Preventing Burnout: An Interview with Cynthia Ackrill

Cynthia Ackrill M.D. is a leader in the field of stress management and an expert in the critical relationships between lifestyle choices, performance capacities, and leadership effectiveness. As the only physician trained in neuroscience and wellness and leadership coaching, she travels the world to teach better ways to lead and thrive in the face of stress and constant change. She heads the Workplace Stress Board for the American Institute of Stress, and is on the faculty of The Physician Leadership Institute.

What do you see as the leading cause of stress for healthcare professionals?
Let’s see. We can start the discussion by going back to 1908, when psychologists Robert M. Yerkes and John Dillingham Dodson developed what is now called the Yerkes–Dodson law.  It states that for optimal performance, some stress is beneficial.  But if you are overstressed, then performance suffers.  The chart looks like a bell curve: too much stress, and performance suffers. And, in the middle, you have the zone of optimal performance.  Research in peak performance shows that a certain level of stress (or arousal) in necessary for performance. We don’t do our best when we are bored. But neither do we when we are overwhelmed or pushed beyond that point of perceiving that we have everything we need to meet the challenge.

Burnout occurs when we are overwhelmed.

Most of us know our “achilles heel,” that part of us that is most vulnerable under high stress. For me, it is headaches–push too hard/too long on my coping systems and I get a headache. My colleague reaches for the Tums. But the bigger challenge is recognizing stress before this stage, before distress is manifested so profoundly, especially before it becomes a silent killer.

Waiting for a big symptom to appear to know we are out of balance is no different than a diabetic waiting for blood sugars to rise off the charts before taking insulin. And unmanaged stress does the same inflammatory damage throughout our brains and  bodies that high blood sugar does. We have to learn more accurate ways to measure where we are on the stress curve–to improve our performance and prevent damage.

This is especially hard for many high achievers who have learned to disconnect from the more subtle signals, to focus on the goals. Achievers often don’t really “feel” stress anymore. They can even be addicted to the adrenaline state it creates. (And sometimes they are the ones causing stress for others!) Some of us need to ask colleagues and loved ones what they notice and re-train ourselves to reset earlier. We need to learn a new metric to stay on the top of the curve.

We’re not built, physically and mentally, for constant stress. Often, high achievers are simply unaware that they are experiencing burnout.  They just try to work harder and harder.

And that’s often a disaster?
It can be. In Japan they have a word for this - Karōshi - death from overwork.

At the Physician Leadership Institute, how do you help these physicians cope?
It starts, like most things, with awareness. One of the biggest symptoms we see is a high level of irritability. Are you irritated by your co-workers, your staff, your drive home, your children?  This irritability may mean that you are on the edge, experiencing burnout, but perhaps not acknowledging it.  In our profession, we often don’t connect the dots for ourselves.  Physicians are sometimes most likely to exclude themselves from asking for relief.  It’s our culture, our modus operandi, to be tough and not ask for help. That can lead to physician burnout.

I have an exercise I do with physicians called “clean up your plate” which helps stressed individuals find their balance.

Clean your plate?
Here’s a quick look at how it works. I ask a physician to take a clean paper plate. I ask them to write down all the things in their lives that suck up their energy. Write them down on your plate. These are all the activities, interactions, and responsibilities–at home, at work–that take energy out of you.  Next, on the flip side – the base – I ask them to write out what gives them energy. What supports you? Renews you?

And then we do an inventory check.  Step three is to clean your plate.  What things are worth doing?  What can be deleted? Delegated? Deferred?

You’ll be surprised with the things people want to cling to and not let go.  Of course by not letting go, the stress just keeps on building.  This all comes down to physician resiliency–a term that’s gaining traction in some circles, but not nearly fast enough.  In so many ways, what we do is resiliency training.  Helping the physicians, staff, and administration understand that it all begins with yourself.  I don’t want to say you can just clear away all the stress of life- that’s unrealistic; but you can learn to manage it and find effective ways to cope.

How should institutions build on this knowledge to prevent burnout?
We have all heard that awareness is the first step to change, but making lasting changes in thought and behavior patterns turns out to be much harder than we like to think! And stress makes it even harder!  As far as institutions go, most are still barely acknowledging the problem.  As burnout and turnover increase, there is a growing awareness, particularly with forward thinking executives, that much more can be done in the way work is designed, policies implemented, coaching and training offered.

I’m not saying that to fight burnout all you need are classes. Even when we become truly conscious of some incongruence in our lives–a choice we make in thought or action that does not support our values or goals–we still really struggle with using that information to drive behavior change. For example, only 1 in 9 people make the appropriate lifestyle changes after cardiac surgery! 1 in 9! Apparently the threat of death is not the easy button to change! We operate with a bias that if we just know enough, that will drive change. But this premise is wrong–personally and in business. Consider obese doctors, accountants in debt, or some choices made by well-educated C-level leaders. Knowledge is necessary and powerful, but… KNOWLEDGE ≠ MOTIVATION. Combining awareness with a curious, mindful mindset and the science of both individual and organizational behavior change, it is possible to greatly improve the odds of success.

So it comes back to the values and culture of an organization?
Yes, and mindsets.  The physician leader knows how to deal with stress at every level.  That’s something that’s a day-to-day practice.  What we do is help them develop this practice.

