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It's unlikely that today’s clinicians learned the skills necessary to lead improvement during their clinical training.
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What Your Clinical Training Didn’t Teach You About Leading Improvement

By Brent James | Wednesday, October 10, 2018

October 10 blog post

Brent James, MD, M-Stat, is an IHI Senior Fellow who trained thousands in clinical practice improvement while he was Chief Quality Officer at Intermountain Healthcare. In the following interview, he describes how the clinical training of today’s clinician leaders most likely failed to teach the leadership skills they need. Dr. James is faculty for the Clinicians Leading Improvement program.

What are some common obstacles to improvement that clinician leaders face regardless of where they work?

Understanding how health care works as a system. How to organize a team — including physicians, nurses, pharmacists, therapists, technicians, and administrators — to design a system for consistently delivering the best medical result at the lowest necessary cost. You also need skills for leading change. Clinical leaders need skills that are generally not taught even in a master’s program at a major university.

What do clinicians need to understand about being leaders?

There’s an old saying in business circles that “culture eats strategy for lunch.” Successful organizations need strong cultures. In the healing professions, we have a deep, embedded culture that goes back literally thousands of years. We select for it. We reinforce it during your initial training. Through your professional life we continue to build on it. If you can tap into that culture, your ability to lead change is going to increase dramatically.

Sometimes it’s called adaptive leadership. I like to think of it as building infrastructure. Your job is not to build a new culture — it’s to fan the flame that burns within the heart of any good clinician. It’s the passion to provide great care. Make it real. Use it on a routine basis. Help others share that passion. And then, together as a team, lead it forward.

What are the benefits of learning about leadership alongside professionals of disciplines other than your own?

These days, all good care delivery happens at a team level. [Care is provided by] a group of physicians and a team of nurses. It extends beyond that to therapists, pharmacists, and technicians. [You don’t just need] one set of eyes to care for patients. You need five sets of eyes. You need 20 sets of hands — every member of the care delivery team.

Somebody has to pull those pieces together. Somebody needs to get that whole team on the same page and moving in the same direction, consistently, accurately. [Clinical leaders] have to get a group of highly trained professionals working together. That requires a degree of coordination never before imagined. It’s hard to understand this without learning alongside health care professionals from a variety of disciplines.

How does most clinical training differ from learning to lead improvement?

Most clinical training is focused on the human organism, on health and disease and ways that we can intervene to change a patient’s future. There’s a whole other level of expertise needed to organize and lead an effective care delivery system, versus deliver effective care for a single patient.

How do you drive effective change without understanding systems — without understanding the basic human psychology that allows people to interact together, not just to deliver good care, but to systematically improve? How do you properly use data? How do you understand variation in the data and appropriately classify and respond depending upon the nature of the underlying problem?

One of my favorite ways to think about this is W. Edwards Deming’s Theory of Profound Knowledge. He identified four areas:

  1. Appreciation of care delivery as a system — Care delivery is a series of interlocked processes. There is a set of tools by which you can manipulate that system.
  2. Understanding variation — There are different types of variation. You have to be able to classify correctly, then respond appropriately, to different variation types.
  3. Human psychology — How do you lead change? How do you understand how human beings interact together in a very complex environment? How do you tap the creative human spirit that defines our professions, that makes coming to work every day fun?
  4. Theory of knowledge — One major element of a theory of knowledge is data-based problem solving. How do I use evidence, data, not just to deliver best care but to drive change to a whole new level?

Most of us didn’t get these principles in medical school. In fact, in most instances a residency training program is probably the opposite: You learn from attending physicians, each a master craftsman. When I was studying surgery, my job was to figure out how each attending did it and then do it their way. You learn by doing, learn by observation, with criticism from that master craftsman.

Care has changed. It’s become massively complex. We live in a new environment that is fundamentally different from the one many of us trained in. We need to go beyond mastery of our respective disciplines to lead effective change.

Editor’s note: This interview has been edited for length and clarity.

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