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The leader as systems thinker

The Laboratory Meeting 2011

Jeffrey Braithwaite

on 8 November 2013

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Transcript of The leader as systems thinker

The leader as systems thinker
Our mission is to enhance local, institutional and international health system decision-making through evidence; and use systems sciences and translational approaches to provide innovative, evidence-based solutions to specified health care delivery problems.

Leadership team
Professor Jeffrey Braithwaite
Professor and Foundation Director, Australian Institute of Health Innovation, University of New South Wales

Professor Enrico Coiera
Professor and Director, Centre for Health Informatics

Professor Ken Hillman
Professor and Director Simpson Centre for Health Services Research

Professor Johanna Westbrook
Professor and Director, Centre for Health Systems and Safety Research
Background - the Centre
Australian Institute of Health Innovation's mission
A preliminary question: what does the literature say about this topic?
Meaning? Lots of talk, not much evidence, no strong evidence
Are laboratory leadership and management the same thing?
The same – largely overlapping constructs?
Different – on a continuum?
Overlapping constructs – but largely distinct?
Another question: if leadership and management are the solution, what’s the problem?
1. The quality and safety problem
7,500 patients would experience an adverse event
some detectable, some not noticeable or attributable
many would be infections, falls and medication errors
Some 1,500 patients would suffer a major disability
350 would die from iatrogenia
A patient would suffer from wrong site surgery perhaps every 2 years or so
Someone would die as a result of anaesthesia on average every 5 years or so
There would be other more exotic examples of adverse events, depending on specialty
To what extent does the quality and safety problem apply in labs?
Assume a 700 bed tertiary referral hospital
5,000 staff
75,000 inpatients annually
50,000 of these are same day cases
complex casemix
lots of teaching and research
a busy, productive place
Health staff are:
Driven by professional values

Highly skilled

Motivated to achieve excellence
Stimulated to achieve professional-level incomes
Relatively autonomous
Self-esteem and status-directed
2. The problem that people you are responsible for are challenging … and tribal
Characteristics of doctors
Personal traits:
IQ, individualist
Occupational traits:
Mobile then stable
Decision-making role
Able to work with risk, uncertainty
Characteristics of nurses
Personal traits:
Hands on
Occupational traits:
More mobile than in the past
Caring, compassion meets technology
Cognitively collective
Characteristics of allied health staff
Construed in small locations
Less obvious power structures
Less certain
Personal traits
Occupational traits
Characteristics of lab staff
Occupational traits
Personal traits
Smart; scientifically- and task-oriented
Focused on detail, precision
Under leveraged to power
Relatively silo-ised
Lab isolation/deprivation syndrome
3. The problem that lots of senior people think the health system [and the laboratory] is a rock not a bird
y=x2 - b
If you think the health system [or lab] is a rock, i.e., inanimate, it is able to be predicted, and definitively analysed and calculated. That thinking leads to attempts to restructure and control it.
If you think the health system or lab is a bird, a complex system with a mind of its own, it needs to be fed, nurtured, and developed
4. The problem that people underestimate the time frames for most activities
1. Responses to the safety and quality problem
Safety improvement programs [training]
Root cause analyses
Incident monitoring
Learn from inquiries where things have gone wrong
Learn from others' good strategies
Engage clinicians
2. Responses to the challenging, tribal problem
People like positive workplaces
They enjoy working in teams
But they often don't belong to sufficiently well-performing teams
So create more team-oriented care
There is variation in cultures
Our work on contrasting hospitals showed this
There are also sub-cultural and professional differences
The iceberg model of culture
Culture change
Culture: sets of beliefs, ideas, practices and behaviours
"The way we do things around here"
Our: worldview, assumptions, taken-for-granted, outlook, norms, values
Strive to change culture both above and below the waterline
Below the waterline lie the underlying beliefs, attitudes, values, philosophies and taken-for-granted aspects of workplace life: ‘why we do the things we do round here’.
Above the waterline lie the observable workplace behaviours, practices and discourse: this is ‘the way we do things round here’.
[Braithwaite, 2011]
Avoid restructuring people as a ‘solution’

Top down solutions are ineffective without bottom up involvement

Engage lab staff in the decision-making processes

Use naturally occurring networks of staff
Essentially, we need very resilient and vigilant organisations which can cope with the unexpected as well as try to tackle the commonly occurring

What might these look like?