For more information, contact the Physician Leadership Institute >>

Definition: Physician Burnout

The concept of “burnout” is a relatively new one in the annals of human history.  Peasants, in medieval times, for example, had no such concept.  You worked or you were in serious trouble.  It is only after two World Wars and the 1960s that human beings start finally experiencing burnout.

Clinical psychologist Herbert Freudenberger first identified the construct “burnout” in the 1970s.  Along with his colleagues, Freudenberger theorized that the burnout process can be divided into 12 phases (not necessarily followed sequential). Many victims of burnout skip certain stages; others find themselves in several at the same time. And the length of each phase varies.*

  1. The Compulsion to Prove Oneself
    Often found at the beginning is excessive ambition. This is one’s desire to prove themselves while at the workplace. This desire turns into determination and compulsion.
  2. Working Harder
    Because they have to prove themselves to others or try to fit in an organization that does not suit them, people establish high personal expectations. In order to meet these expectations, they tend to focus only on work while they take on more work than they usually would. It may happen that they become obsessed with doing everything themselves. This will show that they are irreplaceable since they are able to do so much work without enlisting in the help of others.
  3. Neglecting Their Needs
    Since they have devoted everything to work, they now have no time and energy for anything else. Friends and family, eating, and sleeping start to become seen as unnecessary or unimportant, as they reduce the time and energy that can be spent on work.
  4. Displacement of Conflicts
    Now, the person has become aware that what they are doing is not right, but they are unable to see the source of the problem. This could lead to a crisis in themselves and become threatening. This is when the first physical symptoms are expressed.
  5. Revision of Values
    In this stage, people isolate themselves from others, they avoid conflicts, and fall into a state of denial towards their basic physical needs while their perceptions change. They also change their value systems. The work consumes all energy they have left, leaving no energy and time for friends and hobbies. Their new value system is their job and they start to be emotionally blunt.
  6. Denial of Emerging Problems
    The person begins to become intolerant. They do not like being social, and if they were to have social contact, it would be merely unbearable for them. Outsiders tend to see more aggression and sarcasm. It is not uncommon for them to blame their increasing problems on time pressure and all the work that they have to do, instead of on the ways that they have changed, themselves.
  7. Withdrawal
    Their social contact is now at a minimum, soon turning into isolation, a wall. Alcohol or drugs may be sought out for a release since they are obsessively working “by the book”. They often have feelings of being without hope or direction.
  8. Obvious Behavioral Changes
    Coworkers, family, friends, and other people that are in their immediate social circles cannot overlook the behavioral changes of this person.
  9. Depersonalization
    Losing contact with themselves, it’s possible that they no longer see themselves or others as valuable. The person also loses track of their personal needs. Their view of life narrows to only seeing in the present time, while their life turns to a series of mechanical functions.
  10. Inner Emptiness
    They feel empty inside and to overcome this, they might look for activity such as overeating, sex, alcohol, or drugs. These activities are often exaggerated.
  11. Depression
    Burnout may include depression. In that case, the person is exhausted, hopeless, indifferent, and believes that there is nothing for them in the future. To them, there is no meaning of life. Typical depression symptoms arise.
  12. Burnout Syndrome
    They collapse physically and emotionally and should seek immediate medical attention. In extreme cases, usually only when depression is involved, suicidal ideation may occur, with it being viewed as an escape from their situation. Only a few people will actually commit suicide.

A study** funded by the American Medical Association and the Mayo Clinic found that 45.8% of respondents reported experiencing at least one symptom of serious burnout, such as emotional exhaustion, depersonalization and a low sense of personal accomplishment. Of the surveyed physicians, the study compared 6,179 practicing doctors ages 29 to 65 with 3,442 workers of the same age group in other fields. Doctors had a higher risk of emotional exhaustion (32.1% versus 23.5%) and overall burnout (37.9% versus 27.8%).

The report defines burnout as a syndrome characterized by a loss of enthusiasm for work (emotional exhaustion), feelings of cynicism (depersonalization), and a low sense of personal accomplishment. Burnout may erode professionalism, influence quality of care, increase the risk for medical errors, and promote early retirement. Burnout also seems to have adverse personal consequences for physicians, including contributions to broken relationships, problematic alcohol use, and suicidal thoughts. Incidentally, the term “burnout” was identified 30 years ago to describe “a state of fatigue and frustration among health and service workers arising from excessive demands on their resources.”  Sound familiar?

If anything, the rapid pace of change in the Healthcare industry will lead to an even higher incidence of burnout.  The rising demands for care from aging baby boomers and a projected 30 million newly insured patients under the Affordable Care Act will only make this dire situation worse.

Needless to say, but worth stating anyway, is that the Healthcare industry suffers one the highest rates of burnout relative to the general population. And even more interesting is the wide range of burnout-rates based on specialty:

At the Physician Leadership Institute, we examine the personal and organizational interventions necessary to address this problem through the use of our Physician Leadership Model. The model begins with Leading Self – the fundamental building block of physician leadership.

