week 11 db 6

2 5 1

L e a r n I n g o b j e c t I v e s

C H A P T E R 9

L E A D I N G , M A N A G I N G , A N D G O V E R N I N G W I T H I N O R G A N I Z AT I O N A L D Y N A M I C S

Treat people as if they were what they ought to be, and you help them be-

come what they are capable of being.

—Johann Wolfgang von Goethe

➤ Appreciate the types of leaders and leadership styles.

➤ Understand the difference between leadership and management.

➤ Describe the dyad management model.

➤ Appreciate the importance of managing disruptive behavior in the medical

practice.

In t r o d u c t I o n Many definitions and descriptions of management and leadership have been offered by numerous observers. In essence, and for purposes of this discussion, leadership is the pro- cess of social influence in which one person can enlist the aid and support of others in the accomplishment of a common task or goal. This definition is captured by a quote from former

C o p y r i g h t 2 0 1 7 . H e a l t h A d m i n i s t r a t i o n P r e s s .

A l l r i g h t s r e s e r v e d . M a y n o t b e r e p r o d u c e d i n a n y f o r m w i t h o u t p e r m i s s i o n f r o m t h e p u b l i s h e r , e x c e p t f a i r u s e s p e r m i t t e d u n d e r U . S . o r a p p l i c a b l e c o p y r i g h t l a w .

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F u n d a m e n t a l s o f M e d i c a l P r a c t i c e M a n a g e m e n t2 5 2

First Lady Rosalynn Carter: “A leader takes people where they want to go. A great leader takes people where they don’t necessarily want to go, but ought to be” (Goodreads 2017).

Leaders also need to know themselves, and they need to know their followers. They are good teachers and help their followers understand the nature of the medical practice’s mission. Good leaders explain the “why,” and not simply the “what.” People need to know why they carry out activities to be fully invested in them. They often become so busy focus- ing on the what that they forget the why. Staff cannot demonstrate passion for what they do not understand or support, and they cannot support something they do not understand. If practice members do not support and understand the mission and respect the values it espouses, the practice cannot prosper. Leading a divided practice is difficult, if not impos- sible. To avoid such divisions, leaders must focus attention on aligning practice members with the mission and vision of the practice (Wagner 2003).

Much of leadership and management (later in the chapter, we consider the differ- ences between leadership and management) relates to how the leader interacts with his or her team. Does she delegate or collaborate? Does he direct, dictate, or facilitate? Readers may consider this question as they proceed through the chapter, with the understanding that people do not need to limit their approach to leadership to their natural tendencies. All styles have their place, and each can be learned. Think about the surgeon in the operating room. We expect and desire that surgeon to be directive and dictate what needs to be done. The operating suite is no place for a lengthy discussion or collaboration on solutions if the patient faces an imminent threat. Now place the same surgeon in a practice meeting that requires a collaborative solution and the input of all stakeholders to arrive at an optimal outcome for the patient. In this case, a direct or dictating style of leadership is counterpro- ductive. This scenario represents one of the challenges for medical practice managers and leaders: the need to help people develop the flexibility to use the proper leadership style in the appropriate situation. This skill comes with awareness and with practice, and the modern medical practice is charged with developing leaders who appropriately use multiple leadership and management styles in the operation of the practice.

th e ba s I c s a n d th e o r I e s o f Le a d e r s h I P While a detailed description of each is beyond the scope of this text, some of the most prominent leadership theories are listed here for review. Many of the following focus on the behaviors and characteristics of leadership to explain performance and organizational impact (Northouse 2015; Nohrina and Khurna 2010):

◆ Great man theory

◆ Role theory

◆ Participative leadership

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2 5 3C h a p t e r 9 : L e a d i n g , M a n a g i n g , a n d G o v e r n i n g

◆ Lewin’s leadership styles

◆ Situational leadership

◆ Hersey and Blanchard’s situational leadership

◆ Trait theory

◆ Behavioral theory

◆ Contingency theory

Regardless of the theory one subscribes to in terms of leadership styles and devel- opment, leadership and its proper application are essential elements of a viable medical practice. As in many types of organizations, medical practice leadership is in increasingly short supply (Hay Group 2006).

Exhibit 9.1 summarizes an important aspect of the most prominent theories of lead- ership: the need to either serve their stakeholders or be more self-centered in perspective.

In general, we see two kinds of leaders: those who are focused on power, economic reward, and authority (will to power) and those who are oriented toward service (will to serve). Those possessing the will to serve tend to be more transformational, and those with the will to power tend to work in organizations that are transactional in nature. Transfor- mational leadership is intended to create change in individuals and in the medical practice. The goal of transformational leadership is to encourage valuable and positive change in the followers and promote growth in both followers and leaders. Transactional leadership, sometimes called managerial leadership, focuses on supervising followers and managing group performance; leaders employing this style of leadership promote compliance through rewards and punishments. Transformational leadership is the style most needed in today’s practice environment.

Transformational

leadership

A form of leader-

ship intended to create

change in individuals

and the medical prac-

tice by encouraging

valuable and positive

change in followers

and promoting growth

in both followers and

leaders.

exhIbIt 9.1 Transactional Power Versus Transformational Power

Will to Power

Will to Serve

Transformational

Transactional

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In his book Good to Great, Jim Collins (2001) proposes five levels of leadership, which are applicable to the medical practice:

Level 1: The highly capable person is able to give to the practice thorough knowl- edge, skills, and other good work habits.

Level 2: The contributing team member is a person who begins to use her talents to give to the practice.

Level 3: The competent manager understands basic organization of employees and resources and how to use them to meet objectives and goals of the practice.

Level 4: The effective leader stimulates a higher performance standard for the practice.

Level 5: A leader who builds enduring greatness through humility and profes- sional will.

Level 5 leaders find their success through the success of others and of the practice; they do not put their own ambitions first. The level 5 leader is rare, so it is true that other levels of leadership can be successful; however, leaders can, and should, all strive to become level 5 leaders (Collins 2001).

