Welcome to episode 3, leadership and follower-ship in a culture of quality. While we often make a strong distinction between leaders and followers in everyday life, nearly all of us play a variety of roles that alternate between leading and following. Even the President of the United States has been a follower at times, in terms of a ruling of the Supreme Court or an act of Congress. In a high functioning learning organization, there is almost a seamless set of principles that guide leadership and followership. The name that pops into my head immediately, when I think about leads and quality improvement, is Don Berwick. He's a visionary thinker and transformational leader who is not afraid to think big, and then act to get the overarching goal of improving health care. Dr. Berwick is a pediatrician who held the first position with Harvard Community Health Plan as Vice President of Quality of Care Measurement in the 80s. He's the founder of the Institute for Healthcare Improvement, and was tapped by President Obama to be the administrator of the centers for Medicare and Medicaid. The breadth and the depth of his work has been the catalyst to transform the health system into a much safer and higher quality system. Dan has exemplified someone whose beliefs, values, and actions aligned with his core passion for quality and quality improvement. He has not played it safe, but has advocated at all levels of the health system and in policy arenas to create change. He has had a vision of what a high quality health system can be and has relentlessly worked to share his vision through his remarkable ability to tell compelling stories as well as practical efforts and make the vision a reality. While Don is a visionary leader at a macro level, as we noted it takes leaders at all levels of the healthcare system. I want to share with you the story of August, a housekeeper who worked at a local hospital where I worked. Everyone knew August and knew that he took a great deal of pride in his work, ensuring that the rooms of patients were clean. However, he went beyond that and always notified the nursing staff if he noticed something of concern. He was fully a member of the healthcare team, but also an informal leader at the hospital. He was clear that it was everyone's job to do the best they could for patients and their families. Staff relied on him for advice, both as assessment of what might need to change as well as personal advice. Physicians, nurses, physical therapists and others found his wisdom and caring to be a source of enlightenment as well as an inspiration. CEOs and other high level organization leaders articulate the vision and values of an organization. It's hard to envision a true learning organization dedicated to quality and safety improvement, if the overall leaders of the organization do not share those values, beliefs, and most of all, actions. A leader cannot simple talk about a commitment to quality and safety. There needs to be investment in systems training of staff, ensuring that employee evaluations are strongly related to demonstrated efforts in quality improvements and instilling excitement about team work to solve problems. A quality culture supports people in making the changes needed to continue to improve care. Perhaps the most important task of those in senior leadership positions is how they transmit the vision and values to all levels of managers and staff, since a learning organization with a culture of quality and safety requires everyone to integrate the values, beliefs and actions supporting safety and quality into all of their work. As we noted, all of us are leaders and followers at different times or in different settings. Being an effective follower is perhaps just as important as being a good leader. The concept of followership was first introduced by Robert Kelley in 1988, has gained some attention as a critical component of effective organizations. While most people don't talk about aspiring to be a follower, everyone whoever gets to a leadership position is likely been a follower. McCallum has identified a number of traits necessary to be an effective follower, including maintaining an ethical compass, honesty, competence, strong work ethic, courage, discretion, loyalty and ego management. Followership is important to quality improvement, because everyone on a team needs to do the work that's expected, so that they have an impact. Perhaps one of the most important characteristics that McCallum noted is ego management. On a quality improvement team, high ego needs will interfere with listening to others, treating others as equal and creating an effective team. First followers, also termed early adopters, are often very important. They actually provide the lead for additional people to follow. The first follower needs to trust the leader and see value and share in the vision that the leader is promoting. He or she should also have a sense of adventure and willingness to take risks. In many ways, the early followers are really leaders themselves, because when they join the leader others will follow just because the early follower joined. In addition, there is a continuous feedback loop among leaders and followers. Followers are smart people and have opinions about what works and doesn't work. They have the experience of being front line workers, the people who are taking care of patients. They give feedback to leaders through a variety of means, directly talking to other followers or through action. Leaders then respond to that feedback and the cycle continues with constant refinements. There are attributes of