MGT-20191-XH136 Healthcare C… Project & Resources Table of Contents Announcements Project Discussions JG Project Results FAQs Calendar James Griffin Support Tools Project Instructions Project Instructions # " Listen ! Competency In this project, you will demonstrate your mastery of the following competency: Support cross-func!onal collabora!on by evalua!ng organiza!onal structures Scenario You are the assistant office manager at the new Mendingville Urgent Care, which is part of the Mendingville Health System. Your manager, Karen Foreham, wants to make sure that the organiza!onal structure of the facility fosters cross-func!onal collabora!on and teamwork from the beginning. To that end, Ms. Foreham has presented you with a list of organiza!onal structures that have been successful at other urgent care facili!es in the area. She asked you to review the list, research the structures, and provide your recommenda!on for the organiza!onal structure, either from the list or from your personal knowledge and research, that you believe would best support cross-func!onal collabora!on and teamwork within the clinic. She would like you to provide an evidence-based jus!fica!on for your : choice and a descrip!on of the corresponding teamwork and collabora!on strategies, policies, or procedures that should be implemented as a result of the recommended organiza!onal structure. Direc!ons Ms. Foreham has emphasized the importance of choosing the most appropriate organiza!onal structure for the facility. A#er reviewing her list and researching the various organiza!onal structures, you will submit a 500- to 700word wri$en recommenda!on. 1. Research the following organiza!onal structures: Func!onal Hierarchy Divisional Matrix Flatarchy 2. Recommend an organiza!onal structure. You must iden!fy the organiza!onal structure you are recommending and address the following ques!ons: What are the key components of the organiza!onal structure you are recommending? Which components influenced your decision, and why? How does the organiza!onal structure support cross-func!onal collabora!on and teamwork? What are the roles of key personnel within the organiza!onal structure in suppor!ng cross-func!onal collabora!on? 3. Iden!fy the strategies, policies, or procedures that should be implemented as a result of the recommended organiza!onal structure. What key strategies, policies, or procedures should you implement based on your recommenda!on? How will the strategies, policies, or procedures impact teamwork or collabora!on? (Address expected : improvements, as well as the implica!ons or consequences of not following the strategies, policies, or procedures.) What to Submit Every project has a deliverable or deliverables, which are the files that must be submi$ed before your project can be assessed. For this project, you must submit the following: Organiza!onal Structure Recommenda!on You will submit a wri$en recommenda!on for an organiza!onal structure and the strategies, policies, or procedures that will support cross-func!onal collabora!on and teamwork within your facility. Your recommenda!on must be 500-700 words. Suppor!ng Materials The following resource(s) may help support your work on the project: Reflect in ePortfolio Download Print Open with docReader Activity Details Task: View this topic : Read all about your project here. This includes the project scenario, directions for : completing the project, a list of what you will need to submit, and supporting materials that may help you complete the project. Bokhour et al. BMC Health Services Research (2018) 18:168 https://doi.org/10.1186/s12913-018-2949-5 RESEARCH ARTICLE Open Access How can healthcare organizations implement patient-centered care? Examining a large-scale cultural transformation Barbara G. Bokhour1,2, Gemmae M. Fix1,2*, Nora M. Mueller3, Anna M. Barker1, Sherri L. Lavela4,5, Jennifer N. Hill4, Jeffrey L. Solomon6 and Carol VanDeusen Lukas1,2 Abstract Background: Healthcare organizations increasingly are focused on providing care which is patient-centered rather than disease-focused. Yet little is known about how best to transform the culture of care in these organizations. We sought to understand key organizational factors for implementing patient-centered care cultural transformation through an examination of efforts in the US Department of Veterans Affairs. Methods: We conducted multi-day site visits at four US Department of Veterans Affairs medical centers designated as leaders in providing patient-centered care. We conducted qualitative semi-structured interviews with 108 employees (22 senior leaders, 42 middle managers, 37 front-line providers and 7 staff). Transcripts of audio recordings were analyzed using a priori codes based on the Consolidated Framework for Implementation Research. We used constant comparison analysis to synthesize codes into meaningful domains. Results: Sites described actions taken to foster patient-centered care in seven domains: 1) leadership; 2) patient and family engagement; 3) staff engagement; 4) focus on innovations; 5) alignment of staff roles and priorities; 6) organizational structures and processes; 7) environment of care. Within each domain, we identified multi-faceted strategies for implementing change. These included efforts by all levels of organizational leaders who modeled patient-centered care in their interactions and fostered willingness to try novel approaches to care amongst staff. Alignment and integration of patient centered care within the organization, particularly surrounding roles, priorities and bureaucratic rules, remained major challenges. Conclusions: Transforming healthcare systems to focus on patient-centered care and better serve the “whole” patient is a complex endeavor. Efforts to transform healthcare culture require robust, multi-pronged efforts at all levels of the organization; leadership is only the beginning. Challenges remain for incorporating patient-centered approaches in the context of competing priorities and regulations. Through actions within each of the domains, organizations may begin to truly transform to patient-driven care. Keywords: Patient-centered care, Organizational change, Qualitative methods, Leadership * Correspondence: Gemmae.Fix@va.gov 1 Center for Healthcare Organization and Implementation Research, ENRM Veterans Affairs Medical Center, Bedford, MA, USA 2 Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA, USA Full list of author information is available at the end of the article © The Author(s). 2018 Open Access The article is a work of the United States Government; Title 17 U.S.C 105 provides that copyright protection is not available for any work of the United States Government in the United States. Additionally, this is an open access article distributed under the terms of the Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0), which permits worldwide unrestricted use, distribution, and reproduction in any medium for any lawful purpose. This work was done under the auspices of the US Department of Veterans Affairs. The views presented here are those of the authors and do not necessarily represent the views of the US Department of Veterans Affairs. Bokhour et al. BMC Health Services Research (2018) 18:168 Background Since the Institute of Medicine identified patientcentered care (PCC) as a critical aspect of quality, there have been many initiatives to promote PCC in healthcare organizations [1]. PCC represents a shift from traditional, paternalistic, provider-driven, disease-focused approaches towards healthcare systems that ensure patients—including their preferences, needs, desires and experiences—are fully integrated into every phase of medical consultation, treatment and follow-up [2]. PCC includes empowering patients, focusing on the patientprovider relationship, and enabling providers to partner with patients to better meet patient goals. Research has demonstrated the effectiveness of PCC innovations in improving patient experiences, trust, care quality, chronic disease management and outcomes [2–6]. Yet, despite many years of discussion about PCC and its impact on health, healthcare remains largely providerfocused and disease-driven. Little is known about how best to transform a traditionally provider-centric care system into one where patient preferences and goals drive care and sustain this change [7–9]. One study of hospitals identified several key organizational and patient-level practices associated with high scores on patient experiences on inpatient units, including a focus on nursing practices, leadership rounds and accountability for clinician behavior [10]. Other studies looking at facilities excelling in patient experience identified key practices for fostering PCC, including strong leadership commitment, communicating a strategic vision, systematic measurement and feedback and having accountability and incentives for providing PCC [11, 12]. Yet our understanding of organizational practices necessary to shift the culture of a large healthcare organization to implement and embrace PCC remains incomplete. Implementation science provides conceptual frameworks for understanding how healthcare organizations can implement evidence-based practices. Frameworks such as the Consolidated Framework for Implementation Research (CFIR) typically focus on discrete, evidence-based clinical