In the medical practice, trust is essential, and that trust must be built between the practice manager, its leaders, and the other stakeholders in the organization. Perhaps because of this need for trust, the concept of tribal leadership, developed by David Logan, John King, and Halee Fischer-Wright in their book, Trial Leadership: Leveraging Natural Groups to Build a Thriving Organization, also may be particularly applicable to the medical practice. This theory identifies five stages of tribal culture and demonstrates how managers and leaders can help the entire “tribe” move from one stage to the next. These stages are as follows (Logan, King, and Fischer-Wright 2008):

Stage 1: Members of the tribe are hostile to one another and to the company or practice. According to the authors, this stage is not commonly seen in organizations.

Stage 2: This stage features the presence of tribal members who are negative, antagonistic, passive, sarcastic, and resistant to the positive initiatives of the company. The authors believe this stage is commonly seen, and from the author’s experience, it is where one often finds medical practices in times of change.

Stage 3: This stage is even more common in workplace tribes and can be characterized by “knowledge hoarders” who seek to outwit competitors on an individual level rather than view the whole as a tribe. Tribal members stuck in this stage are lone warriors who primarily care about

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2 5 5C h a p t e r 9 : L e a d i n g , M a n a g i n g , a n d G o v e r n i n g

being seen as the best individual in the tribe. This stage, too, describes many medical practices.

Stage 4: The tribe begins to move from “I’m great” to “we’re great.” Members become motivated to work together for the benefit of the whole organization. Leaders, managers, and practice members must work very hard to achieve this stage, as the practice of medicine is heavily focused on the individual, and the natural inclination is for the individual to see the success of the practice primarily as a result of his or her own personal efforts.

Stage 5: Innovative members use their talents to make an impact on the community for the greater good. According to the authors, less than 2 percent of workplace tribal cultures achieves this stage. Although the medical practice must always focus on its primary mission—the excellent care of individual patients—the emerging interest in and reimbursement for population health management and community health require the medical practice culture to look outward to the communities it serves.

Le a d e r s h I P ve r s u s ma n a g e m e n t Another debate that often occurs regarding leadership and management is whether leadership and management are different. In his article “Are Leadership and Manage- ment Different? A Review,” Algahtani (2014) provides an overview of the scholarship on leadership and management. People often use the terms leadership and management synonymously; however, generally speaking, leadership and management are not the same concept. The two disciplines share a number of overlapping skill sets, especially when applied in smaller practices. That said, leaders tend to be externally focused on the environment, with particular concern for the mission and the future direction of the practice. They are typically visionary, seeking the ideal levels of operational performance, service, and concern for the well-being of their stakeholders. Managers focus on internal issues and the tasks that must be accomplished to achieve an effec- tive degree of operation. They translate goals into action. Successful organizations find a collaborative balance between leaders and managers and the role each brings to the practice (Algahtani 2014).

Some medical practices may be structured in a way that requires practice managers or clinical leaders to serve both leader and manager functions, but even in these situations understanding the difference is helpful so that the leader-manager is capable of assuming the appropriate role for the situation at the correct time and in the context of the individual practice.

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In a discussion of leadership versus management, defining what each term means is important. Leaders need followers, and therefore the number one responsibility of a leader is to paint a compelling vision of the future. Otherwise, why would anyone follow? Exhibit 9.2 provides a list of leadership characteristics compiled from a review of many leading researchers in the field.

The simplest definition of management is the process of controlling things and people. As is often said of healthcare in general, practice management is both art and science. This notion can be seen in exhibit 9.3, which lists management characteristics as described by several leading researchers (see, e.g., Bass, Bennis, Covey, Kotterman, and others listed in the Additional Reading section at the end of this chapter).

th e dya d Le a d e r s h I P mo d e L I n Pr a c t I c e ma n a g e m e n t Modern medical practices often employ the dyad leadership model for running the practice, as practices can have difficulty finding a staff member with the expertise needed to run both the clinical and nonclinical parts of the practice. The typical arrangement is such that a nonphysician executive is in charge of administrative issues and a physician or another

Is adaptable to situations Is alert to social environments

Is ambitious and achievement oriented Is assertive

Is cooperative Is decisive

Is dependable Focuses on people

Has a high-activity level Is persistent

Has self-confidence and takes risks Tolerates stress

Is willing to assume responsibility Is trustworthy and inspires trust

Is inspiring Is influential

Has followers Uses influence

Empowers others Does the right thing

Originates Challenges the status quo

Has a long-range perspective Has eyes on the horizon

Is transformational Follows personal values

Asks what and why Is innovative

Sets strategies and vision Facilitates decision making

exhIbIt 9.2 Leadership

Characteristics

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clinician is responsible for the clinical aspects of the practice. Numerous duties require cooperation where clinical and nonclinical functions overlap; the interdependent nature of administrative and clinical functions is particularly evident in patient care.

In a study by the Medical Group Management Association (MGMA 2016), 58 percent of respondents indicated they used a physician–administrator dyad leadership model, and 75 percent of those dyads were said to meet at least monthly.

d e v e L o P I n g a d ya d m a n a g e m e n t s t r u c t u r e

The first step in developing a dyad leadership model in a medical practice is to establish an agreement, sometimes called a covenant, between the nonclinical and clinical leaders. This agreement answers the questions shown in exhibit 9.4 and records the answers in the form of the covenant framework.

