Field Report: Adaptive Leadership in Practice Expansion

In an effort to expand clinical hours in an academic setting (University of Minnesota Health), the authors use a specific framework to assist and exceed their goals.

ABSTRACT: The authors use an adaptive leadership framework to assist them in their effort to expand clinical hours in an academic setting. Four specific techniques — identifying adaptive challenges masquerading as technical obstacles; listening, reflecting in action and intervening; adjusting pressure to bring clinical teams into productive tension; and giving the work back — enabled the authors to exceed their goals.

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University of Minnesota Health undertook massive ambulatory practice transformation during 2015, transitioning from entirely hospital-based clinics to mostly freestanding clinics with the opening of its consolidated, ambulatory Clinics and Surgery Center on the downtown Minneapolis campus. Thirty-seven individual clinics, historically aligned with the academic departments, moved to a single clinical building with flexible workspaces and clinical modules. The number of examination rooms was cut drastically to match patient demand and improve resource use for the practice as a whole.

We chose to make academic specialty care available beyond the traditional office hours of 8 a.m.-5 p.m. weekdays. With new operating hours of 7 a.m.-7 p.m. weekdays, and 8 a.m.-noon Saturdays, the physician leadership necessary to help faculty physicians get through the transformation was substantial.

University of Minnesota Health moved 37 clinics, historically aligned with academic departments, to its new Clinics and Surgery Center on the downtown Minneapolis campus. The “practice of the future,” designed in response to challenging market forces, required physician leadership to shepherd often-frustrated clinicians through a massive about of changes. | Photos by Angela Lillie (top) and Stephanie Dunn (above)

Historically, academic ambulatory practices have been tied to hospital-based reimbursement models. This revenue has helped to support fixed costs of hospital infrastructure and sometimes created efficiencies that challenge the ability of academic practices to respond to evolving competitive pressures and patient expectations. Multiple external factors have led organizations to rethink hospital-based reimbursement structures, including federal regulations that no longer designate new, offsite hospital outpatient departments as provider-based locations.1 Legislation continues to be discussed nationally in this area, with the potential to limit further hospital-based clinic reimbursement in the future. Additional competitive pressures include cost-sharing for patients with high-deductible insurance plans, and community specialists who perform services traditionally provided in hospitals through construction of outpatient imaging, surgical and infusion centers.

Operational Process

In the wake of these challenging market forces, University of Minnesota Health — also known as M Health, a partnership between the University of Minnesota Physicians and Fairview Health Services — began in the early 2010s to plan for a new, consolidated ambulatory care center. The project team was challenged to create a building that would support a “practice of the future” without hospital-based facility fees. The project architect, Cannon Design of Chicago, Illinois, used the principles of Lean methodology and developed several key innovations in design, including:

• Standard clinical modules that allow any clinical space to be used by multiple specialties.

• Collaboration space throughout the building to better locate clinicians and teams and promote interdisciplinary professionalism.

• Open offices with flexible spaces for care teams previously accustomed to having individual desks.

These design innovations created an environmentally responsible footprint in an urban community, promoted a modern patient experience and led to national recognition for the project.2,3 However, they also raised the stakes for the physician leadership required to transform how teams would deliver care in the new space.

The number of examination rooms decreased from 342 to 162. Meanwhile, leaders decided to increase the number of days and hours clinical services would be available, to maximally use the space and be more attractive for working patients and the family members who often accompany patients.

The decision to forgo hospital-based reimbursement led to an initial estimate of a $40 million decrease in revenue. The operational leadership had to design efficient systems to mitigate these revenue losses, and to grow clinical services in areas where market opportunities existed. Pressure from the university to vacate our existing clinical space added urgency to lead the faculty through a rapid transition. Expanding into evening hours was not an optional enhancement but, rather, a goal that had to be met by the time the new building opened.

On top of the fixed design decisions, these massive changes felt thrust upon the clinicians, who often expressed frustration about the changes and their belief they had little control of, or input into, the process. Shepherding them through these big changes required intense attention to physician leadership in a compressed time frame. The physician leadership team had used adaptive leadership as the basis of its physician leadership academies for approximately 10 years, and used its principles to lead the practice through these changes, too.

TABLE 1: ADAPTIVE CHALLENGES AND OPPORTUNITIES FROM EXPANDING HOURS

Intervention

Adaptive challenges (see Table 1) are those in which significant change is necessary, and where there is nearly always conflict between differing values and perspectives.4 Shifting those values and perspectives often is required; accordingly, people often feel a sense of loss and sometimes resist the change. During such change, leaders must:

Properly identify and name the challenge as “adaptive.”