practices, yet are applicable to assessing implementation of broader system-level PCC transformation [13]. The CFIR identifies a menu of constructs within five areas (intervention characteristics, inner setting, outer setting, individual characteristics, and process) that interact to influence implementation. Examples include: strength of evidence for an innovation (knowledge and belief about the innovation); innovation fit within the organization’s practices (adaptability, trialability, relative priority); organizational readiness to implement change (implementation climate, relative priority); roles of leadership (engagement and resource allocation); and engagement of staff. Examining these Page 2 of 11 constructs may provide a foundation for understanding how organizations foster broad transformational efforts of a healthcare system, such as shifting towards a culture of PCC. In 2010, the Department of Veterans Affairs (VA) embarked on a mission to transform VA healthcare to provide personalized, proactive, patient-driven healthcare [14]. Senior VA leadership recognized that change for such a large complex organization would be a lengthy process requiring on-going piloting and testing innovations, evaluating outcomes, and deploying effective strategies across the system. Office of Patient-Centered Care and Cultural Transformation (OPCC&CT) provided funds to designated VA medical centers considered early leaders in PCC. These facilities became “Centers of Innovation” (COIs), living laboratories of PCC innovations spanning the spectrum from environmental changes, to personalized health planning, to integrative medicine. One front line provider at a COI defined patient-centered care: “[It] is about empowering patients to pursue wellness in service of their life goals and their own values. It’s about strengthening the patient-provider relationship. It’s about empowering providers in the work setting so that they have the best tools available … so that they are able to partner with patients”. Yet how to get this idealization of PCC into practice remains uncertain. This paper describes a qualitative study of four early COIs to inform VA leadership about how best to catalyze and sustain change across the system. Using the CFIR as a guide, we evaluated COI activities to identify key organizational factors that fostered or impeded the implementation of PCC. Methods Study design We conducted qualitative site visits in 2013 at four large VA medical centers in different regions of the country which were established COIs. All four were urban medical centers, considered to be high complexity - that is they provide a wide range of services (i.e. surgical, inpatient care, outpatient care, mental health and substance abuse services, residential and extended care, have educational and research missions and serve complex Veteran populations). These medical centers had been selected to be COIs based on a past track record of engaging with OPCC&CT and implementing some level of PCC innovation in their facilities. All centers had received prior pilot funding from OPCC&CT for targeted initiatives. They had engaged with an outside consultant organization who is a leader in transforming the culture of healthcare organizations to patient-centeredness. The centers were at various stages, with 2 centers further Bokhour et al. BMC Health Services Research (2018) 18:168 along and having embraced PCC for over 8 years, while 2 centers had more recent changes in leadership which chose to focus on PCC as a critical initiative within the prior 3 years. The institutional review board at the Bedford Veterans Affairs Medical center designated the study as quality improvement and was IRB-exempt, thereby waiving the need for review or participant consent for the study. The directors of the medical centers involved in the study provided permission for the evaluation team to conduct the study. Participants In accordance with qualitative notions of validity [15] we sought to gain the perspectives of a range of key participants with a role in PCC innovation at the COIs. We worked closely with medical center leadership, including the medical center director or associate director and PCC coordinators, to identify individuals they considered critical to the implementation of PCC innovation. Their participation in the process reflected the investment of the facility in PCC. They identified key informant providers, administrators and front line staff for interviews who played a critical role in the planning and/or roll-out of PCC innovations and cultural transformation efforts. Potential participants were contacted via e-mail explaining the purpose of the site visit and inviting participation. Data collection procedures Teams of two researchers conducted 3–4 day site visits from January–April 2013. We conducted semi-structured key informant interviews. Although most interviews were conducted individually, group interviews were conducted when the key informant brought others he/she felt were important to answering questions outlined in the e-mail invitation. For example, at one site the integrative medicine head invited other staff involved in integrative medicine programs. Interview protocols – one for leadership and one for front-line staff – were informed by CFIR constructs (Table 1). Topics included perceptions about PCC, roles of leadership, engagement of providers and patients, and challenges and facilitators to PCC innovation implementation. Interviews lasted approximately 1 hour. We audio-recorded interviews with participants’ consent; when participants declined audio-recording, we took detailed notes. Data analysis Audio-recordings were reviewed and transcribed. Team members reviewed 5 transcriptions jointly (2–4 investigators), and coded them using the established CFIR codebook [13]. Discussions regarding applicability of specific codes resulted in agreement on specified coding Page 3 of 11 definitions. Additional concepts arose through inductive analysis and led to generation of 10 additional codes to capture areas important to culture change [16]. Evaluation team members worked iteratively to ensure findings accurately reflected data to reach consensus on a comprehensive shared codebook. Constructs of the CFIR that emerged as predominant throughout the sites were identified. “Memos” were created to document ongoing analysis and constant comparison processes [17]. To make our work salient to the VA policy makers in OPCC&CT, these were then synthesized along with emergent codes, into key domains impacting PCC and cultural transformation. Supporting subthemes were identified in each major domain. Results A total of 108 participants from senior management (SM), middle management (MM), front-line providers (FLP) and other staff (OS) participated in individual or group interviews (Table 2). We found elements of all five main CFIR constructs were relevant for transforming care. These constructs, along with emergent codes, informed identification of seven domains that impacted PCC implementation: 1) leadership, 2) patient and family engagement, 3) staff engagement, 4) focus on PCC innovations, 5) alignment of staff roles and priorities, 6) organizational structures and processes, and 7) environment of care (Table 3). 1) Leadership Leadership commitment to creating a PCC organization was critical to transforming care. This domain was mentioned by almost all participants, equally by leaders themselves and front-line staff. The importance of leadership was infused throughout the interviews, and marked as critical to move forward any initiatives. Two sites discussed that prior leadership had been less supportive and it was with a shift in leadership that PCC could move forward. It was important to have leaders who served as models for PCC and actively engaged staff in local PCC initiatives. Staff reported that PCC had to be a “strategic priority, emphasized by the director” through implicit endorsement of PCC and providing resources for initiatives. We identified several important themes within this domain. Leaders must express support for PCC openly, consistently and frequently Opinion leaders, clinicians, and other staff noted that consistent and frequent expressions of support for individual initiatives and the cultural transformation as a whole were integral to successful change. Bokhour et al. BMC Health Services Research (2018) 18:168 Page 4 of 11 Table 1 Interview Questions with Associated CFIR Constructs Leadership Interview CFIR constructs I. Individuals’ background Characteristics of Individuals II. Perspectives on Patient-centered care. What is it? Characteristics of Individuals III. Pre-implementation experiences – how the organization came to focus on patient-centered care transformation and innovation. Impetus to change; challenges faced. Inner Setting Intervention Characteristics Outer setting IV. Evaluation of the initiative implementation – goals and how it differs from prior practice. Intervention Characteristics V. Description of implementation a. Training, engaging staff members, challenges and evaluation Intervention Characteristics Process VI. Future of the program a. How will PCC innovation look in the future; what will make it work? b. How innovation meets goals of patients and staff. c. Assessment of success and of difficulty in transforming and