This session covers techniques to improve the resiliency and effectiveness of team leadership and teamwork, and identifies the effects of cognitive bias in leadership decision making.
OK, good morning everyone. Thank you so much for this wonderful opportunity. I just want to take the opportunity to really thank Doctor Lynch and Jody and the team and the Orange Jewish uh Health Foundation for inviting me to come and again, what a privilege and a pleasure it is for me to be with you all the day. Virtually. I crave the interaction. I miss being in a room together. I hope that we can make this a conversation. I hope that you'll chat and put well question and answer, right? We heard that that's what we're putting in our comments for the, for the dialogue. Today. I do intend on giving some room for dialogue and just really trying to make this practical for you. Um I, I think we've all in our journey, probably heard a lot of leadership talks, right? And different, you know, theories and really wonderful ideas. But how do we bring that to action? I want to do something practical today. I wanna give you some real tips and tools to really help you uh do something different that might add to your game. And so that's my intent um as mentioned I come to you uh from Jefferson Health. I've got nothing to disclose. Maybe one day I will, I don't yet. Um nothing there. I am coming to you as the vice president for patient safety from really a large health system and the largest poorest uh hospital system city in the country. And working with that incredible patient population is a, is a privilege for me and I really appreciate the opportunity to share perspective of my objectives today with you are just again to illustrate the effects of cognitive bias in leadership decision making and specifically the role of leaders on teams and how leaders interact with teams. And then maybe we can learn practically a couple of techniques to improve the resiliency and the effectiveness of how your teams communicate. And so I'd be remiss to not start by talking about how COVID has changed the game, right? And so I would venture a AAA decent guess here that everything you're seeing on this screen you've probably experienced. And you know, you of all, like we had experienced continuous national, you know, continuous supply chain disruptions and the patients are sicker. And our ability to absorb capacity is certainly the the normal fluctuations ha has significantly been impacted by what is really now a transformation in health care delivery um and all the forces that are pushing that. So what I'd mentioned to you in just framing the dialogue today is that it's probably never been more important for us to function as a really AAA highly effective and highly reliable team and how we organize as a team is gonna be even more important to achieve our outcomes and our goals. And, you know, I think when we think about that the the Tuckman model of, you know, teams form, they storm they norm and they perform is absolutely still true. The, the only difference here is that that's happening way more frequently, right? With uh the sort of travel folks that are in the hospital, the rapid turnover of people coming in and out of health care, our ability to do this quickly effectively is gonna be even more important. And so there's definitely some models out there that we can learn from one such model and this is an old book and, you know, if you haven't read it worth the read um because it's full of wisdom, it's the five dysfunctions of a team. It's looking at teamwork and team science, but really relating the errors that happen in team science to each other. And so what I'd like to do today with your permission is reframe the depth and the learnings of this book and the relationship uh to the present state that we find ourselves in, in health care delivery as it relates to leadership. So here, here is the book in a nutshell, right? And so start at the bottom with me, please. What Lechon really is saying at the beginning of his book very clearly is that there are ultimately five dysfunctions, but they're related and they, they sort of sequentially lead to each other. The first is bottom of the barrel. If you don't have trust on a team, you really don't have a team. And so when there's no trust, ultimately, there's a fear of conflict, you can't resolve issues. Um And when you have a resolve and you have a fear of conflict and you can't resolve in issues. What that will naturally lead to is the human condition of we're not bought in with. There's a lack of commitment and ultimately, you know, when there's a lack of commitment, you know, there's sort of this avoidance of accountability and who today on the call isn't feeling the increased need to be accountable, particularly to our patients and families who are desperately needing care, maybe more than ever, right? And we want to be able to provide that for them. But the clinical operations in which we find ourselves, our ability to act, execute on our goals is gonna be even more important. And so that avoidance of accountability ultimately is putting our ability to deliver the most excellent care to our patients uh at risk. And that's the inattention to results. And so what I'd really like to do is think about, you know, how are we as leaders impacting these uh sequential failure modes if you will. And so to do that, I just wanna really premise why, why are we focusing on leadership? Well, some of the best and most high performing teams in the world are in the military and our military has incredible, uh, you know, the stakes are higher there in many cases. And we, we really need to understand and take a page out of their book and there's a great book. Um, it's an old book now but it's, you know, really focuses on Navy Seals and their experience of leadership. And it's just incredible to read. It's an incredible read. It's a fast read. I recommend it to all of you, but it really calls something out and, and I think Seal language if you will. So I'll, we'll sort of take that um and think about it in the context of health care, but I just want to take this quote because it's, it's something for us to reflect on as we talk about leadership. And so again, there are no bad teams. Only bad leaders, leadership is the single greatest factor, the greatest factor in any team's performance. I find that statement astounding and, and really something that needs to be taken a heart, whether a team succeeds or fails is all up to the leader, the leader's attitude sets the tone for the entire team and the leader drives performance or doesn't. And so again, that concept of how team leadership can