Dyad Leadership
Wanted: Roadmap for Effective Dyad Leadership
Historically our department, in a large academic medical center, had relatively little physician leadership and clinical operations were controlled by non-physician administrators and managers. As new, eager physician leaders have joined our program to effect change, there is tension in clarity of roles. Would love to have input on methods to support effective, positive, nimble, collaborative physician-administrator dyad leadership to support high quality, patient centered care. Am looking for concrete evidence-based methods that have demonstrated success at other large medical centers (beyond “encourage everyone to get along with each other” and “go on a retreat!”) What are best methods to move away from separate organizational structures where one side is administrators/managers and the other side is physicians? Our “functional” organizational structure has led to the two groups having challenges implementing rapid change. It is not clear when there are disagreements who has the final authority to make decisions. The leadership structure and roles are not completely clear. Big decisions seem to pile up at the top and the two groups can tend to maximize their own goals rather than that of the total organization.
We’ve see our dyads grow stronger the more we align the performance and incentive goals.
Dyad leaderhip is challenging according to my experience. It only works if the individuals work well together and complement each other. I would advice you to consider changing the organizational structures so that you have only one leader – either physician or admistrator – and the other reporting to him. If you create a matrix, it must be very clearly clarified and agreed how has the final say when final decisions must be taken. In hospitals it is always practical to have a person with medical background in that role if you just have to skilled physicians to do that.
I must have clear description of the roles and responsibilities documented and agreed. It’s important to set joint goals and KPIs for the medical leaders and administrators. It is also important to create joint leadership forums to increase and facilitate the interactions between the two groups. When setting the goals and KPIs, keep the patient in focus, and start from considering what creates value from them.
Our organization initially experienced what you described above (two camps that run parallel, but not together). The functional success was dependent on how well the two people in the dyad got along. It was difficult to understand who really had authority and who was ultimately accountable. Each hospital had a president who reported to the system COO and also had a CMO who reported to the system CMO. That model created two distinctively separate teams. After our new (new to the organization in 2015) came, he changed the reporting structure. There is one accountable person for the performance of the hospital, and that’s the site president. The CMO reports to the president. (note, some of the hospital presidents are physicians. model is not about physician versus non-physician). Although the change initially controversial, it has been very successful for driving overall performance.
I agree with many of the above comments around alignment and structure within the organization. However, as our healthcare systems become more and more matrixed through acquisitions, growth, and the general complexity of healthcare, I think we will all have to get comfortable working within and making decisions as multidisciplinary leadership teams where hierarchy might not be clear or is lateral. This might be more pertinent to the midlevel of leadership/management where I see a lot of dyad and even triad leadership structures emerging.
We implemented a dyad model approximatley 5-6 years ago in an attempt to improve physician engagement and to help identify future physician leaders. Similar to above comments, some dyads work very well together and some do not. When we originally rolled this out, clear expectations were not set and we ran into similar issues with who was the final decision maker and lines of authority. Over the years we’ve done better at clarify roles and responsibilites, providing training to the dyad partnerships, and setting specific targets and goals for service lines.
We also struggle with our “dyads” however there are several key strategies/tactics that have helped with alignment:
1. You need very tight alignment in the dyad at the top of both the physician and nursing/administrative chain of command. In our case its the hospital CMO and CNO.
2. Set very clear goals and expectations for the dyad and align incentives/compensation to achieving these shared goals. The goals should cascade down from the board. Create a dashboard to measure goals (quality, patient safety, operational metrics, financial, etc.)
3. Focus on coaching rather than solving disagreements or poor accountability. Formal training in Crucial Conversations can help the dyad navigate uncomfortable or difficult conversations.
4. Keep the patient at the center of your decisions.
5. Strong communication – Regular meetings with shared agenda. At least weekly brief check-ins or huddles.
6. Visibility & Managing up – Regular joint leadership rounds. Manage up each other with front line staff and physicians.
We have had dyad leadership at many levels across our organization. We have set tight expectations of working together with shared goals.
The Washington State Medical Association has a dyad leadership course that has been helpful particularly for our newer leaders to help sort out how they work in a dyad relationship. https://wsma.org/WSMA/Resources/Physician_Leadership/Dyad_Leadership_Course/WSMA/Resources/Physician_Leadership/Dyad_Leadership_Course/Dyad_Leadership_Course.aspx?hkey=52afb8c4-f251-4836-89ea-893f550119f6
Triad leadership works best in our organization when very strong leaders are selected for all three positions, and when upper level leadership makes it clear that no one person’s role is more important than another’s. There is a venn diagram of tasks/roles with discrete functions that each person is responsible for, but there is an emphasis on collaboration in the areas of intersection. While there may occasionally be cases where one person has to lead and the other two have to follow, I can’t think of why that would always have to be the same person. There may be situations where a nursing leader has more relevant experience, and others where a physician or managerial leader would have more to offer. Mutual respect is the key; choosing the right people from the start is important; and most important is a mandate from senior leadership that triad (or dyad) harmony is paramount.
at our institutions, dyad management is common. In general, the physician manages the physician side and the admin the staff side. Tactical and strategic decisions are shared and must be common to the two sides. Incentive pay which is about 30% shares the same outcome goals. This helps keep the two aligned. As has been mentioned, interpersonal chemistry and respect is a must.
I recognize the challenge. We have a well balanced system in place, but you always need to put it back on track on regular basis. Here some elements on how a right mix between managers and physicians is put in place in our organization:
1) Governance:
– Our board is composed by a mix of physicians and non physicians –> this allows to also always have at least a medical perspective/points of view in the management décisions taken
– Our Chief Medical Officer is part of the executive committee and reports to our CEO
– Our Medical Counsel is composed by 16 physicians (= kind of medical union)
– Our organization (moving to matrix structure) is composed by medical clusters. A physician is leading every cluster together with a nurse leader and a performance manager
2) Build a strategic and tractical plan together
The executive committee developed a detailed strategic plan based on a clear strategy map. We built it top down + bottom up. Every one in the organization (employees, physicians, non physicians, …) know our strategic plan. Based on this we ask every medical service lead to build his own medical tactical plan –> so we have an alignement between the hospital strategy and the teams stratégies/actions.
3) Presence at leadership meetings
We quaterly organize a management meeting (non physicians managers) where some representative physicians are present to be aware about the information, the problems discussed, performance review, …). And also some non physicians ans executive committee assist to the quaterly medical leadership meetings.
As you may know, “dyad leadership structure” is a social pull for physician migration to a health system and most organizations now adopt this leadership structure as a means of attracting physicians and partnering with them. Personally, I was a Care Division Medical Director in a Dyad partnership with an Administrative Director for our division. We went through a structured once a month Co-Leadership Class for one year where different leadership tools were provided and we were made to think through divisional projects or answer burning questions together during these classes and when we ran into a road block of who should make the call, we got a coach to help us navigate. Bottom line, you have to define the roles of the physician and the administrator abinitio. For my division, I led all clinical decision making process including formulating policies, protocols and procedures, ensuring quality and safe medical care for our patients and my dyad partner runs the day-to-day administrative process and non-clinical patients’ complaints/.concerns. We conduct interviews together but my partner decides on non-clinical staff, I decide on clinical staff.
Our dyads have very intentionally sat down and mapped out who has responsibility for what. At our executive leadership team they also occasionally start a meeting reminding each other to “stay in their lanes”.