“Always” Leadership

September 19, 2007

Consistency seems to be an elusive item in health care. Some shifts, some days, weeks, or months run well. Then issues arise that negate the gains. These methods to create and sustain those gains so interested Wiley publishing that they led to the publishing of my new book, “Results That Last.” In this article, Bob Murphy of the Studer Group has written excellent recommendations for how to become an “Always” leader.

We appreciate your feedback. I am so pleased many of you wrote regarding how helpful Debbie Cardello’s article on butterfly leadership was. Enjoy Bob’s article.

As I travel around the country, it constantly amazes me how much the same we are, how similar the issues are that we face. Right now, whether you are a leader in a hospital, health system, or medical practice you are facing the realities of financial pressures, competition, quality and service mandates, and labor shortages in critical positions.

When I ask leaders whether they think that health care will be more difficult in five years, everyone’s hands go up. Leaders know that if we do the same things we are doing now, in five years our results will be less than they are now. Just like when you’re promoted to a new role, the skills that helped you be successful to this point might not be the same ones you need to be successful going forward. For health care leaders looking to make an impact over the next five years, they need to become “always” leaders.

A recent challenge introduced by the Centers for Medicare and Medicaid Services (CMS), is destined to change the way we think about our roles as leaders. The Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS) “voluntary” survey of patients changes our fundamental language and attitude of leadership. The HCAHPS survey asks patients to rate us on the frequency of how often we do certain things. This is an important distinction from previous patient surveys which asked about satisfaction. Asking how often they saw certain things is very different than asking how satisfied they were with the same things.

Patients are asked: How often did nurses treat you with courtesy and respect? How often did doctors explain things in a way you could understand? How often were your room and bathroom kept clean?

The possible responses are “Never”, “Sometimes”, “Usually” and “ALWAYS.” When the results are  compiled and published on the CMS website, the only results we will see is the percent of “Always.” When CMS uses the data in its calculation of our reimbursement, they will likely use the percent of “Always” to reward high performing organizations.

Because of these external pressures, we are being pushed from being “Sometimes” organizations to being “Always” organizations. That means we likely have to move from being “Sometimes” leaders to “Always” leaders.

What does an “Always” leader look like?

  1. An “Always” leader has a plan! High performing organizations and their leaders have leader performance evaluations that are measurable, specific, objective, weighted and time-sensitive. The goals set forth in the individual leader’s evaluation are linked to the organization’s overall goals. A good, measurable, specific goal aligns the leader’s behavior to the expectations of the organization. Most leaders really appreciate an evaluation like this because it helps set priorities and tells them in advance what is necessary for success. Leaders have told me that they want to know how they are doing and what else to do to succeed. High performing organizations use monthly report cards and 90-day plans to help a leader with all that is on their plate. A good evaluation provides a prioritization roadmap for the leader and keeps leaders focused on what is important. As a leader, I am pulled in many directions at the same time. A good evaluation tells me where to focus my time and helps when I am asked to do “other” work. I can bring my annual evaluation, monthly report card and 90-day plan to my boss and ask them to help me prioritize the new work. If it does not fit into my annual evaluation, I will likely not waste my time and energy. A good evaluation system allows senior leaders to continuously monitor eader performance and provides for organizational agility.
  2. An “Always” leader takes accountability for their own development. If we agree that health care is getting harder and we need to continue to grow our leadership muscle, an “Always” leader does not wait for their boss to tell them to get training. An “Always” leader evaluates their skills and seeks out new ways to learn. An “Always” leader asks their supervisor if they are on track, what are they doing well, and what could they do better.
  3. An “Always” leader uses evidence-based leadership (EBL) tactics when appropriate . An “Always” leader follows best practices in hiring,
    retention, communication, reward/recognition, re-recruiting high and middle performers and dealing with low performers.
  4. An “Always” leader has a balanced approach. Many organizations balance priorities and activities between the focus areas of Service, Quality, People, Financial Performance, Growth and Community. All too often our staff thinks that all we are concerned about as leaders are financial results.
  5. An “Always” leader connects the dots consistently to purpose, worthwhile work and making a difference. Many of the staff we work with have a calling. They choose to come to work every day because of the special feeling they get while taking are of patients or taking care of those who take care of patients. An “Always” leader taps into that core feeling of making a difference by the way we communicate, what we reward and how we lead by example. Methods include sharing stories from other parts of the organization that demonstrate worthwhile work, recognizing staff members when they demonstrate the behaviors we know make a difference to our patients. “Always” leaders use every opportunity to connect to the hearts of their staff. What we do is special. Our patients entrust us with their lives and that is special. We should take every opportunity to tell and show our staff that what they do is important.
  6. An “Always” leader follows a sequenced approach to improvement. Most everyone reading this article is familiar with CPR (Cardio-Pulmonary Resuscitation). If you were faced with a situation where CPR was necessary, you would follow the ABCs of CPR right? First is airway, then breathing, then circulation or compressions. It is understood that you may never get to compressions if you cannot open the airway. Why? Because the compression would not be as effective. The same thing applies to leadership in many ways. Some of the tactics we teach at the Studer Group are advanced techniques and require some foundations or basics in place first. Now, you can skip steps, but the likely outcome is that you will not be as effective, nor will you be as effective for long. We know that Hourly Rounding is a wonderful tool to implement to reduce decubitus ulcers, falls, call lights and the distance nurses travel during a shift, but we usually do not recommend it be the first tactic you employ. We usually first recommend Rounding for Outcomes on your staff and nurse leader rounding on patients before hourly rounding. Why? Rounding on staff and patients by the leader first role models the desired behavior. It helps the leader show that they are aware of the issues on the unit and what patients want before asking staff to do that. Rounding on staff helps improve the personal relationship between the staff and leader. Leaders find out what tools and equipment needs there are on the unit. Leaders find out what is going well and can reward and recognize staff for demonstrating desired behaviors. When rounding is done consistently by leaders, staff are less likely to push back.
  7. “Always” leaders take best practices and standardize across the organization. An “Always” leader is trying to find a way to do their job better and get great outcomes. We find in many organizations there are leaders already getting the desired results such as low turnover, great productivity, high service, but, for some reason, it is not well known throughout the organization. Sometimes other leaders in the organization are aware that there is a leader internally getting great results, but there is a reluctance to do what they are doing. An “Always” leader breaks down those silos and barriers and duplicates what is working well.
  8. Failure to always do desired behaviors. As organizations move to improve results, we commonly find that changing the behavior of hundreds of thousands of staff members is very hard to do. The easiest thing we can do is change our own behaviors first. That requires a good long look in the mirror. I’ve had to do that so many times in my career, and still do since I still make mistakes.