really impact team performance is really the gist of what we're gonna explore together today. I'd like to bring a lens to it that perhaps we haven't maybe thought about together. But really, it's a premise. And so I'd like to really bring out that we all as humans have cognitive errors, we have implicit and explicit biases and a lot of these cognitive errors that we make as leaders have disproportionate impact on these five types of team dysfunctions that Leone is talking about. And so what I'm trying to connect for you here is it's not the reason that leaders have this disproportionate impact is because maybe there's a bias in the way they're leading that can potentially really impact if we can get around that and get our hands around that a little bit, our teams would be even more uh highly performing. And so just a little bit of background on that this concept of cognitive error and implicit explicit bias is an old concept. And if you will to frame it in one way that you sort of have two brains, right? You've got a fast brain and a and a slow brain. And those brains really function differently in us this system, one or fast thinking brain is an unbelievably powerful. And I will point out to you unconscious uh pattern matching and intuitive brain. It is not something that we actively experience and it's a really important point. It's below the layer of our ability to directly impact us. Um That said we have a different part of our brain called our system two brain, which is a slow thinking brain. It's a more conscious algorithm approach. And a lot of the really the challenges that we experience is leaders is when this fast brain, this intuitive unconscious part of our brain, which is really a large part of how we function um can sort of derail our leadership competencies. And so as leaders, if we could get a little bit more ability to influence that part of our brain, which was what I'll try and show you today. Um We may in fact be able to mitigate some of the risks of that. And so what we're gonna do today is called meta cognition. We're gonna think about the way we think. So. Um this is really from a, a sort of a body of literature in the, in the cognitive psychology literature that believes that we can do something called cognitive forcing. We have strategies where we can potentially mitigate the downstream outcomes of our unconscious biases. And so you, you may have heard, right? But I think a lot of us have used the star model. We've talked about star model on, on units and floors where we want folks to, to think out loud, to think about potential, you know, unintended consequences, be deliberate in their actions, et cetera. It's really a good example of this concept of cognitive forcing. So let's get into it, right? So the very, very first um you know, area where we, we have an impact as leaders is on developing trusting teams, teams that trust us, but trust each other. And I think that's really important. Um Some of the things that we can do to create a lack of trust or where we see the impact of a lack of trust is, you know, staff will conceal their weaknesses, right? They won't share mistakes. And then if you're not sharing mistakes, you can't learn, you can't improve. Um There's a hesitancy to either ask for help or, or offer or listen to constructive feedback. Um There's a hesitation to actually share responsibility or extend your skill set beyond your area. And so, um you know, this, this is certainly something that as leaders, you know, we potentially could impact. And Leone has a really interesting and, and, and sort of very astute insight into this. And he says that remember, teamwork begins by building trust and how do you do that? So the only way he says to really build trust is to overcome our need for invulnerability. I think the old adage of, you know, you gotta break bread together. Why does, why is that reality? Why is that sort of have a resonance of truth to it? It's because we all need to eat, right? And we, we're sort of equally vulnerable in that moment, right? And there's sort of this concept that, you know, we can't remain in vulnerable. We have to be willing to be vulnerable with each other. Um and recognize that there is mutual vulnerability particularly now um in, in our, in our reality of health care delivery, that we, the only way forward is to be openly vulnerable with our teams. And recognize that we have a shared vulnerability uh to deliver the most highest quality of care to our patients. And so sort of this denial of our co-dependency, right, when we work as sort of siloed groups that's sort of perpetuating and denying our individual vulnerabilities. And so for a leader, the greatest vulnerability uh of the team is when we are tunnel vision, particularly as leaders, when we don't have what we call global awareness, whatever work team we're leading has sort of a macro world and a micro world. And there is no way as a leader to have a line of sight to all of that, to have the best optics on, on that entire space. And so what we're really gonna need to do is to, to propose a framework where we depend on our teams to share with us the details of what they're seeing and to be able to increase our global awareness. That is one of the greatest spaces where we're vulnerable as leaders. And so being able to really bring the best optics and ascertain and write, raise those small voices is a vulnerability for us. And so we depend on our team to do that and I think it's in health care even more true because we work in incredibly complex systems. We have, in fact what the systems engineers call irreducible system complexity, right? And so we, we have imaginations as leaders about how the work is done or work is planned or sometimes the H F engineers call it imagined. But then go talk to a frontline nurse and they'll tell you how it really happens, right? And what really occurs. And you can see that blue line, there's gaps between that. And so as leaders, we have a huge vulnerability because of the complexity of care and the way things work in reality, that we depend on our teams to share information. And so to perceive the reality as it really is, this work is done, what is really going on so we can be more informed and make better decisions with our teams. We're gonna really need to um get the best information from our teams and we as leaders can bias that we can bias the information that they're giving to us. And so, you know, I think that it's important to recognize that as leaders many times, one of the first reasons that happens is because we can be overconfident as leaders, many people got into leadership because they were confident, you know, people