Our work with physician leaders to reduce burnout includes:

- Reconnecting them with their purpose of WHY they are in medicine
- How to deal with difficult situations
- How to have crucial conversations
- How to recognize burnout and reset through deep breathing and mindfulness
- How to manage demands on time by managing personal productivity
- By engaging and influencing others
- By asking for help from others
- By learning more about themselves and being self aware

As a leader, we recommend that:
  1. You recognize the signs of burnouts in your physicians (we’ll discuss this in a future blog post)
  2. Create opportunities to discuss the issue through education
  3. Create a structural process to address the issue in a safe environment

Contact us at the Physician Leadership Institute to learn more  >>

* Burned Out, Ulrich Kraft, Scientific American Mind, June/July 2006 p. 28-33
** Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population, ARCH INTERN MED/VOL 172 (NO. 18), OCT 8, 2012

Fighting Cynicism: A Growing Challenge for Healthcare Organizations

The continuous disruption of the healthcare industry in the U.S. continues. Hardly a day goes by without a news story that challenges the status quo.

Here are three recent stories that are illustrations of this point:

Washington health systems contract directly with Boeing 
This is the first what is sure to be a new trend: the employer-driven ACO. Employers are increasingly going to build their own options for cost effective healthcare for their employees.

New Analysis of Common Medical Services Shows Staying ‘In-Network’ Does Not Guarantee ‘Low-Cost’
Castlight, a transparency provider for employers, says it is making pricing and outcomes data actionable and accessible to consumers is a vital step toward a merit-based healthcare ecosystem — one in which employers, employees and their families can make informed choices with a clear understanding of the costs and care they will receive.

Insurers Push Back Against Growing Cost Of Cancer Treatments
A trend that sees bills for chemotherapy jumping sharply, reflecting increased drug prices and hospitals’ push to buy oncologists’ practices and then bill at higher rates.

The problem here is that even while your organizational reform agenda is under development, it is being attacked from all sides. We observe, in our experience at the Physician Leadership Institutea rise in employee cynicism - which often extends to every level of the organization.  Left untreated, cynicism results in weaker performance, higher turnover, and burnout. In our work, we’ve identified five types of cynicism in healthcare organizations:

Personal Cynicism: this is cynical behavior that comes from the individual attitude based on their personality, background, and outlook on life.

Organizational Cynicism: a result of a gaps between stated values and actual day-to-day performance.  When this gap becomes a regular feature of the work, the organization itself and its policies are viewed as hurting performance.

Team Cynicism: this is a failure of management building the conditions required to build effective teams. When individual performers are disruptive or don’t share credit when credit is due, collaboration and workplace collegiality are severely weakened.

Job Cynicism: often the result of “the wrong person in the job” or lack of sufficient training, the design of the work itself and the processes and procedures are viewed as obstacles.

Change Cynicism: when the staff is asked to participate in one too many “flavor of the day” change initiatives, we see drop in morale.  This is the result of change initiatives that are not framed or delivered properly.

The opposite of cynicism and burnout is enthusiasm and engagement.

Unless employees – and physicians in particular – are engaged in their work, we find a startling gap in productivity.  Physician engagement is a direct outcome of physician leadership. And they are asking for it.  In 2011, the American Hospital Association (AHA) asked its regional policy boards, governing councils and committees to identify the skills they felt physicians needed to practice and lead in a reformed environment.  Their recommendations are what we have been practicing at the Physician Leadership Institute since 2005.

Respondents cited* the following:

• Leadership training
• Systems theory and analysis
• Use of information technology
• Cross-disciplinary training/multidisciplinary teams
• Understanding and respecting the skills of other practitioners

Additional education was requested for the following topics:

• Population health management
• Palliative care/end-of-life
• Resource management/medical economics
• Health policy and regulation

Finally, specific requests for interpersonal and communication skills included:

• Less “captain of the ship” and more “member/leader of the team”
• Time management
• Empathy/customer service
• Conflict management/performance feedback
• Understanding of cultural and economic diversity
• Emotional intelligence

The involvement and engagement of every employee is the only way to fight cynicism.  It must be a real transformation, not merely an internal PR campaign.  And as we mentioned previously, your company culture really does define your future.

*Lifelong Learning: Physician Competency Development

Can You Design Your Organization’s Culture?

It was the venerable Peter Drucker who said that “culture eats strategy for lunch.”  Unfortunately, this little catchphrase is used as fodder to justify all sorts of actions and behaviors – some of which are questionable to say the least.  In healthcare, it makes sense to say that an organization with a transformation strategy that isn’t aligned with its culture will fail.  But digging deeper into the heart of the matter raises several questions:

- How do we design, foster, and nurture the right culture for our organization?

- How do we build the right organizational “habits” that create exemplify this culture?

- What steps do we take to translate our culture into the right outcomes in terms of performance?

- How do we align everyone – at all levels – in the organization?  What’s our alignment model?

- How do we define what behaviors that are not culturally acceptable?  What must change?

- Is our culture scalable and sustainable?

- Is our culture defined by our purpose and shared values, or is it vice-versa?

By providing compelling reasons for the organization’s existence, a leader builds a narrative that captures the imagination of all stakeholders – from the patients who are receivers of care, to the providers themselves – the clinical and nursing practitioners who serve the patient and society.

