This article is more than 5 years old. Information may no longer be current.
Dyadic leadership model is well suited for dialysis center management
Improving patient outcomes, satisfaction and safety while using resources responsibly is foundational to the ever-changing world of kidney health care delivery. Leadership that succeeds clinically and operationally is necessary for success in this world. Given that this combination is not always easy to find in one person, the requirement for such leadership naturally lends itself to the dyadic leadership model.
Ironically, dialysis facilities are required by conditions for coverage to have dyads in place. These requirements dictate that a facility medical director is expected to ensure the delivery of quality patient care and clinical outcomes with responsibilities that include quality assessment, performance improvement, staff education, training and performance, involvement in the policy and procedure development and review, as well as patient admissions, infection control and patient safety. The dialysis center also has an administrator who is responsible for the management of the center and provision of dialysis services with oversight of staff appointments, the financial operations for the center, the relationship of the center with outside entities, making sure the center is adequately staffed and diverse members of the interdisciplinary care team are appropriately qualified and available to take care of patients.
Despite this logical pairing, dialysis care has been slower to embrace the dyadic leadership model formally compared to other parts of health care. In a recent New England Journal of Medicine Catalyst Insights Council Survey, 72% of respondents indicated their organization uses the dyad model and 85% said dyadic leadership is an effective, very effective or extremely effective leadership model. According to research conducted by the Physician Executive Council, leadership dyads — in which oversight of activities is shared between clinical and administrative managers — can be highly effective and are a powerful leadership solution.1
Case model
While the use of dyadic leadership in nephrology may be limited, within DaVita Kidney Care this leadership model has demonstrated tremendous potential. With one center in particular, the facility administrator and medical director credit their dyadic leadership partnership with measurable improvement in outcomes. They included driving down patient central venous catheter (CVC) rates to 10%, obtaining a five-star rating from the Five-Star Quality Rating System, top ESRD Quality Incentive Program (QIP) scores and improving team member retention and patient satisfaction. The model was credited with helping drive a culture of patient-centered care with a focus on patient safety, high reliability and quality. It also was said to have aided both clinical and operational leadership in navigating the complexities characteristic of the current regulatory and care delivery system.
With such results, it is worth exploring the dyadic leadership model as a method of providing modern clinical leadership in dialysis. Other areas of health care have been developing this management model with success, and nephrology may be naturally well positioned to follow suit.
Leadership dyad
A leadership dyad is a formalized partnership in which an operating leader is paired with a physician leader, aligning their skills and efforts to advance a clearly delineated mission, vision and set of goals. The successful dyad fosters a culture of shared ownership of the operational, financial and clinical objectives of the organization to deliver leadership in a way that is greater than any one individual in the organization. The effective complementary leadership dyad is built on a foundation of trust and respect. It requires leaders and team members to maintain a constant, fluid exchange of ideas and feedback as a cohesive center culture is developed, with each participant in the process acting as a valued contributor and demonstrating a shared commitment to a common vision and strategy.
By necessity, leadership models and relationships have already developed between facility administrators and medical directors in dialysis centers. The dyad is not an alternative; rather, it is a progressive step in the development of the essential partnership to oversee the dialysis center. A leadership dyad formalizes the partnership and creates additional structure and accountability to make that partnership more effective. Through planning, communication and collaboration, it paves a smoother path toward achieving center goals and desired clinical outcomes.
In a successful dyad, the two leaders work to find common ground and present a united position as they navigate the challenges inherent in successfully running a dialysis center. An effective dyad is often referred to as a “work marriage,” with the two partners working toward a common goal, complementing each other’s skills and offsetting each other’s weaknesses.1 The leadership pair must learn to trust each other; support shared decisions even when those decisions represent a compromise; and continually communicate and adjust as situations change and new challenges arise. So it is with a leadership dyad. When successful, the task at hand of delivering high-quality, safe patient care works efficiently and effectively.
Work toward shared goals
In the beginning, perhaps the greatest difference between the status quo and a formal leadership dyad is the intentional thought, strategy and planning underlying the leadership partnership. One way facility administrators and medical directors can take the first steps toward a true dyad is to acknowledge that they both are accountable to their patients. A basic and most important focus is a common denominator that solidifies the dyadic partnership.