Carefully and reflectively observe how people are responding to the change.

Interpret what the responses are about.

Decide how best to intervene to make progress on the issue.

Interventions come in the form of “raising the heat” when people believe there isn’t a problem, “lowering the heat” when people’s capacity to adapt has been surpassed, and getting out of people’s way when they are adapting well to any given change. Once in the productive zone, adaptive leadership requires giving the problem back to the teams to solve.

Leadership authorities Ronald A. Heifetz and Marty Linsky, in their 2002 book Leadership on the Line, say the most common cause of leadership failure is to treat an adaptive problem with a technical solution.

Here’s how we applied adaptive leadership techniques to our circumstances:

1. Naming adaptive challenges masquerading as technical obstacles — Scheduling after-hours call is a classic health care example of an adaptive problem cloaked as a technical one. The challenge of expanded clinical hours was no different. The initial approach was to take the current exam room allocation and schedules and overlay them on the reduced number of rooms and proclaim “this won’t work.” As a senior member of our leadership team stated, we fill our spreadsheet schedules and allocate rooms like “church on Easter Sunday.”

Fulfilling the tripartite missions of clinical care, research and education in both inpatient and outpatient settings makes academic clinic scheduling a challenge. Because of this complexity, it is rare for any individual faculty member to have a consistent and reliable schedule (i.e., that all clinicians who sometimes work Tuesday afternoon actually are there on any given Tuesday afternoon). Using clinical space efficiently in this environment requires more dynamic and flexible scheduling solutions than traditionally used. Even with the most robust scheduling software available, the problem of expanded hours, as we continually reminded clinicians, “isn’t a math problem.”

When we met with clinicians to discuss schedules, the temptation was to delve into the clinic scheduling templates and help devise a technical fix. What the circumstances actually required were the development of relational trust and creating context for these changes. Listening carefully to people’s concerns, asking questions about the deeper issues and storytelling were all used to help create trust and context.

The facility includes collaboration space throughout to better locate clinicians and teams, and to promote interdisciplinary professionalism. Open offices with flexible spaces were designed for care teams previously accustomed to having individual desks. | Photo by Stephanie Dunn

Allowing people to connect to the issues in ways beyond intellectual created the ability to hold steady during trying times and continue to make progress on our unsolvable dilemmas. We used poetry about change5,6,7 and stories of our patients and the challenges they faced accessing us at times convenient to them. Using these nontraditional methods to approach the problem helped identify the gap between our current state and desired state in a vivid and visceral way for clinicians and leaders, and it helped ensure people felt their voices were heard. This led us away from the “math problem” and into the work of shifting hearts and minds to approach the adaptive challenge.

Connecting academic clinicians to the broader mission of the university, expressing gratitude to the people of the state for bonding the building construction and appealing to the faculty’s higher calling of service were additional approaches used to frame the challenge adaptively and allow clinicians to approach it outside of a purely intellectual framework.

2. Listening, reflecting, intervening — These changes highlighted the conflict of values and perspectives that exist within an academic practice. As this project was focused primarily on the clinical setting, many educational and research leaders within the organization expressed concern that their voices and perspectives weren’t being considered. Protecting personal time, as well as concern about clinical team burnout, conflicted with the value of offering clinic hours convenient to patients. Allowing departments to function independent of each other conflicted with developing a cohesive group practice, and standardizing clinical space conflicted with the customization many practices require. Repeating continuous cycles of observing, interpreting and intervening4 when these conflicts arose allowed us to continue to make progress on these challenges.

Heifetz et al. refer to the need to reflect in action during adaptive change.4 This concept was critically important as physicians frequently expressed frustration about their lack of control over the changes. As they did so, physician leaders needed to ask, “What do I think this is about for people?” and “What am I noticing about my own reaction?” Interpreting what the behaviors signified was critical, and intentionally intervening was crucial to the project’s success.

For example, emotional reactions in meetings often were interpreted as expressing concern about loss of control. In these cases, intervention involved explicitly pointing out areas in which physicians did have control — such as fixed schedules versus rotations, and allowing each clinical area to determine equity in sharing evenings and weekends. As we approached group meetings, we continually asked ourselves what we could do or present to help develop capacity in the team to lead this change. With these interventions, there were specific milestones we reached, but we constantly discussed with all that our goal was to make progress on these adaptive challenges, as they can never be solved.

