Ett evidensbaserat ledarskap – Teaming vad innebär det? Carl Savage, PhD Medical Management Centre Clinical Management Research Group Mairi Savage, MPH, PhDc

Medical Management Centre Research and education to contribute to evidence base(d) management practice in health care How to best use and develop resources (material, competence and knowledge) in health care in order to improve human health? Research areas: Clinical management Health System and Patient Safety Health economics Quality imporvement Health informatics Service innovation and entrepreneurship Change and intervention management and evaluation Development of leadership and team work 3’As I said, I work at the medical management centre at KI and our purpose is to contribute to evidence base and evidence informed management paracitce in health care. Our research areas are these and they are very much tied to the challenge of health needing to accomplish the so called Triple Aim. carl.savage@ki.se, mairi.savage@ki.se 2017/05/11

Clinical Management Our Aspiration We strive to bridge the medical management know-do gap by researching and developing innovative management practices together with practitioners that generate value for staff and patients Clinical Management carl.savage@ki.se, mairi.savage@ki.se 2017/05/11

Innovative management practices Clinical management research group: developing innovative management practices Reimbursement systems for primary care Role of resource constraints in innovation (AUH) Business model innovation in health care (NKS, BB Sophia, SÖS, KS) Implementation of innovative care processes (DSAB, ALB, Legevisitten) Alternative approach to quality improvement (SKL) Leadership competencies in health care Role of leadership in quality management (SÖS) Macro Innovative management practices Meso 2’ MJ: Macro (system), Meso (organization), Micro (individual) In our research group, we are curious about and want to develop innvoative management practices for health care. And these are some of the examples of our projects. Micro Multiprofessional group: 5 MD, 2 MPH, 1 economist, 2 post-docs, 1 professor carl.savage@ki.se, mairi.savage@ki.se 2017/05/11

Leadership and management practices matter on all levels of care Doctor-patient relationship (Thygeson et al. 2010) Improving patient health as a complex task Organisational level (Lega et al. 2013; Tsai et al., 2015; Gilmartin & D’Aunno, 2008, Shanafelt et al., 2015 ): Decreased mortality Reduction in adverse events Improved overall quality of care Better financial outcomes Improved work satisfaction, reduced burnout and better employee retention Health system level Planning and executing health system reforms CS carl.savage@ki.se, mairi.savage@ki.se 2017/05/11

Tänk på din egen arbetssituation… Hur skulle du beskriva ett effektivt ledarskap, dvs ett ledarskap som hjälper dig att göra det bästa för dina patienter? CS Tänk på din egen arbetssituation… carl.savage@ki.se, mairi.savage@ki.se 2017/05/11

Effektiva ledare Distinguishing competencies = some competencies matter more! EQ Emotional self-awareness Adaptability Emotional self-control Positive outlook Achievement orientation SQ Empathy Team work Relationship management Social Awareness IQ competencies Systems thinking Pattern recognition MS (Boyatzis & McKee, 2005) carl.savage@ki.se, mairi.savage@ki.se 2017/05/11

Effektiva ledarskap och management utbildningsinsatser behöver fortfarande utvecklas för hälso- och sjukvården För mycket baseras på näringslivet (e.g. MD/MBA) (Weil 2013) Program anpassade till hälso- och sjukvården har haft blygsam effect (Straus et al. 2013) Effektiva ansatser sker: I miljöer där deltagarna förväntas prestera Bygger på deltagarnas eget arbete (Day et al. 2001; Avolio et al. 2009) MS As mentioned, the second aspect of relevance is tied to need for more effective approaches to leadership and management development in health care. The need for this is well-recognized. And to meet this need, the first step was to look towards programs which already existed in other domains (mostly business). Progress was seen when interventions adapted to the health care context were introduced but nevertheless, evaluation studies demonstrate only modest effect seeing impact mostly in terms of career progression and publishing papers but much less so in terms of actual skills. Studies on the effectiveness of leadership and management programs in other industries have shown significant impact of programs which are rooted in the environment where the participants are expected to perform and build on everyday work. Speaking up Experimentation Collaboration Reflection carl.savage@ki.se, mairi.savage@ki.se 2017/05/11

