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2021 Physician Leadership Virtual Journal Club: Change Management

Learning Objectives
1. Contextualize evidence-based research for individual applicability
2. Incorporate leadership strategies to lead multi-faceted teams
1 Credit CME

Join us in discussing recent journal articles uniquely suited to physicians in leadership roles and executive positions. Each one-hour forum will help participants assimilate key leadership knowledge and skills and incorporate management strategies to lead multi-faceted teams. This session's theme is Change Management.

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Video Transcript

Daryl Oakes, MD: Good afternoon and welcome to the first session of the Stanford CME Physician Leadership Virtual Journal Club. I am Daryl Oakes, and I'm a clinical professor and practicing adult cardiothoracic anesthesiologist here at Stanford. I am also Associate Dean of post-graduate medical education and physician lead of the Stanford Center for CME.

Ruth Adewuya, MD: And I am Ruth Adewuya, the managing director of the Stanford Continuing Medical Education, and the podcast host of our accredited CE podcast, Stanford Medcast.

Oakes: Today is the first of our series of monthly Journal Club discussions. We will be hosting conversations with expert panelists on a variety of topics, addressing different aspects of physician leadership. The goal of this series is to provide practicing physicians in all levels of leadership, with insights and management skills, to help them be more effective in their clinical environments. The format of the sessions is, it's live facilitated webinar with pre-assigned topics and articles for discussion. Each month before the session, we will ask for registrations to submit their questions, and we'll use these to guide the discussion.

Adewuya: Today's discussion will focus on change management, whether at the level of direct patient care or the level of the care team or at the larger organization level, having the skillsets and knowledge to guide the implementation of care innovations is critical to providing the highest level of care for our patients. And so we are so excited to be spending some time on this topic today. Today's session will begin with a brief overview of three articles that we will be discussing with our expert guest panelists. Then we will proceed to the panel discussion, utilizing some of the questions that have been submitted by our audience. We will follow this discussion with questions from you, our audience today, which you can submit by the QR code, or if you're unable to use the QR code, feel free to click the link below the QR code on your web page. Let's get started and I will turn this over to, Daryl.

Daryl Oakes: Thank you, Ruth. We're going to spend the next 10 minutes reviewing the articles for this session. Let me go back there for a second, a little head of ourselves. The first article we'll be reviewing is Atul Gawande's piece in The New Yorker called, “Slow Ideas”. This article in it, Gawande is really reflecting on two big questions. First, why are some ideas adopted and others not? And second, how can we best promote the adoption of new practices? To address the first question, Gawande, points to two historical medical innovations. In one case, ether anesthesia, which was readily adopted. And in the other case, Joseph Lister's antiseptic and aseptic techniques that took over a generation to be adopted into mainstream practice. As Gawande points out, ether anesthesia had a dramatic and immediate effect that instantaneously changed the surgical environment from chaotic and loud to quiet and controlled. Live demonstrations of ether anesthetics resulted in the rapid adoption of the practice. And this occurred despite the need to overcome barriers, such as the cultural idea that pain was necessary.

And even the technical complexities related to how to actually deliver anesthetic therapy. Listers innovation, however, was hard to see in real time. Infection, although a huge problem in surgical interventions was less easily directly connected to a specific event since it happened over days or weeks after the procedure. As a result, the inconvenience of needing to wash in carbolic acid or of maintaining a meticulously clean environment was more off-putting since the benefits were harder to connect to any specific action. Infection is similar to climate change or mortality due to neonatal hypothermia since these are all problems that developed slowly, almost imperceptibly over time. Innovations that attack these types of problems, invisible problems, can be harder to promote and often these innovations are less readily adopted. And so that brings us to, Gawande's second question. How can we most successfully promote the adoption of important new ideas? To address this question, Gawande shares the example of the Bangladesh oral rehydration therapy project.

Let's see, here we go. In 1980, diarrheal illness remained the most common cause of death in the world among children under the age of five years. And this was despite the fact that effective therapy with oral rehydration therapy was described for more than a decade at that time. In 1980, a Bangladesh non-profit organization, BRAC, initiated a public health project to get oral rehydration therapy adopted nationwide in Bangladesh. They recruited and trained a team of educators who traveled throughout Bangladesh to teach villagers how to directly in a hands-on way, how to make the actual therapy and how to use it. They created a simple script explaining when this therapy was needed, how to make it and how to use it effectively. And because aspects of oral rehydration therapy, such as encouraging POTS intake in a person who is actively vomiting, can seem somewhat counterintuitive.