As physician practices continue to consolidate and become part of larger inte- grated organizations, the need for practice physicians to increase their management and executive skill set is becoming prevalent. However, in the past practices have often erred in assuming that medical expertise alone confers on physicians the ability to manage

Has subordinates Establishes agendas

Is the classic good soldier Asks how and when

Relies on control Accepts responsibility

Focuses on doing things right Has a short-range perspective

Holds formal authority Is a problem solver

Is tough-minded Budgets

Is analytical Plans

Maintains stasis Focuses on systems

Uses power cautiously Delegates cautiously

Minimizes risk Is a stabilizing force

Administers Has eyes on the end result

Takes a structured approach Is deliberate

Coaches Manages

Decides on action plan Monitors activities against plans

Sets timetables Organizes staff

exhIbIt 9.3 Management Characteristics

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F u n d a m e n t a l s o f M e d i c a l P r a c t i c e M a n a g e m e n t2 5 8

and lead. Management and leadership are unique skills, separate from clinical skills. Good doctors do not necessarily make good leaders or managers. The assumption that a good clinician can be a good leader or manager often leads to the fulfillment of the Peter Principle, whereby individuals are selected for promotion to their highest level of incompetence on the basis of their current role, only to fail (Asghar 2014). There- fore, physician managers and leaders must receive the education and training needed to fulfill the responsibilities of their new roles (Zismer and Bruggemann 2010; Zismer and Person 2008).

exhIbIt 9.4 Development

Template for a Dyad Leadership

Agreement

1. What does dyad leadership look like to us? 2. What is your perception of why we need dyad leadership in our practice? 3. What is our agreement vision for group/practice? Is it different than what is

currently recorded? 4. What are our goals for group/practice? 5. Our goals for the group/practice aligned? 6. What schedule will we commit to for routinely discussing issues affecting the

operations of the practice? Options are daily/weekly/monthly/quarterly and as needed.

7. How do we convey our commitment and support to the dyad leadership process to the members of the practice?

8. How will we handle conflicts between nonclinical staff and clinical staff? 9. How will we resolve our differences of opinion about issues?

10. What decisions do we make together? Examples: a. Strategic decisions b. Recruiting c. On-boarding d. Mentoring e. Team development

11. What decisions do we make independently? a. Daily operating decisions b. Giving feedback

12. How will we develop agendas? 13. Who will chair and coordinate meetings? 14. Other items that may be unique to the practice.

Signed: ___________________________________ Date: _______________

Signed: ___________________________________ Date: _______________

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2 5 9C h a p t e r 9 : L e a d i n g , M a n a g i n g , a n d G o v e r n i n g

Training may be developed internally; sought through external resources, such as the American College of Healthcare Executives (ACHE), MGMA, the American Association for Physician Leadership, the American Medical Group Practice Association, the American Academy of Family Physicians, the American College of Surgeons, the American College of Physicians, the American College of Cardiology, or any of the numerous other professional organizations; or by using a hybrid internal–external training approach.

Medical practices, especially large ones, can offer significant training themselves. Regardless of which approach the practice chooses, management and leadership training should focus on the following:

◆ What must leaders know as professionals in this practice?

◆ What must individual leaders know to be able to achieve personal, practice, and professional goals?

◆ What do leaders require of the practice to enable them to succeed in their new role?

In addition, training specific to dyad-managed practices should cover the following areas:

◆ Leadership and the mission, vision, and strategy

Objective: Clarity about the co-leadership role.

— Discuss models of dyad leadership.

— Discuss and describe the evolution of dyad leadership in the practice (purpose, history, roles, etc.).

— Create and share a dyad leadership agreement.

◆ Communication styles

Objective: Understand your communication style and how you can best work with your co-leader.

— Take the Management by Strengths, DiSC, or Predictive Index profile and discuss the results to understand yourself and others.

◆ Quality and process improvement

Objective: Attain a firm grasp of quality and process improvement. Understand the practice’s initiatives and the tools and resources available to support them.

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F u n d a m e n t a l s o f M e d i c a l P r a c t i c e M a n a g e m e n t2 6 0

— Plan

— Do

— Study

— Act

◆ Recruiting, onboarding, mentoring, and developing

Objective: Understand how best to recruit, onboard, and develop staff.

— Discuss the role of physicians in recruiting other physicians.

— Discuss the purpose and benefits of staff development.

— Review tools to help recruit, mentor, and develop staff.

◆ Managing disruption

Objective: Learn best practices for managing disruption.

— Understand your style of conflict management using the Thomas- Kilmann Instrument or a similar tool.

— Review best practices for managing disruption.

◆ Business decision making

Objective: Understand how to run the practice together while balancing service and profitability.

— Explore the decision-making process.

— Identify and understand the key performance metrics.

The importance of training in these areas is highlighted in the sections that follow.

Le a d e r s h I P: mI s s I o n, vI s I o n, a n d va L u e s Peter Drucker once said that above all else, “leaders must have followers,” and to ensure followership, those leaders must establish the mission, vision, and values of the organiza- tion. In fact, one defining characteristic of the trusted leader is his or her ability to paint a compelling vision of the future.

The mission statement provides the reason the organization exists and the intentions of the organization. The vision statement provides the aspirations of the organization and what the future state of the organization will be when it is successful. The values statement

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2 6 1C h a p t e r 9 : L e a d i n g , M a n a g i n g , a n d G o v e r n i n g

indicates what the organization believes and how it will behave, often declaring how its members will behave as individuals and how they will interact with their stakeholders.

The statements should be clear, concise, and simple. They should leave little room for interpretation, and they should be known and acknowledged by all members of the organization. If anyone in the practice cannot articulate the why, what, and how represented by the mission, vision, and values statements, they need further training. If additional training and support fail to improve the individual’s understanding of the statements, he or she may not be a good fit for the practice. These statements are the framework for all decision making; they should guide all actions of the practice and should have a profound impact on how it operates, what services it provides, and how the work will be performed.

Developing the mission, vision, and values statements is an important function of the governing body because it sets the tone and standard for all that the organization does. Of course, the first question is whether the practice should develop a mission, vision, and values statement at all, considering this activity is more than a simple exercise.

For example, a practice’s mission, vision, and values statements might be as follows:

Mission: To be the leading provider of medical services in the community.

Vision: We will be the community’s preferred provider of high-quality care at an afford- able price.

Values: We provide service to all members of our community regardless of their ability to pay.

Many variations are possible, but they should always be true to the practice’s intentions: what the practice hopes to achieve and how it expects to achieve those aims. These documents must be carefully developed and taken seriously, or they should not be developed at all.