At the Physician Leadership Institute, we help organizations design or transform their culture by contemplating the following questions:

Mission: Why do we exist? What is the purpose of the organization? The department? The physician? The individual? Do we live by our mission in our day-to-day activities? Do we understand that the patient is our reason for existence? Profit, as Peter Drucker points out, cannot be a reason for existence. Instead, he says: “The customer is the foundation of a business and keeps it in existence. He alone gives employment. To supply the wants and needs of a consumer, society entrusts wealth-producing resources to the business enterprise.”  [Management: Tasks, Responsibilities, Practices; Peter Drucker, p.61]

Values: What do we stand for?  What do we hold in high esteem? What will we not do?  Is how we do our work as important as what we do?  Do we screen and hire to these values?

Behaviors: How will we know that we are living our values? What behaviors will we commit to? What are the non-negotiables?  Do we have a clear COMPACT that outlines what is expected of each other? do we hire and evaluate our leaders to the behaviors?

Reward/Consequences: How will we know we are succeeding? How do we measure and reward right behaviors? How do we deal with the consequences of bad behaviors?

Leadership: Do our leaders have the courage to uphold the values, deal with the brutal facts and act when someone is not living the values and related behaviors?

Alignment and Shared Purpose: Does everyone in the organization believe, uphold, and act on the values of our organization? Do we share a common sense of purpose, responsibilities, and outcomes? Are we working collaboratively across departments and functions to achieve our common purpose?

A Physician Leader inspires team members to come together and solve problems in a collaborative way. A shared sense of purpose permeates the workplace environment. This shared purpose gives team members a sense of belonging and motivates them to act in order to achieve positive outcomes. Thus our Model of Physician Leadership is centered around organizational purpose:

Thus, culture can be designed anchoring it to a clear and shared purpose.  Do our actions reflect our beliefs and our values?  Are our organizational habits aligned with our stated intentions?  How do we measure this?

Physician Leadership: An Interview with Dr. Joseph Cooper

Dr. Joseph Cooper is a practicing board-certified ophthalmologist and a member of the American College of Physician Executives. He has been a member of the medical staff of Marietta (OH) Memorial Hospital for more than 25 years and has held numerous medical staff positions including department chair, credentials chair, and president of the medical staff. He has also served as a hospital board trustee and chaired the board quality council. For the past eight years, Dr. Cooper has consulted with various medical staff on governance, credentialing and peer review.  Recently he has also begun working with the Physician Leadership Institute as part of the Center for Transformation & Innovation (CTI). He consults with hospitals and medical staffs across the country in the areas of medical staff organizational functions, governance and bylaws, peer review, credentialing and privileging and leadership training. He is a physician leader who brings more than 25 years of experience in medical staff functions and affairs to his work with physicians, hospitals, and healthcare organizations across the country.   

How do you view physician leadership?  Can physician leadership be taught?

Definitely. There are some people who are born with it, but most people probably aren’t. Just like any skill, it has to be taught otherwise most people I don’t think would have it.

Have things changed in your day-to-day activities as a result of taking physician leadership from the Physician Leadership Institute?

Definitely.  In medical school the problem is that you’re not exposed to any leadership whatsoever.

You’re exposed to clinical activity. You pick up either good or bad habits from the people you get taught by. And a lot of them don’t have leadership skills either. So it’s kind of catch-as-catch-can.

Most people get into a position starting to assume leadership and really have no training, with no insight whatsoever because it’s not something that we’ve been exposed to for all those years.

They don’t have classes or courses about leadership or teamwork. Maybe that world is changing now, maybe some of that is going to occur now. I know medicine is becoming more of a team sport compared to twenty years ago but still I don’t think they get much leadership in their formal training.  I know my son  just graduated med school, and there certainly wasn’t anything like that for him.

Most doctors aren’t exposed to leadership tools like we were in the Physician Leadership Institute unless they’ve also undergone an MBA or an MMM program. I think for the average doctor these things are very new.  The leadership training is very valuable in that once you get exposed to it, it changes the way you approach and work with others.  You start using different styles of interaction depending on the type of person you’re dealing with. This is not something we were taught before.

In calm moments, we’re humans.  But in emergencies, we do become more technical – trying to make the best decisions to save a patient.  All doctors have to learn to balance their emotions and their clinical skills.

In your opinion, who should enroll in these physician leadership programs?

If just the people at the top are the only ones trained, it doesn’t work as well. What you need is a culture of leadership and responsibility. Anybody can benefit from leadership training because everyone is a leader at one point or another. You see the benefit in interactions with others.

Doctors are autonomous animals, we were taught to do things by ourselves, make decisions on the fly all the time, as I said. But to be a team player and look for consensus, that’s sometimes an alien world for even some very good doctors. Of course there are some doctors who may say something like I don’t have the time for this, but sometimes those are the very folks that need this training the most.

What would you tell someone who is skeptical of the idea of physician leadership?

I would tell them that there are benefits beyond simply your job. The benefits extend to your practice, whether it’s a group or individual practice, your day-to-day interactions with everyone you come into contact  with. The life skills we learn we also use with our families and friends.  It is a transformative process not just for the
organization but for individuals as well.

Did you notice an impact on business performance after the leadership training?

Because ours was  a diverse group, I think the biggest changes you would  see are in the groups that work together in the same organization or practices.  Also, in  teams that work together on action projects.  Because of the personal coaching, you create specific plans for interactions with specific people.  This was very helpful for me personally. I would hope that even my son would take a class like this so he could benefit from it for his future career.