why. d. What are your lessons learned? Intervention Characteristics Process Outer setting Staff Interview I. Background of the individual CFIR constructs Characteristics of Individuals II. Perspectives on patient-centered care. What is it? Characteristics of Individuals III. Pre-Implementation experiences Learning about PCC innovation, challenges faced; how the organization came to focus on patient-centered care transformation and innovation. Inner Setting Intervention Characteristics IV. Evaluation of the initiative implementation a. What is your understanding of the goals of this initiative? b. How is this different from what you were doing previously? Inner Setting V. Description of implementation Training received; fit of the initiative with clinical practice; how staff get engaged; patient perceptions of the innovation; feedback received. Intervention Characteristics Process VI. Future of the program a. How will PCC innovation look in the future; what will make it work. b. How innovation meets goals of patients and staff. c. Assessment of success and of difficulty in transforming and why. d. What are your lessons learned? Intervention Characteristics Process Inner setting “I’d have to say the office of the director, without support from the top, you can forget about it, but our hospital director is awesome … mentions it at every single chance.” (MM). “Having the full support from the leadership at this hospital, it’s been frankly shocking. I’m a frontline worker bee and to have our hospital director saying ‘this is what we want to do, this if the future, we have to transform our healthcare culture,’ sure makes a big difference.” (FLP). As seen here, leadership’s dedication to transformation was reinforced by talking with staff, motivating them to become equally dedicated. Having senior leaders participate in each PCC subcommittee represented this ongoing support: “You’ve got to have leadership at the table … [making] decisions for it to move forward.” (SM). In this way, ideas for new initiatives and challenges could quickly be shared with senior decision makers for consideration. Encouraging staff risk-taking and getting staff feedback fosters staff engagement Leaders who encouraged risk, were open to new ideas, and actively sought feedback from staff facilitated staff buy-in and spread of PCC. One hospital director was described as “thinking outside the box,” encouraging individuals to “pilot” ideas and share lessons learned about what worked and did not work. One participant noted: “I am supported and encouraged to be a risk-taker. If [I] look at things from a Veteran-centered perspective, I will be supported.” (MM). Another way leaders garnered input was by providing an “idea box” for staff to submit ideas for PCC activities. Bokhour et al. BMC Health Services Research (2018) 18:168 Table 2 List of Participants* ROLE N Senior Medical Center Leadership Medical Center Director Assistant Director Senior Management Team Chief of Staff Associate/Deputy Chief of Staff Chief Financial Officer Nursing Leadership 13 interviews; 22 people Table 3 Seven Domains for Implementing Patient-Centered Care and Associated CFIR Constructs Domain CFIR broad construct CFIR subconstruct Leadership Inner Setting Leadership engagement Opinion Leaders Champions Patient and family engagement Middle Management Patient-centered care Coordinators and Leaders Patient-centered care Committee members Service Chiefs Voluntary Service Information Technology Pharmacy Engineering Environmental Management Services Specialty clinical Service Anesthesiology Home based primary care Integrative and alternative medicine managers Educational Leaders Health Promotion and Disease Prevention Coordinator Page 5 of 11 23 interviews; 41 people Focus on PCC innovations TOTAL Intervention Source Design quality and packaging Outer Setting Patient needs and resources 7 interviews; 7 people Networks and communications Culture Implementation climate Relative priority Learning climate Access to knowledge and information Process Engaging Opinion leaders Reflecting and evaluating Intervention characteristics Intervention source Relative advantage Inner setting Implementation climate Relative priority Learning climate Readiness for implementation Leadership engagement Characteristics of individuals Self-efficacy Process Opinion leaders Champions Alignment of staff Intervention roles and priorities characteristics Staff were given feedback regardless of the feasibility of the innovation. Leadership should model PCC for the staff and engage staff Leadership was perceived as most effective when they modeled PCC in every interaction with staff and patients. Leaders set the expectation that staff have an emotional commitment to caring for Veterans, setting the stage for practice changes. One senior manager, describing the cultural shift for all employees said: Adaptability Complexity Characteristics of individuals Identification with organization Knowledge and beliefs about intervention Self-efficacy Inner setting Networks and communication Culture and climate Organizational structures and processes Inner setting Networks and communication Culture and climate Outer Setting External policy & incentives Environment of care Inner setting Culture and climate N = 77 interviews or group interviews; 107 people *All sites had participants who represented each of the following categories. In the ‘other’ category, some sites identified these individuals as important, while others focused more on the leadership, middle managers and front line providers Design quality and packaging Inner setting 34 interviews; 37 people Other Staff Systems Redesign Coordinators Architects Interior Designers Public Affairs Officers Information Technologist Program Specialist Engaging Intervention Characteristics Staff engagement Intervention characteristics Frontline Providers Psychologists Physicians Recreational Therapists Nurses Dietitians Social Workers Process “My role within VA …is certainly to model that behavior and to be sure …that we’re driving the initiative forward, …always focusing on the Veteran, and involving the Veteran in the decision making process.” (SM). One provider noted the importance of modeling at all leadership levels: Bokhour et al. BMC Health Services Research (2018) 18:168 “The executive leaders, the formal and informal leaders, the supervisors start off sort of being this shift, being this change and modeling and very intentionally choosing, behaving different in meetings and behaving different in every interaction. Because that’s how this grows and that’s how we teach everyone all the time, every day.” (FLP). Modeling PCC also came in the form of demonstrating staff-centeredness, such as respecting and engaging staff as individuals rather than just employees. One senior manager stated he actively listened to staff’s personal stories, concerns, and needs; doing so was believed to foster staff’s similar treatment of patients. A Core cadre of leaders is needed to move PCC forward Effective leadership meant the establishment of several core leaders actively involved in PCC, including a PCC committee with members having dedicated time to pursue PCC initiatives. Moreover, middle managers played important roles. One participant described how the chief of her service leads the team towards providing PCC: “She has this vision which includes relationships, staff engagement and empowerment. That’s just what she’s like…She just puts that into reality.” (FLP). Experiencing PCC fosters leadership engagement Leadership became engaged in PCC transformation in two ways. First, several senior managers stated they visited state-of-the-art patient-centered hospitals; seeing the quality and environment of care at these facilities convinced them to initiate transformation in their own facilities. Second, emotionally salient experiences made some leaders rethink the quality of care. One member of senior management described a clinical scenario in which he realized that “providing good evidence-based care might not be sufficient.” Reviewing a case where a Veteran had committed suicide, he reflected: “His diabetes was under control, his cholesterol was good, his CHF, all his numbers were good. We’re providing this man very, very good clinical care… There was something going on with this man that for whatever reason, through nobody’s fault we didn’t discover… It was one of those ‘AHA’ moments, you know?” (SM). For this leader, the nature of quality care had shifted from traditional clinical care performance measures to one in which attention to the patient as an individual was critical. Page 6 of 11 Leadership at several facilities described spending time listening to and learning from Veterans’ stories. One director discussed how hearing a Veteran’s story of combatting alcohol abuse with yoga opened his eyes to the variety of ways people seek spirituality and comfort. He became a proponent of Complementary Integrative Medicine (CIM). 