Chapter 9 Mike Taigman and Stephen Dean In their wonderful book Transforming Health Care Leadership, Maccoby et al. say, “Leaders are people others follow. If no one follows you, you are not a leader” [1]. In this chapter we will equip you with the tools to be the person people follow. The primary leadership activities are setting the direction for team members to follow, monitoring and analyzing system performance, and intervening to make improvements. One easy way to build a solid foundation for EMS physician leadership is to have robust answers to these five questions. The answer to this question is the system’s purpose or mission. For example, “Our purpose is to reduce suffering.” An effective purpose clearly describes the philosophy of the leader and hopefully the culture of the people in the system. It is tangible and actionable. The real purpose of an EMS system is something that people who are served by the system will be able to figure out without reading fancy wall posters or wallet cards. It lives in the actions, the focus, and the conversation of the people working in the system. Avoid platitudes like, “We are the best EMS system in the world” as they are difficult to lead toward and measure. For medical directors it is also important to be clear about the reason you are part of the EMS system. Part of the purpose of an EMS system is to provide clinical care to patients with the same attention, style, and treatment that the system’s medical director would provide. The 2001 Institute of Medicine report Crossing the Quality Chasm lists “patient-centered care” as one of the six domains that define quality health care [2]. If one were to stand back and look objectively at the design and operation of most EMS systems in America, very few actually put patients’ needs and perspective at the center of their design. One EMS system’s purpose is “to reduce suffering,” which aligns with a patient-centered system design. The answer to this question is the system’s vision. A vision is a crystal clear description of a “place” that you’re working toward that does not exist today. The more clearly defined the vision is, the easier it is to align everyone’s work toward making it real. It should be something that people can visualize in their mind so when it manifests in reality they will know that it’s been achieved. For example, Physio-Control’s wild and challenging vision, “A world in which no one dies suddenly as a result of an acute, treatable medical event” is crystal clear and measurable. On the other hand, one EMS organization’s vision, “To be the best provider of out-of-hospital patient care services,” is vague, difficult to measure, and difficult to lead people toward. The answer to this question is values. A solid set of values helps people on your team adjust their decisions and actions to better align with the purpose and vision. “To gain trust and support from the people you lead, they need to know what they can expect from you” [1]. The most widely used EMS values were written by Thom Dick in 1990 for BayStar Medical Services, the then-new 9-1-1 EMS provider for San Mateo County, California. These STAR CARE guidelines are used by EMS systems throughout the world today. A shortcut for deciding whether a planned action is ethical or not is to imagine how you would feel if what you are about to do were featured as the headline story in tomorrow’s newspaper. If you and the people in your system would be proud of the article, it is probably an ethical decision. If not, then it is probably not something you should do. This STAR CARE checklist is copyright free and can be printed on wallet-sized cards for everyone in any system. (You are welcome to put your own logo on STAR CARE cards; all we ask is that you please give credit to Thom Dick and BayStar.) It provides a very simple yet powerful framework for decisions, education, coaching, and investigation of unusual occurrences. When health care providers take care of patients, they constantly monitor vital signs. This ongoing monitoring allows them to give a good answer to the question, “How’s she doing?” A patient’s pulse, blood pressure, respiratory rate, oxygen saturation, Glasgow Coma Scale, end-tidal carbon dioxide, pain level, temperature, etc. highlight the performance of various organ systems in the body. When viewed as a system, these vital signs provide a reasonably reliable picture of how a person is doing. If one of these vital signs is off, it inspires the clinician to investigate the cause and possibly intervene to improve the patient’s health. A good clinician knows that an intervention designed to address one area of the body is likely to have an effect on other aspects of the patient’s health. For example, epinephrine administered to open the airways, improve oxygenation, and decrease the work of breathing for someone having an asthma attack can cause unintended cardiac arrhythmias. Effective leaders view their organization as a system of interrelated processes that are aligned to produce good results for customers. Like clinicians monitoring vital signs, it is important for leaders to monitor key performance indicators for the processes in their system. The first thing to do is to identify the key macro processes, categories such as clinical, employees, fleet management, materials management, safety, etc. Then for each of these categories, identify one key performance indicator (KPI). If the KPI is healthy, you can be reasonably confident that the whole process is healthy. For example, for fleet maintenance, a common measure is the number of vehicle failures per month. If the vehicles work well all of the time, it is reasonable to assume that preventive maintenance is being done regularly, oil is being checked regularly, and the tires are being replaced at the appropriate time. One measure covers a lot of territory. For the clinical category, several attempts have been made to define a set of subcategories to address what is most important. While there is no universally accepted framework, the following clinical subcategories offer a solid foundation. Developed by Ed Racht, Scott Bourn, Lynn White, and the clinical leadership team from AMR Medicine, these are the 7 Things That Matter (TtM). In thinking about specific measures within each of the TtM clinical subcategories, it is helpful to distinguish outcome measures (lagging measures, those that come after a process is complete) from process measures (leading measures, those that drive performance to produce the desired outcome). One of the outcome measures for cardiac arrest is the percentage of witnessed (visual or auditory) cardiogenic, cardiac arrests, with shockable rhythms that are discharged alive with a Cerebral Performance Category (CPC) rating of 1 or 2. Process measures that if improved have a high likelihood of improving outcomes in this domain would include the percentage of patients with cardiac arrest who receive bystander CPR, the percentage of cardiac arrests that are identified by the 9-1-1 call-takers in the dispatch center and provided with telephone compression-only CPR instructions, and the CPR fraction (percentage of time compressions are being performed while the patient is pulseless). The outcome and process measures that you want to monitor for the macro categories in your system should be displayed using run charts or Shewhart control charts (Figures 9.1, 9.2) [3]. The advantage of displaying the performance of these dynamic processes in their naturally occurring time order is that it allows the viewer to draw statistically valid meaning from the charts rather than reacting inappropriately to something that does not really exist. For dynamic processes, it is best to avoid static displays such as bar charts, pie charts, or traffic light color-coded dashboard indicators. These displays often lead viewers to attribute something unusual to performance data that do not have anything special going on. Leaders who take action based on these inappropriate displays run the real risk of decreasing performance, or doing what Deming called “tampering.” All processes monitored through KPIs have variation, whether it is the percentage of false-positive STEMI activations or the average lactate levels of patients with sepsis. Effective leadership requires the ability to distinguish between common cause variation (the variation inherent in the process) and special cause variation (the variation caused by something outside the normal process). For example, when an EMS system added 12-lead ECGs for non-traumatic chest pain, its average scene time increased nearly 6 minutes, a special cause due to a change in process. As the medical director, your questions carry a lot of weight and have the potential to inspire a lot of action by your team. Therefore you have the responsibility to ask statistically valid (good) questions. For a process with common cause variation, the valid question is, “Is this good enough?” For one with special cause variation, the valid question is, “What happened here?” Deming said, “Prediction is the problem, whether we are talking about applied science, research and development, engineering, or management in industry, education, or government.” He adds, “The question is, ‘What do the data tell us? How do they help us to predict?’” [4]. Knowing how to accurately read the data so that you can make predictions is a key leadership skill.
Leadership and team building
Introduction
1. Why are we here?
2. Where are we going?
3. What guides our day-to-day decisions?
4. How are you doing?
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