Effective Leadership and Healthcare Quality

Yesterday I had the fortune to present at Grand Rounds for the Department of Anesthesiology here at Yale. There remains a dearth of research on the connection between effective leadership and healthcare quality and outcomes. It is an area and subject ripe with opportunities for research projects and discussions. However, there are significant challenges in performing this type of research.

First, how do we define effective leadership? A validated, universal tool for defining and categorizing leadership does not exist. Not all 360 evaluations are the same. A validated and standardized tool combining qualitative and subjective data with objective data would permit researchers to create a linear scale and use logistic regression to compare the aggregate scores to selected healthcare outcomes.

Second, which outcome measures are markers of high quality? The six areas and attributes of quality most healthcare organizations use include: safe, effective, patient-centered, timely, efficient, and finally, equitable care. There are thousands of quality measures—standards for measuring the performance of healthcare providers to care for patients and populations. Each quality measure focuses on a different aspect of care delivery. Where do we fail often? What can we change now? Where do we spend our resources? Finally, measuring and collecting the data consumes a lot of resources--both financial and human. Changing processes is difficult. Changing human behavior is difficult. But change, we must. And as Yoda from Star Wars said, "Do or do not. There is no try."

We know effective leadership impacts care delivery. There is ample evidence from research in other industries connecting effective leadership with higher productivity, profitability, and better customer service. Furthermore, other businesses and industries can measure quality and output far more easily than we do in healthcare. Both the input variables and outcomes in healthcare are influenced, too, by thousands of complex tasks and processes.

In 1966, Dr. Avedis Donabedian from the University of Michigan wrote an article, Evaluating the Quality of Medical Care. This article laid the groundwork for the Framework for Health Care Quality. The graphic above shows the three components of the model. Why is improving healthcare quality so difficult? The structures, environments, resources, and training of personnel has a huge impact. People then use processes and systems with the available resources. It is easy to see how and why there are numerous opportunities for success or worse---failure. Finally, these resources and processes lead to an outcome. The common denominator throughout this framework is the impact leadership has on the performance of the people and the creation of effective and efficient processes. I think effective leadership is critical to success.

None of this takes place in a vacuum. And there is another reason why improving quality is incredibly difficult. The hospital organizational structures are a multi-layered cake of complexity. Here it is:

1. Board of Directors (most hospital board members are not in or from the healthcare industry, and there is a wide range of understanding from these individuals regarding quality measures. This needs to change because the boards are ultimately responsible for the provision of quality care).
2. CEO (High CEO turnover kills projects and initiatives. Great CEOs can have an enormous impact).
3. COO, CFO, CMO, CNO (Finally, at the third layer, we are assured some of the C-suite individuals are clinically trained).
4. Chief-of-Staff, President of Medical Staff, Medical Executive Committees (This is the first layer with a lot of influence and clinical experience).
5. Managers, Committees, Chairs of Departments, Directors (Buried in the middle are the people in the middle who must answer to those above them and are in charge of hundreds of frontline staff. It's not an easy place to work).
6. Frontline Staff (nurses, doctors, pharmacists, techs, housekeeping, transport, etc.).

The frontline staff provides the care with the resources in the systems.

The organizational structure is a 6-layer cake, and changing care delivery is glacially slow as a result. It can be enormously frustrating for engaged leaders and staff who want to improve care. Effective leadership can improve the administrative performance for change as well--perhaps a new term for this would be the administrative efficiency quotient (AEQ). What is the timeframe, for example, from collecting the data to initiating a new protocol or process and then using the Plan-Do-Check-Act cycle? What is the impact financially during this process? How can we make positive change happen more rapidly? I have a lot of questions. I remain deeply curious.

Finally, in a short-staffed, high stress environment, middle managers, department chairs, and directors are caught in the cross hairs from staff below and administrative leadership from above. Effective, compassionate, communicative leaders are more important than ever throughout the cake. The AHA, the Joint Commission, and other leading professional healthcare organizations should create a framework and curriculum for educating hospital board members. The urgency and initiative for change must come from the top. And everyone below the top layer of the administrative cake needs support and resources. Without effective leadership, collaboration, cooperation, and change is throttled. Improvement requires people working in a respectful, supportive environment with the common goal of improving care. Meaningful relationships created by effective leaders is the path forward.