The training team had to help villagers see for themselves and understand why it was so important to encourage sick individuals to drink the solution. In order to teach the therapy, they went door to door and sought out families with ill family members and help the family implement the therapy themselves under their direct guidance. And remarkably, because of this direct, in individualized education campaign, the project was able to dramatically impact attitudes and change behavior related to oral rehydration therapy. Three decades later, as a result of the campaign, nearly 90% of children in Bangladesh with severe diarrhea were treated with the solution. And child death from diarrheal disease decreased by more than 80%. And interestingly, other countries where oral rehydration therapy programs were implemented to try to get increased use, but they were done in a hands-off maybe more PSA education style type campaign, but it did not use a community-based training approach. In these countries, efforts to promote the uptake of therapy were largely unsuccessful. The key lesson here is that successful change is a uniquely local phenomena. As Gawande puts it, people talking to people is still how the world standards change.

In summary, Atul Gawande's article demonstrates that change efforts occur from the ground level up, and importantly, sustainable change does not occur by mandate or even just by better education. Change actually requires creating a new cultural norm. And to do this, you need to first understand the existing norms and the barriers to change. And these need to be acknowledged and addressed. Since change occurs at a very local and personal level, new ideas need to be socialized to help individuals fit this new idea into their worldview. To do this, the new idea needs to be presented by someone the individual trusts and feels understands them, really, a personal connection. And in addition, change efforts need to connect with an individual self-image. And this image needs to be used to reshape the behavior. For Lister's antiseptics, this meant connecting the image of a surgeon to that of a scientist, and then reframing the operating room into a pristine scientific laboratory.

The second article is by, Jenna Breckenridge and colleagues, and it is called, “Motivating Change”. This paper presents a conceptual level explanation of the conditions necessary to facilitate and sustain change improvement at scale. This theory of organizational change harnesses the learning experiences from several large improvement organizations. The authors use a participatory grounded theory approach, which involved workshops with 42 staff from three leading change organizations in the UK, the Unicef UK, NHS Highland, and Health care Improvement Scotland. These organizations work in health education and social care. In the workshops, the lessons learned from major projects were analyzed and they co-created as part of the workshop this theory of motivating change. The central premise of the theory of motivating change is that organizations must create the right psychosocial cultural conditions for large-scale successful and sustainable change. This means that the following conditions must exist. The individual motivation to act, the psychological conditions. The collective support for action, the social conditions. And the institutional structures that create capacity, capability and opportunity for actions, the structural conditions.

For example, the need to create the right psychological conditions for change was illustrated by a Unicef UK project called, “The Baby Friendly Initiative”. The project involved implementing a rigorous new gold standard certification program whose aim was to make permanent and sustaining changes in infant health, such as increased rates of breastfeeding. Although the many of the goals of the care was already been achieved in previous efforts, the certification required significant changes in institutional culture and structure to make these achievements permanent. The progress of the project, however, was threatened by the belief of many practitioners that the requirements for certification were too difficult to achieve, and maybe unattainable. This presented a practice paradox where the policy being instituted is in conflict with the concerns of the practitioners. This barrier was addressed by creating a convincing argument for why this change was needed.

This was done by doing a survey of parents to see in what ways the current services were inadequate and it needed to be improved. And this was then presented to the providers. The providers were then also surveyed regarding what they felt to be the biggest challenges for change. And then their concerns were addressed by involving them actively in the project design process. And finally, people were provided with evidence throughout the project, that change was actually working and they received regular shared metrics and outcome measures to help them see change throughout the project. Creating the social conditions to motivate change requires building trust through effective leadership, harnessing positive peer pressure and managing infectious negativity. And also, by utilizing data from constructive resistance. Trust can be built by using evidence of change as evidence for change. Effective leadership builds trust and motivation by harnessing both positive and negative results of the project and use them to illustrate, whether the progress was going well, or whether there needed to be some opportunity for redirection. Effective leaders taking count the values of their team and they stay connected with them.

And then they're also able to respond to what motivates and de-motivates them. Peer pressure can be harnessed in a number of ways, including utilizing a core group of people who are early adopters to help champion the change efforts among colleagues who may be slower to adopt the change. Peer pressure, however, can turn into infectious negativity if important concerns about the change effort go unacknowledged and unaddressed. One way to address infectious negativity is to harness constructive resistance. This involves actively listening to opposing views and concerns and using them to make adjustments in the project. This process and listening to these ideas can often improve the project and increase engagement in the effort.

And finally, the structural conditions to sustain change need to be created. Change can be created through the use of visual cues, financial rewards, carefully chosen incentives, and both by thoughtful timing of the project and by providing adequate time to actually implement the improvement effort. One example of creating the right structural conditions was a process improvement effort by the NHS Highland, which involved introducing a weekly review of financial and performance information among a series of clinical teams. As part of the project, each team chose a priority area to work on. Evidence for success was made visible with weekly box scores, which provided metrics in five areas, including safety, quality, patient experience, staff satisfaction and finance. Teams were able to see their data directly and how it aligned with their chosen priorities and current improvement projects. Staff could also see the expenditures on their service in real time, so they could better see the cause and effect of their actions.

