American Association for Physician Leadership

Reflections on Leadership and Quality

O. Scott Lauter, MD, MBA, FACP, FHM

Jan 4, 2024

Volume 11, Issue 1, Pages 25-29


During the author’s seven-year tenure as chief medical officer of Atlantic Medical Group (AMG), Atlantic Health System (AHS), in Morristown, New Jersey, AMG grew 67%, to 1,047 physicians and 301 advance practice clinicians (APCs), 210 practices, 450 sites of care, in 14 counties in Central and Northern New Jersey. The author was recognized for his clinical leadership related to COVID and developed a bench of clinician leaders to continue the work at AMG. On the date of his retirement, he emailed his clinician leaders the following communication, sharing reflections on leadership and quality. It has been edited for length and clarity.

Leaving AMG, I want to share some personal leadership and quality reflections, followed by a teaching and a reflection from the parent of healthcare quality, Dr. Avedis Donabedian, who created the quality improvement concept of Structure → Process → Outcomes. And then the big closing finale.

  • Remember that as healthcare leaders, your jobs are to 1) protect the patient, 2) protect the organization, 3) be fair to all parties.

  • Leadership is about We, not Me. You all have well-developed crap detectors. Use your crap detector to identify the We leaders and the Me leaders. Emulate the We leaders. Be careful around the Me leaders. More on that below.

  • Genuine leaders don’t proclaim how they lead; they allow their leadership in action to demonstrate and inform you of how they lead. Deeds, not words.

  • Be an owner, don’t be a victim.

  • To do nothing is a conscious choice and belongs at the bottom of the pit of bad leadership. Always choose to do something. You can always fix it. This leads to the next reflection.

  • What you permit is what you promote.

  • Think systems — roles, relationships, politics.

  • When you are addressing an issue, get the facts, think systems, get in touch with your guiding principles, and take a stand.

  • Deal with issues promptly. In real time. Put out brush fires before they become blazing forest fires.

  • Get comfortable with uncertainty and ambiguity.

  • Don’t avoid your opponents, embrace them. If you win them over, they will be your best allies. Be careful with your adversaries. Learn how to tell one from the other.

  • Leadership is about influence and persuasion. Not manipulation. No one likes feeling manipulated. Which leads to the next reflection.

  • Be clear about your intent so no one has to assume what your intent is. No one likes hidden agendas. Which leads to the next reflection.

  • I stands for Integrity.

  • Speaking of intent, in all situations, for yourself and others, focus on impact as well as intent. Noble intent can have disastrous impact. Don’t dismiss or downplay the impact. Which leads to the next reflection.

  • Never dispute or dismiss how people feel. How they feel is how they feel.

  • Remember this sequence: thoughts → feelings → actions. The first thing to do in dealing with actions is to ask questions, listen and understand the thoughts and feelings that led to the actions. No one chooses to go to work and do bad actions.

Addressing people’s actions without seeking to understand their thoughts and feelings that led to their action reduces adults to infants. When another leader comes to you with concerns about a clinician’s actions and asks you to solve the situation (AKA the “Dump and Run”), ask them to inform you of the clinician’s thoughts and feelings that led to the action. If the other leader can’t tell you because they didn’t ask, gently request that the leader go back to the clinician to ask, understand and address and solve the issue at their level. If they won’t do it, maybe they are in the wrong line of work.

  • Seek more facts and objectivity, and fewer anecdotes, stories, or subjectivity. Ask clarifying questions. Avoid broad brushes, extension, or generalization. Put things and keep things in perspective. “AMG doctors are___” should prompt clarifying questions of who, how often, how many — get the facts. If it is only two doctors out of 1,047, I’ll take a 0.2% failure rate, or conversely a 99.8% success rate. Outliers are outliers; they are not the norm nor are they representative of the greater number.

  • Always be open, expressive, assertive, and connecting. Avoid being aggressive.

  • Avoid these toxic leadership behaviors: 1) posturing/boasting; 2) withholding/suppressing; 3) diminishing/dismissing/demeaning/disrespecting; 4) ambushing/playing “gotcha”; 5) hijacking/co-opting/credit stealing; 6) undermining/sabotaging; 7) blaming/dumping/offloading. The last item leads to the next reflection.

  • Avoid stepping into someone else’s pile of dung they created. No good deed will go unpunished. Likewise, don’t create a pile of dung and leave it for someone else to clean up.