2) Patient and family engagement Capturing the patients’ voices, obtaining patient perspectives and finding out what matters most to patients and families were essential to selecting, planning and implementing PCC initiatives. This was achieved in multiple ways. First, facilities had formal mechanisms of obtaining feedback, such as open meetings for patients to speak with hospital leadership, patient surveys, and inviting patients to serve on PCC committees. For example, one site used surveys to ask patients what they would like to see done with funds received to improve the facility. This site also reported involving patients in hiring decisions for key positions. Second, informal communication between staff and patients was viewed as an invaluable mechanism to receive feedback. While unstructured in most facilities, this was viewed to be a critical first step towards PCC. “[Asking for feedback] helps create a relationship between the patient, the family, and their caregivers.” (SM). This relationship was seen as a critical aspect of providing PCC, and through ongoing informal interactions with patients and their families, providers learned what they deemed most important for their care. Finally, participants described different ways of communicating and marketing information to patients about novel PCC innovations. At some COIs, informational signs detailing specific PCC activities were placed around the facility, thereby orienting patients to the Veteran-centered nature of the facility. For example, a sign at one facility stated: “This healing environment was created for Veterans to experience activities that embody the spirit of personalized, proactive, patient-driven care.” Such signs orienting both staff and patients to the innovations driving PCC cultural change were present throughout the facility. Staff also noted the importance of directly communicating about initiatives with patients. Yet staff and leadership reported challenges finding time to do so in typical clinical encounters. Bokhour et al. BMC Health Services Research (2018) 18:168 3) Staff engagement Getting staff engaged with PCC innovations involved a process of enculturation to change attitudes and priorities. It was critical that staff see PCC as essential to care, not as another fleeting VA initiative. This relied on explicit PCC trainings and frequent messaging. One leader noted: critical. “We didn’t want employees, patients, and stakeholders to think, ‘Well, that was just a flavor of the month’….that’s just something we did for a year or so, and now we’re going to move on to something else.” (SM). Another participant emphasized the need to meet with staff in person to facilitate engagement. “Go in person as much as possible. Walk down the hall and share the vision of what you’re trying to do and ask what they think…Build consensus from the beginning.” (MM). This demonstrated the commitment of leadership, but more importantly provided an opportunity for staff to provide input and get them engaged in the process. Staff training was one mechanism for reinforcing cultural change. One attending physician described how he incorporated PCC into his training of residents to make it clear that PCC was inherent to all clinical tasks. Facilities conducted PCC specific trainings to encourage staff to integrate PCC practices into their jobs. These trainings emphasized that PCC was an extension of current practices and attitudes, rather than wholesale replacement of current ‘wrong’ practices. Moreover, one site had begun developing higher level trainings and staff meetings to reinforce the messages and ensure continued engagement in providing PCC. One key strategy in training staff was to capitalize on staff’s emotional connections through the use of Veterans’ stories of illness and VA healthcare. For example, one site created a video featuring a homeless Veteran describing how his life had improved since being in VA care. As one participant explained, “What he said on that video just always brings tears, because of the caring and partnering with him to identify what his priorities are.” (SM). Thus, the video engaged staff emotionally in the mission of taking care of Veterans. Another site discussed having Veterans tell their stories at orientation and training sessions. Emotional connections were also built at staff trainings by asking participants to describe their own, or family Page 7 of 11 members’, healthcare experiences. As one participant explained, “I think what’s the turning point for people is a personal experience. When we go to our retreats, that’s the first thing in our retreat….We make people talk about an experience, and all of a sudden the light bulb goes off.” (FLP). Another strategy for enculturating staff was to infuse PCC through multiple media modalities. Sites messaged staff about PCC frequently using computer screen savers, regular e-mails and bulletin boards. Participants at several sites described awards given to staff when their practices reflected PCC. For example, at one site the “patient-centered employee of the month” award was distributed. One PCC leader stated that she could see the effect of the work: recent award nominations referenced more of the criteria for PCC that leadership had been encouraging. Finally, opportunities to reflect on patient care practices fostered PCC. Several sites conducted “literature and medicine seminars” – in-depth discussions of literature pertaining to patients’ experiences. A participant noted, “We talked about ‘The Diving Bell and the Butterfly’, what it’s like to be a patient who can’t communicate. And that had a profound effect on me. The series is remarkable.” (FLP). The same participant also commented favorably about Schwartz rounds [18], a multidisciplinary forum where clinical caregivers discuss social and emotional issues that arise in caring for patients. “The cases are usually very challenging, and … and you don’t know how you would have done it differently, because the patients are so difficult and there’s no answer. But to listen to it, they’re very well done, and there are a number of people on the panels.” (FLP). 4) Focus on PCC innovations Novel patient-centered innovations of varying magnitude and scope were initiated by all levels of personnel: senior management, middle management and front-line staff. Notably, there were two ways in which success required involvement by all. First, innovations that started with senior leadership required mid-level champions and staff involvement to be successful. Bokhour et al. BMC Health Services Research (2018) 18:168 “[The medical director] ‘paints the landscape,’ and says: ‘Make it happen.’ Then service chiefs pick people to engage in PCC activities and that’s how front line staff become involved. [New initiatives] are occasionally mandated by leadership, and when they are, they are likely to get eye-rolls. It’s easier to have a physician champion introduce them, show that they work, be enthusiastic and willing to put in the effort: this translates to the staff.” (FLP). This could be seen at one primary care clinic that was implementing a novel personal health planning tool. Staff interviewed agreed that while the innovation started as a leadership initiative, they were fully involved in designing the process for implementation. The clinic leader collaborated with front line staff to revise the tool to improve ease of use and strategize to integrate its use into clinic flow. When asked who started the personal health planning pilot, one MM underscored this shared ownership of the initiative, saying “Everyone you talk to will say that they did it.” Second, it was important to start with simple projects that would provide early wins. These types of innovations allowed for an early introduction to patientcentered care and could be implemented quickly, and when successful could further garner the engagement of staff. When leadership was receptive and willing to take a chance in supporting a novel idea, they found “quick wins” and created “sparks” of innovation throughout the hospital. In this way, PCC was thought to be ignited in one area of the hospital and then spread to others. One participant noted: “You have to pick a project, like noise or customer service. It’s one small project and I think what I learned from our director…was the change is going to evolve over years.” (MM). One site fostered these early wins through a unit designation program. Individual units could apply for designation by indicating what steps they were taking locally to improve PCC. Specific innovations came from the units themselves, and were not dictated by the leadership. Designated units received public accolades and a sum of money to make specific improvements on their units. 