Many practices expand the concept of the values statement by providing a list of their values and the commitment they have made to the patients of their practice. Some examples of values that might be articulated and posted or given to the patient as a com- mitment to them include the following:

◆ Putting the patients’ needs first

◆ Treating the patient and his or her family with courtesy, respect, and compassion

◆ Communicating information clearly and thoroughly

◆ Always using integrity and sound judgment in all decisions

◆ Working collaboratively with the patients, staff, and other colleagues (patient- centered care)

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F u n d a m e n t a l s o f M e d i c a l P r a c t i c e M a n a g e m e n t2 6 2

◆ Using evidence-based care and best business practices

◆ Having a high-performing culture that attracts and keeps the most talented individuals

◆ Delivering the highest-caliber care possible

◆ Earning trust through action, service, and behavior

◆ Maintaining an atmosphere of quality improvement and continuous learning

Pr o f e s s I o n a L I s m In today’s modern practice environment, professionalism and ethics are paramount con- siderations. What is professionalism?

◆ It is a vocation or calling and implies service to others.

◆ It involves knowledge of a distinctive base of expertise that is kept up-to-date.

◆ It is determined by a set of standards and examination of achievement in those standards.

◆ It involves developing a special relationship with those the individual serves.

◆ It involves the adoption and demonstration of particular ethical principles.

All the above points apply to professionalism in medical practice. In addition, pro- fessionals exhibit the following attributes:

◆ Honesty

◆ Altruism

◆ Service

◆ Commitment

◆ Communication

◆ Commitment to excellence

◆ Accountability

◆ Lifelong learning

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Dr. Gerald Hickson and his colleagues at Vanderbilt University have worked for many years to perfect a system for improving professionalism in medical practice. As shown in exhibit 9.5, professionalism and ethical behavior require the right balance of intentional system design and professional accountability. To put it another way, the practice must develop rules of acceptable conduct and make its expectations for that conduct known while relying on the individual professionals to be accountable to ensure that the highest standards of professionalism and ethical behavior are maintained.

Hickson and colleagues (2007) have also found a strong connection between negative behaviors by members of the practice and malpractice litigation. By progressively addressing negative disruptive behaviors, in almost all cases behaviors are decreased, with a resulting significant decrease in malpractice claims and other negative consequences in the practice. Exhibit 9.6 shows the spectrum of disruptive behaviors seen in medical practices, ranging from the most common to the most severe.

P r o f e s s I o n a L I s m a n d s u b s ta n c e a b u s e

Medical practice leaders need to be in tune with potential causes of disruptive behavior that hinder professionalism; in some cases, it may be due to substance abuse or mental ill- ness. In these situations, many barriers can impede early diagnosis and intervention with professionals, including the following:

◆ The “conspiracy of silence”

◆ Denial on the part of family, friends, colleagues, and even patients

exhIbIt 9.5 Balancing System Design and ProfessionalismProfessional

Accountability

Intentionally Designed System

The Right Balance

Source: Hickson et al. (2007). Used with permission of Gerald Hickson.

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These barriers are the products of a lack of education concerning the true nature of addiction as a primary biogenetic and psychosocial disease. Tenacious denial is the com- mon feature of alcoholic or addicted physicians, as knowledge of the effects of drugs and alcohol create the delusion that special insight provides immunity from addiction. Alcoholic or addicted physicians usually cannot see themselves as sick and often do not accept dependency as a disease. Furthermore, family members and colleagues contribute to the denial by covering up or making excuses for the physician and do not demand he or she seek help.

However, signs and symptoms emerge in professional life, family life, and social life. The practice must have clear policies and procedures in place to help colleagues in this area. In most states, the medical boards operate a medical professionals’ health program, which is designed to provide assistance to the individual while protecting him or her from actions that would permanently affect the ability to practice. The Federation of State Physician Health Programs (2016) offers additional information regarding these programs. Practice managers and leaders should be familiar with these resources should the need arise to tap into them.

exhIbIt 9.6 Spectrum of

Disruptive Behaviors

Aggresive Passive Passive

Aggressive

Hostile notes, e-mails

Inappropriate anger, threats

Failure to return calls

Inappropriate/ inadequate chart notes

Avoiding meetings and individuals

Nonparticipation

Ill-prepared, not prepared

Yelling; publicly degrading team members

Intimidating staff, patients, colleagues, etc.

Pushing, throwing objects

Swearing

Outburst of anger and physical abuse

Derogatory comments about institution, hospital,

group, etc.

Inappropriate joking

Sexual harrassment

Complaining, blaming

Source: Swiggart et al. (2009).

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Le a d e r s h I P st y L e s A brief discussion of leadership styles may be useful for leaders of medical practices. Weber (1958) categorized leadership styles as bureaucratic, charismatic, or traditional. More impor- tant for our purposes, Burns (1978) and Bass (1999) added to this perspective by propos- ing the categories of transactional and transformational leadership. With transformational style being the preferred approach over transactional leadership, exhibit 9.7 illustrates some key attributes of the transformational leader and shows how they vary from transactional leadership (Bass 1990; Bass and Avolio 1994).

Burns (1978) noted the attachment of morality to leadership, proposing that moral leaders are sensitive to the needs, beliefs, and values of their followers, whereas immoral leaders disregard the beliefs of followers. Furthermore, he suggested that amoral leaders rule followers through coercion and fear, an approach that is generally discounted as ineffective.

Rather, transformational leaders use internal, or intrinsic, motivating factors to influence, and they provide individualized consideration, inspirational motivation, and intellectual stimulation to achieve outcomes. Transactional leaders use external, or extrinsic, motivating factors and manage by exception and contingency.

Transformational leaders and managers are able to articulate their attitudes and demonstrate their behaviors in a way that is inspiring and motivating to their followers. This cycle is illustrated in exhibit 9.8.

exhIbIt 9.7 Results of Transformational Leadership

The additive effect of transformational leadership

Transformational Leadership

Transactional Leadership

Idealized Influence

Contingent Reward

Management by Exception

Expected Outcomes

Performance Beyond

Expectations

Inspirational Motivation

Individualized Consideration

Intellectual Stimulation

Source: Adapted from Bass and Avolio (1994).

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or g a n I z at I o n a L co n s c I e n t I o u s n e s s Most people recognize conscientiousness as the personality trait of being careful and vigilant. In an organizational sense, we add the notions of efficiency, orderliness, and the general desire to complete the task at hand well. In a sense, organizational conscientiousness is a summation of the traits of all the individuals in the organization. When considered in those terms, care and vigilance in operations require leadership to set the tone and demonstrate conscientiousness as an organizational value.

