Transcript Department of Emergency Medicine Patient Satisfaction

SAEM Business of Academic Emergency Medicine Boot Camp
Putting It All Together Managing Multiple
Priorities
Brian J. Zink, MD
Professor and Chair,
Dept. of Emergency Medicine,
Alpert Medical School
Lifespan Partners
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.
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
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
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?
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.
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.
12 Beyond Budgeting Principles (2011)
Governance and transparency
www.bbrt.org/beyondbudgeting/bb-principles.html
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
Before Budgeting, Before Allocating…
There is the big picture.
Positive organizational
change
Abundance Theory
Appreciative Inquiry
Adaptive Enhancement
Bandelier National Monument, New Mexico
Moving Toward a
Fundamental State of Leadership
Self Focused
Internally Closed
Other
Focused
Internally
Directed
Externally Directed
Externally
Open
Results
Centered
Comfort Centered
From: Quinn, RE. Building the bridge as you walk on it. Jossey-Bass, 2004
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Four Questions as You Craft Your Vision
Four Questions
What are we really asking?
1. What result do we want to
create?
What is our real purpose?
Are we in a proactive life stance?
Do we have a sense of meaning?
Are we challenged and engaged?
2. Are we internally directed?
What are we afraid of?
What are our core values?
What would we do if we had 2% more
courage?
Are we moving forward no matter what the
punishment?
3. Are we other-focused?
Who is in the relationship?
Are we pursuing a purpose larger than us?
Are we sacrificing for the common good?
Are our relationships full of trust and respect?
4. Are we externally open?
Are we doing what we do not know how to
do?
Have we let go of control?
Are we embracing feedback?
Is our awareness expanding dramatically?
Adapted from: Cameron KS: University of Michigan Business School, 2006
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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.
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
What is Appreciative Inquiry?
Appreciative Inquiry is a collaborative and
highly participative, system-wide approach to
seeking, identifying, and enhancing the “lifegiving forces” that are present when a system is
performing optimally in human, economic, and
organizational terms.
From: Don Schutt, Ph.D., NCC, LPC, MCDP; Univ. of Wisconsin; A StrengthBased Approach to Career Development Using Appreciative Inquiry
“AI is the ability (a kind of intelligence) to perceive the
positive inherent generative potential in the present.” –
David Cooperrider
Appreciative Inquiry: The “4-D” Cycle
Discovery
“What gives life?”
(The best of what is)
Appreciating
Destiny
“How to empower, learn,
and adjust/improvise?”
Sustaining
Affirmative
Topic Choice
Dream
“What might be?”
(What is the world calling for)
Envisioning Results
Design
“What should be--the ideal?”
Co-constructing
From: Cooperrider, DL, Whitney
D, Stavros, JM. Appreciative
Inquiry Handbook. Crown Custom
Publishing, Inc 2008.
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
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!
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.
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 …
High Performance Teams
(source: Losada & Heaphy, 2003)
Team Performance
Positive Statement
Ratio
High
Medium
Low
5.6 to 1
1.8 to 1
0.36 to 1
0.67 to 1
0.05 to 1
0.62 to 1
0.03 to 1
22
18
(supportive, encouraging, appreciation)
Inquiry/ Advocacy
Ratio
1.1 to 1
(questioning versus asserting)
Others/Self Ratio
0.94 to 1
(external versus internal focus)
Connectivity
Average
33
(mutual influence, assistance, interaction)
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?
Comparing Approaches to Improvement
PROBLEM SOLVING
APPRECIATIVE CHANGE
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
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 overcome major
problems.
BASIC ASSUMPTION:
Our job is to embrace and
enable our highest potential.
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.
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.
If you see your cup as half full,
it may one day runneth over;
if you see it as half empty, it never will.
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?
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.
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.
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.”
USAir
United
Continental
USAir
United
Northwest
Continental
Am West
American
Delta
Alaska
0%
Southwest
5%
Am West
10%
American
15%
Delta
20%
Northwest
0
-10
-20
-30
-40
-50
-60
-70
-80
-90
-100
Alaska
25%
Stock Values September 2001 to September 2002
Southwest
Employee Layoffs After September 11, 2001
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).
The Competing Values Framework
Individuality
Flexibility
Long-term
Change
Internal
Maintenance
Incremental
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
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
Stability
Control
Cameron K. and Quinn R., Diagnosing and Changing Organizational Culture, Jossey Bass, 2006
New
Change
External
Positioning
Fast Change
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: 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:
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:
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
Organizational Leadership Profile
The Collaborate Culture
The Create 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
human resources development
Collaborate
with high cohesion and morals
50
being important. Success is defined
40
in terms of sensitivity to customers
and concern for people.
