How to Understand It, How to Achieve It Hershey, Pennsylvania

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Leadership in Perioperative Medicine: How to Understand It, How to Achieve It
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Berend Mets M.B., Ch.B., Ph.D, F.R.C.A.
Hershey, Pennsylvania
Objectives:
1) Outline concepts of leadership from contemporary business and medical literature;
2) Define and give examples of universally accepted characteristics of Leaders;
3) Describe a framework within which Leadership can occur;
4) Enumerate practical steps to foster Leadership in Perioperative Medicine.
Leadership Challenges in Perioperative Medicine
Creating the Appropriate Environment
The Perioperative environment in which we work is changing ever more rapidly, as new paradigms of quality in
care, efficiency, and regulation, in the face of decreasing reimbursement, add to the already substantial stress
experienced in the work environment.
At the same time the profession of medicine has been considered by some as being diminished (1) as physicians are
increasingly seen as providers in an industry, where healthcare is simply a commodity, rather than an art. The
increased emphasis on standardization of processes and measurement of outcomes and so a perceived professional
diminishment, may manifest as decreasing “Professionalism” and ultimately early burnout, ironically decreasing
performance and productivity.
Ensuring Optimal Team Functioning
As perioperative care becomes ever more complex (and through potential errors, dangerous) a leadership challenge
is to develop interdisciplinary teamwork recognizing teams as “a small group of people with complementary skills
who are committed to a common purpose, performance goals and approach, for which they hold themselves
mutually accountable” (2).
Dealing with Change
To thrive in perioperative medicine and anesthesiology there is a need to be able to constantly change as individuals,
and collectively as a perioperative care group. This is because the external landscape is continually changing (3).
These challenges can be addressed through an understanding and application of sound Leadership Practices, the
basic principles of which will be addressed below (4). We will outline the concepts of Leadership and Management
from contemporary business literature, and then describe a “framework” within which leadership can occur. This
“framework” will incorporate the concepts of Vision, Mission, Values, Strategy and Commitment as they pertain to
Leadership (5). We will further explore the concepts of teaming, and change management. As there is little
published work on this in the anesthetic literature we draw on business examples (similar to the perioperative arena),
that function in time pressured, stressful and highly regulated environments where a premium is placed on safety
and quality. Thus we will highlight examples from the Airline Industry, as potential models for Perioperative
Medicine to emulate. We will conclude with how Leadership and Management principles can be applied to the
Perioperative Setting.
Definitions of Leadership
• “Leadership is the accomplishment of a goal through the accomplishment of human assistants.” (6)
• “The first responsibility of a leader is to define reality. The last is to say thank-you. In between the two,
the leader must become a servant and debtor.” (7)
• “Leadership defines what the future should look like, aligns people with that vision, and inspires them to
make it happen despite the obstacles.” (8)
Relationship of Leadership and Management
Leadership and management are interrelated and many good leaders require strong managerial skills, they are
complimentary but not the same. “Managers do things right and leaders do the right thing”(9) is oft quoted. In fact
managers create order, predictability and stability through planning and budgeting, organizing, staffing, controlling
and problem solving. Some view the manager as the catalyst that looks inwards and enhances the efficiency of
organizations through unlocking the talent of employees (10). The Leader, in contrast, looks outward, and sets a
vision while serving as a strategic thinker, setting direction, aligning and motivating and inspiring people.
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Leadership is about coping with and producing constructive change (11), in this process Leaders are “chief
disorganizers” through probing, challenging and finding better ways of doing things (12).
Attributes of Successful Leaders
Kouzes and Posner have identified the key characteristics that followers seek in their leader (13). These investigators
have surveyed more than 75,000 people in six continents over a period of more than eleven years and asked; “what
do you expect from a leader that you would willingly follow?” The four characteristics most consistently identified
by the highest percentage of respondents, were, that they wanted their leaders to be: Honest (88%), forward looking
(71%), competent (66%), and inspiring (65%) (13).
Effective leadership is dramatically ordinary stuff according to a George Binney, a management consultant (14). The
three leadership qualities that are most important in business are (i) A clear sense of direction and the ability to
communicate this, (ii) A knack for motivating people, and (iii) a measure of adaptability (14).