Hur Blir man en effektiv ledare inom hälso- och sjukvården? Seniora och blivande ledare MJ Hur Blir man en effektiv ledare inom hälso- och sjukvården? carl.savage@ki.se, mairi.savage@ki.se 2017/05/11

Vad har fungerat för framstående och framtida ledare? 20 intervjuer med två grupper av läkare Seniora läkare i chefspositioner Blivande ledare som nomineradas till MedUniverse "Framtidens ledare inom läkarkåren“ Syfte: Att förstå vilka egenskaper och förmågor effektiva läkare ledare tillskriver sina framgångar i att leda förändring, och hur de utvecklade dessa MS Aim: to understand what qualities and capabilities effective physician leaders attribute to their success in leading change, and how they developed these (Savage, M. et al, 2017, submitted) carl.savage@ki.se, mairi.savage@ki.se 2017/05/11

Qualities of effective physician leaders enable a learning orientation (Dweck, 2007) Clarity of purpose Positive outlook Endurance Authenticity MS carl.savage@ki.se, mairi.savage@ki.se 2017/05/11

Ability to adapt one’s knowledge, skills, and attitudes in unfamiliar environments to address unfamiliar challenges (Fraser and Greenhalgh, 2001) CS Capabilities carl.savage@ki.se, mairi.savage@ki.se 2017/05/11

Ground management practices in medicine Identify medical consequences of management decisions through clinical knowledge Maintain integrity of purpose tied to the Triple Aim Identify and resonate with the mental models of different professional groups CS (Savage, M. et al, 2017, submitted) carl.savage@ki.se, mairi.savage@ki.se 2017/05/11

Syftet med hälso- och sjukvården The Triple Aim Syftet med hälso- och sjukvården REDUCED COST IMPROVED PATIENT EXPERIENCE IMPROVED POPULATION HEALTH CS Sjukvården handlar om hälsa, kostnader, och upplevelser. Triple Aim Quality as STEEEP Outcome costs (Berwick, 2008) pamela.mazzocato@ki.se & carl.savage@ki.se 2017-02-09

Don’t just follow the money! REDUCED COST IMPROVED PATIENT EXPERIENCE IMPROVED POPULATION HEALTH Nurses & midwives Politicians Managers Physicians CS Triple Aim Quality as STEEEP Outcome costs Patients Källa: Storkholm MH, Mazzocato P, Savage M, Savage C. Money’s (not) on my mind: a qualitative study of how staff and managers understand health care’s triple Aim. BMC Health Serv Res. 2017;17(1):98. pamela.mazzocato@ki.se & carl.savage@ki.se 2017-02-09

Money’s (not) on my mind Dominant among Staff Managers What drives change in health care? Economics of health care Research EBM Technology Socio-political discourse CS ↓ money → opportunity to ↑ quality ↓ money → ↓ quality Källa: Storkholm MH, Mazzocato P, Savage M, Savage C. Money’s (not) on my mind: a qualitative study of how staff and managers understand health care’s triple Aim. BMC Health Serv Res. 2017;17(1):98. pamela.mazzocato@ki.se & carl.savage@ki.se 2017-02-09

Become a systems catalyst Identify and act on interdependencies Spot strategic opportunities See your own role Connect ideas and people Use yourself as a learning tool when testing ideas Create vision in concert with others Embrace complexity MS (Savage, M. et al, 2017, submitted) carl.savage@ki.se, mairi.savage@ki.se 2017/05/11

Develop a scientific mindset Guide the analysis of problems and measurement of progress Anchor decisions in evidence In case of no evidence, use data to inform decisions and learning, i.e. generate evidence MS (Savage, M. et al, 2017, submitted) carl.savage@ki.se, mairi.savage@ki.se 2017/05/11

