Medical Student, Researcher, Penn State College of Medicine
Chief Quality and Clinical Transformation Officer, University Hospitals
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In today’s complex healthcare landscape, we are in increasing need of medical students to develop not only clinical skills but leadership skills in the fields of innovation and process improvement. This new role that medical education is undertaking in teaching and adapting to clinical science curricula is fundamental to creating well-rounded physicians and requires the expertise of those leaders who have paved the way in this field. In this paper, we explore the mental models and perspectives of Peter Pronovost, MD, PhD, one of the most accomplished physician leaders in modern healthcare. His viewpoints on leadership through leading with love, approaching fear, ownership, and communication create a rich framework for learners to use as they develop their own identity in this field.
Peter Pronovost, MD, PhD, is one of the world’s most renowned medical innovators, patient safety champions, and clinical researchers. His impact first gained notoriety with a revolutionary checklist addressing central line infections. This intervention in patient safety led him to be named in Time Magazine’s 100 most influential people and winning a McArthur Fellowship grant. Dr. Pronovost has had a profound career as anesthesiology and critical care physician, Founder and Director of the Armstrong Institute of Quality and Patient Safety, and Co-Founder of Doctella leading up to his current role as the Chief Quality and Transformation Officer of University Hospitals health system. Dr. Pronovost has had a meaningful impact in not only promoting change and patient safety but cultivating the minds of learners in that pursuit. Dr. Pronovost and I (Shayann Ramedani) had a career development discussion which resulted in this paper. In this, Dr. Pronovost provides insight to learners starting their careers in healthcare and clinical medicine in driving change. He goes into detail on what mindset a clinician needs, the barriers that one can come across in the journey for change and how learners can work to remove them.
Did you always know your calling was in operations and process improvement? If so, since when?
As a medical student I always knew that I wanted to work towards something that reached a large amount of people in medicine. The face-to-face patient connection whether in the operating room or ICU is moving and meaningful, yet I also sought to pursue something that could impact many patients at once. The best way to accomplish that was through optimizing systems and making the space in which we practice medicine safer. However, the foundation of being an innovator in the space is being an excellent clinician first. You must be excellent in your field before you move on to improving a process as a whole. My interest in quality and safety began as a fourth-year medical student at Johns Hopkins, with an error. My father, at the young age of 50, died painfully from a misdiagnosis. If he had the correct diagnosis, a bone marrow transplant could have saved his life. He came home to die with hospice. He writhed in pain for a week, with the hospice team stating they gave him the pain medications that have been ordered. He and my family suffered needlessly. That experience etched in my soul the recognition that patients deserve better than the healthcare provides them and the desire to change that.
What is the framework you use to develop a project or enact change? In what way do you see learners developing ideas for the greater good of their future practice?
When you act on an idea, the first priority needs to be its scalability. That in itself is not an indicator of success, but it needs to be a component when you start asking questions. A good question is dynamic in its application. There also needs to be an emphasis on perspective when asking these questions. The more viewpoints you have to weigh in, the more impact the conclusions of a study or process can have. If a clinician stays in their own lane and doesn’t seek the counsel of others, then their findings remain static as well. Too often researchers think that asking an important question is enough. This often leads to interventions that are too burdensome, or costly to spread.
The elephant versus the jellyfish
To drive change with a framework that takes diversity of opinion, asks complex questions, and aims for scalable answers, you need to be a dynamic learner. This means you need to be familiar with adjacent fields in addition to your area of study. For example, if a question addresses the outcome of health in the outpatient population, then the investigator needs to know concepts regarding public health, municipality issues, infrastructure, systems engineering, social psychology, human factors engineering, behavioral economics, amongst other issues. The important consideration here is also to have fluency in the language these adjacent fields communicate with, as opposed to an in-depth subject matter knowledge. Being able to speak with industry experts in their own terminology goes a long way as it decreases friction and frustration. A good investigator in this sense has to be a jellyfish, with one long and many short tentacles to represent the many depths of different fields of knowledge they are fluent in. In contrast, someone who is only an expert in one field with no dynamic understanding, is similar to an elephant, with only one thick trunk. It is important to have strong methodological grounding in one discipline, yet it is also important to be humble, curious, and compassionate enough to be like a jellyfish and develop many short tentacles.
When leading, what is the most important tool that can make or break its success?
While there is no single tool that can make or break the outcome of an idea, the greatest skill also one can have is to predict and adapt to change. Flexibility comes in restructuring or just being conscious of culture, but it never comes from compromising the integrity of an initiative. Integrity involves being inclusive and actually scoping out the problem. Inspire change but be open to it from all directions.