and, and ultimately, that can, that strength can also be a a liability. And so, you know, how many of you think you're overconfident and just you know, answer yourself that question. And it turns out actually that in health care, um 90% of people actually have an overconfidence bias and that's consistent through almost every study that they've done in health care. Um And so what is, what happens when we're overconfidence? Well, I think it means that we're, we, we think quicker and faster, right? We're willing to accept intuition, we act on incomplete information. Um We, we may even deny certain discriminatory information and facts uh when it's presented to us. And, and our mental model isn't being totally encapsulating of all the information. We may even pre prematurely close our thinking on, on something. And so this is a particular vulnerability when we're overconfident and it can lead to two kinds of biases call the confirmation bias. Um And even search satisfying and in that regard, when we are overconfident, we, we may already confirm and accept only the facts that confirm our mental model. And we may even look for those facts. You might search to satisfy our mental model, which is a slightly more nuanced and and honestly, more perverse version of this bias. Again, bias, this happens unconsciously. So what can we do to maybe disrupt this? Let me just convince you that this is a real thing. First, this is this kind of study has been done many times over. I I think it's really amusing. So I'm sharing it with you. Um The University of Bordeaux actually, uh, did an interesting study. They took 57 people and they blinded, uh, two kinds of wine. Right. It's actually the same wine just so, you know, but one of them, they, they labeled, you know, uh, vino de tab, which is cheap wine. It's a table wine in France. And, uh, the other one, they actually gave it a very prestigious name. Now, I don't know if Grand Crew is a wonderful wine. Maybe someone here on the desk, certainly not had it. But supposedly that was a very good wine. Um And they just asked them, you know, they, they sampled it and they, they tried to ask them, you know, is it good wine or is it weak wine? And you can bet by just labeling it the vino de tab or cheaper wine, um You got a lot more cheap. Uh We kind of votes for that wine, but when they labeled the same wine as a prestigious name, you know, 40% of the people or 40 people, excuse me, actually, uh voted it as a wonderful and, and really exceptional wine. So, you know, our brains even light up when, when we confirm information that we, I've already been thinking and so this is something that again, we're sort of wired and, and are, you know, for various uh anthropologic reasons we've developed this way, but it's a huge leadership uh by really liability for us. And so what's a good indication that you may be saying yourself. OK. I got a gut, you know, we're human, we have this problem. But how do you know that I have this problem? So here's my reflection question for you. What's a good indication that confirmation bias is affecting your leadership? So, think about that for a minute and I'll, I'll give you a decent uh a decent litmus test, an acid test if you will. Have you been in a meeting lately? Um where um you feel like you, uh you, you don't really have voices that are sharing any discriminatory information. Have you been in a meeting where there is a lot of yes and not, and maybe not a lot of uh questions. You may be uh expressing an overconfidence bias if that's the case. And, you know, I can share with you that, you know, ineffective meetings are a decent sign that probably in some way overconfidence bias and confirmation bias maybe even search satisfying is affecting your thinking. So we're all on zoom meetings now. So I added this in. So I, I think I'd be remiss not to, right? You know, I, I don't know about you, but it's what's really challenging is going from actual live meetings to back to zoom meetings. We're in this hybrid world and there's not a lot of shift time between those things. So I'm going from camera to physical anyway, I'm just sharing my, my pains with you. Maybe you can uh commiserate with me. But that be yet as yet as it may, I think that when we see people off camera, when there's no dialogue or when people are directly texting each other about what's happening in the meeting and they're not engaged, right? They're having this sort of sub meeting to me that's having the meeting after the meeting, right? Or the meeting outside the room that's not entering the pool of meeting, that's not entering the opportunity for folks to hear that reflection. Um If you're not getting to your agendas, you know, there's really, you know, it's not even clear why you're meeting to begin with. I think those are still true. Um You don't have everybody you need in the room. Um And you know, when you have tasks, they're not really clearly pro uh project managed. So I think a lot of these things uh you know, are probably indicating that meeting and effectiveness can really reflect and potentially a uh a bias in our thinking and how we are trying to receive information that the leader may be impacting disproportionately. And so what I'd like to suggest to you is to adopt a different process um in order to optimize your situational awareness. And this really interestingly enough comes from the computer science literature, they call it adversarial review. And so high level when they make a program and they write a program, they try and poke holes and where is there? You know, holes in the code and, and could they potentially, um, you know, derail the program. And so that goes through what they call an adversarial review process. And, you know, I, I would just like to, um, you know, think, for instance, you know, how we can use this to better, better help us think about, um, you know, what reality really is. So, you know, what do you see, you might see a mouse, you might see a, a cat. Um But here's the point as leaders, you know, you really need to know both of those things. Um And so this is really a process that I'd like to share with you for generating the best optics on a situation. You know, how, what are the avan, one of the advantages of this form of review is you, you sort of mitigate the risk of group think and, and, you know, that is a really significant uh risk in groups. And I think anecdotally, I haven't seen this published anywhere. I think it's even a greater risk on zoom. Um And so I would offer you that, you know, some of these things could be uh potentially really useful to you in that regard. So again, it is an ideation process and, and it