE CHANGE Appreciating and Valuing: Identify peak experiences Explaining Success: Identify elements of the best past successes Creating Sustainability: Identify what should be continued in the future Designing a Destiny: Design interventions that create an ideal future BASIC ASSUMPTION: Our job is to embrace and enable our highest potential.

23. The Heliotropic Effect • Focusing on abundance gaps, compared to deficit gaps, leads to the organization turning toward the positive, instead of reacting to the negative.

24. Capitalizing on Strengths • Identifying people’s strengths and building on them creates more benefit than identifying weaknesses and trying to correct them. • Managers who spend more time with their strongest performers achieved double the productivity. • In organizations where workers have a chance to “do what they do best everyday,” productivity is 1.5 X greater than in normal organizations. • People who are given feedback on their strengths are significantly more likely to feel highly engaged and to be more productive than people who are given feedback on their weaknesses. • Students who are given feedback on their talents have fewer days of absenteeism, less tardiness, and higher GPAs than students who get no feedback on their talents.

25. If you see your cup as half full, it may one day runneth over; if you see it as half empty, it never will.

26. Yeah, but… • Aren’t most organizations fraught with problems? • Can any leader or manager afford to ignore difficulties? • Is a positive approach to change just a white-wash of serious challenges? • Won’t any organization fail if it doesn’t focus on its weaknesses and liabilities? • In light of major challenges faced by most organizations and leaders, what is the relevance of virtues and an abundance approach to change?

27. Why Don’t Positive Factors Get More Attention? • A systematic bias exists in people - negative factors are more powerful and influential than positive factors. • People are: • More upset by losing $50 than elated by winning $50. • More affected by one traumatic or negative event than by one positive or happy event. • More affected emotionally & do more mental work from a single negative piece of feedback than from a single positive piece of feedback. • Therefore, the abundance model faces some stiff resistance.

28. Associations Between Organizational Virtuousness & Performance • An abundance culture, virtuousness and positive dynamics are significantly and positively related to organizational performance. • A long term view is part of the abundance culture. • A study of the airline industry after 9/11.

29. Approach to Downsizing - Southwest • Despite losing $1 million per day in the weeks following the attacks, Southwest refused to lay off employees. CEO Jim Parker said: “Clearly we can’t continue to do this indefinitely, but we are willing to suffer some damage, even to our stock price, to protect the jobs of our people.”

30. Why Does Virtuousness Enhance Performance? • Virtuousness has an amplifying effect. • Virtuousness perpetuates more virtuousness (psychological broadening & building effects). • Builds social capital (trust, information sharing, learning, etc.) • Fosters pro-social behavior (inherent disposition toward helping). • Virtuousness has a buffering effect. • Virtuousness serves a protective function against trauma. • Resiliency is developed (strengthening, limbering and replenishing). • Negative effects of downsizing are mitigated (psychological, emotional, psychological and social effects).

31. The Competing Values Framework Long-term Change Individuality Flexibility New Change Culture Type:CLAN Orientation:COLLABORATE Leader Type: Facilitator Mentor Team-builder Value Drivers: Commitment Communication Development Theory of Human development Effectiveness: & high-commitment produce effectiveness Culture Type:ADHOCRACY Orientation:CREATE Leader Type: Innovator Entrepreneur Visionary Value Drivers: Innovative outputs Transformation Agility Theory of Innovativeness, vision, Effectiveness: & constant change produce effectiveness Internal Maintenance External Positioning Culture Type:HIERARCHY Orientation:CONTROL Leader Type: Coordinator Monitor Organizer Value Drivers: Efficiency Timeliness Consistency & Uniformity Theory of Control & efficiency with Effectiveness: capable processes produce effectiveness Culture Type:MARKET Orientation:COMPETE Leader Type: Innovator Entrepreneur Visionary Value Drivers: Innovative outputs Transformation Agility Theory of Innovativeness, vision, Effectiveness: & constant change produce effectiveness Incremental Change Stability Control Fast Change Cameron K. and Quinn R., Diagnosing and Changing Organizational Culture, Jossey Bass, 2006

32. Values and Profiles of the Four Cultures • Value:Community & Knowledge • Typical Situation: • A communication united by shared beliefs • Competency is closely linked to unique abilities • Strong identification with a lifestyle • Think…Harley-Davidson, Bloomsbury Publishing, Universities • Value:Innovation & Growth • Typical Situation: • Differentiation creates significantly higher margins • A new methodology changes the game • An industry is situated around blockbuster invention • Think…Pixar, Schwab, Start-ups • Value:Efficiency & Quality • Typical Situation: • Scale & scope of organizational processes is very large & complex • Government regulations & standards determine business practices • Failure is not an option • Think…Boeing, US Army, Medical Centers • Value:Speed & Profits • Typical Situation: • Shareholder demands are the primary driver • Aggressive competition changes the market dynamics through mergers & acquisitions • Investors demand quick financial results • Think…GE, Microsoft, Investment Banks