5) Alignment of staff roles and priorities Staff described challenges they faced incorporating PCC practices and innovations into daily healthcare practices. When PCC was associated with implementing specific innovations, participants struggled with increased workload without alleviation of existing work burdens. Staff perceived a constant stream of shifting prioritized Page 8 of 11 initiatives, and in conjunction with other clinical responsibilities. One MM reflected, “We are all fractured like an exploding star.” Participants reported that some staff viewed practicing PCC as an additional, collateral duty which was not well aligned with their top priorities. “Some nurses do not feel that it’s aligned, because they’re saying, ‘You’re talking about… aromatherapy… and I’m trying to get a new bed so that my patient won’t fall.’” (MM). Clinical performance measures were another competing priority. The time needed to address traditional clinical performance measures on which they were evaluated interfered with attending to PCC. As one participant explained, “How can I really be patient-centered, and how can I really sit there and listen deeply when I’ve got about 11 s to do it?” (FLP). Providers not being held equally accountable for providing PCC made it appear less valued by the organization. Leaders did recognize this potential conflict. In response, they spent time trying to emphasize that PCC didn’t require a big shift in priorities, and viewed the changes to be integral to providing care. 6) Organizational structures and processes Organizational structures and processes mandated by VA and individual medical centers were often barriers to implementing PCC innovations and this was noted especially by senior and middle managers. Some participants noted that VA rules and regulations sometimes seemed at odds with a patient-driven approach to care. “Being bound by rules can steer the decision making process, instead of the very human desire to help people.”(SM). Providers remaining in organizational silos impaired abilities to provide patient-driven care. Finding ‘flexible’ and creative ways to capitalize on synergies among multiple VA services and initiatives was cited as a key strategy. “The messy work to integrate care instead of keeping up the silos that separated services [is] the only way to do PCC.” (SM). The hiring processes in VA also made it difficult to hire PCC staff. One participant describing the issues with staffing noted that, “It may not be possible to weed out the bad seeds,” referring to employees who did not Bokhour et al. BMC Health Services Research (2018) 18:168 exemplify PCC attitudes. Hiring complementary integrative medicine staff such as massage therapists or acupuncturists was hindered by issues with determining position specifications and which service would be responsible for such staff. One facility solved this by identifying existing staff with some of those capabilities. 7) Environment of care Changes in the environment of care represented a nontrivial investment and mobilization of resources. One facility, for example, focused efforts on changing the environment of care for women Veterans, creating a separate mammography suite to help them feel more comfortable coming to the VA for women’s health needs. Some participants argued that environmental changes alone might not actually have an impact on patientcenteredness with one noting that: “patient-centered care is more than just the smell of cookies.” Yet many viewed such changes as important for both staff and patient experiences. As one participant stated: “How a patient feels about a place upon entering dictates how he/she feels about the entire experience.” (MM). Environment of care changes were seen as most effective when accompanied by functional changes that facilitated patient-provider interaction. Single patient rooms were said to improve communication with providers and facilitate healing. One primary care clinic re-designed spaces to minimize unnecessary patient movement through the clinic and have mental health, social work and complementary medicine providers in close proximity. This was thought to facilitate team collaboration and encourage patient engagement with these providers. Discussion Patient-centered care cultural transformation is a complex and long-term endeavor. Our study revealed that efforts to transform the culture of care must be multifaceted and occur at multiple levels of the organization, including leadership. Efforts should work toward enculturating staff, encouraging innovation, addressing staff priorities, addressing policies and procedures that may interfere with PCC and incorporating the patient perspective in innovations. Our findings provide a deepening of understanding of how culture might change, the role of leadership in this change and other key domains that must be addressed to ultimately impact the ways in which healthcare professionals care for patients. Further, while PCC is often addressed solely at the level of engaging patients in their health care at the clinical level, our study demonstrates that change at all Page 9 of 11 levels of the organization are required for a patientcentered approach. Our findings regarding the importance of leadership, and engaging staff, patients and families mirror findings from other studies of organizations leading in PCC [11, 19]. Having a committed leadership was frequently discussed as being important for success in all other domains, such as fostering innovation and engaging staff. Our findings enhance the leadership literature by demonstrating the importance of having leaders model patient-centered care, participate in frequent direct communication with staff and encourage risk taking to foster acceptance of PCC. We saw that leadership support of feasible, easily integrated innovations could provide a foothold for subsequent innovation. But not all leaders may be on board with PCC as a high-priority initiative. For some facilities, it was a change in leadership with a new director who had already believed in PCC. For those facilities where leadership is well established, it may take some time learning about the success of PCC initiatives, such as early wins, in order to garner buy in. Having leaders experience high performing PCC facilities may help; when it’s not possible for leaders to experience PCC directly, sharing stories of PCC impact and success in implementation may be keys to garnering leadership support. These domains may work in distinctly different time frames. Enculturating staff and getting them engaged and on-board with PCC transformation takes time. Notably, sites that were further along were engaging staff repeatedly, with development of higher level trainings and the use of frequent messaging. Similarly, leadership support could take time to build up, and as we note, doing so may take repeated exposure to PCC practices. In contrast, small initiatives in discreet contexts in the medical center may be the earliest wins, and lead to the ‘sparks’ of PCC transformation. Other studies have identified the importance of measurement and feedback regarding patient experiences. The sites we evaluated were only engaged in more informal mechanisms, such as town meetings, to obtain feedback from patients. We also found that the lack of accountability and incentives was a barrier to engaging staff in PCC practices. Organizations that have such incentives in place may be more effective in transforming care [10, 11]. In our evaluation, we found that facilities were able to engage leadership and staff. Nonetheless, PCC alignment and integration within the organization, particularly surrounding roles, priorities and bureaucratic rules, remained major challenges. Notably, the VA used our findings to create policy level incentives to change by incorporating theses seven domains into senior executive performance measures [20]. Basing metrics for changing Bokhour et al. BMC Health Services Research (2018) 18:168 organizational processes on studies such as ours may yield greater success in fostering change. One systematic review of large-system change argues for engaging individuals at all levels of the organization to lead the change, establish feedback loops, attend to local history, engage physicians, and involve patients and families [7]. Extensive research on transforming primary care into patient-centered medical homes found that a focus on shifting roles and transforming mental models through staff trainings were essential [8, 9, 21]. Whereas much of the current work focuses on ambulatory care, patient-centered medical homes, our study begins to examine how PCC can spread beyond primary care to an entire healthcare organization. Several have focused on policy and legislative level mechanisms for fostering change [22]. Our findings demonstrate that change cannot be simply implemented from the top down; rather levers for change in multiple aspects of the organization, from leadership to front line staff, must be engaged for success. Our study has limitations. The study was conducted in the US Department of Veterans Affairs Medical Centers and these facilities differ from other US medical centers in that it is a government agency, not dependent on insurance reimbursement for services, and also serves a unique patient population. Other healthcare facilities implementing patient-centered care may not encounter as many administrative burdens, but may find identifying resources for implementation to be more challenging. By studying only medical centers considered leaders in PCC, we may not have uncovered critical barriers that might influence implementation at other facilities. By the very nature of being Centers of Innovation, these centers already had established key leadership support. Site leadership chose to apply; thus we may not have fully captured barriers to implementation from the perspective of those less engaged in PCC. Additionally, although many participants reflected on the history of the transformation, our site visits captured one moment in an evolutionary process. Continuous engagement in the field may yield more insights. Also of note is that some of these sites had been working towards transformation for only 3 years, and this is a first look into the organizational change that was occurring. A longitudinal study