Organizational conscientiousness has often been expressed as, “First do the right thing; then do it right.” Practice managers and leaders must take this simple phrase to heart as they examine the operations of the practice and its interactions with all its stakeholders in the spirit of the conscientious relationship. Organizational conscientiousness is fundamental to having an organization that demonstrates integrity (Becker 1998).

em o t I o n a L In t e L L I g e n c e Most successful leaders have a high degree of emotional intelligence (EQ). As discussed in chapter 8, Daniel Goleman’s (1995) book Emotional Intelligence: Why It Can Matter More Than IQ brought EQ to the forefront of theories in the management world. His insights and application are based on the work of Mayer and Salovey (1997), who define EQ as “the ability to perceive emotions, to access and generate emotions so as to assist thought, to understand emotions and emotional knowledge, and to reflectively regulate emotions so as to promote emotional and intellectual growth.”

exhIbIt 9.8 Transformational Leadership and

Management

I know why I am doing this

I believe in what I am

doing

My behaviors will demonstrate

I am doing it

I will do it and want to

I know how to do it

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EQ involves the recognition and regulation of ourselves and our relationships. According to Goleman (1995), EQ traits can be described as follows:

◆ Self-awareness

— emotional self-awareness

— accurate self-assessment

— self-confidence

◆ Social awareness

— empathy

— organizational awareness

— service orientation

◆ Self-management

— self-control

— transparency

— adaptability

— achievement driven

— initiative

◆ Relationship management

— inspirational leadership

— developing others

— influence

— change catalyst

— conflict management

— building bonds

— teamwork and collaboration

A 2009 literature review found an important connection between highly successful nursing practice and EQ, a relationship that also applies to other providers in the medical practice (Smith, Profetto-McGrath, and Cummings 2009).

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One exercise for developing EQ in the organization is to ask your team, or an indi- vidual team member, to close their eyes and think about a person on whom they really rely and whom they trust—someone they consider the ideal team member. Then ask them to think about someone who would be in the opposite camp: difficult, untrustworthy, and hard to get along with—someone they generally dread dealing with. Now ask, at the most basic level, what is the difference between these two people? The answer is probably their EQ. One lacks self-awareness when he disregards his effect on the people he interacts with. He is not service oriented, he lacks self-control, and he responds poorly when changes are necessary. The individual lacking EQ cares little about developing others and seems to enjoy conflict instead of building bonds and collaboration.

Although task-oriented competencies are important in determining success, the critical factor is EQ. The practice manager should strive to help practice members develop this intelligence.

ge n e r at I o n a L Is s u e s I n t h e me d I c a L Pr a c t I c e Generational issues are emerging in the medical practice as never before. According to a report released by the Pew Research Center, 10,000 people turn 65 every day in the United States, and that trend is expected to continue to at least 2029 (Heimlich 2010). This shift toward an aging population has a profound impact on the medical practice in a number of ways. As people age, in general they need more medical care, and practices need to be adept at caring for older people.

Although some physicians and practices specialize in the care of older individuals, most seniors receive care from practices that see a wide range of ages. Consider that older individuals may need more time, not only for navigating the practice but also to explain their medical needs. In addition, those medical needs are often for treating multiple diseases (Shi and Singh 2015). As of 2009, 56 percent of people over age 65 had at least one of five serious chronic conditions, and many had three or more (Lee, Cigolle, and Blaum 2009). These factors present a resource challenge for the practice in determining ways to provide care to a population that is getting increasingly older while the practice is simultaneously experiencing restrictions on reimbursement.

Our workforce is also aging, and individuals are choosing, for many reasons, to delay retirement. As stated in chapter 1, for the first time in history, five generations are present in the workplace, a situation that offers both opportunities and challenges for medical practices. The two largest groups are the baby boomers and the millennials. On the one hand, boomers bring experience and a long-term perspective, place work as a high priority, and are comfortable with hierarchy. On the other hand, millennials generally enjoy collaborative working relationships, technology, and a desire for greater work–life balance (Smola and Sutton 2002).

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Furthermore, millennials tend to be less oriented toward planning than members of the baby boom generation are. Consider a little story about going to dinner. A group of boomers decide to go to dinner. They will plan for this event and even make a reservation at the restaurant. They go to a place they are familiar with. They may recall their favorite dish and look forward to having it again. In addition, they have planned what they will do after dinner. The millennial group going to dinner decides to get something to eat and tweets or texts that information among themselves and with other friends. “Getting something to eat. Join us?” They look online for a place to get the type of food they are in the mood for; the location and number of people to dine are not determined ahead of dinner. They drive by the first choice and notice that the parking lot is too full, so they tweet that they are proceeding to the next possible location. In the meantime, more and more of their friends join in and plan to meet with them. Finally, they come to a place where they all are satisfied and they get something to eat.

The point is that the goal of getting something to eat was accomplished by both parties; the difference was in the process. Which is right? Which is wrong? The answer, of course, is neither, but recognizing the approach that each group took in getting the goal accomplished is helpful. Planning has its place, and so do flexibility and spontane- ity. Extending the example to the medical practice, leaders and managers must be open to incorporating new ideas and processes into the workplace by taking into account the aptitudes and values each generational group brings.

Furthermore, they must work to effectively develop teams that take advantage of the many positive attributes of each group. Open dialogue regarding their differences in which they are acknowledged is key because each brings its own set of strengths and weaknesses. The more practice leaders recognize the value of each group, the more effectively they can manage the practice. For example, a practice converting its records system to an electronic health record is wise to consider the points of view of all the generations working in the practice. Younger team members may have a solid grasp on the use of new technologies, and older workers see the limitations of the technology that balance the team’s deliberations.

dI v e r s I t y a n d In c L u s I o n Is s u e s f o r Le a d e r s h I P We have now seen how age and generations can have a great impact on the operations of the medical practice. And age is only one aspect of diversity. Next, we explore other diversity elements and how we can effectively manage them to improve the practice.