As health care leaders, it is our responsibility to move our organizations from “Sometimes” to “Always.” The journey will be hard work, but one that is achievable if we use proven tools and techniques to guide us.

Please add your comments to this blog and share your thoughts with our readers. We can all benefit from each other’s experiences.

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5 Responses to ““Always” Leadership”

  1. Ryan Hayden Says:

    It’s unfortunate that the reason for this “Always” movement stems from the root cause of many problems in healthcare…that is we wait until a new regulation or compliance mandate says we “have” to do something. Then a new methodology is formed (“Always Leadership”) that is reactive to these mandates. I wish we could move to a position of being proactive rather than reactive.

  2. lynette Saul Says:

    On the floor or pounding the corridors with newly registered nurses it is very easy to deflate there eagerness to learn esp. related to competency in the clinical setting. Using a scaling system of “sometimes” to “always” allows the preceptor an avenue to recognize that a skill has been achieved whilst reinforcing the factor that consistency (always) is expected before a competency can be achieved

  3. Scott Thompson Says:

    As a member of the public education sector, I have found both the Butterfly and Always Leadership pieces to be applicible to those of us involved in schooling. I took the liberty to slightly modify these articles-changing the healthcare terminology into education vocabulary- and forwarding them to my staff. These are simple, no-cost solutions to moving from good to great. I am excited about what these tools can do to make a difference in our schools.

  4. Tom Mayer Says:

    When I taught high school English, my superiors often tried to box up some great teacher’s techniques and impose those same techniques on everyone else. The result? A a myriad of forms and techniques for teaching English, all of which would save we beleaguered teachers from mediocrity. I suggest that the intangible qualities of a leader, and a teacher, for that matter, are what make them good at what they do. Therefore, of all the good insight offered in this article, I would be wary of submitting to the idea that we should always try to “duplicate[] what is working well.” Instead, perhaps we would do better to be motivated by those who show us that something can be done well. Our style is often less important than finding that deep well of motivation that stirs us to our best.

  5. Tony Muniz Says:

    Sadly, even great leaders can suffer from “sometimes” leadership. Great leaders can create low performers as well. I liken it to a ship. A ship has a destination. In order to reach the destination, coordinates are set and the ship goes in that direction until it reaches it’s destination. Every employee on that ship fills a specific role to assure the ship continues on it’s course until its destination is reached. When I ask the engineer to do the chefs job as well as his own, or assign the Navigator the duties of the cargo master, I get mediocre results at best. In time neither job will be done to it’s most effectiveness. When I choose to run an entire ship in this manner, I will have a slow moving ship with continuous operational problems. I will eventually label people low performers because I placed them in situations where they could not perform according to thier ability. Sometimes in the name of Multitaking we overload employees, managers and departments and wonder why we get inconsistent results. Even a computer slows down if you run too many programs simultaneously. As I look at the problems in my department, it is plain to see that my constant “refocusing” of priorities to the hourly staff does not get me maximum results in any of the areas. I do not allow enough time for one or two priorities to take root and become hardwired. My goal is to have a goal. My goal is to reach a maximum of three goals BEFORE I refocus on a set of new goals. I have found that taking this approach has allowed me to successfully complete 90 day goals in much less time and allowed me to freely throw all of my attention on new goals and initiatives.


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