has, I think one of the advantages of really bringing discriminatory information and, and even potential innovation an idea. So again, the challenge here is that most people are gonna call that a pig. But it's gonna take a unique sort of perspective to realize. No, that's an owl, right? And to say an owl, here's the point. It takes courage, it takes courage to do that. But you as a leader can, can make that environment more possible by increasing and welcoming and actually actively seeking out alternative views and and and contradictory information because you're gonna need that uh potentially in your decision making, particularly as this system of health care delivery gets even more complex and nuanced. So, you know, how do you make it safe to, to, to really say that it's an owl and not a pig. Well, there's a few techniques. Bottom line, we're gonna get a little bit in the weeds here, but I'm, I'm gonna, you have to slide. So I won't, I won't believe this. I wanna get to dialogue. But here you go, you know, one, you've heard a brain storming, right? But there's a challenge with that. One person can only speak at a time if you move it to something called brain writing. Um You get a lot more ideation and it's a technique where folks are writing out their reflections. It gives them a little more time to be uh mindful and thoughtful of what they're trying to say and get their message, right? But it also gets more people being able to, to really share information and it, you know, it does provide anonymity um and psychological safety. So bottom line is, again, you can probably do this virtually. Um, but you could pull together a bunch of people. It takes about 30 minutes and the intent here is, you know, when you put things on cards, using the same color, same sort of font, that kind of thing, you can exchange these things and have folks react almost like volleyball where you're rotating to other people's reflections. You have a set number of questions and not too many. Um And you're asking for reflections on them and then people can react to those reflections by sort of rotating them, you know, best practice, rotate them three times, right? So, and someone gives an answer and then two other people are reflecting on that person's answer and it's a wonderful way to get ideas and to bring, bring forward and, and sort of break silence and, and raise small voices. Uh Another mechanism, this is actually a pneumonic for a complex word that I can't pronounce fully. So I'm not gonna try, but it's referred to as tris and, and this is a, a really great way to encourage heretical thinking if you will. And, and particularly when there are things that are sort of taboo and it's hard to actually, you know, ask questions around those things for whatever political reasons. I think this is a great process. And so it at its core, what it's trying to do is ask the question, what must we stop doing? To make progress on our deepest purpose. So it's asking it in reverse, right? Not what we have to do but what we have to not do. Right. And so it's a powerful way to think about this. I won't go through the details here. It'll be in your slides. But um certainly this is a, a wonderful tool to encourage heretical thinking that can help you sort of break through barriers in particular. Um I like this one in particular, I think it's very practical. Um, and it's called What and Why rounds? And so it's, you know, you can do it as a team and you can do it as an individual. Um You'll see a reflection of this in a, in a later slide around feedback, but it's, it's just a really great way to get pointed feedback on what you think you need and it's just a very practical set of questions. So, moving on, right? So we talked about trust and, and leading to fear of conflict and what are the biases related to fear of conflict? So a couple of them, right? You recognize that people do have an outcome bias, right? All is well, that ends well. So why are, you know, we're not gonna talk about it, right? It's because everything ended up, ok? Or, you know, no harm, no foul, right? Like if we got to a certain process and ultimately, if that process got us that outcome, there's really no reason, even if we deviated from what we thought we were supposed to be doing, we don't have to reflect on that. That could be what's feeling a fear of conflict. And then again, even omission bias can play into a fear of conflict if it ain't broke, you know, don't, don't fix it. Um That's a challenge, you know, I think, um getting all of these biases and even preferences that people have can lead to a fear of conflict. And again, these are unconscious biases. What can we do to mitigate that risk? So one is honestly this is an old hat for many of you debrief, like you actually have to debrief. Um The one thing I would ask about when you're debriefing is to add a tool, right? Don't just ask what went well, but rather ask why it went well. I think this is maybe one of the missing pieces, right? We just, we sort of collect what went well and then we move to what didn't go well, think about why things go well because I think a lot of the safety to science literature will tell us that we, we miss a lot of great opportunity as it relates to why things are going well and scaling what's really going well. And so it's hard to scale it if you don't understand why it came about that way. Many times people are making all kinds of micro adjustments to make sure that things are actually going well. And so when you ask why on that, you get into the process that produced the outcome and that, that's where the learning is. That's just a small sort of tweak to something we normally do. Um I think, uh the sort of the next layer of, of dysfunction again, when we have, we don't have trust, we're, we're scared to have conflict and when we don't have conflict, we can't resolve our issues. And we get to a lack of commitment, I break this down into again when you don't have buy in. And so, you know, I think many times there's a lack of commitment and we don't have buy-in because we haven't thought about motivators and de motivators. So we're gonna play a really quick game. This is actually the only polling question I have today. It's a fun game. So I'm gonna present the scenario to you and then we'll run the, run the poll. It, it's why don't you meet my friend John? John has a coin. It's not a bit coin. It's a normal coin and he's gonna flip it to a normal, really honest uh game, but it's really simple. Head sales. If John throws a head, so you're gonna win 10,000 in cash, he's gonna hand it right to you. Now, if John throws the tails, you are gonna have to go to your ATM