The process starts with the recognition that “We don’t know what we don’t know.” Practice managers and leaders are charged with helping practice members become aware of diversity and inclusion issues.

The following steps are involved in improving diversity and inclusion in the medical practice (Holvino, Bernardo, and Merrill-Sands 2004):

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1. Establish clear expectations in the policies and the values expressed by the practice that it supports a diverse and inclusive environment. These expectations should apply to employment issues, educational activities, patient care activities, and community outreach efforts.

2. Shape attitudes and policies toward diversity and inclusion through training and education, recruiting, onboarding, and development. When possible, practices should strive to be representative of the communities they serve.

3. Measure and evaluate the practice’s current status regarding diversity. Have conversations with community leaders and activists to gain feedback on their perspective of the practice in terms of diversity and inclusion issues.

4. Take corrective action when necessary, such as making operational changes, addressing performance issues, and curbing any activity that will affect the practice and its stakeholders. Such action might be taken by members of the practice toward each other and the patients or by patients toward practice members.

Following are two illustrative stories.

One day, Mr. Jones calls the practice administrator of Happy Practice USA. He complains that he did not want to be cared for by a doctor because of his race. Does the administrator accommodate the patient and assure him that he will not have to see a phy- sician because of his race? The ideal conversation might go like this: “Mr. Jones, I assure you that all of the physicians in our practice are highly qualified and that they work as a team. In our efforts to make sure you receive timely and appropriate care, we would be irresponsible if we guaranteed you would not see a particular physician in the practice. In fact, you may need to see this physician when you are in the most difficult of circumstances, as in the emergency department when our physicians are on call. For these reasons, it is not possible, nor is it our policy, to have patients change caregivers solely on the basis of what you have described. We would certainly like to have you as our patient, and we want you to feel comfortable and confident in the care that we provide. Mr. Jones, please consider what I’ve said, and if you feel you cannot have the confidence in all our caregivers to provide the care you need, it might be best for you to find another practice to care for you. Of course, we will give you adequate time to make your decision and find a different practitioner if that is your desire. We will do everything we can to make that a smooth transition.” This dialogue should be followed up with a letter indicating the essence of the conversation to prevent complications and the potential for an allegation of abandonment. (All states and medical societies have standards on appropriate ways to dismiss a patient. Failure to follow these rules can result in an abandonment complaint, which can lead to sanctions from the state medical examining board.)

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One day, a supervisor frantically enters the administrator’s office and says, “I have a serious employment question that I need to discuss with you.” The administrator listens carefully to the story. “I just had a person with a disability apply for a position in my department. I don’t know why human resources would send me an applicant like this. What should I do?” An appropriate discussion could proceed as follows: “Is the person qualified to do the job? Is she the best applicant to perform the job that we have posted to fill?” The supervisor replies, “Yes on both counts.” The administrator asks, “Can we make reasonable accommodations so that she can do the work?” The supervisor replies, “It will not take a lot to do that.” The administrator replies, “Then you should hire her.”

These conversations are also great opportunities to coach supervisors on diversity and inclusion practices. They should be treated as a learning opportunity rather than in a punitive manner. The supervisor’s contact with people with disabilities may be limited, and his or her reaction in this situation may have arisen from a lack of understanding rather than due to malicious intent. Remember, “We don’t know what we don’t know”; effective practice managers and leaders help develop people in all respects, including diversity and inclusion.

They should never miss an opportunity to provide leadership on diversity and inclusion and, when necessary, coach on the values that the practice espouses. Although in some cases, legal issues may be involved, such as discrimination on the basis of age, race, ethnicity, gender, national origin, and disability (EEOC 2016), in all cases, hiring for inclusion is the right thing to do.

One final thought on diversity and inclusion goes to an issue that is not often included in this category, and that is the way individuals think. Practices must allow some diversity of thought; failing to do so means they miss opportunities to include innovative ideas in practice operations. Encourage members of the practice to provide ideas and speak up with innovative thoughts. Diversity and inclusion can be a strength for any medical practice.

gI v I n g a n d re c e I v I n g fe e d b a c k Among the most difficult tasks of managers and leaders is providing feedback to subordi- nates; receiving feedback is fraught with difficulty as well. Successful practices master the art of giving and receiving feedback to all members of the practice.

Why is feedback so difficult? Many people have had poor experiences in receiving and giving feedback. Because it is a skill that requires time and attention to develop, much of the feedback people have received in the past may have been given in an inappropriate way, resulting in negative feelings about feedback in general—even about accepting posi- tive feedback.

Effective medical practices see giving and receiving feedback as essential skills, and they seek to cultivate those skills in everyone in the practice. To begin, establish a clear understanding that the practice engages in providing feedback to one another and that

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feedback is a gift (Stone and Heen 2014). If managers and leaders are unaware of behaviors, performance issues, or other opportunities for improvement, they cannot address those issues. Likewise, failing to provide reinforcement for constructive behaviors and excellent performance is a missed opportunity to institutionalize the behaviors the practice seeks and the performance it desires. We all want recognition for what we do, and much of the time, that can be in the form of constructive feedback.

When giving feedback, always consider what your intentions are and what you hope to achieve from the session. When receiving feedback, consider what the intentions of the person giving feedback might be, and listen to that feedback carefully.

g u I d a n c e o n P r o v I d I n g P o s I t I v e f e e d b a c k

Following are tips for providing positive feedback:

◆ Express your positive intent, and describe the behavior your feedback is intended to address.

— Describe the behavior in a specific manner.

— Avoid generalizing about the behavior. Generalizations are always less effective than concrete, specific comments, and they are less meaningful to the recipient.

— Be sincere in your presentation.

— Do not mix criticism with praise.

◆ Describe the impact of the behavior in terms of the goals of the practice or department.

◆ Always thank the recipient for his or her contributions to the practice or department.

g u I d a n c e o n P r o v I d I n g n e g at I v e f e e d b a c k

Considerations when giving negative feedback are as follows:

◆ Giving feedback when it is not positive but constructive in nature is often challenging. Prepare for the feedback session carefully by determining the desired outcome. Make the feedback useful and actionable.

◆ Be sure you have observed the behavior directly. Do not rely solely on hearsay before conducting the feedback session.