of transformation would lead to greater understanding about the how each of these domains contribute to further patient-centered care cultural transformation. Finally, we did not include patient perspectives in this study; future work should include these perspectives to understand how innovations actually impact patient care. Conclusions Although this study examined patient-centered care implementation in VA medical centers, the seven Page 10 of 11 domains we identified suggest a useful starting point for organizations for whom being patient-centered is increasingly a focus of high quality care. Understanding innovation in facilities that are leaders in PCC may be an important start to attaining broader transformation in a large healthcare organization. Even among these leading facilities, some historically supported PCC; others’ efforts were more nascent. Thus we observed variation in the degree to which each facility was engaged in each of the seven domains. Importantly, the findings regarding these seven domains were quickly taken up by VA policy makers and incorporated into key performance metrics for all VA facilities. The use of these domains has thus begun to shape the ways in which facility leaders are working towards implementing PCC. Future work in which measurement of success in attaining PCC would further illuminate those processes that move the needle furthest towards transformation. PCC requires changing the conversation and interaction between healthcare professionals and patients; however providers work within systems of care that shape these interactions. Epstein et al. argue that achieving PCC depends on three factors: 1) an informed involved patient, 2) receptive and responsive health professionals, and 3) a supportive health care environment [23]. Others are calling for a greater transformation to collaborative care further shifting the roles of patients and providers to more of a partnership [24]. Transforming healthcare systems to focus on these elements and better serve the “whole” patient is a complex endeavor, and as others have argued, requires a systems level approach [25]. Like many other healthcare systems, VA has achieved technically high quality care [26], but our findings indicate more is needed to facilitate a focus on personalized, proactive and patient-driven healthcare. Abbreviations CFIR: Consolidated Framework for Implementation Research; CIM: Complementary Integrative Medicine; COI: Centers of Innovation; FLP: Front-line providers; MM: middle management; OPCC&CT: Office of Patient-Centered Care and Cultural Transformation; OS: Other staff; PCC: Patient-centered care; SM: senior management; VA: Department of Veterans Affairs Acknowledgements We would like to thank Tracy Gaudet and Laura Krejci from the VA Office of Patient-Centered Care and Cultural Transformation for their support in this work. We also thank all of the medical center leaders and staff who allowed us to watch them work and took time to participate in interviews. Funding This study was funded by the US Department of Veterans Affairs, Quality Enhancement Research Initiative and Office of Patient-Centered Care and Cultural Transformation (OPCC&CT), Grant PEC 13–001. OPCC&CT assisted the investigators with access to the medical centers, but were not involved in study design, data collection, analysis or interpretation of the data. Availability of data and material The datasets generated and/or analyzed during the current study are not publicly available in order to avoid compromising individual privacy. It is Bokhour et al. BMC Health Services Research (2018) 18:168 difficult to adequately de-identify this type of qualitative data. Data may be made available from the corresponding author on reasonable request. Authors’ contributions Data collection: BB, GF, NM, JH, JL. Data analysis: BB, GF, NM, AB, SL, JH, JS, CVL. Data interpretation and manuscript completion: BB, GF, NM, AB, SL, JH, JS, CVL. All authors read and approved the final manuscript. Ethics approval and consent to participate This study was designated quality improvement by the ENRM Institutional Review Board. Therefore consent was not required. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Author details 1 Center for Healthcare Organization and Implementation Research, ENRM Veterans Affairs Medical Center, Bedford, MA, USA. 2Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA, USA. 3Department of Behavioral and Community Health, University of Maryland School of Public Health, College Park, MD, USA. 4 Center for Innovation for Complex Chronic Healthcare (CINNCH), Department of Veterans Affairs, Edward Hines Jr. VA Hospital, Hines, IL, USA. 5 Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. 6Independent Research Consultant (formerly VA), Chicago, IL, USA. Received: 16 March 2017 Accepted: 19 February 2018 References 1. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, D.C.: The National Academies Press; 2001. 2. Mead N, Bower P. Patient-centredness: a conceptual framework and review of the empirical literature. Soc Sci Med. 2000;51(7):1087–110. 3. Mead N, Bower P. Patient-centred consultations and outcomes in primary care: a review of the literature. Patient Educ Couns. 2002;48(1):51–61. 4. McMillan SS, Kendall E, Sav A, King MA, Whitty JA, Kelly F, et al. Patientcentered approaches to health care: a systematic review of randomized controlled trials. Med Care Res Rev. 2013;70(6):567–96. 5. Jha AK, Orav EJ, Zheng J, Epstein AM. Patients' perception of hospital care in the United States. N Engl J Med. 2008;359(18):1921–31. 6. Epstein RM, Street RL. The values and value of patient-centered care. The. Ann Fam Med. 2011;9(2):100–3. 7. Best A, Greenhalgh T, Lewis S, Saul JE, Caroll S, Bitz J. Large-system transformation in health care: a realist review. The Milbank Quarterly. 2012; 90(3):421–56. 8. Cronholm PF, Shea JA, Werner RM, Miller-Day M, Tufano J, Crabtree BF, et al. The patient centered medical home: mental models and practice culture driving the transformation process. J Gen Intern Med. 2013;28(9):1195–201. 9. Nutting PA, Crabtree BF, Miller WL, Stewart EE, Stange KC, Jaen CR. Journey to the patient-centered medical home: a qualitative analysis of the experiences of practices in the National Demonstration Project. Ann Fam Med. 2010;8(Suppl 1):S45–56. S92 10. Aboumatar HJ, Chang BH, Al Danaf J, Shaear M, Namuyinga R, Elumalai S, et al. Promising practices for achieving patient-centered hospital care: a National Study of high-performing US hospitals. Med Care. 2015;53(9):758–67. 11. Luxford K, Safran DG, Delbanco T. Promoting patient-centered care: a qualitative study of facilitators and barriers in healthcare organizations with a reputation for improving the patient experience. Int J Qual Health Care. 2011;23(5):510–5. Page 11 of 11 12. Shaller D. Patient-centered care: what does it take? The Commonwealth Fund. 2007. 13. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4(1):50. 14. VA Office Developing Innovative Patient-Centered Model of Care for Veterans https://www.va.gov/opa/pressrel/pressrelease.cfm?id=2034. Accessed 5 Jan 2018. 15. Understanding MJA. Validity in qualitative research. Harv Educ Rev. 1992; 62(3):279–301. 16. Patton M. Qualitative research and evaluation methods. Thousand Oaks, CA: Sage Publications; 2002. 17. Charmaz K. Constructing grounded theory: a practical guide to qualitative analysis: sage publications; 2006. 18. Rounds S. Supporting providers. Improving Quality of Care. http://www. theschwartzcenter.org/supporting-caregivers/schwartz-center-rounds/. Accessed 5 Jan 2018. 19. Hernandez SE, Conrad DA, Marcus-Smith MS, Reed P, Watts C. Patientcentered innovation in health care organizations: a conceptual framework and case study application. Health Care Manag Rev. 2013;38(2):166–75. 20. Bokhour BG, LaVela SL, Fix GM, Hill JN, Barker AM, Locatelli SM, et al. Lessons from the field for implementing patient-centered care and cultural transformation. Center for Evaluating Patient-Centered Care in VA (EPCCVA). 2013. 21. Scholle SH, Asche SE. Support ans strategies for change among small patient-centered medical home practices. The Annals of Family Medicine. 2013;11(Supplement 1):S6–13. 22. Millenson ML, Berenson RA. The road to making patient-centered care real: policy vehicles and potholes. Washington, DC: The Urban Institute; 2015. 23. Epstein RM, Franks P, Fiscella K, Shields CG, Meldrum SC, Kravitz RL, et al. Measuring patient-centered communication in patient-physician consultations: theoretical and practical issues. Soc Sci Med. 2005;61(7):1516–28. 24. Millenson ML. When "patient centred" is no longer enough: the challenge of collaborative health: an essay by Michael L Millenson. BMJ. 2017;358:j3048. 25. Bergeson SC, Dean JDA. Systems approach to patient-centered care. J Am Med Assoc. 2006;296(23):2848. 