Jim Collins: 13 Questions to Take You from Good to Great (Part II)

In the previous blog post, we went through the first six questions, now let’s continue with the discussion of Jim Collins’ 13 questions.

7. How can we better blend empirical creativity AND fanatic discipline, and thereby scale innovation?

Collins describes a tripartite formula for success in another one of his bestsellers - Great by Choice: Uncertainty, Chaos, and Luck–Why Some Thrive Despite Them All:

Fanatic discipline: extreme consistency of action—consistency with values, goals, performance standards, and methods (remember the 20 Mile March?); utterly relentless, monomaniacal, unbending in their focus on the goals.
Empirical creativity: decisions are made primarily on empirical evidence, based on direct observation, practical experimentation, and direct engagement with tangible evidence. Bold, creative moves are derived from a sound empirical base.

Productive paranoia: maintain hyper-vigilance in order to detect and react to threats and changes in their environment, even when—especially when—all’s going well. Assume conditions will turn against them, so they channel their fear and worry into action, preparing, developing contingency plans, building buffers, and maintaining large margins of safety.

Great innovators fire “bullets” first and correct their aim before firing big fire balls to hit their targets.

What is a bullet? For Collins, a bullet is “an empirical test aimed at learning what works and that meets three criteria: 1. A bullet is low cost. Note: the size of a bullet grows as the enterprise grows; a cannonball for a $1 million enterprise might be a bullet for a $1 billion enterprise. 2. A bullet is low risk. Note: low risk doesn’t mean high probability of success; low risk means that there are minimal consequences if the bullet goes awry or hits nothing. 3. A bullet is low distraction. Note: this means low distraction for the overall enterprise; it might be very high distraction for one or a few individuals.”  Thus, innovation is not about home runs, it starts with singles!

How do you accomplish this in healthcare?  By creating a culture of curiosity, testing, and improvement – with the discipline to stay the course.

8. What is our BHAG – our Big Hairy Audacious Goal?

In their book Built to Last: Successful Habits of Visionary Companies, Collin and Porras state:  ”A true BHAG is clear and compelling, serves as unifying focal point of effort, and acts as a clear catalyst for team spirit. It has a clear finish line, so the organization can know when it has achieved the goal; people like to shoot for finish lines.” An example of a BHAG is SolarAid‘s mission: to eradicate the kerosene lamp from Africa by the end of the decade.

In healthcare, a now famous BHAG for the entire industry was Dr. Ezekiel Emanuel‘s “limit per capita cost to 0% + GDP by 2020.”  

Has your organization developed a meaningful BHAG that resonates at every level of the company?

9. What is the right 20% to change, so as to best Preserve the Core and Stimulate Progress?

Collins advice here is to stimulate progress and innovation, while retaining your core purpose and values.

The Yin and Yang approach, as Collins describes it, makes organizational values the exacting standards that drive the organization.  These principles are the DNA of an organization.  Change is embraced, but only as it furthers organizational purpose and values.  The tension between these two forces is what keeps an organization healthy.

This is a great way to approach the healthcare transformation.  How else is meaningful change possible?

10. How can we increase our Return on Luck (ROL), adapting our strategy to both good luck and bad?

Most companies have their share of good and bad luck. What matters is what they do with their opportunities.  It’s called Return on Luck (ROL).

How can you get a high return on luck at work? Here’a an answer to that question from Collins’ co-author Morten Hansen.  The point: “prepare intensively, commit all the resources you can, and be maniacal about execution when the good-luck moments arrive!”

11. Do we show any signs of the Five Stages of Decline, and what should we do about them?

Collins explains why it’s a good idea to know where your organization stands on the road to doom and gloom:

“With a road map to decline in hand, institutions heading downhill might be able to apply the brakes early and reverse course. We’ve found companies that recovered—in some cases, coming back even stronger—after having crashed down into the depths of Stage 4.”

Where do you stand?

12. What should we Stop Doing?

If you have to-do list, then you should also have a NOT-to-do list!

An exercise worth doing: take your long to-do list (both at home and at work) and divide it into the following categories:

  1. Start doing
  2. Stop doing
  3. Continue to do
What have you learned?  Remember, saying no to something actually is saying yes to the things that matter most.

13. How will you Change the Lives of others?

This is the promised bonus question that is not on Collins’ website.  How will you Make A Difference today?  (I call it “go MAD”!)

The best leaders find ways to be useful with real people in the present. Think beyond your life as a physician. As a leader, how do people feel that you changed their lives? How can you be helpful, useful to others?

Remember, people don’t care how much you know until they know how much you care.  It was John Quincy Adams who said: “If your actions inspire others to dream more, learn more, do more and become more, you are a leader.”  The job of the leader is to serve.

And now for some criticism. There has been some criticism of Collins’ Good to Great, most notably from Phil Rosenzweig, a professor at IMD, Lausanne.  In his book, The Halo Effect, he explains that the problem with business books like Good to Great is that they are based on faulty data. Rosenzweig urges leaders to develop their critical thinking skills, and be driven by evidence, not stories.  Here’s his take:

How does the halo effect manifest itself in the business world? Imagine a company that is doing well, with rising sales, high profits, and a sharply increasing stock price. The tendency is to infer that the company has a sound strategy, a visionary leader, motivated employees, an excellent customer orientation, a vibrant culture, and so on. But when that same company suffers a decline—if sales fall and profits shrink—many people are quick to conclude that the company’s strategy went wrong, its people became complacent, it neglected its customers, its culture became stodgy, and more. In fact, these things may not have changed much, if at all. Rather, company performance, good or bad, creates an overall impression—a halo—that shapes how we perceive its strategy, leaders, employees, culture, and other elements.