Work with others through teaming ”The ability to quickly build resonant relationships… with a wide range and shifting mix of colleagues… as opposed to assuming an idea of stable teams with well-defined tasks” (Nawaz et al, 2014) MS (Savage, M. et al, 2017, submitted) carl.savage@ki.se, mairi.savage@ki.se 2017/05/11

Diagnose Design Act Reflect Assess the situation Design Develop specific plan for action Act Execute and record process Reflect Evaluate process and outcome CS ----- Meeting Notes (2015-01-30 00:35) ----- The first step of the cycle is defined as analyzing the situation and the challenge that lies ahead. The second step is a shift from evaluating the situation to consid- ering and selecting possibilities for action. In what order will each comorbidity be treated? In essence, this is the general plan of patient care. Which symptom is the most serious, and which aspects need to be prioritized? The third step is the shift from talking to doing. The final step is crucial for understanding what worked and what did not as well as for preventing any identified failures from recurring. (Edmondson, 2012) Nawaz et al., "Teaming: An Approach to the Growing Complexities in Health Care." The Journal of Bone & Joint Surgery 96:21 (2014) carl.savage@ki.se, mairi.savage@ki.se 2017/05/11

Execution- as-Learning Teaming for learning Execution- as-Learning Diagnose Design Act Reflect Organizing to Learn Reaching Across Boundaries Learning from Failure Creating Psychological Safety Framing for Learning CS Teaming Speaking up Experimentation Collaboration Reflection (Edmondson, 2012) carl.savage@ki.se, mairi.savage@ki.se 2017/05/11

How did we get into this mess? Stress Look to authority Pressure on authority to ”do something” Temptation for a ”quick fix” (Heifetz, 1994) CS How did we get into this mess? carl.savage@ki.se, mairi.savage@ki.se 2017/05/11

= A leadership challenge Stress Look to authority Pressure on authority to ”do something” Temptation for a ”quick fix” (Heifetz, 1994) CS = A leadership challenge carl.savage@ki.se, mairi.savage@ki.se 2017/05/11

What’s the [type of] problem? Situation Problem definition Solution and implementation Primary locus of responsibility for the work Kind of work Type I Clear Physician Technical Type II Requires learning Physician and patient Technical and adaptive Type III Patient > physician Adaptive Adaptive Leadership (Heifetz, 1994) 2017/05/11 carl.savage@ki.se, mairi.savage@ki.se carl.savage@ki.se

What’s the [type of] problem? Contextual Situation Problem definition Solution Primary locus of responsibility for the work Kind of work Decision (Work) process Type I. Simple Clear Ordered universe with clear causality Clear Correct solutions are self-evident, undisputed, and can be determined based on facts and evidence. Often one best solution. Manager Technical Often a question of solution implementation Sense Categorize Respond Type II. Complicated Ordered universe with clear causality, though not perceived by everyone. Requires learning May contain multiple correct answers. Involves analysis, expert consultations, and the creation of working groups. Requires coordination and collaboration. It is time consuming, and often requires a tradeoff between finding the correct answer and making a decision, but complete data becomes available, eventually. Manager and staff Technical and adaptive Often a question of solution implementation and evolution Analyze Type III. Complex Requires learning Unordered universe with no clear causality. No correct answers exist. Decisions often based on incomplete data. Staff > manager Adaptive Often a question of solution evolution Probe Type IV. Chaotic Requires action to create stability in an unordered universe. Requires action to stabilize in order to gain perspective and enable diagnosis. No point to search for correct answers. Act CS (Storkholm MH, Mazzocato P, Savage C. (2017) Make it complicated. Manuscript.) carl.savage@ki.se, mairi.savage@ki.se 2017/05/11

”What the best may have, above all, is a capacity to learn and change – and to do so faster than everyone else.” – Atul Gawande CS carl.savage@ki.se, mairi.savage@ki.se 2017/05/11

”Live life as a leadership laboratory” CS Live life as a leadership laboratory. – Heifetz, Grashow, Linsky (2009) Utveckla din förmåga att utveckla dina kompetenser genom reflektion (Heifetz, Grashow & Linsky 2009) carl.savage@ki.se, mairi.savage@ki.se 2017/05/11