and friends and family and pull out 2000 in cash and give it to John right on the spot. So it's real simple. Heads. You wanna play the game? Tails, you lose. So here's the, here's the options option. A play the game option. B pay 100 bucks right now and don't play the game. So you can play for free or you have to pay $100 right now and not play the game. Those are your only two options and let's run the pol. All right, I won't sing Jeopardy for you because I think you won't appreciate that. Ok? I think we're probably getting close here. Um Give it another 10 seconds. OK? And let's see if we can get our results. Um And oh, whoops, I won't go back there. Let's see. So, uh, wow, that's pretty impressive. So 50 50 split half, wanna play and half don't wanna play. So thank you for participating. And I, I probably asked this question, I don't know, maybe 1000 participants in, in the course of various, uh you know, talks I've given and I will tell you that about two thirds actually do not want to play the game. So you guys are a little bit less risk averse, which I think is interesting. Something's going on over there in Saint Louis. Um So I wanna talk about why folks may not buy in and, and I just walk with me for a minute into something called loss aversion. So again, this, I think you guys know that you may have heard the old adage, right? A bird in the hand is better than two in the bush, right? But we can actually count on. And if you were gonna play this game and be purely rational, there's a really simple way to think about this in decision analysis. It's something called the expected value and it's, it's pretty straightforward. It's what's the probability and what's the payoff. So if you were purely rational scenario, one, right, if you chose to play the game, the chance of the heads is 50%, it's a, you know, a normal coin and your expected uh payoff is, is $10,000. So your expected value is $5,000. So at this point, you should play the game, right? Tails, right, 50% chance I could throw tails and you have to pay $2000. That's negative 2000. Your expected value of tails is negative 1000. You have to lose 1000. So the overall of playing the game has a positive expected value of $4000. If you're purely logical, you should play the game, 100% play it all day as many times as you can if you didn't want to play the game. So that's really easy. That's a probability of one you're choosing immediately. I'm not playing the game, I'm giving you $100 and you lose $100. So your expected value is to lose $100. So purely rationally, you should play the game as many times as you can. And I will tell you that in again, the course of doing this, about two thirds of folks don't want to play the game. And the question is why, why is that? And it's probably because again, this unconscious bias called loss aversion that it hurts twice as much to lose as it does feel good to win. That's just how our brains are, are wired. And maybe that's because we've got four primal emotions. Some people might tell you five and may probably three of them are negative emotions, you know, fear, sadness and anger, right? And when we think about how that sort of maps out to loss, aversion, you know, three of them are really powerful emotions, right? That we try our best to avoid. We, we, we want to avoid fear, anger or sadness, we do everything we can to avoid that. And so this is a really powerful insight to how we as leaders work with our teams. And, you know, I'll just give you AAA sort of anecdotal story about Steve Jobs. I think everyone's aware, you know, he had pancreatic cancer. But strangely enough, he actually had a, a very curable and rare form of pancreatic cancer and he could have actually had surgery and removed any, you know, no one knows. But the chances of survival, there were a lot better than sort of the usual run in the mill pancreatic cancer, but he chose to not do that. Um And he chose to not do that because his preference for having his body open up was, was not favorable to him. And you know, that uncertainty of what would happen afterwards to him was a perceived loss, right? And so again, purely logically, right, as opposed to what his preferences and how that powered his loss, aversion were really influential in that medical decision and better than that, you know, than the one that you don't, you've probably heard that before. So how does this work? Well, know that, you know, there is a bell curve on risk aversion, right? And, and we as leaders are certainly uh not, not immune to that. I mean, I think we have, we think about leadership styles, right? It, you can really map this out based on your ability to tolerate risk as a leader and, you know, in particular forms of leadership, which are, you know, are, that's really risky, right? And we could potentially derail our teams in that regard. So, here's the, here is the insight to really think about when we work with our teams. You've seen Maslow's pyramid before, I'm sure many times, right. But here's the insight, the stuff on the first two, that's that, that's stuff that triggers sort of pain and suffering, right? Those are not motivators, those are de motivators, right? To really get to the sort of motivational stuff. Well, you can't progress there until you've taken care that you're not creating de motivation for your teams. And I think this requires reflection because I don't know how, well you know, we do that as leaders are we making sure that we're eliminating de motivators? Because remember that that relates to loss aversion, that's 2 to 3 times more powerful than trying to get people to self actualize. How many people can you honestly say are functioning at the top of their Maslow pyramid? I mean, really think about that. It takes real courage to do that as a person. It's a life journey and maybe we don't always show up on the top of our Maslow period every day. But what I'd like to suggest is that as leaders, you have the ability to impact this. Um and to really remove the de motivators to help folks have that opportunity to then motivate them towards uh higher self performance. So one other tool to to to sort of effectively do this is called framing, right? I think the way we frame information is very impactful on those we communicate with particularly as leaders and when we're talking about influence. So here is a really interesting very old study in New England that I just really brings up the point. And the study said, you know, 100 and 67 subjects, we were asked to imagine that they had lung cancer. And then half we're told of the 100 people having surgery. 10 will die in surgery. 