In our experience, we find that despite the criticism, the Good to Great model does serve as a useful transformation blueprint for most organizations.  Of course each organization does need to examine its own case, its own circumstances, and act accordingly.  But that is another story – we call it terrain-based strategy.

Jim Collins: 13 Questions to Take You from Good to Great (Part I)

A short while back, I met Jim Collins at the AMGA conference where he was a keynote speaker. I’ve always had tremendous admiration and respect for his work over the years, and now his message applies to our industry more than ever.

What makes a company great? In his landmark book Good to Great, Collins argues that great companies share certain attributes, among them:

    • Level 5 Leadership: Leaders who are humble, but driven to do what’s best for the company.
    • First Who, Then What: Get the right people on the bus, then figure out where to go. Finding the right people and trying them out in different positions.
    • Confront the Brutal Facts: The Stockdale paradox—Confront the brutal truth of the situation, yet at the same time, never give up hope.
    • Hedgehog Concept: Three overlapping circles: What lights your fire (“passion”)? What could you be best in the world at (“best at”)? What makes you money (“driving resource”)?
    • Culture of Discipline: ”Rinsing the cottage cheese” (a practice named after Dave Scott, the triathlon champion, to eliminate excess fat from his cottage cheese).
    • Technology Accelerators: Using technology to accelerate growth, within the three circles of the hedgehog concept.
    • The Flywheel: The additive effect of many small initiatives; they act on each other like compound interest.

Collins asks us 13 questions (his website lists 12 so the 13th question is a bonus) that help us think things through. Let’s look at each of these questions through the lens of the healthcare industry.

1. Do we want to build an enduring great company (or social sector enterprise), and are we willing to strive for Level 5 Leadership?

Level 5 Leadership is how Collins describes leaders who are humble, but driven to do what’s best for the company. You know you achieved level 5 leadership when people are willing to follow you when they have the freedom not to follow you. At the Physician Leadership Institute (PLI) we’re dedicated to developing level 4 and Level 5 Physician Leadership in healthcare. At Level 5 Leadership, the crucial factor is the selfless dedication to organizational purpose, cause, and legacy. In the PLI, we recognize that purpose is the critical factor of leadership and it is one of the five factors of physician leadership.

2. On what core values and enduring purpose will we build our culture for 100 years?

Organizational core values and belief define organizational culture. Jim clarifies that culture is strategy.  Our alignment model has demonstrated that lasting success requires leadership development that is well-targeted, high quality, delivered and embedded on-site, and customized to the unique needs of physicians and the organization. The goal is to transform physician leadership at all levels and build the next generation of physicians to successfully lead healthcare transformation.

3. Do we have the right people on the bus, and are 95% of our key seats filled with the right people?

Organizations that succeed are continuously assessing their talent.  At the top, its about getting the “right people on the bus” and the “wrong people off the bus.” Often times, organizations create difficult situations in remote areas or in a hard-to-recruit specialty, ending up with the wrong person on the bus. This sort of recruiting based on scarce talent is extremely destructive. Think: what message are we sending our team members when we hire someone with the wrong values fit? Great leaders have the ability to make superb people decisions by assessing who is best fit for the organization culture and purpose. Your company is your people. It is always about “the who.”

4. What are the brutal facts, and how can we better live the Stockdale Paradox?

The Stockdale Paradox is named after Admiral Jim Stockdale, the highest ranking US military officer imprisoned in Vietnam.  As a POW,  Stockdale was repeatedly tortured over 8 years – his shoulders had been wrenched from their sockets, his leg shattered by angry villagers and a torturer, and his back broken.

Collins writes about a conversation he had with Stockdale regarding his coping strategy:

“I never lost faith in the end of the story, I never doubted not only that I would get out, but also that I would prevail in the end and turn the experience into the defining event of my life, which, in retrospect, I would not trade.”

When Collins asked who didn’t make it out of Vietnam, Stockdale replied:

Oh, that’s easy, the optimists. Oh, they were the ones who said, ‘We’re going to be out by Christmas.’ And Christmas would come, and Christmas would go. Then they’d say, ‘We’re going to be out by Easter.’ And Easter would come, and Easter would go. And then Thanksgiving, and then it would be Christmas again. And they died of a broken heart.

Stockdale then added:

This is a very important lesson. You must never confuse faith that you will prevail in the end—which you can never afford to lose—with the discipline to confront the most brutal facts of your current reality, whatever they might be.

What are the brutal facts in healthcare? The brutal facts include:

- the transformation from volume to value – and the relentless requirement to drive down cost

- the need to work collaboratively in teams

- the need to manage population health and not episodic care

- disruptive innovations that alter the way we deliver care

- the consumerization of healthcare

- retail healthcare is a reality, quality and cost are expected to be demonstrated. What got us here, will NOT get us there!