There was no direct incentive for cost savings. Just the awareness that care could be improved with more efficiency. And staff found the line of sight between information improvement and capacity was very motivating to help them make new changes. The incentive for the change effort was that the providers were able to have more direct control over their team services, and it allowed them autonomy to enhance and improve their service that their team provided. Although incentives can be a powerful motivator, it is also important to recognize and incentives that are not aligned with the values of the team, can actually be de-motivating and sometimes counterproductive.

And last, the amount of time required for the project was minimal as it was integrated into an already existing workflow. Also, the project was initially initiated really in a timing that was immediately after a workshop that was done for the teams to learn about rapid process improvement. The teams were actually really well primed to initiate this type of change effort. In summary, the motivating change theory requires that organizations create the right psychosocial cultural conditions for change that address the motivation to act on an individual level, the community level and the institutional level. And the third article is by, Stewart Gable, and it is called, “Transformational Leadership and Health Care”. Gable, presents the concept of the transformational leader as one that engages in a relational process that motivates the moral purpose of the team. The concept of the transformational leader involves four basic tenants. Idealized influence, that is the idea that the influence of the leader is due to the leader's vision and the principles and values on which this vision rests. Inspirational motivation, the ability of the leader to communicate and inspire individuals through confidence, optimism, and enthusiasm. Intellectual stimulation, the leader's ability to appropriately challenge individuals to seek out new solutions to difficult issues that go beyond the usual approaches and expectations. And individualized consideration. The concept that leaders need to attend to and support the growth and development of the individuals they lead.

Gabel, demonstrated this potential of transformational leadership in the health care space with a vignette of a ward attending, interacting with the trainee. The trainee was very focused on being able to perform a procedure, one that he'd never done before in a patient with a newly diagnosed advanced cancer. Rather than a [inaudible] the trainee for not being focused on the patient's experience, the attending reframed the plan for the procedure in terms of the patient and family needs, noting that she hoped that the procedure would help the patient in his quality of life would improve. She also asked the trainee how the patient was handling the new concerning diagnosis. By setting this example, the attending was able to model the principles and values of compassionate, patient centered care and support the trainee to learn and adopt new approaches in a safe learning environment.

Empirical evidence has demonstrated that this type of leadership improves staff satisfaction, decreases burnout and improves overall clinical outcome measures. The implementation of this leadership model in the health care environment is intuitively appealing. And this type of leadership has the transformational potential to improve performance by inspiring an elevated level of conduct by the entire team. In summary, Gable's article presents transformational leadership as a useful leadership model for health care and medical education. This leadership style is relationship oriented based in trust and focused on elevating the entire team, both ethically and professionally. That brings us to the end of our high level of review of the articles. And now we're going to move on to our discussion portion with our expert panelists.

Adewuya: Fantastic. Thank you so much, Daryl, for that high level of review of the articles for today's discussion. We are very fortunate to have with us today two experts in change management as panel discusses. I'll start by introducing, Dr Karen Frush. She is a Stanford Clinical Professor of Pediatric Emergency Medicine and the immediate past Chief Quality Officer for Stanford Health Care. In this role, she has helped lead a zero health care acquired infections program with a focus on reducing central venous line infections and has worked to enhance a culture of safety at Stanford through a survey and assessment process. Dr Frush, has over 20 years of experience in patient safety and risk reduction projects. I also want to thank Dr Frush, especially today for joining us, despite a family emergency. Thank you so much for being here today.

Karen Frush, MD: Can I just do a check? Ruth, can you hear me okay?

Adewuya: Yes, I can hear you.

Frush: Okay. Just real quick before we introduce, Dr Hopkins. I believe in transparency, as you'll hear when we have this discussion, one of my sons is in surgery right now. I just got a text. He was playing softball over the weekend, though for a catcher, missed the ball, but broke his clavicle, fractured his clavicle enough to need a plate. He is in surgery. And I am going to ask your forgiveness at this point in case I have to step out for a minute. But he is in very good hands. A good friend is doing his surgery and I'm thrilled to be here. Thank you so much.

Adewuya: Thank you so much for being here today. And with that, I'd like to introduce, Dr Joseph Hopkins, who is a Stanford Clinical Professor of Medicine - Primary Care and Population Health. Stanford. He has served as the Associate Chief Medical Officer for Stanford Health Care since 2007, and is the senior medical director for quality since 2005. He's been the director for the Stanford Leadership Development program here, which provides leadership skills to both Stanford faculty and staff leaders. Thank you, Dr Hopkins, for being here today. Fantastic. I think we can see both, Dr Hopkins and Dr Frush. Fantastic. I will now transition to the question portion of our discussion. And I just want to remind folks that you are able to send your questions to us live using the QR code that's on the website or the form, whichever works for you. But we'll start the discussion with some of the questions that actually were submitted prior to this session.