  • Responsibility is internal. You are responsible for doing your work. Accountability is external. You are accountable to someone else for your outcomes. Someone else is accountable for your outcomes. Being overly responsible means allowing yourself to assume the accountability of others. Don’t let that happen, either from yourself doing it to yourself, or others trying to do it to you (see toxic leadership behavior above).

  • Don’t be a bully and don’t be a jerk. Remember, bullies never act alone. They don’t have the courage. They always need company and involve others in their schemes. If you perceive a bully, look around to see who else is on their bullying team, determine who are their minions. If you have to confront the bully, confront the bully, not the minions.

  • Whatever you do, don’t be the leader who is presented an idea, proposal, or solution, dismisses it, and presents it 6–12 months later as your own idea. Give credit where credit is due. Acknowledge it and celebrate it. Doing so is a sign of respect, validation, and appreciation, and will encourage future contributions. The person who says “credit doesn’t matter” is the person waiting to steal your credit. That person is a Me leader, and one trait of Me leaders is they say one thing and do the opposite. Be forewarned.

  • Don’t use silence to hide your disagreement. If you disagree, speak up and share your concerns. Collegially, professionally, respectfully. When all issues and concerns are discussed openly and transparently, and the group agrees to the direction and plan, leave the room supporting the direction and plan. Do not undermine or later say, “Well, I never agreed to doing that.” Leadership is a team sport. Don’t tackle the quarterback, ball carrier, or wide receiver on your own team.

  • Likewise, don’t assume silence from others means they agree with you. Ask them.

  • Don’t be too free with your advice. Better to offer when asked. Unless you are retiring.

  • Don’t try to be the smartest person in the room. Try to be the best leader in the room.

  • Surround yourself with people smarter and better than you.

  • You are the company you keep.

  • Leadership starts with showing up.

  • Leadership starts with listening, mindfully and in the moment. Your time spent listening should far exceed your time spent talking. Which leads to the next reflection.

  • To be understood, first seek to understand.

  • Acknowledgment does not mean agreement. “I acknowledge your concern” does not mean “I agree with or support your concern.”

  • Leadership is about asking the right questions. Your volume of questions should far exceed your volume of declarative statements.

  • Get comfortable with and make good use of silence. Resist the urge to fill it. Take your foot off the gas pedal and turn off the ignition. It gives people time to reflect and speak and increases their sense of safety.

  • Leading others starts with establishing and communicating the end in mind or the desired goal, the why, and the role they will play. Leaders explain the desired outcome, set the direction, help the stakeholders understand how they will contribute to success, and clarify the swim lanes or rules of engagement — who does what.

  • Telling people to figure it out without providing guidance or expectations is a leadership cop-out and also belongs at the bottom of the pit of bad leadership. Don’t forget from HRO training that when they are in the figure-it-out mode, people get it wrong half the time. Don’t set people up for failure. Set them up for success.

  • Good leaders don’t careen from crisis to crisis. If they do, we have to ask why everything is always a crisis. Good leaders are proactive, they anticipate and plan, planning for all possibilities as best they can, to minimize the number of crises that do occur. Which leads to the next reflection.

  • Activity is not achievement. “Don’t mistake activity for achievement. To produce results, tasks must be well organized and properly executed; otherwise, it’s no different from children running around the playground—everybody is doing something, but nothing is being done; lots of activity, no achievement.”— John Wooden

  • Never argue with idiots. They will always drag you down to their level and beat you with experience. Which leads to the next reflection.

  • Always take the high road.

  • Pick and choose your battles wisely. If everything is a battle, you are in the wrong line of work.

  • Learn to control reactivity. Don’t allow amygdala hijackings. Read up on strategies for this. Then on those very rare occasions it is appropriate to be reactive, emotional or angry, people will notice and pay attention.

  • You will be less likely to be reactive if you arrive on time and are prepared. Dramatically rushing in at the last minute, fumbling around and being disorganized doesn’t reflect well on you and disrespects the others present. Remember: deeds, not words.

  • As my closest team members will attest, it helps to set expectations for those who report to you. Mine are: 1) No excuses, no surprises — stay in contact and keep me informed. This leads to 2) Don’t turn in shoddy work; and 3) Don’t turn in work late.

  • Celebration of just showing and just doing the work we were hired to do occurs every two weeks with a deposit from AHS to our financial institutions. What we should celebrate are hard work, good work, and good outcomes.

  • Stay true to HRO and NJ STRONG principles. It is about the process, not the people; finding process solutions and not assigning blame. And remember that if at the end of the Root Cause Analysis (RCA), the recommendation is “Re-educate,” the RCA has failed. Education is the weakest tool. Think processes and systems.