32 will die in one year and 66 will die in five years of the 100 people having radiation therapy. None will have died in, in during treatment. 23 will die before one year. Excuse me? And 78 will die in five years. Ask them a question. You want surgery or radiation. It's interesting. They, about 5050 split. Ok. Watch what happens when you frame this differently. They changed it to physicians and they changed the reflection to how many survive instead of how many die. So can you see that set of 10 die 90 will survive instead of 32 die, 68 will survive, right? And they literally just changed the paradigm and how they set it. And what do you think happened there? 84% wanted surgery. And so I just think this is an incredible reflection because it just really emphasizes your ability, your personal influence and how you frame things for your team as a leader really can motivate or demotivate them. And I just bring awareness to that because framing is a really powerful tool in human cognition again. So how we, how we frame things again, really will help us uh make the experience for folks move away from transactional and, and really move them into transformational. Another idea is that, you know, you know, you really have to do address the what's in it for me and that's the sort of bottom de motivators. You gotta make sure that we've, we're taking care of those things so that we can get teams on board. We move forward with the next uh you know, cause of a lack of commitment, its role, ambiguity. And I think this is a big one. I had the opportunity to work in the past with uh Doctor Eduardo Sales. He's, I think really the world's foremost expert on team science and team training. He's a standing grant with NASA to uh you know, mission to Mars. And I asked Ed, you know, as a mentor, I said, what do you think the number one way teams fail is? He says, that's easy. He says, lack of role clarity, that is the 100% um cause number one cause of how teams fail. But I venture to tell you that the reason teams have a lack of role clarity is because their team leaders haven't always made that really clear. And so I, I would venture to sort of move that forward and think how as leaders do we create an ambiguity that can potentially lead to a lack of commitment. I think that first space is there's role confusion, right? We don't share with people what we need specifically from them. And you know, it's really important as leaders to set clear expectations on your team because it's, it's really hard to win if you don't know everyone on the team's role in contribution to how you collectively as a group, create the opportunity for a team success. Um And so when you haven't been able to create role clarity, you can't really set expectations, you can't set expectations, you know, there's ambiguity and ultimately, it leads to that next failure in the, in the pyramid, which is a lack of accountability. So here's maybe AAA diagnostic if you will to help, you know, um if you, where you are and your ability to uh really uh align your talent, it's not just getting people on the bus, it's getting them in the right seats on the bus. If you've got the wrong person on the wrong task, you'll see actually the project will regress if you've got the wrong person, meaning the wrong skill set on, but it's the right task. Um You might get them frustrated, right. Um And then the reverse there, I use this as a diagnostic. So if you see on a team confusion, I'll ask the question, maybe I have the right person, but I got him on the wrong task. I see regression. We're making progress, but we're regressing. Maybe I've got the wrong person on the wrong task. And i it's just a practical tool to help you make that reflection and sort of guide your thinking around that. And then, you know, finally another mechanism to I think really increase uh and avoid ambiguity is to increase your transparency, right. When you, when you don't set clear expectations with your team, right? You're leaving the sort of the daily work to those that report to them very nebulous. But I think giving them more transparent feedback can really help um to drive the expectations that you have and will create that lack of ambiguity which will drive higher performance. How do you do that? I think you have to commit as a leader to doing more frequent rounds on feedback. And I, I think these are things that, you know, we recognize as leaders, you know, these are sort of the, the soft skills, the stuff that, you know, maybe is doesn't always, we don't always pay attention to, but we maybe do naturally or need to work on. These are things that are important. But I, I think the most powerful insight here is that there is a bias involved. Folks make the assumption that no news is good news and you as a leader may be holding on to something that you're not sharing with your team. Well, the problem is is that if you don't share that with them, then you lead to the next, which is a lack of accountability, they can't self correct if you haven't actually shared that with them. But why don't people always share that with them as leaders? It's because we don't have a really good model to do it all the time. And so I think there's things that you do that you should be doing when you give back what's called feedback and things that you shouldn't do. Right? I think you probably have heard this in various forms and iterations. What I want to offer you is a really simple model to actually do it. And it comes from H B R. It was um originally referred to as the S K S model. Had three questions. I've seen it blown up to five. I think it's more practical because it just gives you some more space and more flexibility and its bottom line is start doing this, do more of that change, how you do this, do less of that and just stop doing this right. And this allows for micro adjustments. And I think that's important to do because again, part of the failure mode here for accountability is a lack of commitment. Well, there's a lack of commitment when there's a lack of, there's ambiguity and, you know, if you're on a roll, but you could be in that role, but you're not getting feedback on, on what you're doing in that role and what you need from them as a member of your team, that's a failure mode. So moving forward based on that and recognizing time, you know, um that I mentioned can lead to a lack of accountability. And, and when there's a lack of accountability, you know, you, you don't always have a shared mental model on your team. And so that ultimately, you know, can lead to various kinds of errors, right? Things that should have happened, don't things that happened shouldn't have happened, you know, duplication of efforts, um the