And what I'll do is I will throw the question out to either one of our panelists first. And then you can answer, and if you have anything to add to the first person's response, then feel free to do so. Okay. I'll start with the Atul Gawande article. And Atul Gawande as, Dr Oakes mentioned, discusses how all change is essentially local. Dr Frush, I wanted to maybe start with you. How do you think we can apply this lessons from public health efforts to our clinical level or institutional change efforts?

Frush: It's a great question. And it's a great place to start, I think, by talking about the fact that change is local. Change is local is actually the primary focus that we use when we begin to evaluate culture at an organization and think about how one changes culture, which I know we'll talk about in a minute. It's really about making the effort to understand where we're starting. And culture is very local at any organization at any hospital. If you move from one unit to another, you realize that there's not a culture of an organization, there's a culture at a unit level. You can walk from the intensive care unit into a different intensive care unit. Both wear the same level of care is provided, the cardiac ICU and the neuro ICU. And it's a very different place. You can walk from the pediatric emergency department to the adult emergency department, and it's a very different place. The feeling is different.

And it's not that there's a culture of emergency medicine, which is what I practice. You can look at the culture of an ED at Stanford, and it's very different than the culture of an ED at UCF. Culture is local because culture reflects the norms of the people who are there. I think it's the idea behind, Atul Gawande's comment about, when you think about a public health effort and you're trying to reach everybody, it has to actually be drilled down all the way to individuals who are together in a common place. I'll stop. And I've learned so much from Joe, myself having been at Stanford. I'm sure he has much to add. But I am a big, big believer in these grand ideas about changing the world with public health and changing organization. And it all does start very, very locally.

Adewuya: Dr Hopkins, anything to add to that comment?

Joseph Hopkins, MD: Thank you, Ruth. I very much agree with what, Karen, was saying, and we certainly find that here. And I think one of the things that can go wrong is when things start from a higher level of, you may be able to bring some change in some localities and not so well in others. And it really becomes difficult to get the really high level last 10% or 15% change when you haven't really engaged those frontline people and understand how they experience what it means to them and how it fits into their own sense of who they are and what they do. So completely agree with, Karen.

Adewuya: That segues into the next question, actually. I think, Dr Hopkins, you almost responded to my second question, which was around the fact that change requires attention to culture. And I was going to ask, either of you to maybe talk about your experience with culture change efforts, but I want to highlight what you just said that I think it seems like it's key that we need to engage with people. And I think that's the first step. But maybe, Dr Hopkins, can you expound on that? What has been your experience with culture change efforts and what have you seen to be effective around motivating culture change?

Hopkins: That's a very good question. And I think, again, it has to be approached through local and individual experience. The people have to experience the change and see that it actually has value to them that it has value to their patients and our profession, that it is valued to our trainees and talk with other people about their experience about that. And gradually, that builds on itself. Talk with other units about it, other colleagues, and that builds up eventually to bring us to a point of a different way of viewing how we do things, which is a definition of culture. I don't think you can implement that from the top down. It really has to start working, the psychosocial structural model fits very well in that context.

Adewuya: Great. Dr Frush, any other comments to that question, which is your personal experience, maybe with some culture change efforts?

Frush: Yeah. I just want to add to what, Joe said. I think he described exactly the challenge. And I actually think another challenge of cultural change is that it's so amorphous, people talk about culture and it's this thing that you can't quite grab onto, or hold, it's not tangible. If you think of culture as collective attitudes, beliefs and behaviors, it actually means we have to change our behavior. The reason that culture change is so hard is because we, as individuals have to change our behavior, our habits, our patterns, that's really hard. And we have to influence the change of others, behaviors and patterns and habits, which is why I think to Joe's point, the opportunity to change culture comes all the way back to trainees.

The formation process is what helps form these patterns and behaviors and we're training people way too much like we trained people in the past. We're still training through a hierarchy kind of system. We're still training people in ways where, especially with COVID, just reflect on a minute of residents and the experience as agents to be used wherever we need them. We have to be really, I think, Joe, brings up a hugely important point and that is the formation process and what we're telling people messaging to the next generation of health care providers. You've got to start thinking about more and think about how we help people develop relationships, mutual respect, teamwork, skills. I'll stop. I could talk forever about that.

