The Four Pillars of Engagement For Healthcare Leaders

Early in my career, I received the following advice from a mentor about an important success factor for leaders in large healthcare delivery systems: “It’s all about the relationships,” she said, adding, “this is a world that is built on connections – with people, with missions, with communities.” I have tried to take this advice to heart during my career, seeing that a fundamental role for a leader (or leadership) in a complex environment like a large academic medical center, hospital or health system is establishing, promoting and nurturing positive connections. These relationships, and the engagement they engender, are core to producing organizational effectiveness, operational results and greater accountability. Never has this been more important than since March, 2020.

Now is the time.  It will take years to fully assess the personal and professional casualties Covid-19 is delivering upon us, as they are happening in an effect and manner most in the current generations have not heretofore known. Add to this the fundamental societal questions around racism now being asked, and the caustic and divisive tenor of the current election cycle, we are living through a time when all manner of relationships are strained. 

That said, I am an optimist by nature and experience, so I believe it might be worth tempering this challenging reality with the fact many organizations have internally built deeper connections and relationships through their management during the pandemic. This is especially true in many hospitals and delivery organizations; the early days of the crisis forced away much extraneous, non-value-adding activity, and allowed for focus on only two vital tasks: safety of patients and safety of colleagues. These circumstances created a palpable esprit de corps within these organizations, and showed the world what those of us within these institutions have known forever: all of our healthcare teams are a collection of heroes.

Often a community’s largest employer and economic engine, whether urban, suburban or rural, hospitals and health systems have been hugely affected by the financial perils of the pandemic. Thankfully, as we are now starting to see in many areas, our healthcare institutions are supporting (and, hopefully, sustaining) the longer-term financial recovery, as they operate, lead and grow in the new reality of healthcare delivery defined by pandemic management.

A new aim? One could argue that this situation points to a ‘new’ triple aim for healthcare providers: supporting sustained economic recovery, promoting and engendering positive social change, and focusing intently on the experience of patients for assurance (and reassurance) of safety, quality and efficacy of care. This doesn’t replace the original Institute for Healthcare Improvement triple aim of , lower costs, higher quality and improved clinical outcomes, but rather complements and reinforces it. 

Without question, though, achieving these goals will engender is the need for more dialogue, connections and engagement within and among the actors in the healthcare ecosystem. Let’s dissect what good looks like in terms of engagement.

The Four Pillars. There are four critical points of engagement upon which healthcare provider organizations should focus on fostering: First and always, patients have to believe (and see) they are placed at the center of engagement efforts. Second, clinical staff (nurses, physicians, advanced providers), along with other administrative and operational staff, have to be authentically engaged to make the relationship with patients -- as well as with each other -- be meaningful. Next is the community; even large and elite healthcare institutions operate very much as part of the environment in which they serve and where their patients and employees live. They are -- and should be seen as -- an asset of the community. Finally, I would offer that an essential connection to be made in this environment is to data. Let’s look at each of these in some detail.

Patients. What does it mean to really engage patients? It requires that there’s a real relationship between the organization and the people who’ve come there seeking care. Critical to manifesting this is: an active, discernible focus on the patient experience – all the time; evidence -- not just assumption -- of clinical quality; and, seeking the voice of patient / customer at all levels of the organization. Whether this is formal (such as Patient and Family Advisory Councils) or informal via rounding and ad-hoc interactions, purposeful discussion and involvement with patients and their families is critical to secure meaningful engagement. I know that some of my greatest insights have come from spur of the moment conversations with patients in a hospital cafeteria.

Staff. For our clinical colleagues, dialogue needs to be hard-wired into management.  Often it seems that we in leadership mistake the creation of another meeting or committee to be an appropriate surrogate for real dialogue and shared management. Engagement of physicians, nurses and other clinical leaders is less about the ‘meetings’ and more about the intent, and purpose of the interaction, with clarity that the dialogue is goal-based and not just process oriented. “Don’t mistake activity for accomplishment” as UCLA basketball coach John Wooden famously said. 

Engagement of non-clinical staff is equally as important, though often involved in substantively different discussions. The key point in this dialogue is clarity over the desire to engage, with purposeful and genuine intent. People will know if the interchange is form over substance. “Listen hard and challenge with respect to move together as one” is a mantra adopted by a leading biotechnology company that captures this spirit. For both front-line clinicians and non-clinical staff, a critical but often over-looked element of making positive connections is visibility by leadership – literally being seen. While prescribed team, departmental or all-hands meetings are critical, often more casual ‘walking rounds’ contain a real-time, unscripted element that can positively bend the dialogue towards the authenticity mentioned above.

Community. Turning to connecting with the community, this is fundamental for mission fulfillment for many provider organizations. I believe one of leadership’s goals is for the community to always believe the hospital is prepared and operating to serve all (or most of all) the healthcare needs locally and with the highest quality. Most such institutions serve as public goods, and the expectation that they will constantly orient themselves to substantially to meet the needs of patients at home in their communities is a fundamental one. Leaders should take lessons from the management of the Covid crisis to understand how to integrate further into the fabric of the community, emphasizing issues such a population health-based approach to care and commitments to understanding and embracing the social determinants of health.  Engaging the community with the goal of fostering a broad improvement agenda will require leaders to see the community as allies in the drive to both protect the public health as well as to serve as a foundational partner in the economic recovery from the pandemic. This same approach should be applied when considering how to be a part of the solution to issues of bias and racism.

Data. Finally, a point of engagement that is often assumed but sometimes not fully developed is the connection with data. While without question, leaders are often awash in data and push out voluminous newsletters and dashboards, the tactile sense for these numbers is often not clear to employees outside of the leadership circle. Putting effort into making data transparent and translatable to each group or constituency is a critical factor and responsibility for leaders. While I believe transparency is an essential building block for trust among those leadership is seeking to engage, I also feel strongly that this is the foundation for productive accountability – you say what you’re going to do, you identify what the outcome is expected to be, and you transparently share the results.

Easy? What makes this approach to engagement work? Some fundamentals are: clear, crisp and consistent communication; process discipline, using proven tools consistently; transparency through a genuine (and discernable) desire to engage all constituents; and, adaptability, realizing that nothing works perfectly every time and adjustments are required.   Is it easy to implement these steps? Definitely not, but leaders will be more successful if they incorporate four essential principles: Compassion – how would we want to be treated? Accountability – you are prepared to be judged against your engagement goals. Respect – treating everyone with dignity and professionalism. Excellence – aiming for great, not good.

As I was advised a number of years ago, relationships are a key to success for leaders and institutions alike in complex operational environment like hospitals or health systems. An authentic commitment and intentionality to engaging constituents and stakeholders can produce meaningful improvements.  As we continue to evolve into a brave new world that increasingly relies on the relationships between communities and the healthcare ecosystem, such relationships are vital for the good of all concerned.