  • Study quality improvement.

  • Seek to achieve the quintuple aim: improving patient care quality and experience, improving population health, reducing cost of care, improving the experience of those who deliver care, and advancing health equity.

  • Seek to achieve the Six Aims for Healthcare Quality: Safe care, Timely care, Effective care, Efficient care, Equitable care, Patient-centered care. It is a STEEEP healthcare quality journey that never ends.

  • Quality is everyone’s job. Provide quality care and improve care quality.

  • Classics are classics for a reason. They work. Structure → Process → Outcomes is one of those classics. No structure or no process = no outcomes. If performance is not meeting expectations or desired outcomes, go back and examine the structure and the process.

  • Another classic is the Institute for Healthcare Improvement (IHI) three-step Model For Improvement (MFI): 1) Aim — what are we trying to accomplish? (remember the problem statement; see below). 2) Measures — how will we measure improvement? 3) Changes — what changes will we implement and test, using PDSA cycles? Remember to never skip step 2 and always determine measures of improvement, determining a pre-improvement baseline and measuring post-improvement outcomes.

  • What gets measured gets managed and motivates improvement.

  • Remember to not only measure the aggregate performance but also determine the internal distribution of the performance; see what your frequency distribution curve looks like. If your overall performance is 80%, but there’s a sizable number of clinicians or practices performing at 10%, you want to know about it and address it. But also remember you want to see the bell-shaped curve pushed to the right (if right is better) and compressed. Don’t just move the left tail to the center; do that, but also move the entire curve to the right. Everyone improves and everyone performs well. That is quality improvement in action.

  • Know the difference between process measures and outcomes measures.

  • Remember the five stages of physician data transparency: 1) Denial — your data is wrong; 2) Anger — I’ll join Barnabas; 3) Bargaining — can I tell my patients to give me all 10s? 4) Depression — I need a new career, medicine sucks; and 5) Acceptance — maybe we are not optimally meeting the needs of our patients, we can and should do something to improve. Accept this as a fact, the same as the sun rising in the east and setting in the west. Anticipate it. Let people vent. Then bring them along. Which leads to the next reflection.

  • Many things are negotiable. A commitment to patient care quality and safety is not.

  • Quality of care = Appropriateness of care times the sum of outcomes of care and experience of care. Q = (A) × (O + E). If care is inappropriate, quality is zero.

  • Value of care is quality of care divided by cost of care V = Q/C.

  • Study operational improvement, Lean (reducing waste) and Six Sigma (reducing defects and unnecessary variation). Which leads to the next reflection.

  • The greatest waste is waste of human talent.

  • In any proposed or suggested project that would involve you and your precious time, remember: always define the problem statement. No problem statement = no project.

  • For projects, or anything you do, lead or collaborate, plan the work, and work the plan.

  • Remember, perfect is most definitely the enemy of the good. Don’t let trying to be perfect out of the gate impede or derail a project. Get started somewhere and somehow, do your PDSA cycles, and engage and empower those you lead to be part of the PDSA cycle continuous improvement process. Don’t succumb to analysis paralysis. Get comfortable with “MVP”— Minimum Viable Product. We strive for perfection in clinical care. In leadership, it is much different. Be OK with failure and learn from it. Learn from the course corrections. Remember, if you are playing baseball and get three hits in every 10 at bats, you are in the Hall of Fame.

  • Leading change is a lot easier than sustaining change. Starting pilots is easy. The hard part is extending, expanding, spreading, and sustaining the change.

  • Learn to identify and label your unconscious biases. We all have them. It is not our fault. Deal with it.

  • Be mindful of triangles. If two parties are in conflict, don’t let one of them triangulate you into the conflict and put you in conflict with the other party. Push the two parties in conflict back together. Which leads to the next reflection.

  • Problems are best solved at the level where they are occurring.

  • Don’t let the loudest voice in the room determine your direction. Create the psychological safety for everyone to speak up, and listen to everyone’s voice. People will contribute when they feel safe, respected, and know that they will be sincerely listened to. Which leads to the next reflection.

  • The solutions we create together will always be far better than any solution we create individually.

  • Role conflict is OK, and expected, and has to be managed. Do not confuse role conflict with personal conflict. If conflict is personal, address it and resolve it, respectfully, collegially, and professionally. That starts with looking in the mirror to critically examine what part of the personal conflict you own.