These trends driving radical change in the industry are the brutal facts in healthcare. Physician leaders must understand, prioritize, and create a transformational road map based on existing and future organizational capabilities.

5. What do we understand so far about our Hedgehog Concept—what we are fanatically passionate about, what we can be the best at (and cannot), and what drives our economic (or resource) engine?

Collins uses the fox vs. hedgehog analogy to describe a company’s commitment to its core business. A fox knows many things while a hedgehog knows one thing and does it well.  Collins gives us three overlapping circles: What lights your fire (“passion”)? What could you be best in the world at (“best at”)? What makes you money (“driving resource”)?

Healthcare is a complex system and the prevalent temptation is to try to be good at everything versus great at fewer things. Big does not equal great and great does not equal big. How are we focused on what matters most?  Are we saying “no” to the right things?  What do we say “yes” to?  Is it technically and economically sustainable?  What do we have to change to get there?  These are the questions the Physician Leadership Institute (PLI) helps clients answer as we work with them to build a high-performance culture defined not by platitudes, but by results.

6. How can we accelerate clicks on the Flywheel by committing to a 20 Mile March?

Collins uses the story of the race between Robert Falcon Scott and Roald Amundsen to reach the South Pole. Both were accomplished leaders, but Amundsen’s team made it to the South Pole and back in time, whereas Scott’s team got there second, and perished on the way back.

\Why? What was the difference between the two leaders?

Scott displayed courage, perseverance, and determination in the face of obstacles but was unwilling to adapt his strategy when conditions changed; he neglected to learn from those who best understood the terrain; he used a command and control leadership style and failed to inspire his team or gain their trust and commitment.

Amundsen, on the other hand, was all about discipline and committing his team to a 20 Mile March on a daily basis. His success factors included:

- Terrain-Based thinking: Amundsen was willing to learn from others (he lived among the Eskimos to learn keys to survival and success in that terrain using dogs and sleds)

- Thought strategically

- Inspired and motivated people

- Managed the process with discipline (20 mile/day)

Ask: What’s my 20 Mile March? What are our organization’s disciplined goals? Is everyone on board and aligned?  What will it take to achieve commitment at every level of the organization?

In the next post we cover seven more questions raised by Collins and look at the criticism that some have leveled against the Good to Great approach.

Engaging Doctors in The Health Care Revolution

The June issue of Harvard Business Review includes an article titled Engaging Doctors in the Health Care Revolution*, by Thomas H. Lee and Toby Cosgrove.

The authors start by affirming the core philosophy of the Physician Leadership Institute, namely:

Fixing health care will require a radical transformation, moving from a system organized around individual physicians to a team-based approach focused on patients. Doctors, of course, must be central players in the transformation: Any ambitious strategy that they do not embrace is doomed.

The authors ask the all important question: how can leaders best engage physicians to redesign care?  

They make an important distinction between cooperation (an agreement not to sabotage) and collaboration(engagement in relentless improvement).

They also point out a fundamental flaw in the current approach healthcare organizations are employing:

Many organizations hope that they can win over physicians by combining good intentions with a few broad interventions, such as putting doctors in leadership roles and creating financial incentives for desired behavior. But as we have seen too often, such uncoordinated, piecemeal efforts are insufficient.  

The remedy?  The authors give us a motivational framework adapted from Max Weber’s typology of social action:

In our experience at the Physician Leadership Institute (PLI), this framework may not be enough to create the transformation. We need physician leadership to motivate, align and engage physicians. This corresponds with our Physician Leadership Model:

Leading with Strategy and Results: We believe engagement is like a muscle that needs to be exercised. After appealing to a common and higher purpose, physicians want to engage in a meaningful, relevant and tangible problem solving. Physicians do not dispute the need to focus on the patient; many believe that they already do. Our Physician Leadership Institute (PLI) gives physician leaders direct, hands-on training via our action projects that strive to solve real world strategic problems. These are  collaborative projects that build engagement and leadership simultaneously. One of our most popular projects asks: “How do you engage physicians in owning patient satisfaction?” A team of physicians work together for the duration of the Institute (12 months) to analyze why physicians are typically not engaged in efforts to enhance and improve patient satisfaction. The objective is to identify obstacles and to develop sustainable solutions.

Typically we discover, through surveys and interviews, that physicians believe in the false notion that they already deliver patient satisfaction. This is a real obstacle to meaningful change.  Over time they realize that the patient (and their families) judge their experience on the total visit and not the 10 minutes with the provider. The ultimate power of this approach is that physicians share their stories along with data-driven findings. This peer-based sharing of best and next practices is far more powerful and stimulating than simply watching videos or taking a traditional leadership course. For example, at Quincy Medical Group the initial team of physicians tasked to explore “physician engagement in patient satisfaction” where very skeptical of the process. At graduation, not only were they enthusiastic converts, but they led the training for all the physician groups (more than 200 providers) instead of hiring an outside speaker. Since then, patient satisfaction has topped 90th percentile on the AMGA survey and the organization was recognized as the most improved physician group by AMGA.

Leading People: the importance of peer-to-peer communication and influence cannot be stressed enough. PLI dedicates its mission to developing physicians into physician leaders that understand how to proactively use the power of language to influence and address the concerns of their peers. They learn how to tailor their communications to influence not just behavior, but outcomes.