An effective leadership dyad also must articulate the common vision, mission and shared goals that will serve as the basis for their co-leadership efforts. While many centers already participate in this type of exercise, formalizing, verbalizing and documenting these key foundational elements of the partnership is a logical next step in securing a commitment from both leaders for their joint work. The leaders must agree on the work that needs to be accomplished and establish a structure and management processes for completing that work as a team. Along the way, it may be helpful to establish clinical, patient service and business goals in addition to a strategic plan and related goals.2
A common thread that can weave these goals together is often beneficial in accelerating the process of establishing shared goals and articulating a common vision and mission for a center. For example, driving a collaborative culture of patient-centeredness — achieving what is most important to patients — is a fundamental shared goal that can unite leaders in a dyad as they strive to improve operational efficiencies and patient outcomes. Another reasonable starting point to determine shared goals and a common vision is the quadruple aim. As with all health care institutions, a dialysis center must strive to perform well in all of the following four domains: improving the health of populations; enhancing the patient experience of care; reducing the per-capita cost of health care; and improving the work life of its clinicians and staff.3 Successfully delivering on these objectives serves as a foundation for a center’s activities, goals and processes.
By collaborating in this way, the facility administrator and medical director balance priorities to ensure there is not too much emphasis in one domain. Likewise, the continual and open communication between the leaders ensures all major areas of performance are properly addressed. The clinical voice is fortified in fundamental management decisions, while clinicians learn to appreciate the fiscal and regulatory pressures and operational goals of a center. The joint leaders work together to constantly prioritize available resources for the benefit of patients, providers and the center.
As the relationship continues to develop within the dyad, the partnership can address day-to-day concerns that present themselves and can coordinate on how to tackle core concerns of the center. “What keeps you up at night?” is a recurrent question in dyadic leadership meetings. Once items have been raised, various approaches can be taken such as root cause analyses to help identify what may be interfering with a center’s ability to meet its goals. These thoughtful conversations can help generate new ideas or re-direct existing resources and time toward continually making the care environment safer, achieving better outcomes, improving job satisfaction for clinicians and elevating the business success of a center.
When a dyad works well, everyone within a center has a forum for their concerns to be recognized and their voice to be heard. That lends a sense of well-being and security to the team, sets the stage for shared learning, and creates a culture where anyone can lead, regardless of title. Performance pressures exist in a dialysis center, and the learning culture fostered by a dyad can create a better understanding of those pressures while at the same time identifying not just which individual in the dyad but who among the team can help alleviate those pressures. It is important both leaders have the proper authority and institutional support to effect change within their respective domains to achieve the goals of the dyad.
Overcome challenges
As with any relationship, trust and respect must be present in the dyad relationship for it to thrive. Likewise, a dyadic leadership partnership also requires an investment of time, patience and effort.
If a center involves the medical director in the hiring of the facility administrator, it helps to emphasize the importance of this partnership. It also underscores for incoming administrators the value of the clinical voice in the center’s operation. For centers with well-established leaders in these roles, coaching, mentoring and emotional intelligence training may be necessary to help them form a more effective dyad.
There are many variables outside of the dyad itself that can influence its evolution. In evaluating whether to implement this type of leadership model, the adaptive capacity of the organization should be taken into consideration, as well as the external environment and pressures and the internal organizational culture. For a dyad to be successful long term, the organization must commit to the design and support that commitment, including by investing in the development of physicians as co-leaders and co-managers.2
The leaders must be able to communicate openly and honestly with each other; agree to disagree at times and still commit to final joint decisions. They should present a unified front as difficult decisions are implemented. Despite differences in opinion, both leaders must recognize and focus on their common interests, as outlined in the center’s vision, mission and goals. In the event a dyadic leadership team is unable to resolve its differences and lead together, there should be a clear escalation process in place to facilitate a resolution.