We continue to be impressed with the importance of acknowledging how challenging these changes were for everybody. Uncovered in conversation after conversation was a sense of loss. Clinicians expressed loss of comfort, loss of identity and loss of a known way of operating in a clinic setting. Acknowledging this loss for all clinicians was important. While operational leaders tended to focus heavily on the opportunity ahead with new clinical space, the need to acknowledge what the clinicians lost proved vital.

Hearing “the song beneath the words,” to use adaptive language, we heard loss and fear expressed as anger and frustration (see Table 2). An informal medical leader reminded us that “people just want to feel their practices are understood.” Normalizing the difficulty of these challenges to bright clinicians who are used to feeling competent in all areas of their lives and are being asked to publicly learn new ways of working together was necessary throughout this process.

TABLE 2: EXPRESSIONS OF LOSS DURING TRANSFORMATION

3. Raising and lowering the heat to create productive tension — Expanding clinic days and hours uncovered significant challenges of fairness and equity across the group practice. Initially, nearly all groups stated their clinics would not participate because expanded hours wouldn’t fit their schedules or their patients didn’t desire these hours. Fleeing the problem in this manner was interpreted by our leadership team as “work avoidance,” to use adaptive language.

When work avoidance is identified, a diagnostic discernment must be made by a leader if it’s because the heat — or pressure to perform — is “too high” or “too low” on the teams. When the heat is too high, individuals and teams become overwhelmed and effectively paralyzed and unable to step into the work. When the heat is “too low,” the issue has not yet connected to the individual or team in a way that raises its importance against competing priorities. The end behavior of work avoidance looks the same, but the techniques used to intervene vary (see Table 3).

Our diagnostic assessment was that most groups were avoiding the work because the heat was too high. In response, we undertook a process to clarify expectations — which can be used to both lower and raise heat — and define where there was choice for teams and with whom those choices rested.

To set and clarify expectations, we considered multiple approaches. One option would be to assign requirements for expanded hours by clinician (i.e., every clinician works an evening shift every six weeks). Similarly, we considered assigning each clinic a number of evenings irrespective of its size. These approaches failed to stand up given the vast differences in evening and weekend call responsibilities among clinical units. For example, the pulmonary service provides overnight ICU coverage for multiple hospitals in our health system, and inpatient rounding on multiple services. Despite having a relatively large number of faculty members, there aren’t many clinicians present in clinic on any given day because so many are on service or post-call. In contrast, other clinical areas only cover a single clinic and inpatient service, so the number of faculty corresponds roughly to the number of physicians in clinic on any given day.

TABLE 3: METHODS EMPLOYED TO ADJUST ‘HEAT’

We chose to connect expectations for evening and Saturday clinics to the budgeted patient volumes for the new center. This approach seemed to “cut through” some of this variability in clinical responsibilities. This initial step helped to clarify standards and helped orient clinicians to the adaptive work of expanding hours. Soliciting feedback from stakeholders on what seemed equitable across the practice, and participation in development of those criteria, were key steps in setting the minimum criteria. Undergoing a deliberate and transparent process for setting practicewide minimum standard hours allowed the issue to “ripen,” and clarified what was negotiable and what was not.

Once we set minimum standards for clinics, we left them to do the work of determining what was fair and equitable within their clinical staff. This approach effectively gave the work back4 to the teams and allowed them to find their own solutions to meet the expectations. These conversations were challenging for all, but particularly for areas that had not historically functioned as teams until this point.

Some groups were able to work through meeting the standards well, either because some clinicians preferred to work evenings or there was a broad agreement to share the burden. Clarifying expectations and giving local control for how the expanded hours were staffed lowered the heat for some and raised the heat for others, bringing the bulk of the practice into a productive zone of tension for the work.

Critically important to this entire process was consistent support from senior leadership, from the University of Minnesota Physicians board to the university’s medical school. The board and the health center leadership set clear expectations and held steady when approached with countless requests for exceptions to participate in expanded hours. These influential organizational leaders kept the tension productive and used their authority effectively to mobilize teams through exercising their leadership.

4. Giving the work back — Once individuals and teams are in the productive zone of tension around the work, adaptive leadership principles suggest giving the work back to the teams. After our formal medical leaders were in a productive zone of tension around the schedules, we sought their help in approaching the questions of consideration for providing incentives for working during expanded hours.

