Author: James Adams




"In the pure and physical sciences, each generation inherits the consequences made by its predecessors. But in the moral sciences, particularly the arts of administration, the ground never seems to be incontestably won."
Edinburgh Review, 1843


"Business pundits seem to be forever rediscovering the truths known to those who lived generations earlier."
Hayes Law of Circular Progress
Robert Hayes, Harvard Business School


There is an art and science to management that can only genuinely be gained with experience. The director must begin with medical expertise and the ability to work as part of a team, possess a strong character, and exhibit professionalism and ethics. Without these, there will be no operational respect or enduring success. Added to this mix is other technical knowledge: quantitative methods of operational performance, basic economics, service principles, the role of technology, human resource management, how to develop strategic alliances, and a keen sense of how to manage from the middle. If all of this sounds like an impressive skill set, it is. Yet it is highly achievable for those with the desire.

The greater challenge is to be truly effective, to continue to improve the department, to advance the quality of care, and to promote good relationships along the way. To also be successful at an academic career is a rare achievement. This chapter will offer thoughts about how to achieve maximal success. Fundamental skills and insights will be offered for your consideration and academic opportunities will be proposed.



The Art of "Followership"
Every good leader must also be a good follower, a follower of principles, of values, of a worthy goal, and of principled others. This is the big secret of success. The best leaders follow a vision, have a goal, and profoundly believe in something that it is worth the time and effort devoted to accomplishing it. The best leaders also find wise mentors from whom to learn. To be a leader, one must first and always be a follower, a listener and a learner.
The first question is whether there are principles that you believe in strongly enough to make the sacrifices required for real success. If so, you will find abundant opportunity to make a difference. The specialty of emergency medicine, the health care system, and society in general, not to mention ED patients, need moral leaders who are willing to struggle with the realities of our health care system in order to provide better care for all who require it. This is not an easy fight. In this struggle, however, is personal and professional fulfillment and, ultimately, a life well lived. At the end of your career you will have made enough money. It would be good to leave a positive legacy as well. You can do this in an administrative role by helping, in ways small and large, to improve the system of care delivery.

At the outset, one must have conviction, but must listen and learn. Arrogance has no place. Humility is the better guide. Listen more than you talk. Learn as much as you can. Get to know people, systems and processes better than anyone else. Understand the priorities of the organization, of the CEO, of your Chair. Be a good follower, but do not be a blind follower. Understand the good goals of the leaders and commit to them for the proper reasons. Commit to the goals because they promote service to the patient.




Professionalism and Ethics
When taking on administrative roles, one must be keenly aware of professionalism and ethics. Self-serving behaviors or actions not in keeping with the ideals of the profession will weaken you and the department. The profession of medicine is, after all, grounded in service: to the patient, to society, and to each other. Realizing that our practice is as much a moral undertaking as a scientific one will help you comprehend the challenges and confront the dilemmas that will surely arise.
Grounded in proper ethics, the effective administrator is less a dictator and more a steward. Stewardship embodies the realization that all who work in the ED are parties to its success or failure. The enterprise is not exclusively a competitive, self-aggrandizing, financially enriching corporate undertaking. It an ethical, intensely human activity that defies autocratic control. Often the greatest authority is gained not from the power of position, but from moral authority.



Key Skills of the Clinical Director


The Secrets
Perhaps you are a good follower, an aware, astute, confident, but humble emerging leader. Perhaps you do understand the importance of professionalism and ethics. Perhaps you can be confident in your ability to learn the details of administration. Will you then be a great director? A few more secrets must first be revealed to you.

1. As George Carlin once said, "Don’t sweat the petty things and don’t pet the sweaty things." You must learn when you should act and when you should not. You cannot possibly deal with every issue, each problem, every conflict, every behavioral outburst, every inefficiency. You cannot solve every problem, nor should you try. You should not even solve every issue that you can. Some will go away. Other people can solve some. You must choose your challenges wisely.

2. Do not forget to reward good behavior. Positive reinforcement changes behavior most efficiently. Don’t just be a behaviorist, though. Be a good steward. Recognize and reward those who help you solve problems, those who demonstrate efficiency, those who exhibit kindness. A complimentary word in public, an expression of confidence, and recognition of a job well done is a powerful driver of cultural change.

3. Remember the words of Winston Churchill, "You make a living by what you get, you make a life by what you give." You will be happy and more rewarded in the end by giving of yourself, your time, your values, your commitment, and your best effort. You should choose the job for the goals you can achieve, not for what the job can do for you. Advocate for the mission, not for yourself. A self-centered person has a terribly difficult time as an ED director.