Because both leaders in a dyad face significant time constraint, specific and measurable goals for the partnership — as well as for each individual leader — are essential. Accountability measures help ensure that the joint work of the dyad remains a priority. This can take many forms. Measures already exist for physician, employee and patient satisfaction. The effectiveness of a leadership team also is evident in the clinical outcomes metrics that reflect a reduction in harm and improvements in patient safety, including reducing central venous catheter rates and infections, improving five-star ratings and QIP scores and reducing hospital admission and readmission rates. Finally, performance scorecards can be useful in monitoring and evaluating both clinical and business performance. Specific and measurable goals within these performance areas underscore the importance for each leader to dedicate the necessary time to accomplish his or her work and to prioritize the joint work of the dyad.
Benefits of dyadic leadership
While the successful implementation of a dyadic leadership model requires planning and effort, the potential return on that investment can include a culture of operational and clinical excellence, improved clinical, regulatory and business performance and improved clinician satisfaction and retention.
Establishing a shared vision, mission and goals and keeping open lines of communication about how to achieve those objectives can help reduce the tension that naturally exists between operational and clinical leaders in a center. Prioritizing a healthy relationship built on trust and mutual respect between these leaders also sets a tone of cooperation that can help improve the culture of the entire center.
The presence of a unified and focused leadership team helps build confidence and a sense of security among staff and patients alike. It creates a format for resolving problematic issues, as well as for identifying opportunities for increased efficiencies that do not sacrifice the importance of patient interactions and patient care.
Francis W. Peabody said, “... for the secret of the care of the patient is in caring for the patient.”4 The dyadic leadership model reintroduces a significant opportunity for physicians to participate actively in discussions and decisions that are meaningful in caring for their patients. This can feed into the philosophy of practice of a physician.
Physician burnout also has been associated with negative consequences on health care system costs, the care and safety of physicians, and patient care. The dyadic leadership model also provides a framework for clinicians to develop critical leadership skills and provides them with an opportunity for professional and personal growth. With physician burnout symptoms near or exceeding 50%, these opportunities are increasingly important.5
Health care worker job satisfaction has been shown to be a parameter that influences productivity as well as quality of work.6 On the operational side, retaining skilled clinicians who are satisfied in their roles also allows for the dyad to build and retain the right team that then affords an opportunity for a center to focus time and resources on achieving target performance metrics and goals, particularly in terms of patient safety and outcomes. This clinical and regulatory success serves clinicians and operators alike and is important in helping ensure the fiscal success of a center. Clinical and operational successes in nephrology are interconnected: They do not exist in silos. The dyadic leadership model recognizes that reality.
Models worth exploring
The practical lessons from the success of the dyadic leadership model in other parts of health care and the fact that the dialysis center, a novel health care construct for a specific set of patients, has the regulatory requirement for two leaders,1 sets the stage for additional study of this model in kidney care. The partnership, if executed successfully, can create an exceptional blend of clinical, operational and business expertise that can elevate performance of a center and drive what is of greatest important to all of us in this industry: clinical outcomes. It also provides a unique opportunity to consider how this model facilitates better management of other complex, high-risk patients, such as patients with late-stage chronic kidney disease where combined clinical expertise and operational excellence are of great value.
- For more information:
- Bryan N. Becker, MD, MMM, FACP, CPE, is chief medical officer for DaVita Integrated Kidney Care.
- Shawana Rivero, RN, is group facility administrator.
- David A. Roer, MD, FACP, FASH, FASN, is vice president of medical affairs for DaVita Integrated Kidney Care in Denver.
- References:
- 1. Trandel E. Advisory Board Co. 2015; www. advisory.com/research/physician-executive-council/prescription-for-change/2015/03/dyad-leadership-slides.
- 2. Zismer DK, et al. Physician Exec. 2010; 36(1): 14-19.
- 3. T Bodenheimer, et al. Ann Fam Med. 2014;doi:10.1370/afm.1713.
- 4. Peabody FW. JAMA. 1984;252:813-818.
- 5. West CP. J Intern Med. 2018;doi:10.1111/joim.12752.
- 6. Janicijevic I, et al. Hippokratia. 2013;17(2):157-162.
Disclosures: Becker, Rivero, and Roer report no relevant financial disclosures.