Adewuya: Which aspect? Keep going. I think you highlighted the importance of the training of medical students and our trainees. And we did have a question that came in from a medical student, that takes a little bit of a tangent from what you're talking about, but I think it's important to highlight that question. The question, I'll read it verbatim, as one of the papers mentioned that organizations must create the right psychosocial or structural conditions for successful large scale sustained change. What if the organization where we study does not meet those conditions? Is the question. Is there anything we, as medical students can do to reach them? This particular medical student says, where I study, there's a lot of competition between students and coworkers, so it's making it more difficult. Dr Hopkins, I'll throw out this question to you first. I know you probably have some examples around the work that medical students have done, but what are your thoughts about this comment and question from this medical student?

Hopkins: Well, I think competition is not necessarily a bad thing. It can be, it can be a driver for people wanting to seek improvement by doing a little better or even joining as a team. If it's done in a way in which solutions, knowledge, data is hidden, and of course, that's very destructive. I think medical students underestimate their power to drive change. They have a certain flexibility, a certain freedom. They're very busy, but in terms of beyond achieving their educational work, they have a lot of opportunity to do things. And we've seen examples here. For example, the students decided to start a Quality Improvement Interest Group, very small number of students, I think, initially about a half a dozen, said, we want to learn more about quality improvement. We're not really being taught that.

They came together, they began to talk among themselves. They ask a couple of faculty in that field to come talk to them. They eventually recruited us, a faculty sponsor. They began a project that they did as a group, and gradually, we have what are called scholarly concentrations in our curriculum. And then in addition to the basics, you can add some emphasis. And that grew into one of the scholarly concentrations here, right along with genomics, and some of the other things that are scholarly concentrations. Similarly, students were wanting to see more primary care. Unbeknownst to anybody, they started a chapter. If you know what a Primary Care Progress is, it's an organization that promotes primary care at multiple levels from communities to clinics, to institutions. And trainees, they just started a chapter, a local chapter on their own and it began to generate enthusiasm among them. Go medical students. I think you underestimate your potential to actually do some great things.

Adewuya: Great. That's a great point. Comments on that, Dr Frush?

Frush: Yeah. I'll just give one more example. First of all, can I just say thank you to the medical student who submitted a question? Can we just celebrate the fact that we, I think one of our opportunities as faculty to encourage medical students is to celebrate and acknowledge when they have the courage to speak up and to provide examples. Joe, I thought, gave great examples of structural things that medical students helped put in place. I want to also comment on how medical students influence from a psychosocial perspective as well. There's a true story of a clinical team that was going into an exam room. And the faculty member, the attending physician started to examine the patient without washing his hands.

And this came up during a session I had with medical students. And so they talked about the fact that, how are we supposed to learn these things when they're not modeled? And the question was, “Well, what can I, as a medical student do about that? I'm at the bottom of the totem pole. I can't say anything to the attending.” I said, “Well, what could you do?” And one said, “Well, maybe, could we put in a voluntary safety report?” Well, maybe that's one thing. And then the faculty member would get feedback later.

And hope, cough, make some signs. Could we do something like that? And then one medical student said, “What if I just went and washed my hands?” And I said, “Wow, what if you did? Would that be a powerful influence?” Again, to Joe's point, the opportunity for medical students to influence things, create structural opportunities, et cetera, is huge. And the opportunity for us, I think, as faculty to acknowledge and celebrate that is huge as well.

Oakes: I just want to thank both of you for those wonderful examples and to follow up with, I think, one of the points in the article is this idea that as leaders, if you're trying to create change, you need to do it from the ground level up. But that also means that change can occur from the ground level. And that people who are on the front lines can lead that change and really are in a good position to do that. And I think whether we have a flattening of these opportunities to be visible and to make change whether, it's through social media or through our organizations. And I think this is a really unique opportunity for that. Thank you both for those thoughts.

Adewuya: That's great insights there. I want to switch gears to the second article, laid out by, Breckenridge, and talking about the framework of motivational change. The framework of motivational change highlights the need, and we talked about this, the need for the right psychological conditions, the right social conditions, the right structural conditions. I'm curious to get your insights and we'll start with you, Dr Frush, how does this framework fit within other change management approaches, PDSA, A3? With your expertise with that kind of assessment, curious to get your thoughts there?

Frush: Yeah, it's interesting. It reminds me when I think of the psychological social piece and then the improvement processes PDSA, et cetera. It reminds me of what I learned early on when I came to Stanford from ED Schein, Edgar Schein, who is known as the guru of organizational culture, I think, globally really, he's a professor Meredith out of MIT. And he refers to health care as a socio-technical industry, associate technical reality. And the fact is that there are important processes and practice and systems that need to be changed. And there is a change process and because it's healthcare, which is about people taking care of people, there's a social side of that as well. And the social side requires that we understand, learn how to create relationships, which allow us to work together effectively. And again, I think sometimes that comes back to some self-reflection and what we've learned and how we've been trained.