26. O’Hanlon C, Huang C, Sloss E, Anhang Price R, Hussey P, Farmer C, et al. Comparing VA and non-VA quality of care: a systematic review. J Gen Intern Med. 2017;32(1):105–21. Submit your next manuscript to BioMed Central and we will help you at every step: • We accept pre-submission inquiries • Our selector tool helps you to find the most relevant journal • We provide round the clock customer support • Convenient online submission • Thorough peer review • Inclusion in PubMed and all major indexing services • Maximum visibility for your research Submit your manuscript at www.biomedcentral.com/submit BioMed Central publishes under the Creative Commons Attribution License (CCAL). Under the CCAL, authors retain copyright to the article but users are allowed to download, reprint, distribute and /or copy articles in BioMed Central journals, as long as the original work is properly cited. WHITE PAPER Collaborative Healthcare Leadership A Six-Part Model for Adapting and Thriving during A Time of Transformative Change By: Henry W. Browning, Deborah J. Torain, and Tracy Enright Patterson Contents Introduction: A Leadership Model for Healthcare Transformation 1 Six Essential Organizational Capabilities 3 The Payoff: A Culture of Collaboration 10 Conclusion 11 About the Model: CCL’s Research and Experience 12 Impact Stories 16 References 16 About the Authors and Contributors 17 Introduction A Leadership Model for Healthcare Transformation For decades, US hospital administrators and medical professionals have operated within a challenging, rapidly changing, and fragmented healthcare system. Today, this environment is even more complex as sweeping healthcare reform and market forces transform the way healthcare is delivered and managed. This profound shift is both structural and cultural. New alliances and unlikely partnerships are beginning to emerge. Belief systems, values, and attitudes are shifting. Creative thinking and agile, adaptive leadership will be required to make hospitals, health systems, and networks sustainable as the healthcare delivery landscape transforms. As this unknown future state unfolds, one thing is a given—incremental responses will not be enough. The competencies required of leaders and their organizations must continue to evolve in order for both to thrive. Rapid innovation and adaptation to change require a collaborative, interdependent culture and solutions that cut across function, region, and profession. Leaders must learn to shift away from the “individual expert” model so common in today’s healthcare systems and move towards a model that leverages cross boundary groups and teams and spans disciplines, levels, functions, generations, and professions. These new collaborative groups will be able to integrate knowledge throughout the system and to anticipate and solve unprecedented challenges—all while delivering efficient, highquality, compassionate patient care across the continuum. ©2016 Center for Creative Leadership. All rights reserved. 1 The Center for Creative Leadership (CCL®) has developed a model that health systems can use to adapt and thrive in uncertain times by creating direction, alignment, and commitment. It is based on multiple research studies, our in-depth involvement with a diverse group of hospital systems and networks, and our leadership development work with thousands of healthcare leaders from across the sector. Our model focuses on six essential organizational capabilities that are a prerequisite for success in this new world order: 1. Collaborative patient-care teams 2. Resource stewardship 3. Talent transformation 4. Boundary spanning 5. Capacity for complexity, innovation, and change 6. Employee engagement and well-being We’ve also identified key leadership practices needed in each of these six areas in order to maximize effectiveness. Through this leadership lens, healthcare organizations can clarify their business challenges and become highly adaptive and innovative in response to change. They can shift their culture and transform the business and mission of healthcare. In the white paper that follows, you’ll find details on CCL’s model, as well as the research projects and real-world experiences that have led to its development. 2 ©2016 Center for Creative Leadership. All rights reserved. Six Essential Organizational Capabilities The successful healthcare organization of the future will develop and implement a leadership strategy that systemically addresses priorities and is supported by the leadership practices needed to achieve organizational goals and to adapt to rapid change and uncertainty. CCL offers a six-part model that healthcare organizations can use to assess their own leadership strengths and weaknesses and to customize their leadership development efforts. In a practical way, it matches up very real needs with the leadership skills and capabilities that will make the most difference—with the common, underlying thread of collaborative leadership. Healthcare organizations will, as a result, have the opportunity to approach leadership development in a strategic, comprehensive way while dealing with real and immediate pressures. As an organization’s commitment to collaboration becomes visible and is reinforced, it will see improvements in the ability to set direction, establish alignment, and gain commitment. ©2016 enter for Creative Leadership. All rights reserved. 3 1. Collaborative Patient-Care Teams Delivering safe, quality, compassionate care is the primary mission of any healthcare organization. Given that roles within the patient-care team are highly interdependent in nature, collaboration skills are crucial. This is especially true in acute care situations involving doctors, nurses, and the teams they manage. With healthcare reform, though, the patient-care team will likely extend to include clinicians outside the hospital environment. Accountable care organizations, integrated clinical networks, and other new delivery models will place a much greater emphasis on higherorder collaboration skills that go far beyond “working well with others.” Concrete group process skills are needed to promote open communication, learning, trust, and quality decision making. While collaboration is important throughout the hospital, it is especially important at the patient interface. The ability to ensure patient care is determined not only by technical expertise, but also by the leadership effectiveness of all those involved in solving the presenting medical issues. These individuals are leading the patient-care experience as they foster a new contract for working together. Often, true leadership is independent of formal roles and responsibilities. It also shifts throughout the patient-care experience. Therefore, effective care depends on collaborative teamwork. This is especially true between physicians and nurses. While diagnosis and prescription of treatment has traditionally resided with the physician, nurse practitioners and physician assistants have increasing responsibility for carrying out the treatment plan. It will be essential that management systems take into account shifting responsibilities over the course of the patient’s care. While new structures are evolving, clearly the distribution centers for care are expanding, and who is responsible for impacting the patient’s long-term health and well-being is changing. From a leadership development perspective, the key to tackling these daily team-effectiveness challenges lies in greater employee engagement, collaboration, and learning agility. Leadership Practices • Engaging doctors, nurses, and other caregivers in shared ownership of the patient-care experience using concrete dialogue and listening skills across roles • Creating an environment that supports learning agility and adapting to change • Collaborative problem-solving and decision making with all members of the patient-care team 4 ©2016 Center for Creative Leadership. All rights reserved. 2. Resource Stewardship In an age of increasing accountability, resource stewardship is both a big-picture, system-level obligation and a series of daily decisions. As healthcare reform unfolds, new business models and restructuring will emerge to manage costs while delivering compassionate, quality care. On the macro level, healthcare organizations must look far ahead to understand how the unfolding future impacts their current structures and business models. They urgently need to seek out opportunities to reduce costs. Decisions about investments and partnerships are made knowing that trade-offs will be required. Resource stewardship requires individual ownership and accountability for the decisions that will ultimately allow the system to thrive and manage its resources judiciously. At the micro level, administrators, physicians, nurses, and other stakeholders must manage the tension between individual patient care and operational constraints. They need to adapt to new models and structures and be innovative and visionary in their approach to cost-effective patient-care models. Hospitals need both patient-focused business professionals and business-minded clinicians who can keep patient care top of mind. Only through education and dialogue can comprehensive solutions be reached. Alignment is created when caregivers and business leaders reach a common understanding of the clinical strategy as well as the business strategy. To be effective resource stewards, leaders must have a solid understanding of performance metrics, including financial indicators, employee engagement, patient results, and satisfaction. In addition, leaders need to identify key measures, apply data in strategic ways and identify, discuss, and resolve problems. Leadership Practices • Accountability, transparency, and integrity • Scanning the environment and seeking innovative solutions • Appreciating and combining compassionate care needs with business strategy • Entrepreneurial—generating new ideas and seizing opportunities ©2016 Center for Creative Leadership. All rights reserved. 