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◆ Always choose a private location and allow adequate time for the session.

◆ Always show that your intent is positive. Be objective with your wording and approach, and discuss what you have observed, not what others have told you.

◆ Describe the behavior and its impact on the work group, department, or practice. Focus on the behavior, not the person, and express your desire for a mutual solution. Avoid being accusatory or creating a confrontational environment.

◆ Encourage the person to respond, and listen carefully to that response. The dialogue is an opportunity to demonstrate active listening by summarizing the speaker’s key points and clarifying any statements that may be unclear.

◆ Ask the person for solutions, and, if appropriate, suggest a specific change.

◆ Summarize the discussion.

◆ Agree on next steps. Express encouragement, show confidence in the person, and be sure that the steps are clear and that a follow-up date is established.

g u I d a n c e o n r e c e I v I n g n e g at I v e , c o n s t r u c t I v e f e e d b a c k

None of us is perfect, and in a high-performing practice, every member should expect to receive constructive or negative feedback on occasion. In fact, an absence of the occasional constructive feedback is a sign that the organization is not committed to being open and honest with its members.

Following are considerations for receiving negative or constructive feedback:

◆ Think about how you react to feedback of a constructive nature. Is your manner defensive? Do you quickly apologize, or do you react in a positive way by seeking to learn and understand what the feedback is meant to tell you?

◆ When possible, think about your responses before the session takes place. Often, people have a sense that a constructive feedback session may occur, especially in a practice that is open and honest about feedback.

◆ Listen actively and calmly. Be sure you understand the points being made and acknowledge the concerns.

◆ Discuss a mutually appropriate solution, and develop an action plan.

◆ Always reflect on any feedback session to learn not only about the specific behaviors and situations discussed but also how to improve your management and leadership skills in the future. Self-reflection is a powerful tool for growth.

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g u I d a n c e o n r e c e I v I n g P o s I t I v e f e e d b a c k

Who doesn’t like positive feedback? Surprisingly, many people feel uneasy when receiving positive feedback, and such feedback sessions can become awkward. To avoid difficult positive feedback situations, first, understand that the feedback is a reflection not only of your performance but also of what the practice values. More than a simple expression of appreciation, it is an indication of activities and behaviors you should continue to do to support the practice. Next, seek advice on learning to be gracious and appreciative of positive feedback.

Learning to give and receive feedback of all types is essential for the high-performing medical practice. A culture that respects and engages in consistent, fair, and well-executed feedback does not develop by accident; it requires the organization to establish an envi- ronment conducive to open and honest feedback (Stone and Heen 2014; Patterson et al. 2011).

go v e r n a n c e a n d or g a n I z at I o n a L dy n a m I c s The governance and organizational dynamics of a medical practice cover a wide range of issues, many of which have been discussed in other parts of the text. For our purposes in this discussion, we cover the key aspects of governance and the manner in which these functions influence organizational culture.

The governance of a medical practice involves numerous areas of responsibility, including the following.

◆ The appropriate legal structure for the organization. This function includes considering and balancing the framework of governing bodies with attention to these elements:

— The size of the board and committees. Board size varies greatly among organizations on the basis of the size and diversity of the practice, as an inverse relationship exists between the size of a governing body and its ability to act, so careful consideration must be given to size. In addition, think about the time frame in which action is needed. Often, operational and strategic issues may be separated, with consideration for the need to act more quickly on operational issues and more deliberatively on strategic ones.

— How members are chosen. If members are elected, how? By majority? Or by a specified percentage greater than 50 percent (called a super majority)? By appointment? In some cases, individuals are simply appointed by the practice. For example, the board may appoint members

Organizational

dynamics

The script for the

organization’s human

capital, or the ways in

which individuals and

processes interact in

the company.

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of a quality management committee. By rotation? In this structure, an individual may rotate into a position of authority on the basis of an agreed-on schedule or process.

— Extent of authority held by members. Most practices, like most other types of organizations, place limits on the authority of any one person or group of individuals. Authority typically is limited in terms of the amount of money that can be spent, what contracts and obligations can be entered into by the group or individual, and so on. It also includes changes in the bylaws or voting rules, legal changes to the practices, or merger and acquisition activity. The practice should avoid an overly complicated oversight process, for example by giving responsibility to a committee or an individual only to require their decisions to be reviewed or revised at one or more additional levels of governance.

— What committees to establish. Committees, such as an executive committee, a compensation committee, a quality management committee, a safety committee, a medical records committee, or a research committee, may be ad hoc or permanent committees. An ad hoc committee is formed for a particular purpose or task and disbanded once that task is completed. An example is an ad hoc committee seated for the selection and purchase of a medical records system (a permanent IT committee may also be in place, which would have responsibility for system oversight going forward).

◆ Record-keeping of the activities of the governing bodies. Accurate minutes and other documents related to meetings must be kept and distributed as appropriate. One area related to record-keeping is ensuring proper follow-up occurs on action items. Failures to establish and execute follow-up procedures result in forgotten items resurfacing as even more problematic or urgent concerns.

◆ If incorporated, development and maintenance of the corporate mission, vision, and values statements and the organization’s culture. This area of responsibility should be visited yearly or when appropriate depending on current events. For example, a practice merger or acquisition should prompt this action.

◆ Development and maintenance of the practice’s strategic plan and its implementation. This area should also be visited yearly or when appropriate depending on current events. For example, the possible repeal and replacement of the Affordable Care Act may compel the practice to consider changes to its strategic plan.

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◆ Setting compensation standards for physicians, other professionals, and staff. Compensation standards may be established with the help of the compensation committee, survey data from MGMA, and benchmark information from other physician practice organizations. A compensation consultant may be needed in some cases, as when the issues are particularly problematic, are complex, or involve legal questions.

◆ Approving expectations or programs for the practice. Expanding the scope or geographic reach of the practice represents major commitments that require careful planning and support, so thorough vetting by the governance structure is essential.

◆ Facilitating and encouraging physician leaders to become knowledgeable, participative stakeholders. The practice’s management and leadership must devote time and resources to educating the members of the governing bodies. Retreats devoted to reflection and renewal of the practice are opportunities for education on good governance.