  • Remember: it is about the behavior, not the person. Including yourself.

  • EQ must balance technical expertise; this is the yin and yang of relationships and results, of style and substance.

  • Be able to balance being at the high level and focusing on vision, and being in the trenches and focusing on execution. Be able to go to the press box, observing what is happening on the playing field and calling the plays, and also be able to be on the playing field, running the plays.

  • Your greatest strengths are also your greatest weaknesses. In other words, a strength taken to extreme becomes a weakness.

  • Under stress, we all become the worst caricatures of ourselves. Which leads to the next reflection.

  • The person you want to watch the closest on the playing field is yourself. When you are in the press box watching yourself on the playing field, use this as an opportunity to observe and improve your choice of language, communication style and body language, thinking of your impact vs. your intent.

  • Reflect on the impact of the following versions of the same message: 1) “Does anyone have any questions?” asked with an agitated, loud, fast-paced voice, and a pointed finger. Impact on the recipient: He’s in hurry, don’t ask questions. 2) “What questions do people have?” asked with a calm, soft, slow-paced voice, with open palms followed by silence. Impact on the recipient: He wants our questions.

  • People pay attention and hear you better when you talk softly and don’t yell. Likewise, when someone is yelling at you, you can consider saying “If you would lower your voice I could hear you better.”

  • If you have to do something you don’t want to do, do the opposite action of your emotion, make yourself do it, and go all the way.

  • Don’t forget that, as a leader, everyone else is watching you. Lead by example.

  • Earnest effort, persistence, and perseverance will always win in the end. It is the I Do, not the IQ.

  • Aim high for yourself.

  • Take time to reflect and self-congratulate.

  • Humility is a virtue, but so is belief in yourself. Find the right balance. Avoid hubris but at the same time never sell yourself short.

  • Every day, reflect on what you are grateful for, what you will focus on, and what you will let go of.

  • My core values are integrity, respect, collaboration, and excellence. Take time to define your core values. Then live them, every day.

  • Study leadership. If leading were as simple as giving orders, there would not be hundreds of leadership books and thousands of leadership articles published every year. The leadership learning and improvement journey never ends. Sharpen and polish your leadership tools every day.

  • Keep practicing leadership. Nothing improves without practice.

  • No one is indispensable. Put yourself and your family first.

Lastly, a quote from an interview [with Dr. Avedis Donabedian], which I have displayed in my office for all to read and reflect.

I have never been convinced that competition by itself will improve the efficiency or the effectiveness of care or even that it will reduce the cost of care. I think that commercialization of care is a big mistake. Health care is a sacred mission. It is a moral enterprise and a scientific enterprise but not fundamentally a commercial one. We are not selling a product. We don’t have a consumer who understands everything and makes rational choices—and I include myself here. Doctors and nurses are stewards of something precious. Their work is a kind of vocation rather than simply a job; commercial values don’t really capture what they do for patients and for society as a whole.

Systems awareness and systems design are important for health professionals but are not enough. They are enabling mechanisms only. It is the ethical dimension of individuals that is essential to a system’s success. Ultimately, the secret of quality is love. You have to love your patient, you have to love your profession, you have to love your God. If you have love, you can then work backward to monitor and improve the system. Commercialism should not be a principal force in the system. That people should make money by investing in health care without actually being providers of health care seems somewhat perverse, like a kind of racketeering. https://www​.healthaffairs​.org​/doi​/full​/10​.1377​/hlthaff​.20​.1​.137

And the big finale…

Going forward, I hope, and I trust, that as leaders, you will continue to make AMG better for our patients, communities, team members, clinicians, and the health system.

For your consideration I humbly offer three guiding principles for your doing this good work:

Compassion and acceptance — knowing in the moment, today, you are doing the best you can, working and leading with integrity, respect, collaboration, and excellence;

Commitment to improvement — knowing you must and will improve and do better tomorrow; you will not only do your work, but [also] improve your work, with humility, empathy, grace, curiosity, and a growth and learning mindset; and finally

Conviction of love — to always work and lead with love for those you lead, for yourself, and for each other.

I firmly believe that the future of healthcare will be determined by whether clinicians step up to lead in all areas of healthcare leadership and collaborate with non-clinician leaders. We need their expertise and they need our expertise.

Please continue stepping up, speaking up, and leading.

O. Scott Lauter, MD, MBA, FACP, FHM

O. Scott Lauter, MD, MBA, FACP, FHM, is retired chief medical officer for Atlantic Medical Group, 2016-2023.

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