Referring to our own specialty, in a recent survey of Chairpersons of Academic Anesthesia departments, we found
that fully 64% had decided, as a career goal, that they wanted to take on the leadership of a department early in their
career (when they were a fellow or Assistant Professor). Further, 30% had been Chairs previously and 29% had
been previous Vice Chairs while 28% had been Division Directors. This suggests future academic leaders planned
their career experience to prepare to lead Anesthesiology departments (15).
Emotional Intelligence (role modeling)
A key leadership competency, some would say the key competency is that of emotional intelligence. This is
because, the Leader’s “emotional style” or mood is quite literally contagious (16), and sets the tone for the work
environment and culture. Thus to ensure optimal performance in the perioperative environment, the leadership
challenge is for leaders to regularly be optimistic, authentic and energized so that through her chosen actions
perioperative staff feel and act that way (16). More specifically, Leadership has been defined with respect to 6
leadership styles, namely, visionary, coaching, affiliative, democratic, pacesetting and commanding (17). Leaders
use these styles to varying degrees at different times. In a recent survey of Academic Anesthesiology Chairs in the
USA, Chairpersons ranked visionary and coaching styles as most commonly used, while a commanding style
received the lowest rank order (18).
Framework for Leadership
A simple way to view the framework within which leadership occurs (19), is according to the adapted schema
depicted in below.
Our Mission in perioperative anesthesia might include clinical care, education, research and community out reach.
Shared Values (Figure 1) such as respect, integrity, collegiality, compassion, as well as excellence are the enduring
beliefs that drive decisions and strategy in a department (8). Core values are those that would be held even if they
were against the departments’ economic interest (20).
Commitment
Mission
Values
Vision/Goals
Strategy
Martin Luther King did not say I have a business plan, he said “I have a dream!” (21). A key goal is developing a
Vision for the endeavor based on established values (8). A vision is not something “mystical” but a practical
embodiment of a goal, which is both inspiring and sets direction. As an example when the CEO of Scandinavian
Airline Systems (SAS) set, as a goal, to be the best airline for the frequent business traveler, this Vision, set that
purpose (11). Such a vision in the perioperative setting would be the focus for human energy, and make the
perioperative setting singular and unique, thus fostering a sense of pride (22).
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Strategy are the actions that will be taken to achieve the established vision and goals (23). In business this is not
improved process or efficiency, as this is not sustaining, but should define what will be done differently (from
others) to give the company a distinct economic advantage that it can preserve. An example of strategy in an
academic department, defines not only what will be done, but more importantly determines what will not be done.
So a department that has the Vision of being number one in National Institutes of Health (NIH) funding would not
invest in research endeavors unlikely to result in NIH grant applications.
Commitment by an individual is the glue, energy and creativity that people bring to the department to ensure success
(22). Leaders cannot command commitment only inspire it (13). It is built through identifying an individual’s
passion and through the sharing of accountability and responsibility (13). Commitment is the result of a learning
process in which followers become persuaded that a vision is worthwhile and then apply their talents to realizing
this (24). To ascertain commitment, disagreement needs to take place with resultant engagement; otherwise people
will just fall in line (24). In turn, to allow this to happen, a culture of trust and openness needs to be developed so
that it is safe for team members to dissent and offer solutions so engaging their creativity and energy (22,25).
Teaming
The hallmark of a team effort is both individual and mutual accountability and a common commitment to a goal (2).
A study of 16 cardiac surgery teams adopting a novel approach to cardiac surgery and comprising teams of a
surgeons, anesthesiologists, nurses and perfusionists has highlighted commonalities in successful teaming (26). The
new procedure, involving TEE monitored endovascular clamping, and minimal surgical incision size, required more
interdependence and communication between practitioners than conventional “command and control” cardiac
surgery. An overriding lesson was that the most successful teams, (measured as the average improvement in
procedure duration times) had team leaders who actively managed their teams learning efforts.
While the procedure initially took 3-4 times longer than usual; the pace of improvement differed dramatically from
team to team. The authors (26) identified factors that improved team success. Educational background, surgical
experience, or the status of the surgeon were not regarded as important factors. Important factors were found to be
the selection of a consistent team of members based on competence, willingness to work with others and the
willingness to accept ambiguous situations and converse with members of higher status. Keeping these teams (and
not allowing substitutions) improved performance. Framing the challenge as organizational (rather than technical,
vide infra) was also important. Finally, creating an environment of psychological safety and allowing “learning in
action” rather than “after action review”, sped team performance. These findings by Edmondson et al (26) are
certainly consonant with the authors experience when we were developing techniques of surgery and anesthesia for
Robotic Cardiac Surgery (27).