33. Organizational Leadership Profile The Collaborate Culture An organization that focuses on internal maintenance with flexibility, concern for people and is sensitive and friendly place to work where people share a lot of themselves. It is like an extended family. The leaders, or head of the organization, are considered to be mentors and, maybe even, parent figures. The organization is held together by loyalty or tradition. Commitment is high. The organization emphasizes the long term benefit of 50 50 40 40 human resources development with high cohesion and morals being important. Success is defined in terms of sensitivity to customers and concern for people. The organization places a premium on teamwork, participation and consensus. 30 30 20 20 10 10 10 10 20 20 30 30 40 40 50 50 The Create Culture An organization that focused on external positioning with a high degree of flexibility and individuality. A dynamic, entrepreneurial & creative place to work. People stick their necks out & take risks. The leaders are considered to be innovators & risk takers. The glue that holds the organization together is commitment to experimentation being on the leading edge. Readiness for change & to meet new challenges are important. The organization’s long term emphasis is on growth & acquiring new resources. Success means having unique & new products, or services. Being a product, or service, leader is important. The organization encourages individual initiative & freedom. Collaborate Create The Compete Culture An organization that focuses on external positioning with a need for stability and control. A results oriented organization. The major concern is getting the job done. People are competitive and goal oriented. The leaders are hard drivers, producers and The Control Culture An organization that focuses on internal maintenance with a need for stability and control. A very formalized and structured place to work. Procedures govern what people do. The leaders pride themselves on being good Control Compete coordinators, organizers, and efficiency minded. Maintaining a smooth running organization is most critical. Formal rules and policies hold the organization together. The long term concern is on stability and performance with efficient, smooth operations. Success is defined in terms of dependable delivery, smooth scheduling, and low cost. The management of employees is concerned with secure employment and predictability. competitors. They are tough and demanding. The glue that holds the organization together is an emphasis and success are common concerns. The long term concern is on competitive actions and achievement of measurable goals and targets. Success is defined in terms of market share and penetration. Competitive pricing and market leadership are important. The organizational style is hard-driving competitiveness.

34. Negative Aspects of These Cultures Overemphasis & Loss of Balance Negative Zones Tumultuous Anarchy Irresponsible Country Club Individuality Flexibility • Culture Type:CLAN • Orientation:COLLABORATE • Attributes: • Excessive discussion • Unproductive participation • Emotional dominance • Individualism • Culture Type:ADHOCRACY • Orientation:CREATE • Attributes: • Unguided opportunism • Ungrounded vision • Program of the week • Premature responses Internal Maintenance External Positioning • Culture Type:HIERARCHY • Orientation:CONTROL • Attributes: • Micromanagement • Procedural rigidity • Over-regulation • Ironbound tradition • Culture Type:MARKET • Orientation:COMPETE • Attributes: • Over-exertion • Tyrannical goal focus • Unproductive conflict • Blind ambition Frozen Bureaucracy Stability Control Oppressive Sweatshop Cameron K. and Quinn R., Diagnosing and Changing Organizational Culture, Jossey Bass, 2006

35. Organizational Culture – Congruence, Strength and Type • There is no best or right culture, and balance is not necessarily advantageous. • Outcomes, strategies, culture and competencies should be congruent to achieve high performance. • Key metrics will be different, depending on the values and culture of your organization. • Culture change occurs through crisis, evolution, or leadership.

36. Achieving Spectacular Performance – Deviating from “Normal” • Over time, most organizations tend to settle in to a normal, “fallen” state characterized by routines, conformity, hypocrisy, and with a palpable gap between what is and what might be. • “They became what they beheld.”William Blake

37. Organizational Culture ProfilesAn Example of Life Cycle Development in Organizational Cultures 50 50 50 50 50 50 50 40 40 40 40 40 40 40 30 30 30 30 30 30 30 20 20 20 20 20 20 20 10 10 10 10 10 10 10 10 10 10 10 10 10 10 20 20 20 20 20 20 20 30 30 30 30 30 30 30 40 40 40 40 40 40 40 50 50 50 50 50 50 50 1 2 3 4 50 40 30 20 10 10 20 30 40 50

38. Dept EM Culture Previous Compared to Today Collaborate Create 50 50 2007 Desired 40 40 30 30 20 2007 Current 20 10 10 10 10 2008 Current 20 20 2008 Desired 30 30 2010 Current 2010 Desired 40 40 50 50 Control Compete Results 2007 Current Desired Results 2008 Current Desired Results 2010 Current Desired 38

39. Competing Values Framework – for the Department • Recognition that subgroups in the Department may have their own subculture. • Most team efforts will require “competency” in all 4 quadrants. • The tendency is to get “bottom heavy”, so we need to maintain our good qualities in the Collaborate and Create quadrants.