Leading Self: At PLI, we provide individual physicians with a personal coach that works with them one-on-one to improve self awareness. Physician get to reconnect with their life purpose and connect it to their work. The physicians learn that their behavior has the tremendous power to influence others. They realize the impact of what they say and do could accelerate or derail a transformation.

Finally, the HBR article does not address the fundamental underlying challenge of physician engagement – trust.

Far too many physicians do not trust their organization’s administrators. We believe the techniques we use to engage physicians and administrators allow them to build trust and see the world from a shared perspective. It’s the age-old alignment conundrum. Purpose drives strategy, and strategy must be linked to operations. Operational policies must be relevant and guide the everyday actions of staff, physicians and administrators.

What is required is physician leadership at every level.

What do you think?

See also:

Why Leadership Development Programs Fail
Physician Engagement: The Outcome of Physician Leadership

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* Engaging Doctors in the Health Care Revolution, Thomas H. Lee, Toby Cosgrove, Harvard Business Review, June 2014

The Road to Transparency: Sharing Insurance Healthcare Data on Price and Quality

The march to healthcare transparency continues. Previously, we had seen how transparency in Medicare had raised a storm of controversy. Imagine the day when we’re able to shop for healthcare online just like we search for travel deals on Expedia.

Well, we’re getting closer with this latest announcement. The Health Care Cost Institute (HCCI) has announced that it will work with three of the nation’s largest health insurance companies, Aetna, Humana and UnitedHealthcare, to develop and provide consumers free access to an online tool that will offer consumers the most comprehensive information about the price and quality of health care services. The independent, not for profit HCCI will create and administer this information portal, which is expected to be available in early 2015. The health benefit companies will provide information on health care costs to HCCI, which will maintain and manage access to the information in a secure, protected environment. Other major carriers have expressed interest and HCCI expects additional carriers to participate in the near future and be part of the initial release in 2015. Participating insurers will continue to offer their own cost transparency tools and solutions as well. The cost data will be supplemented with quality and other information to provide consumers a transparent and comprehensive destination to make more informed decisions about health care.

Health care costs have been rising more than three times as fast as wages. Official estimates project that U.S. health spending will reach $4.7 trillion by the end of the decade – an 80 percent increase from $2.6 trillion in 2010 – underlining the need to better understand the prices of health care services to help make decisions and choices about purchasing care.

The new transparency tool that HCCI is developing will aggregate pricing data from commercial health plans, as well as Medicare Advantage and Medicaid health plans, if the states agree. The information will be available to consumers, purchasers, regulators and payers in an accessible, comparable and easy-to-use format.

• For consumers, this will provide consistent and accurate transparency in the shopping experience with the most comprehensive cost data and quality information; uninsured individuals can access more reliable information about the relative prices of care, treatments and procedures;

• For employers, this will foster more employee engagement in managing health care costs regardless of payer, health plan or plan design. This will provide a seamless experience regardless of payer;

• For care providers, this provides timely and accurate information about costs and quality and allows them to see information on other providers as well;

• For regulators, this provides a single source of information to support market studies, including evaluation of market efficiency and accurate review of cost drivers. This will help inform geographic rate adjustments and provide guidance for addressing important public policy issues;

• For payers, this provides the most accurate and timely data to meet customer needs and protects proprietary data while allowing customers access to multi-payer information.

Is your organization ready for radical transparency?  It’s coming, and if trends are any indication, it’s coming soon. What will be your strategy? Defensive? Wait for information to be out and then react? Or will you develop and post your own pricing information and let the market react to you!? Where to start? The Physician Leadership Institute is here to help.

Physician, Disrupt Thyself!

Traditional healthcare is being disrupted by new entrants – upstarts that are shifting the balance of power by changing accepted business models almost overnight.

Over ten years ago, Professor Clayton Christensen warned us:

Dominant players in most markets focus on sustaining innovations—on improving their products and services to meet the needs of the profitable high-end customers. Soon, those improvements overshoot the needs of the vast majority of customers. That makes a market ripe for upstart companies seeking to introduce disruptive innovations—cheaper, simpler, more convenient products or services aimed at the lower end of the market. Over time, those products improve to meet the needs of most of the market, a phenomenon that has caused many of history’s best companies to plunge into crisis. **

Now, the time is upon us.  Institutional disruption is here:

As is disruption of the profession itself:

A recent report from PWC brings home the reality:

The New Health Economy represents the most significant re-engineering of our health system since employers began covering workers in the 1930s. It goes beyond the recent period of convergence in which business roles blurred. Yes, siloes are coming down as providers, insurers and life sciences companies begin to coalesce around the pressure to demonstrate value. But in the New Health Economy, as the money flows from consumers to new players, today’s siloed disease treatment industry will be replaced by a wide open health marketplace. 

Of course, traditional healthcare providers are justifiably nervous, but the choice is clear. Either disrupt yourself, or be disrupted.  

And the customer/patient is ready for change. Every service you currently provide will be disrupted.

The consumerization of healthcare will bring a sea change in the market. Here are a few questions to ask at this point:

- How will we disrupt ourselves?

- Do we know where to begin?

- What are the strategic priorities?

- Do we have a framework for innovation that produces results?

- Do we have capable physician leaders to drive the transformation?

Stay tuned.

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