inefficiencies and the substitution errors that could occur. And so 11 issue and one way to deal with that is um to create mutual accountability, right? How do we create mutual accountability on our teams and so simple things, but things that we overlook and I, I would offer you can be potentially with technology to do a little bit better. So mutual accountability means you depend on me and I depend on you. If I'm a partner with you, you're counting on me to do certain things. In fact, you may not be able to do your step in the project unless I do mine. Right? And so how do we create accountabilities? I, I would take a step from the old, you know, team science that we've all familiar with, right? Close the communication. But how about we bring that to tasks, right. So there's lots of apps. I do not own any stock in wonder stock or wonder wonder list or just so, you know, I have nothing to do with this company. It's just, there's one of 1000 like this, but I, I think that the concept is good, right? So when we are on a project together, one thing that's really great about this app is that um it does create mutual accountability for our shared vulnerability on a team, right? When we are all working towards some goal, be it discharge on day four, be it, you name it, right? Whatever it is that we're all working on, we have to know about each other's tasks and when they're going to be completed by the progress that we're making to that effect. And so I think this is uh a wonderful mechanism to welcome us into that shared space where we can share. You can put tasks on here, you put sub tasks on here. My my message is leverage technology to create better accountability through transparency, right? You can see who's assigned to every single task here. And when the last time they worked on it was and when the last, you know, when it's due and and who needs help. So I think this is a just a great tool. One of many to drive better performance, I will move now into the very last failure mode. Again, bringing it from the bottom. When we have a lack of trust, people are scared to have conflict and resolve their issues, which ultimately can, you know, really affect your buy-in can impact your commitment, your ability to set expectations, which ultimately leads to an avoidance of accountability. And when you're not accountable to your team and you're not holding them accountable, there is ultimately, you're not gonna hit your benchmarks and your targets and there'll be an intention of results So finally, how do we, how do we help that? Well, I, you know, simple page out of the book Four D X four disciplines of execution. Wonderful read is you can't win if you don't know the score, right? And so I, I think asking these questions to yourself as a leader, does your team know what it means to win? Like what does winning mean? Um How do you know, how do they know how they're doing along that process? Do they know the score? Um And is that score visible? Right? Can they re really keep it top of mind? We're all really busy. We've got a lot of things going on. Prioritization is difficult in this environment of health care today. And it's becoming even more important when you know that there are cannot fails. And so keeping the score, the process metrics and the outcome metrics present is gonna be even more important. Um Other ways to keep uh focus on attention and to results is to, to think heavily about leveraging healthy competition. I I emphasize the word healthy. Um You know, we, we certainly recognize that it is human to want to be competitive. We can leverage that through data transparency in a positive way um by and here's the nuance by celebrating the high performers, right? And I think that's really, really key, we want to celebrate high performers, we want to raise everyone to that level, but it it starts by making sure everybody is fully aware of how we're doing together. And so again, you know, doing that in a sensitive way is incredibly important, but this is a human condition, right? We like to compete. And so certainly, um once you've verified and validated your data, it is an incredibly powerful tool to uh be able to share that uh in a public way that celebrates those who are doing extraordinarily well, sharing their insights and raising everybody up. I think um we're, you know, we're, we're in a world now that's very virtual. But we have to remember that visual management helped us significantly in the last 20 years. And I, you know, I think we go through cycles of evolution of what old is new. I would venture a guess that, you know, as we continue to engage on the units and as patients continue to bring even more complex disease and clinical operations gets even more uh challenging visual management, knowing the score on the process metrics is gonna be even more important. And so I, I encourage you to think about that to uh mitigate the risk of inattention or results as it relates both both to uh process and outcome metrics. And, and really my final slide here is to bring it back to something that's tried and true. We're going through an unbelievable time in health care today. The industry has changed, it's changing and what is tried and true and what will remain. The core is that we all got called to this, to serve our patients, to serve their families, to bring about an opportunity for healing. And the only redeeming thing that will keep us engaged and help really prevent the burnout that we're all experiencing to different levels is to support each other. And so, you know, if I get to make one ask from the leaders here on the call, it's to make sure you support each other in simple things. It would be amazing if everyone went and started a peer to peer board where you're shouting out your peers in some way and giving them support, not from those above them, but lateral to each other. And that's an incredibly powerful recognition of the human element that we just cannot lose. As we continue to fight this good fight to uh help folks get the most excellent care and eliminate preventable harm. I'll stop there. And really again, I wanna thank everyone for this opportunity to be here with you to share with you. And uh my expectation is that you'll share with me back. I'm hoping that I can learn from all of you. And again, here's my information. Please reach out to me. I'm very accessible. Um And just really thank you again to the uh entire team for inviting me and I'm happy to take any questions, Doctor Gutman. Thank you so much for that fabulous talk. Um really insightful and I think provides a lot of fantastic tools for our teams. We're currently, you know, B J H and B J C having goal