Change management
Change is difficult. This is so because often what we did in the past works, is comfortable and the need to alter is not
clearly apparent. This leads to the quote so often heard as a counter to the wrenching process of change: “If it ain't
broke don’t fix it”. The Center for Creative Leadership has conducted an inventory of the 10 flaws that can result in
managerial derailment. The most commonly cited reason for derailment was the inability to adapt (change) and the
most common cited success factor in North America was the ability to develop or adapt (28).
Understanding Technical vs. Adaptive Change
At its essence, it is important to define the Challenge of the required change as a technical or an adaptive challenge.
In the 1980’s Colin Marshall, the then CEO of British Airways, (nicknamed Bloody Awful at that time)(29) wanted
to change the company to be customer oriented (Worlds Favorite Airline). He recognized that to do so would not
require (only) changing schedules, routines and time tables (Technical change) but more fundamentally an Adaptive
change. Marshall identified that Values had to change throughout British Airways; People had to learn to collaborate
and develop a collective sense of responsibility throughout the airline and not be beholden to the approval of their
boss driven silos, but instead, directly to the customer. Marshall identified the essential Adaptive challenge of
creating trust in the organization (29). To address this, Marshal and his executive team realized that they would need
to be the embodiment of this change and determined whose behaviors and values needed to change. They saw
conflicts in the work place as symptoms of Adaptive challenges needing to take place, often clothed in Technical
issues such as lines of authority or schedules, masking the real issue of a conflict of values and norms. Identifying
the change initiative as an Adaptive one and defining the values and norms that needed to be altered was critical in
BA’s bid to become World’s Favorite Airline. It will not be lost on the reader that the latter was an appropriate
vision statement for the airline.
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Leadership Role
In such change initiatives the leadership role is complex. It is crucial that the leader is able to understand the
problems on the ground i.e. the “dance floor” while also being constantly able to remove themselves from the action
on to the “balcony” to see the big picture (29). The leader needs to regulate the inevitable distress that occurs
keeping enough pressure so that people feel the need to change while avoiding colleagues from becoming
overwhelmed (30). To achieve this the leader needs to attend to three areas (29). Firstly a “holding environment”
must be established where the issues, norms and values needed are debated and shaped and from which these are
communicated to the organization. This was implemented in BA when its focus changed from inward to outward
(customer oriented). Again, the reader will note that this concept, in the form of “patient centered care” is now
manifesting in the perioperative environment. The leader needs to establish priorities and focus, (not everything is
important) and pace and sequence events. Secondly the leader must protect, orient, provide norms and reestablish
values. Thirdly the leader should have presence and poise and should have the emotional capacity to withstand
ambiguity, frustration and anguish. She will be observed by colleagues to see if she has the intestinal fortitude to
hold steady and tackle the tasks ahead.
Anatomy of a Change Initiative
The fear of change (Metathesiaphobia) is often a result of the fact that the benefits of the change are not clearly
established or realized while the loss that change evokes is immediately felt. The leadership challenge lies in
defining a compelling vision, setting and creating an urgency (not anxiety) around the change imperative, building a
guiding coalition, communicating, addressing obstacles, and celebrating and noting short term wins (8). An
adaptation of this universal approach has been recently described in a Curricular Change initiative at UCSF (31) and
in moving to Universal Start Times in the Perioperative environment in our own institution (32). The Table below is
adapted from the latter work.
Table: Ingredients for a Successful Change Initiative
Development of trust
Information Sharing
Shared Values
Role Modeling Change
Development of compelling vision
Creating an urgency.
Guiding coalition.
Communication
Short-term wins: monitor progress.
Don’t declare victory too soon.