4. Never separate authority and accountability. Everyone in the ED wants control, wants authority, and wants to be in charge, but few want the responsibility that goes along with it. Many people will want to give input, offer suggestions, and exercise control. This is only good and proper as long as the authority of the person is concordant with accountability. It is easy to complain, it is easy to make suggestions, but it is difficult to deliver solutions. Insist that any person that has authority also has responsibility for the outcome. To the biggest complainers, offer responsibility, but never reward bad behavior. If a person wants to act with authority, make them responsible for the result, as much as possible.

5. Be aware of incentives. Every human being acts according to the way that they are incentivized to act. Be careful what you reward. If all you track is billing and clinical hours, that is all you will get. Reward the behaviors that you seek: maybe with money, but also with attention, awards, newsletter articles, and other non-tangible incentives. Give an award for collegiality, best leader, or most team spirit. Back it up with some reward in the schedule if you can, but do not behave as though clinical work is a penalty. Never incentivize the complainers. If you attend to those who complain the most, you will get more complaints. Make sure that you have an equitable system (no system is ever perfectly fair), and provide disincentives to complain. When a tough call on the schedule has to be made, give it to the complainer, never give it to the person who will take it quietly.

6. Early in my career, a senior physician pulled me aside and gave me some of the best career advice ever. He said, "You don’t topple a wall by punching it. You line up all of your strong forces and push slowly and steadily. The wall will fall." Applied to any ED problem, this advice remains true. The ability to align forces and push together, with patience and perseverance, is a rare talent. Sometimes it is more natural to punch. However, great emergency departments are never built by impulse, only by deliberate, thoughtful work of talented, persistent people who can enlist strong allies from inside and outside of the department.

7. Control things, lead people.
 

The Bad News

Unfortunately, the skills of talented directors are not fully appreciated. It is difficult to evaluate success because the nature of the emergency department is that of an uncontrollable morass. External forces often shape ED performance and the patient’s experience. The best efforts of great directors are often overshadowed by the looming problems of insufficient inpatient bed availability and uninsured patients. Major problems of the emergency department rest outside of its walls. Still, we have immense opportunity to improve internally. We can generate better teamwork, more highly coordinated processes, and more efficient ways of providing care. This is not an easy challenge. So the job is one of great frustration. Worse, academic promotion rests on teaching, publications, generation of research grants, and national recognition. So while the director labors against local challenges and external uncontrollable forces, academic promotion can suffer.
So who would possibly want this job? Many who take on this job would be even more frustrated if they were not involved in attempting solutions. Others have missionary zeal in their effort to take on insurmountable challenges. All are dedicated and motivated to create an excellent environment for care. The best and brightest also turn the operational work into their academic opportunities.



Academic Opportunities for the ED Director
Public Health


The ED director is confronted with care for the uninsured and underinsured, those with nowhere else to go, and patients that overflow from other parts of the health care system. The emergency department is presumed to be infinitely expansible. Doctors offices can close, inpatient units can cap, operating room schedules can fill. When these events occur, the emergency department is expected to handle it all. As a specialty, however, we must continue to illustrate the problem, through data. This data must be scientifically reported and properly disseminated or it cannot be influential. This is a natural academic opportunity, for it is the ED director who understands the important research questions.


Clinical Epidemiology

Public Health and Health Services Research are based in the science of clinical epidemiology. The emergency department is a unique window to the health of the population and the health care delivery system. The director has the opportunity to set up surveillance systems, to participate with public agencies, to standardize reporting and to generate databases of disease, and to implement follow up mechanisms to track outcomes. The ED director can work with the Centers for Disease Control and Prevention, state agencies, or local partners. The ED director can find mentors, training opportunities, and funding. None of this is easy, but the director has the ability to slowly, methodically, construct a system that helps us gain a larger view of the diseases we treat, the people we care for, and the system in which we work.


Technology
We might believe that technology will make the ED run better. Perhaps this is true, but the opportunities have not yet been fully realized. Done properly, technology promises to transform our care delivery system. If we persist in the historical mindset that the job of physicians is to search for patient data, search for information, and search for critical results, then technology will have us do the work to log on, wait, punch, peck, and click. Done properly, the information needed will be delivered to the right person at the right place at the right time. The ED director is in a position to develop such standards and must be a forward thinker in this regard. Critical analysis of technology and the emerging role of information systems can be led by emergency department directors.