We've been trained in silos still. I went to nursing school and then medical school, and those were two very separate silos. And I still see that happening. And we all train in different silos and then we're supposed to magically work as teams and create these relationships. We have to focus on what it takes to create strength in the social side, as well as the technical side, and the tools and methods and process to change both sides. I think that's the reality. And as Edgar Schein says, health care is so complex, it's the most complex of all industries. And in such a setting, relationships are essential. No one can do it by himself or herself.

Adewuya: Yeah, absolutely. Dr Hopkins, comments on that?

Hopkins: Well, I think one of the basic principles of Lean is go and see, go to the people that are actually doing the work, watch the work happening and learn from that. Another example of applying the local, the importance of engaging stakeholders particularly when you are… I think, the most important times to engage the local stakeholders are when you're understanding the problem. Then as you begin to understand possible solutions to that problem and prioritizing those, part of the A3 process. And then when you actually begin to implement things. First of all, if you do it the first two times, you'll have a better chance implementing it, but also then through PDSA, getting the feedback from people, how is this going? I think it fits very, very well with some of the more established models that we have used.

Adewuya: Great. Next question, I have on the same article, this participant says, Breckenridge, discusses turning evidence of change and into evidence for change. Right? Dr Hopkins, in your experience, have you seen this concept at work?

Hopkins: I definitely have. You mentioned earlier, Karen's leadership in working to reduce hospital acquired infections here. And we share data. When we have a meeting of the medical director and the patient care manager, the nurse of each unit once a month. And we share learning across those units, as they have investigated an infection and found what was really going on. And then what they actually did to correct what they discovered and that sharing across units and across locations, I think is very, very powerful for bringing, first of all, a sense of progress. A sense of this is doable. A sense of this is actually not just something that some external standard has been imposed on us, but it actually makes a difference to patients in terms of their wellbeing, whether they get infected, whether they even die with sepsis or something. And so I think that really goes a long way to helping people make it a personal experience, not just a project.

Frush: Yeah. I so agree with that. And I think also the evidence itself, the metrics that one chooses to use to show the evidence are so important. For instance, the metrics might be numbers of infections, a rate of infection, but when the rate gets so low, what's a 0.54 rate of infection versus a 0.39?. And so instead of that, you start to count by real numbers. We had three CLABSIs, we had two CLABSIs, we had zero CLABSIs. And when it's two or one, boy, that's pretty good, until you put, Mr. Bill Jones, beside one. Or Ms. Susan Clark on the other. And you recognize that these numbers represent people. I think it's really important that as we spread successes in healthcare, and we talk about evidence and use metrics, that once again, it's not about numbers of infections, is suffering of people who experience those, and that we keep that in our focus so that the numbers have much more meaning.

Oakes: I think that's a wonderful way to put it that. We're trying to improve care for people. And I think we need to make sure that, that message stays connected, I think, that in terms of getting to people's values. And I think interesting that concept, that when I was reading it, that there's two sides to it. I mean, it's not just championing, and it's not just having a party because you only picked out the good outcomes. And we're saying, we succeeded, but you're also looking at things that didn't work. And so there's this transparency element to it. And I'm just wondering how to balance that transparency and provide the data for what was good and what didn't, but not maybe, while you still keep the motivation, is there a trick to that or how do you balance those two?

Frush: I think that's an opportunity for us going back to trainees. We're not very good at receiving or asking for feedback on our performance. We don't like it when somebody comes and watches our performance, the joint commission, et cetera, et cetera. When we do a lot of work with giving feedback, I think, we do much less teaching and practice with receiving feedback. And so when we get feedback we don't like, we personalize that and get defensive, rather than understanding different ways of receiving feedback that aren't so threatening and so defeating. I think one of the ways to increase transparency is to help us all come through a formation process in a way that allows us to keep ourselves intact and receive feedback in a way that helps to modify some of this when we get to faculty level.

Hopkins: Yeah, I would add to that. I think that we struggle with a big problem of a tradition of being a blaming culture. And we need to turn that into a learning culture. It's certainly very, very prominent in traditional peer review among physicians. And really beginning to understand why things happen in terms of human and team factors and systems and processes is very empowering to help that person, first of all, feel that they can do something about. They feel bad about it happening, and there's actually something they can do other than just say, “Gosh! I feel bad. I feel terrible. I won't do it again.” That doesn't really help. The learning culture, the learning organization, I think is where we need to move to.

Adewuya: That's a really great point, Dr Hopkins. And I think it's highlighted in the third article where we talk about transformational leadership. And I think one of the key takeaway points that, Daryl, had mentioned was the model of leadership that focuses on raising an entire team ethically and professionally. And part of that is raising a team that has that learning culture. And so I want to switch gears to maybe do a little bit of a deep dive into that article. And my question, as starting this, Dr Frush, is in relation to this model for health care and medical education, how do you see this leadership style, these transformational leadership styles synergizing with change management efforts? And do you think it's versatile or do you find that there's a need for other types of more traditional leadership approaches?