leaders that tend to generate strong followership. These attributes include trust, stability, hope, and compassion. Followers want to be able to trust that the leader will keep his or her promise, and the key information will be shared. Stability is the sense of knowing the mission and the direction of the organization as opposed to having a constant change of direction and being left wondering, where is the organization going? Stability is not stagnation, followers need hope that they will succeed in their mission. They also want to know that their leaders care about them and will support them through hard times. Even though this attribute seem pretty straight forward, finding a leader with this set of attribute who values and believes in creating a culture of safety and quality can often be a challenged. In every formulation or model, communication is identified as a critical factor in building a culture of quality and leadership. It's almost impossible to communicate too much and very easy to communicate too little. Newsletters to patients, information communicated to staff, stories to newspapers, research conducted and reported, whenever possible should be considered in the context of quality. In addition to verbal and written communications, communication around quality and safety should include a great deal of action and nonverbal communication as well. As leaders at all levels work with their teams or talk at the coffee machine, quality improvement and safety should be a frequent focus and implicit in many conversations. It's not enough to hang posters highlighting the importance of quality improvement or have a single column in a newsletter. The message must be infused throughout every communication. An important way of communicating quality is for leaders to connect with the daily on the ground work. For example, a hospital leader might make rounds on the floors and engage staff in conversation about quality improvement and safety. This conversations should be positive and give a message of support for the quality efforts. A common way to sabotage a growing culture of safety and quality is to give negative messages about the efforts of staff. To blame or just point out shortcomings rather than focus on successes and positive outcomes whenever possible. As with other areas of safety and quality, it's essential to know how well your organization functions in relationship to creating a culture of quality and safety. There's several staff surveys that are very helpful in understanding the strengths and weaknesses of your setting in relation to various attributes of the culture of safety. In the US, the agency for health care research and quality maintains a set of surveys relayed to culture safety that can be used in a variety of settings. There's also a good deal of benchmarking data available using these surveys that can be used to see what aspects of the culture may need to be strengthened. The Agency for Healthcare, Research, and Quality Standford University the institute for healthcare improvement and the veterans administration as well. As others have tools and programs that can be used to build a strong culture of safety and quality in nearly all settings. Up to this point, we've been focused on leadership and the use of intrinsic valuation based on professionalism and the deep human motivation to succeed and do well. Intrinsic motivation is doing something, because you enjoy it and get a sense of satisfaction or pleasure by doing it. However, we know that not everyone or every organization is always in this mode. In these instances, extrinsic motivation may be important. Extrinsic motivation can come in the form of either positive or negative incentives. Incentives may be financial or include other interventions, such as publishing data on rates of errors or levels of performance. Again, it'll be critical for leadership within an organization to be able to effectively use extrinsic motivation to drive organizational change. An example of extrinsic motivation at a macro level, using a negative incentive is non payment to hospitals for the cost of care of hospital acquired infections or readmission within 30 days for the same diagnosis. It's thought that putting hospital payment at significant risk may drive financial incentives and actions that will reduce the likelihood of hospital acquired infection, or reduce readmission. On the flip side, there have been programs to provide positive financial incentives to physicians and institutions to improve care, as well as widespread use of various forms of public reporting data on safety and quality. Other types of incentives that have been used to motivate commitment to quality improvement include, linking staff pay increases to work on quality improvement. Employee recognition for leading QI teams. Publishing stories in organizational newsletters, highlighting people who created quality improvement success, and others. There's still a good deal of controversy about the overall impact of extrinsic incentives with some studies showing small marginal effects using either financial incentives or public reporting. Regardless of the empiric data, most consumers, purchasers and payers believe that intrinsic incentives are useful, and have continued to expand their use at least within the United States and the UK. Being a leader carries a lot of responsibilities and expectations. An effective leader promoting better quality and safer care must have many skills, be adaptable, and maintain a sense of passion for their work. In the next episode, we'll be talking about knowing yourself as a leader.