◆ Ensuring the quality of the medical care provided by the practice. The governing bodies of the practice must ensure that the practice delivers high-quality care. This responsibility is accomplished through the following steps:

— Establish quality goals, and educate everyone in the practice on those goals.

— Develop and monitor appropriate quality benchmarks using data analysis and surveys, such as patient satisfaction surveys.

— Take action when quality measures are not met by engaging in quality improvement projects.

— Take action when serious or recurring complaints arise.

— Take all patient and provider complaints seriously.

— Review individual quality data with all providers, and establish an action plan for improvement when necessary. Schedule regular follow-up sessions for reviewing progress.

◆ Participating in advocacy endeavors at local, state, and federal levels. Efforts include the following:

— Membership in local civic organizations, such as the Rotary Club. These organizations are often unaware of or uninformed on important healthcare issues.

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— Participation in local business organizations, such as the area’s business roundtable or others that may be unique to the community.

— Engaging with state legislators. Be available to help and inform when issues affecting patients and practices arise.

— Engaging with members of the US Congress and their committees.

— Involvement in professional organizations, such as ACHE, MGMA, and other specialty-specific organizations.

On a regular basis, the governance process should be reviewed and the governing body educated on its responsibilities and obligations to the practice and to the patients it serves. Unlike many other organizations, the governing body of a medical practice may have a limited knowledge of business and governance. Because the governing body is often composed of the practice’s physicians and providers, this makeup presents challenges whereby decisions can be influenced by personal preference or interest. An important step is to remind members of the governing body that they should act in the best interest of the practice.

Governance and organizational dynamics have taken on additional importance for all organizations in recent years. The modern medical practice is no exception, and in a sense, it is in greater need for focused attention to this topic as healthcare comes under ever-increasing scrutiny. Rising costs, medical errors and other quality concerns, potential conflicts of interest, and spiraling technology costs all lead to the need for much more attention to governance and organizational dynamics than has been required in the past.

In a practical sense, however, governance and organizational dynamics can be summed up as a need to change and to protect the new status quo in a cycle of continuous improvement. Effective governance and the management of organizational dynamics are essential to a successful medical practice. Governance and organizational dynamics must have a higher priority for practices in the future. Above all else, leaders must develop their followers in the standards and expectations of governance to facilitate the flow of new ideas in the changing healthcare environment.

co n d u c t I n g me e t I n g s An important skill for practice leaders is the ability to conduct an effective meeting. This task may sound simple, but in reality, it requires a great deal of thought, preparation, and execution to have meetings that produce results.

An effective meeting is divided into three sets of activities:

1. Before the meeting:

a. Determine the structure of and purpose for the meeting. Ask yourself if the meeting is necessary. Can the issue be handled in some other way?

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b. Carefully consider who is being asked to attend the meeting and why they are there.

c. Determine the objective and desired outcome of the meeting.

d. Compile and distribute (well in advance) any prior communication, documents, or other information that will help the attendees prepare for the meeting.

e. Develop and distribute an agenda that includes the items to be discussed, the time allotted for discussion, and the actions needed. Meeting items that may be listed as “information only” often can be handled by memo or other means of communication.

f. Establish rules for the conduct of the meeting.

2. Conducting the meeting:

a. Always start the meeting on time.

b. Remind participants to limit discussion to the items on the agenda to make sure all are addressed.

c. Go over the rules of the meeting and ask if any participants have changes or objections. Obtain agreement that the meeting will be conducted under these rules.

d. Any important items that arise that are not on the agenda may be placed in the “parking lot,” a device for recording and deferring critical but unplanned issues for later consideration.

e. Manage the discussion. Medical practice meetings involve people who often have strong personalities and opinions. The facilitator of the meeting should manage the discussion in a way that provides for all attendees to have input, such as allowing each attendee to comment in turn in “round robin” style.

f. Limit discussion to the time allotted for each agenda item. Time management of meetings is important to maintain interest and credibility for future participation.

g. Stay on topic. The facilitator can bring the discussion back to the topic at hand should the conversation drift to other areas.

h. Follow-up actions should be decided by the group. The group should also decide who is responsible for completing each action.

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i. Minutes of the meeting should be recorded, including required follow-up activities.

j. Set follow-up meetings if appropriate. In medical groups, one strategy is to establish standing meeting times that account for provider schedules. That said, beware of standing meetings that have no purpose. Meetings can always be canceled, and should be when no useful purpose is apparent.

k. Always end the meeting on time.

3. After the meeting:

a. Thank the participants for their attendance and contribution.

b. Prepare and distribute minutes.

c. Develop an action list of the items requiring follow-up. Distribute those action items to the responsible parties, and establish a time frame for their action.

d. Inform stakeholders of important actions that resulted from the meeting, including follow-up activities and timelines.

e. Monitor progress on follow-up activity.

as s e s s I n g Le a d e r s h I P su c c e s s The professional practice manager goes through career stages from competent to expert, from studious to intuitive. When others ask for her opinion and not for the facts, it might be said that she “has arrived.” Opinions are based on the integration of knowl- edge and facts, of skills and insights—and above all, trust. The trust that we speak of is authentic trust, not naive trust. Authentic trust is built over time and, unlike naive trust, does not require that we always be right, only that we always be worthy of the trust we have been given.

Authentic trust is a close ally of integrity. Think about someone you really trust. What makes that person trustworthy? Is he or she infallible? Probably not, but that indi- vidual has done all he or she could to make appropriate decisions given the information available. This person recognizes when he or she is wrong and takes actions to correct mistakes (Wagner 2003).

When one’s judgment is valued and one’s professionalism is respected, that individual has achieved success.

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1. In your own words, explain the difference between leaders who have a will to power and those who have a will to serve.

2. Compare the transformational and transactional leadership styles.

3. What is meant by a dyad leadership system?

4. What are some leadership characteristics?

5. What are some management characteristics, and how do they differ from those of leadership?

6. Describe some examples of disruptive behavior, and discuss their implications.

7. What choices does the practice manager have in dealing with disruptive behavior?

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