Frush: Yeah. I think it's interesting to me when I'm in conversations with leaders about how things should be. We talk a lot about values and role modeling and the importance of that. And we provide training for people as they progress through leadership stages. I mean, I would guess many people on this call, certainly, the people I'm looking at screen have been through leadership training beyond medical training. And that there are some very specific, all the theories, et cetera. I think part of the importance of transformational leadership for me, again, I'm very much on the social side of a socio-technical health care thing, but it does come down to, in many ways values and recognition of the fact that because health care is about taking care of people, that we have to keep that in the forefront.

And I think that when we want to be a leader in a transformational way, I don't know how one does that without living it. One of the goals I had in coming to Stanford was to try to promote teamwork. I don't know how one promotes teamwork without being a team member and a team leader and living out the tools and the methods and the techniques of teamwork. I do think that transformational leadership requires reflection and self-inspection and just recognizing some opportunities. I think we can all improve. I think improvement at Stanford is huge. We improve a lot of processes and systems, and I think we can improve ourselves and improve each other as well. And I think that starts to get at the heart of what transformational leadership is.

Adewuya: Dr Hopkins, any comments on that?

Oakes: My internet may be a little slow right now, but can you hear me okay?

Adewuya: Yes.

Oakes: Okay. Well, I think the question related to that, and I'm going to turn my camera off for just a second. But related to that, and I think it gets at one of the earlier conversations about culture that within a unit, I think we know as much as everyone should feel empowered within their unit to create change, a leader within a unit has a very powerful ability to influence culture within that small unit. And so I do maybe sort of linking that piece together with this idea of transformational change. I think it's not total control, but it is a unique opportunity for a leader to have transformational power over a group.

Adewuya: And I think I just wanted to comment, one of the comments that came through and the questions that came through is, well, who else can be a leader? Are the leaders always necessarily the people in charge? And I think from what we just discussed, you would agree that, no, anyone. Dr Hopkins, would you agree with that?

Hopkins: Yes, very much. One of the principles of transformational leadership is really activating the creativity and the talents of the frontline person who can become a leader, articulating a subject, an insight and take that into a project perhaps, or certainly, as a very influential team member. And so there's formal leaders, informal leaders. People can emerge as leaders at any level, it's the job of the formal leaders to be sure that they are paying attention, that they are asking that they are going and engaging people on their ideas and encouraging that through compliments and rewards to be sure that people feel safe and empowered to offer what they have, which is a great deal.

Adewuya: Yeah. [inaudible] fantastic. In the same vein, when we talk about the fact that anyone could be a leader and we're meant to inspiring the team to think of themselves in that way. What would your comment be around this question, Dr Frush? How can leaders have a transformational impact when their vision differs from that of the institution or from the higher level leaders? Maybe the formal leaders in this case. Thoughts on that?

Frush: Yeah. I'll say that's tough in that depending upon how fundamental this is. But it's interesting because people will seek out organizations where there's alignment of values to work. And I'll just take the opportunity to say at SHC, I think, David Entwistle, is a great leader and CEO as an example of a leader of a hospital. And I find his personal values align with what I understand is the values at Stanford at SHC. And that made it easier for me to put a lot of energy and effort into it, because that alignment, I think is really, really important.

I do think that when one finds themselves at odds with values of the organization or the values that the organization, again, are a bit amorphous and seem to change from time to time or place to place within the organization, it does make it a lot harder. There are two choices, do the work to change the values at the top of the organization or find a way to influence things more locally and it circles right back to what we're talking about in that. I do think that there are many examples of individual teams, whole units, whole service lines where leadership at that level has helped to move toward an environment and values that the group of people align with.

Adewuya: Dr Hopkins, any comments on that question as well?

Hopkins: It is a very interesting question. I think it's an example of application of a leadership skill that's sometimes referred to as managing up. And to do that, you really have to understand that leader that you're not agreeing with. And imagine that, that person is not totally wrong, is not totally lost, is not totally driven by wrong values, but in fact, has many of those things, if not all, and has a particular way of manifesting them. And as you understand that person's problems and approaches and needs and goals and responsibilities and accountabilities, you can maybe then begin to influence that person by addressing what they need and trying to be at least begin aligning some of the things that you or think are important by helping solve one of their problems, is a good example of how leading up could begin in a small way that you can then build on.

Adewuya: Fantastic. And I know we have a few more minutes, like three more minutes until time. Perhaps, I'll just ask for one more question. And after that question, maybe some reflections from both of you around this topic, maybe a general comment or two around everything that we have discussed. I think my final question, I'm trying to choose the last question. There's some questions that have just come in, I'm trying to pull what question I should ask you. But I'll go with the case vignette that was in the transformational leadership article, which talked about the internal medicine specialist and time at bedside. And the question is, when you have a limited amount of time to inspire with bedside teaching, how can you inspire effectively? And so maybe, Dr Frush, I'll start with you and then go to, Dr Hopkins.