A common theme that emerged was clinicians’ desire to be compensated additionally for the time spent in clinic on evenings and Saturdays. This proved difficult to manage, as there is only one source of revenue and any additional payment to one group would necessarily come from another area of clinician compensation. When we think of this challenge in adaptive terms, it is about changing hearts and minds, and realizing that no technical incentive plan would magically draw people into this work.

To address this request, we convened a group of medical directors who wrestled with this question. The group ultimately recommended nonmonetary rewards for evening work (such as dinner vouchers and concierge service credit) and reserve monetary compensation for working on Saturdays. Throughout the course of the 14 months of implementation, physicians would remark that what they wanted was acknowledgement of the sacrifice of family and leisure time that these changes were causing, and appreciation and recognition of this by leadership. Again, these stories highlight the adaptive nature of this problem.

This recommendation was taken to the department chairs who ultimately have accountability for individual faculty compensation. There was a lack of agreement among that group about the ability for all groups to pass the incentive through to faculty. For example, some suggested that faculty members who hadn’t fully supported their salaries through clinical, research and educational funding shouldn’t be eligible for the Saturday incentive. Additionally, some departments that previously had offered Saturday hours without additional pay did not want to compensate faculty who already had stepped into this work. Ultimately, the chairs desired a more local solution to determine any monetary incentives.

As we reflect on this failed initiative in hindsight, the issue did not likely “ripen” enough for those with formal authority, and we did not clearly enough socialize the process we were undertaking to develop a recommendation in advance of bringing it to this group. Clinicians working evenings appreciate the nonmonetary incentives implemented.

Results

By the end of 2016, nine months after we opened the Clinics and Surgery Center, we exceeded our goal of 5 percent and were providing 8 percent of our patient care outside the previous window of 8 a.m.-5 p.m. weekdays. We identified a 6 percent shift toward commercial payers for those patients seen outside that previous window.

As our practices already have grown, hired and recruited, we need to continue to increase our expanded-hours offerings to accommodate the growing practice. The adaptive leadership model our team used to bring us to this point has served as a great basis for taking on the next phase of this work.

Operational Implications

Being able to operate across 12 hours of the day Monday through Friday has allowed our practice to be accommodated in a smaller, more-efficient, environmentally friendly footprint, grow in imaging and laboratory services at times convenient for patients, and generate staffing efficiencies through shared staffing models.

Conclusion

The challenge of expanding clinic hours necessary to transition to a flexible workplace required intense focus on physician leadership in the year before the building opened. Using an adaptive framework allowed us to face these challenges. The techniques of identifying and naming the adaptive versus technical nature of the problem; listening, reflecting and intervening; raising and lowering the heat; and giving the work back all proved useful. We continue to make progress on moving the practice forward together — building adaptive capacity among formal and informal leaders to better face the challenges ahead.

Lynne Fiscus, MD, MPH, is chief value officer and executive medical director for the University of North Carolina Physicians Network and a practicing internist and pediatrician. She is a former executive medical director of ambulatory clinics at University of Minnesota Health.

Loie Lenarz, MD, is the retired director of physician leadership for Minnesota-based Fairview Health Services.

Levi Downs, MD, is the chief medical officer for University of Minnesota Health and an associate professor of obstetrics and gynecology at the University of Minnesota.

REFERENCES

1. Centers for Medicare & Medicaid Services. cms.gov/newsroom/mediareleasedatabase/fact-sheets/2016-fact-sheets-items/2016-07-06.html . Accessed Jan. 5, 2018.

2. Fast Company. “What Health Care Designers Can Learn from the Apple Store,” May 5, 2016. fastcodesign.com/3059543/what-health-care-designers-can-learn-from-the-apple-store/21. Accessed Jan. 5, 2018.

3. Stat. “This medical center looks and feels like an Apple Store,” April 27, 2016. www.statnews.com/2016/04/27/minneapolis-health-clinic-apple-store . Accessed Jan. 5, 2018.

4. Heifetz RA and Linsky M. 2002. Leadership on the Line: Staying Alive Through the Dangers of Leading. Boston, Mass.: Harvard Business School Press.

5. Hopi Elders Speak, The Elders Oraibi, Arizona, Hopi Nation.

6. Center for Courage and Renewal, “Circle of Trust Touchstones,” couragerenewal.org/touchstones /. Accessed Jan. 5, 2018.

7. Parry D., 1990. “The Parable of the Trapeze,” Warriors of the Heart. Createspace Independent Pub.