Parallels in Industry with respect to the Perioperative Setting
There is very little published on how leadership principles might be applied to the perioperative setting however the
aviation industry may serve as an example, (similar to the perioperative arena) of an industry that functions in a time
pressured, stressful and highly regulated environment where a premium is placed on safety and quality. South West
Airlines is a celebrated example of this industry. While many have filed for bankruptcy (33) ( Northwest, USAir,
United, Delta), Southwest Airlines, was considered the best of all airlines in average return on investment capital
from 1985-2002 by Michael Porter, and, in a recent US Transport Report Card received the second highest ranking
for 2006 (second to Jet Blue) for all categories (34). Among all industries in 2006, FORTUNE has listed Southwest
Airlines as number five among America’s Top Ten most admired corporations and the airline was named to
Business Week’s first ever list of “Customer Service Champs” while being ranked as one of the top 50 Best Places to
Launch a Career (35).
The leadership and management practices of this airline have been dissected to evaluate the leadership style of its
founding CEO, Herb Kelleher. Herb has created a “culture of commitment” practicing as a servant leader with a very
distinct customer orientation, both outward (passengers) and inward, to each employee, called associates (36) (See
“framework for leadership” above). The airline has a clear vision/mission, “to the highest quality of customer
service delivered with a sense of warmth, friendliness, individual pride and Company spirit” (35). Strong core
values; “maintain principles, while changing practices” (36) and competitive strategies; to compete for price with
the car, while using a point to point service, using a single plane type (737’s) for efficiency.
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What Leaders Do
Leadership is a set of skills that leaders develop. According to Souba (5), LEADERS, Listen to the environment and
their people, Exemplify and embody core ideology, Applaud others, Deal with problems, Empower, enable and
inspire people, are Results oriented and Serve their people.
In a recent Survey of Anesthesia Chairs (18). Chairs spent 8% of their time Leading, 10% Managing and 18% of
their time was used in Administration while fully 31% of their time was spent in clinical anesthesia.
Application of principles to Perioperative Medicine
It must be clear to the reader that a cook book recipe for Leadership in Perioperative Medicine will be of little use as
each institution is different. Nevertheless a focus on Key Areas of Concern and Principles of Leadership may be of
advantage.
Creating the Environment
Creating an environment for work that is collegial, respectful, equitable, safe (for patient and practitioner), adaptable
and results oriented, is a key concern for leadership. In order to create and sustain this environment, leadership does
well to consider all participants volunteers. Leaders can and should:
(1) Be visible and role model the established values.
(2) Build trust and trustworthiness through transparency and their own actions
(3) Be ever mindful that their emotional style sets the tone for the environment
(4) Be results oriented
(5) Be prepared to deal with problems, timeously and decisively
(6) Communicate, communicate, communicate, using all media at their disposal.
Leadership shared at all levels
The view that there is a single leader at the top from whom all initiatives flow is insufficient to deal with today’s
complex perioperative environment (37). Leadership is about relationships (13). Thus, Leadership is created
together. To be effective, leadership needs to occur at multiple levels (8). Leadership is an interchangeable
phenomenon, “now you lead, now I lead” depending on the circumstance and the particular skill set required.
Leaders can and should:
(1) Foster leadership at appropriate levels
(2) Cede responsibility (and accountability) to allow leadership development
Building interdisciplinary teams
The case studies of 16 cardiac surgical teams illustrates the strength of interdisciplinary team development vs. the
“command and control approach” (26) Nevertheless, in a crises an established leader must make decisions adopting
the commanding style of leadership (17).
Leaders can and should:
(1) Decide where processes can benefit from the development of Teams
(2) Create an environment of psychological safety, allowing “learning in action” for such team
development
Change management,
Leadership is about managing constructive change. As Mahatma Gandhi said, the Leader should “Be the change you
want to see.” Leaders can and should:
(1) Identify and articulate clearly the need for change and the advantages of the future state
(2) Establish what Adaptive Change is required and what values may need to be addressed to effect this
(3) Recognize that change is “loss”
(4) Set Priorities, re-iterate values, protect and support
(5) Maintain an urgency while regulating the pressure
(6) Recognize short term wins
(7) Don’t declare victory, too soon
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Conclusion
The concepts of leadership are universal and can be applied with advantage to the perioperative setting.
Leadership can be learnt and it is as well to remember the quote below:
“Leaders learn best by leading and learn best in the face of obstacles.
As weather shapes mountains, problems shape leaders.”
Warren Bennis (9)
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