Leading with love
Those who try to implement change can have the assumption that others are being obstructive. Yet most people are not trying to be. They see that they are trying to give their best care possible. The real reason behind most conflict is a misalignment in mental models or understanding. The best way to approach this issue or differences in approach is to lead with love. Leading in this manner starts with allowing yourself to dedicate your effort to the process rather than serving your ego. The downfall of many innovations come from a leader’s ego being wrapped up with the outcome as a reflection of themselves. In contrast, the success of most projects come from empowering stakeholders to lead it their way. Dictatorial tendencies of micromanagement decrease the morale of a project and create an antagonist relationship. Lao Tsu said, “The worst leaders are feared, the next best revered, and of the best leaders the people say we did it ourselves.” Always seek to ensure people are engaged, energized, and empowered.
Written and oral communication is integral to expressing ideas and developing credibility amongst peers. Someone who writes well comes across as knowledgeable and passionate. Learners have a great opportunity to establish themselves as well since there is ample time to hone these skills. Through classwork or research, the more exposure to good writing and good communication one gets, the more it will impact their future writing and speaking. Clear communication not only comes from proper grammar, but also from knowing one’s audience. Good communication is not focused on communicating intelligence, but about inspiring the audience to know or feel something differently. To help this, I often begin and end talks by asking the audience for their personal “I will” statement. It is so rewarding to have people share these statements and in doing so they inspire others. An important point I learned from my years of developing communication skills is to not overwhelm others with statistics and numbers. Communication needs to be about a narrative that can articulate your idea, in a captivating sense, but that can be supported with statistics. Though it’s not the focus, you should always have them in your back pocket.
When things become tough, and you are getting frustrated with the process, how do you stay grounded?
No project is perfect and sometimes what you spend time leading will end up frustrating you. This is natural, but the way you react is important. A common thing to do is to create an adversarial dynamic with people causing your frustration, rather than working the issue out. How you avoid this is to always stay grounded, assume positive intent, and always respect others. Remember that everything we do in quality is in the service to others first, so never shame or judge anyone. Alternatively, instead of starting with anger, you can start with openness to others to hear them out. This involves being curious and compassionate enough to understand the other person’s concerns and views. The instant you start to judge, you stop people from growing and adapting. Every problem and frustration is an opportunity to lead and mature if you approach it from a place of humility, curiosity, and compassion. It is incredibly difficult to truly get irritated when you start from the understanding that everyone is there to help. Instead of malice, more often it’s that there is a misalignment of mental models. This can be different in many institutional cultures, since ecosystems can have internal conflicts. No matter what organization you are trying to work for, the risk of systemic issues leaking into projects is inevitable, so always work despite the system, not for the system.
Why are people resistant to change and how do you change your approach when views do not align?
Fear of loss rather than change
We often state that people fear change. Yet if we unpack this, people fear loss more than change. If you received a lottery ticket for $500 million, it would likely change your life in multiple ways. Yet few of you, if any, would not accept the ticket. That is because, if change is perceived as positive we embrace it. What people fear is loss. Loss could be in perceived status, control, and power. Loss has a real change component and a perceived component that often grows when there is not a vehicle for communication. However, the intention is to minimize the losses and be better than where they started.
When someone resists change, it needs to be addressed. Understandably, people have a fear of confrontation. People think confrontation is with heated emotion but the best way to approach this is quite the contrary. Your perspective is the least important one, it’s always the other side that you should be listening to. Assume positive intent of the other person and seek to understand rather than judge. It’s very easy to let your own thoughts dominate a conversation, but if you want to reach an alignment of ideas, then it’s best to listen, not speak. Instead start with asking, “I know you want what’s best, what is going to help me understand how we can make that possible?” Here is an opportunity where ego can cloud your judgment if allowed; this is why it’s essential to leave ego at the door and lead by service.
Leadership is bringing people together to solve problems that make the world a better place. An important component of leadership is to inspire people to believe they can improve and help them belong to a community of learners. Assuming control of a process, is not only incorrect, but leads colleagues to be disengaged. The leaders of a project role is to clarify and communicate why the effort is important, what the goals, roles and resources are, and what are the principles to guide behavior. The team then figures out how to realize those goals. Too often leaders tell teams how to do something, without communicating why and what.
Healthcare does so much good, yet it could be so much better. Healthcare still harms too often, costs too much and learns and improves too slowly. Healthcare needs new young leaders to change this. Leaders who focus on solving problems, leaders who lead with love, leaders who remain humble, curious, and compassionate and remain grounded. Leaders who bring joy to their work.
NAHQ’s Healthcare Quality Competency Framework is a solid foundation from which to build teams and align to the suggestions in this paper. For example, competencies around Health Data Analytics, Performance and Process Improvement, and Quality Leadership and Integration are needed to activate the workforce and advance strategic and operational priorities. Visit NAHQ.org for more information on the Healthcare Quality Competency Framework.
Pronovost P, Zeiger TM, Jernejcic R, Topalsky VG. Leading with love: learning and shared accountability.J Health Organ Manag. 2021;ahead-of-print(ahead-of print):10.1108/JHOM-10-2021-0383. doi:10.1108/JHOM-10-2021-0383
Medical Student, Researcher, Penn State College of Medicine
Chief Quality and Clinical Transformation Officer, University Hospitals
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