40. The Hedgehog Concept in the Social Sectors What are we deeply passionate about? What drives our resource engine? What can we be best in the world at? 40 Adapted from Good to Great and the Social Sectors, Jim Collins, 2005

41. POSITIVERESULTS ACCOUNTABILITY SENSE OFCOMMITMENT HANDLECONFLICT TRUST Adapted from: Overcoming the Five Dysfunctions of a Teamby Patrick Lencioni THE FIVE KEY CHARACTERISTICS OF A HIGHLY FUNCTIONING TEAM

42. Balance and the Long Term View • Positive organizations with an “abundance theory” approach achieve long term success by: • Having well-developed MVV, with each member of the team “buying in” and helping to develop and achieve the MVV. • Encouraging high quality work and performance with clear expectations, but avoiding high stress or burn out. • Support balance in personal-professional lives of the team • Responding to periodic crises and change in an effective manner, but stay on track in MVV – long-term view. • Having plans for leadership growth and succession

43. Where Do We Spend Most of Our Time? Uniqueness Strengths Competencies Weak Areas

44. Managing Multiple Priorities • If you can use mission-based management, and positive organizational change approaches in your day-to-day departmental leadership, balancing and tending to multiple priorities becomes much less onerous. • Priorities and bubble up from the organization as high performance and opportunities. If you can do a good job of BIG THINKING as a leader and and develop and communicate the MMV very well, then the small things have a way of working themselves out.

45. ALIGNMENT • OF COURSE we need to be aligned with our hospitals, academic medical centers, medical schools and community. • As the nexus, intersection, and enabler of much in health care and medical education, EMERGENCY MEDICINE is naturally positioned to be essential, at the table, and given a voice. • But, there is an ART to ALIGNMENT.

46. The Art of Alignment • Possess Institutional Situational Awareness. What are the: • PRIORITIES (if articulated!) • PRESSURES • RISK TOLERANCE • TIMELINES • TENURES • Where Are the Win-Win’s? • What are We Both Good At? AI Approach

47. Case One: Clinical – What Are We? • Your hospital system is forming a new outpatient network and wants to partner with your EM Department to open an Urgent Care with you providing the staffing. Initial analysis suggests that it would be financially neutral for the Dept to staff it with an EP/midlevel team. • Some members of your leadership team feel that urgent care is not really in the realm of EM, and are concerned that this initiative will distract from your educational and research activities. • The hospital system wants an answer in a week and will consider outsourcing the staffing to other EM groups or urgent care entities.

48. Managing Multiple Priorities • First, take a deep breath and recite or chant your MISSION, VISION AND VALUES. • Assess: do you have enough objective information, data, points of view, and understanding of the options or paths you can follow? If not, take the time to get it. • Discuss: open dialogue; knowledge transparency; input from ALL stakeholders, not just your own people • Decide a Course: use the tools of positive organizational change as a guide; “dream the answer”; find the Win-Win • Communicate the Decision: reference MVV; explain but do not reopen

49. Case Two: Clinical v. Educational Needs • You and your hospital are concerned about your ability to manage increasing ED volumes. Wait times are up, attending physicians are stressed. The hospital wants to provide three PA positions to help the situation, BUT in return they are requesting that you surrender two of your residency slots so they can expand their neurology and neurosurgery residencies. • Your residency director is apoplectic, but some attending physicians and nurses are supportive. • How do you manage this?

50. Case Three: Educational v. Clinical Needs • Your Residency Director wants to nix the current Orthopedics rotation for your interns, citing poor education, lack of procedures, and resident dissatisfaction. An ED-based rotation is planned with some Orthopedics involvement. • The Orthopedics faculty members believe the EM Ortho rotation is strong, and are upset that EM wants to change it. They are making some veiled threats about responsiveness to consults in the ED if you do this. Orthopedics consults are already a problem, and you don’t want it to get worse. • How do you manage this?