Frush: How can you inspire effectively? Interesting. I'll have to say that in the end, this comes down to connecting. You inspire somebody by connecting. And I do think that we often don't have the opportunity to quote, “Get to know the people on our teams.” But you can make that opportunity just by inviting some information beforehand. I shared with you all before we started that my son's in surgery right now, because I did that in case I get pulled away.

I hope you forgive me for when I look at my phone, et cetera. You know that about me now, you understand that a bit more. There are tiny things that we can do, just making sure we know the names of the people on the team before we walk in the door and make a comment to that person individually. So that when you make a comment to, Ruth, Ruth, hears it and knows it's meant for her. And that connection, I think is one way to inspire at the bedside and use an opportunity not in this conceptual way, but in this very meaningful way to the very people who are there. One example.

Adewuya: Great. Thank you so much for that. Dr Hopkins, how can you inspire effectively, is the question?

Hopkins: Well, first of all, the point about connection that, Karen, made is so important. But one specific point we haven't touched on is really modeling the behavior that you want other people to be doing. In education, we talk about the concept of the hidden curriculum. Our trainees learn from not what we tell them and the facts that we share, but actually watching us and seeing how we behave and how we handle certain situations, how we relate to patients, how we relate to other members of the health care team. And that is a very powerful. It probably, is more powerful than us telling them how we think they should do something, is actually seeing how we do it. And so, being sure that you're setting that role model, that is what you want people to do. And that'll be very, very powerful.

Adewuya: Great. I actually think [crosstalk]. Okay.

Oakes: Sorry, Ruth. I was just going to jump in. I think too, were great concept for leadership in that last summary moment of is connection in modeling. And I think you have both been leaders who do both of that a lot. And so again, quite a gift to get to hear from both of you and learn from you today. So wonderful. Ruth, I'm sorry I cut you off, if you had a though.

Adewuya: No, that was a perfect segue. I think that I was going to just comment that the last question seemed like actually a great question to end in terms of talking about, how do we inspire and connect with people. And so I'll transition to you, Daryl, for last comments.

Oakes: I just want to thank everyone for joining us for this first of our monthly virtual Journal Clubs. And I, again, just want to give my deep thanks to, Dr Frush, and Dr Hopkins. And especially, Dr Frush, in the midst of all of the other things you're going on with grace to be able to also be present for us and really appreciate that from both of you. Thank you. And we're looking forward to more wonderful discussions in the months ahead. Hopefully, the audience will join us for those as well. And Ruth, you have a few comments before we go?

Adewuya: Our next session will take place on May 11, the second Tuesday of the month, and we look forward to your participation. Also, on the webpage, you'll see a link to join our mailing list so that you can continue to keep informed on all of the latest news and to register for the next session as well on our website. With that, again, I echo the thanks for, Dr Oakes. Thank you, Dr Hopkins, and Dr Frush, for being here with us today and thank you to our audience for taking the time to have this discussion with us and participate in this session. Have a good rest of your day.

Hopkins: Thank you.

Oakes: Thanks everyone. Thanks so much.

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Accreditation

In support of improving patient care, Stanford Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Credit Designation Statement: Stanford Medicine designates this Enduring Material for a maximum of 1.00 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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Authors

Stanford Medicine adheres to the Standards for Integrity and Independence in Accredited Continuing Education.

The content of this activity is not related to products or the business lines of an ACCME-defined ineligible company. Hence, there are no relevant financial relationships with an ACCME-defined ineligible company for anyone who was in control of the content of this activity.

Daryl A. Oakes, MD

Clinical Associate Professor of Anesthesiology, Perioperative and Pain Medicine

Stanford University

Karen Frush, MD

Chief Quality Officer, Stanford Health Care; Clinical Professor, Emergency Medicine

Stanford Medicine

Joseph Richard Hopkins, MD

Assoc Chief Medical Officer

Stanford University

Ruth Adewuya, MD

Managing Director, CME

Stanford University School of Medicine

References:
1.
Breckenridge  JP, Gray  N, Renfrew  MJ,  et al.  Motivating Change: a grounded theory of how to achieve large-scale, sustained change, co-created with improvement organisations across the UK.  BMJ Open Quality. 2019; 8:e000553. doi:10.1136/bmjoq-2018-000553Google Scholar
2.
Gabel  S.  Transformational Leadership and Healthcare.  Med.Sci.Educ. 2013; 23:55–60. https://doi.org/10.1007/BF03341803Google Scholar
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