The
30
organization places a premium on
20
teamwork,
participation
and
consensus.
10
10
The Control Culture
20
An organization that focuses on
30
internal maintenance with a need
for stability and control.
40
A very formalized and structured
place to work. Procedures govern
50
Control
what people do. The leaders pride
themselves on being good
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.
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
Create
emphasis is on growth & acquiring
50
new resources.
Success means
40
having unique & new products, or
services. Being a product, or service,
30
leader is important. The organization
encourages individual initiative &
20
freedom.
10
The Compete Culture
10
20
30
40
Compete
50
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
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.
33
Negative Aspects of These Cultures
Overemphasis & Loss of Balance
Negative Zones
Irresponsible
Country Club
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: MARKET
Orientation: COMPETE
Attributes:
Over-exertion
Tyrannical goal focus
Unproductive conflict
Blind ambition
Culture Type: HIERARCHY
Orientation: CONTROL
Attributes:
Micromanagement
Procedural rigidity
Over-regulation
Ironbound tradition
Frozen
Bureaucracy
Tumultuous
Anarchy
Individuality Flexibility
Stability
Control
Cameron K. and Quinn R., Diagnosing and Changing Organizational Culture, Jossey Bass, 2006
Oppressive
Sweatshop
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.
35
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
Organizational Culture Profiles
An Example of Life Cycle Development in Organizational Cultures
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Dept EM Culture Previous Compared to Today
Collaborate
50
40
30
Current
50
2007
Desired
40
Results
2007
Create
30
20
Desired
Results
2008
2007
Current
20
10
10
10
10
Current
Desired
Results
2010
20
2008
Current
20
30
Current
Desired
2008
Desired
30
2010
Current
40
2010
Desired
50
40
50
Control
Compete
38
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.
39
The Hedgehog Concept in the Social Sectors
What are we
deeply
passionate
about?
What can we
be best in the
world at?
What drives
our resource
engine?
Adapted from Good to Great and the Social Sectors, Jim Collins, 2005
40
POSITIVE
RESULTS
THE FIVE KEY
CHARACTERISTICS
OF A HIGHLY
ACCOUNTABILITY
FUNCTIONING
TEAM
SENSE OF
COMMITMENT
HANDLE
CONFLICT
TRUST
Adapted from: Overcoming the Five
Dysfunctions of a Team
by Patrick Lencioni
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
Where Do We Spend Most of Our Time?
Uniqueness
Strengths
Competencies
Weak Areas
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.
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.
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
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.
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
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?
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?
Case Four: Research v. Clinical Faculty
Your Department offers seed grants to stimulate
research activities in junior faculty members.
Some clinically-oriented faculty members want you to
use one half of the seed grant money each year to
support clinical QA projects (non-research) for clinical
faculty members. They argue that departmental
revenue is almost totally derived from clinical activity,
and they contribute the most to this, so they believe
they should be able to get seed money as well.
How do you balance your research v. clinical priorities?
Case Five: Research Outlier
Your leadership team has established two main
research areas of focus and support within your
department - cardiovascular emergencies and
infectious diseases – and support goes to these areas.
A bright and energetic young faculty member has gone
out on her own and secured a small research grant in
interpersonal violence against women. She wants to
grow in this area and requests more protected time so
she can do the research and apply for a K Grant.
How do you manage this conflict between the
departmental stated areas of focus, and this faculty
member’s interests and desires?
Case Six: IP Opportunity
An enterprising faculty member has developed some
innovative, patented software for the ED and wants to
form a small company to commercialize it. He is
requesting that his commitment to the department be
reduced to one shift a week while he starts up the
company. With his intellectual property and patents,
the venture could return a million dollars to the
Department if it is successful.
Some of your Departmental leaders think this is a very
risky proposition, and do not feel that a “special deal”
should be made for this faculty member?
How you manage this opportunity while being fair and
open?
Case Seven: International EM
You have a successful and growing international
program in Africa. More and more faculty are
requesting time to go for month long clinical and
educational experiences at the Africa site. The
department is covering at least half the costs of these
international experiences.
Some faculty members who do not do international
work resent the fact that their schedules are altered to
allow the international EM faculty to go to Africa, and
feel that it is too costly and diverting funds from other
areas.
How do you manage this tension between the IEM
program and your “stay at home” faculty members?
What Will Be Different When We Go Home?
After this SAEM Bootcamp, we hope that you have
better sense of:
Cost accounting, Reimbursement
Funding for GME and Research
Revenue Generation
Strategic and Business Planning
Marketing
Risk Management
Human Resources
And, an approach that emphasizes positive organizational
change and appreciative inquiry.
So, MARCH on out of here and APPLY WHAT YOU HAVE
LEARNED!