cascading and K P I S that we're rolling out and have a process called the MS A P that people may be familiar with. And really thinking about applying these tools, you know, to the strategies on the units to improve patient safety and quality. Um Can I really see being very impactful? It's also interesting because I've seen a lot of these um ideas about the different cognitive biases, thinking about diagnostic error, but such a, you know, insightful and interesting way to apply it to how we're acting as leaders and how we're collaborating on the on teams. We have a couple of questions in the chat. Um The first one is um any insight on how to facilitate interactions between multiple teams and how maybe these bias biases could become an effect or maybe some of the techniques you can use as teams are interacting together. Yeah, that, that's a wonderful question. And, and thank you for the question. I I'm gonna make a reference to a book. So I think it's really important to read this book called Team of Teams um by, by General mcchrystal. It's his sort of dissertation on the Iraq war. There's some big insights there into how you coordinate teams of teams. I I'll share one insight that I think is, is important when you're talking about multiple teams because each team has its own culture. And each team, by, by definition is exclusionary of other teams, right? Because you are on the team and there are those that are not on the team, right? And so by definition, you have to sort of overcome that exclusionary reality of being I am unique to this group and not to this group that happens by creating social connection and social equity with those teams. So I I know this is gonna sound crazy, but very practically get together and, and have a beer, but it's OK that I say that. But I mean, you really need to get to know each other. Like you need to know that they have a dog named, you know, Brick and you know, his daughter is, you know, and, and goes to my daughter's high school and so that when you have personal equity and personal connection with people, you may have different roles on these teams. But because we've now found common ground, I have a relationship with you. I can stay in my scope of team and you can stay in your scope of team and that enables collaboration. I hope that's helpful to you. Yeah, thank you so much. Our next question was, are there any strategies to manage up on a team if it's not clear to the team, what the score is or what it means to win? You know, so if you're, you're part of that team and you know, how do you kind of manage up, you know, to your leader? Yeah, so that, that's great. Thank you for the question. So I relate this to the part of the discussion where I shared that leaders need to offer opportunities to speak up on the same time, right? Flipping the the paradigm followership and, and team members need to manage up to your point. One way to do that. I think to encourage that is for the team members to ask the leader if there's a way we could share information with you on a more regular basis in an unbiased way. I didn't share this in the talk. I have shared it in prior talks. There's a book called Liberating Structures which I recommend to all of you and it has all kinds of various teaming and ideation ideas. One technique is called wise crowds. This is gonna sound a little little funny here. So forgive me, but it actually works. Imagine a team leader with his, his or her team, turn the chair around. Don't face your team as a leader. Have the ask the question as a team member and then have the team, your other members offer an answer to your team leader. Why are you turning around? There's cognitive psychology literature that the team is reading the leaders, eye eyes and body expression, the nonverbals, all the N LP stuff and literally simply just turning it around like literally faced the other way. I know that sounds crazy. But with permission and respect, you'll actually get better ideas doing that. I don't think it's something you can do all the time practically. But I think there are times where if you feel like you need to manage up and it's a difficult conversation. You as a member asking the question and your other colleagues supporting you and offering feedback with your leader, not biasing it um can be a potential method forward. Um We've had a couple of comments about you mentioned two books really quick. Could you just give the names of those books one more time? Sure, liberating structures, um structures. And then there's a book called Team of Teams, which is on the, the, the reality of, of multi teams and how they, how they team. Um And I guess one last question, um you know, here in Saint Louis, we uh sometimes are what we call Midwest. Nice. Um And I love that. Um you know, the, the question was, how do we, what's the best way to provide to provide feedback without being labeled as negative, you know, and especially in our atmosphere of Midwest? Absolutely. And, and let, let me first say how much I appreciate that. I, you know, I don't know if you consider Texas Midwest, but I've lived there and certainly spent time in the Midwest at various points in my career. So, um I recognize that that's really important. That's a cultural reality that everyone on the call is dealing with or many anyway, um what I start with is framing, right? And frame this as moving away from loss. So when you talk with someone and say, look, you know, there's something we need to do in order to avoid this impact on this patient or, or, or this loss that could happen. Remember, loss, aversion is a powerful tool, right? And so when you're expressing something, as I want to share information that's gonna help us avoid this loss. And my intent, my mission is aligned with your mission. We're both along the same side of the table as the patient. We're both trying to bring about a reality that will benefit the patient and the family. But when you, when you express it as the reason I'm saying this is because I we should avoid this loss that will impact the patient, the ears change the tone changes and it's no longer about you. It's about maybe something you're that you impact about the patient, it's about the patient. And so, you know, framing it that way while it's nuanced is incredibly powerful because it's disarming. Yeah. Fantastic. Well, again, Doctor Gutman, thank you for the wonderful talk. Um very timely and really appreciate the the the tools and techniques, you know that you've given everybody uh listening in today. Um So that will have a brief break. Um And then we will return with uh do with Brian Sexton for our next talk. Thank you, everybody. Have a good day.