Recent research of ours and others is shining a light on this
an approach which involves patients in care processes

superior accreditation results

better than average performance on clinical indicators
4. Responses to the underestimating timeframes problem
Give yourself space and time wherever you can to deliver
Be a systems thinker
You need to understand the lab system and sub-systems and their interfaces very well
And the other larger systems of which the lab is a part
Penultimately ... my answer to the question
What do managers and leaders do?
Managing and leading
It’s always risky to generalise, but there’s a lot of attempts to:
Fiddle with the structure
Finally … what do you have to do to create high performance leadership?
all of the above, plus these ...
[Source: Rogers Diffusion of Innovation 1995, Callen et al, 2008]
Be persistent
Negotiate with multiple stakeholders constantly
Navigate through uncertainty and complexity
There’s too much management and not enough leadership

There’s a lot more management activities such as restructuring, controlling and micro-managing than leadership activities like supporting, engaging and developing

This isn’t a systems view it’s a structural view
Napoleon once said: “An army of rabbits, led by a lion, will defeat an army of lions, led by a rabbit”
So it means being a lion-leader as a countervailing force to the excesses of restructuring, controlling and micro-managerial tendencies

The mission should be: grow empowered, articulate, democratic leaders, not necessarily more managers
From short term to longer term

From control to empowerment
References … available on request
But don’t think this means being a wimp – all namby-pamby soft and cuddly stuff
THE LABORATORY MEETING 2011: Leading Transformation
Professor Jeffrey Braithwaite, PhD
University of New South Wales
21st and 22nd July
Christchurch, New Zealand
The Centre for Clinical Governance Research undertakes strategic research, evaluations and research-based projects of national and international standing with a core interest to investigate health sector issues of policy, culture, systems, governance and leadership.
you have your own view - I'll give mine later
Here are four
Do all these things really well
We use the iceberg model of culture
3. Responses to the mechanistic, rock-like thinking
Micro-manage things to within an inch of their existence eg waiting lists, the press, bad news
Control events and people
‘Fix things’ via top-down means
Characteristics of clinicians
Characteristics of lab staff
How different or similar is this list in the lab?
Where will high performance leadership come from?
It will come if we change emphasis:
From structural to systems thinking

From top down to bottom up

From rocks to birds
Or learn how to under-promise and over-deliver
Most people overpromise and under-deliver and don’t meet their deadlines
There are increasing grounds for believing that organisations will be safer and less risky if they have:
a generally inclusive organisational climate

effective leadership

a positive culture and sub-cultures
[Health Foundation, 2004]
[Chen et al, 2003]
[Collopy, 2000]
[Svyantek and Bott, 2004]
[Health Foundation, 2004]
[Boan and Funderburk, 2003]
[Braithwaite, 2005; 2006; 2007]
[Braithwaite, 2006]
[Braithwaite, Runciman and Merry, 2009]
[Searches done: 23 June 2011]
Google laboratory management and leadership: 4,110 hits

Pubmed: 308 articles

Cochrane Effective Practice and Organisation of Care [EPOC]: nil
Google: clinical management and leadership: 348,000 hits

Pubmed: 3,348 articles

Cochrane Effective Practice and Organisation of Care [EPOC]: nil
4. The people underestimating time frames problem
3. The mechanistic, rock-like thinking problem
2. The challenging, tribal people problem
Fortunately there are responses to each of these problems
1. The quality and safety problem
[1] Andrews et al, 1997; [2] Schwendimann et al, 2006; [3] Andrews et al, 1997; [4] CCGR data, average across studies in Australia, Canada, Denmark, New Zealand, UK and USA; [5] Andrews et al, 1997; [6] Pittet, 2005; [7] Multiple sources of data, averaged by CCGR across studies in Australia, Canada, Denmark, New Zealand, UK and USA; [8] Kohn et al, 1999; [9] Gawande et al, 2003; [10] Kwann et al, 2006; [11] JCAHO,1998; [12] Lackritz et al, 1995.
Professor Jeffrey Braithwaite
Centre for Clinical Governance Research
Australian Institute of Health Innovation

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Ms Danielle Marks
Research Assistant
Centre for Clinical Governance Research
Australian Institute of Health Innovation

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