5 3. Talent Transformation CCL’s research shows that healthcare organizations need visionary leaders who can inspire and develop employees, build and mend relationships effectively, lead and motivate teams, and engage in participative management. In addition to these core competencies, new and different leadership skills will be required to see healthcare organizations through a change that has not been equaled since Medicaid and Medicare were established ( Jarousse, 2010; Dolon 2010). Leaders of healthcare systems will need to hire and develop talented individuals who can see the next wave of plausible solutions and innovations and lead transformational change. Hospitals and health systems are managing a transitioning workforce. The physician’s role is evolving from independent practitioner to hospital employed collaborator. The roles of executive nurse leaders are expanding, and the responsibilities are being elevated. As new staffing models emerge, hospitals still face an ongoing nursing shortage and an aging nurse and physician workforce (RWJF Committee on the Future of Nursing, 2011; Buerhaus, 2009). Hospital, outpatient, and clinical workforces are stretched thin as the talent pool shrinks and demands increase. An investment in leadership talent is one way to engage employees, build bench strength, and prepare for future leadership needs (McAlearney, 2010). Physicians and nurses who are promoted into leadership roles need support and development as they make the transition, enabling them to approach the role as effectively as possible. As in business, often the most technically proficient individuals are promoted to managerial positions without the self-awareness, emotional intelligence, and other leadership competencies required for success. Throughout the system, leadership talent can be grown and supported in multiple ways, including extensive use of feedback, coaching, and developmental assignments. As part of a well-articulated business strategy, healthcare organizations need comprehensive strategies for identifying, hiring, developing, and retaining leadership talent. Building a culture rich with assessment, challenge, and support helps to grow the talent pipeline. Building and growing a pool of people capable of taking on larger and more complex leadership roles can transform the organization. Leadership Practices • Accessing a larger talent pool, beyond the traditional arena of healthcare specialty • Redefining a new leadership strategy in the face of the new structures and models associated with reform • Identifying, developing, and retaining the leadership talent needed to create and implement solutions in the face of rapid and evolving change • Creating a culture that encourages and values mutual respect and professional practice 6 ©2016 Center for Creative Leadership. All rights reserved. 4. Boundary Spanning At the beginning of a planning retreat, the president of a large regional hospital told his staff, “We’ve solved all the problems we can by people working in their functions and groups. The next wave of solutions will have to come from people working across boundaries to create innovative and novel answers to the complex problems in healthcare.” Even within a single hospital, numerous layers of hierarchy, multiple departments, and a variety of service lines can serve as bureaucratic boundaries to systemic innovations. The hospital-employed nursing staff, technicians, assistants, and physicians work around the clock—exchanging information and trading roles across shifts. Each department has its internal hierarchy and roles, but each relies on and interacts with several specialties to support even a single patient. Further complicating the situation are the many and varied hospital/physician relationships. Hospital-owned physician practices and physicians in private practice who contract with the hospital (and may even partner with hospital competitors) all have demands and circumstances that make collaboration a significant challenge. In such a fragmented system, boundaries (any form of “us versus them”) are prevalent and powerful. While these boundaries may have been frustrating or challenging in the past, today they are serious liabilities that lead to arduous and slow processes and watereddown policies. The role of senior hospital administrators is to coordinate between and among these layers in a broad way. But leaders at all levels must have boundaryspanning capabilities. The most pressing challenges in hospitals and health systems cannot be solved by one person, one specialty, or one organization. They require expertise, ideas, and support from multiple perspectives and stakeholders. Healthcare leaders must develop the ability to bridge departmental, cultural, organizational, and industry divides. They must learn to break down barriers and silos and lead across traditional boundaries. Boundary-spanning leaders draw on networks and relationships as they work systemwide to meet the mission of healthcare. Leadership Practices • Expanding and leveraging strategic networks to fast-track solutions • Thinking, acting, and influencing systemically • Leveraging differences to drive innovation • Cocreating tools for practical application and sustainable change ©2016 enter for Creative Leadership. All rights reserved. 7 5. Capacity for Complexity, Innovation, and Change The political, regulatory, and marketplace forces driving healthcare reform have everyone guessing what the landscape will look like when the process unfolds. What is clear is that change is coming hard and fast. Healthcare leaders must navigate a continuous whitewater. While influencing, monitoring, and responding to unfolding change, they must respond to demographic shifts in the workforce and among patients, technological advances, the tumultuous nature of employee relationships, insurance and reimbursement processes, and current regulatory practices. Complexity and change come from all directions: regulation and mandates, diagnostic and treatment protocols, technological advances, and implementation of new systems. Hospital staff must adapt in the moment to the crisis at hand, while looking ahead to changes that will come from new patterns of illness and emerging ethical and caregiving issues. Complexity is often less about solving a problem and more about managing an organizational, situational, or market paradox. Managing the paradox and the opposing camps of stakeholders is a highly specialized skill set that is often developed in parallel with organization savvy and wisdom. Effective leaders help move populations from old established processes to new models of effectiveness. They understand the underlying emotional impact of change and how it varies by individual. They act with empathy and authenticity to help individuals make the mental shift to embrace change rather than resist it. In addition to complexity and change, healthcare organizations also must master innovation. Challenges cannot be solved through heroic individual efforts. True innovation stems from collaboration across departments and functions internal and external to the organization. To innovate, leaders must adapt ideas from outside their area of expertise—within the hospital as well as from outside the industry. Reading and thinking more broadly is the responsibility of all those sitting in leadership positions. Interdependent leadership in support of a common purpose needs to become the cultural norm (not the exception) in order to get people thinking more broadly and more strategically. Open and responsive leaders learn together to make collective sense of ambiguity and to find innovative solutions to complex problems. This is not just the strategic view at the top of the organization but a way of operating at all levels, especially on the frontline of caregiving. From the care of an individual patient to managing the restructuring of a multisystem organization in response to healthcare reform, healthcare organizations are pressed to build their capacity for complexity, change, and innovation. Leadership Practices • Driving innovation and risk-taking in the midst of ambiguity and uncertainty • Transforming the culture from dependent to interdependent • Leading both the structural and human side of change and transition 8 ©2016 Center for Creative Leadership. All rights reserved. 6. Employee Engagement and Well-being Why are employee engagement and well-being leadership issues? Both impact the very mission of a healthcare organization. Research on healthcare effectiveness suggests that quality of care is positively influenced by nurses being satisfied with their jobs and feeling empowered in their roles (Regan & Rodriguez, 2011). Frontline supervisors often do little leading and serve mainly as information conduits for a myriad of new regulations, policies, procedures, and mandates. To compound this problem, nursing shortages and long shifts have healthcare professionals struggling to maintain their own health and well-being. Those working in hospitals are often plagued with a host of medical problems related to the physical and mental demands of the job. Energy drain and staff burnout create safety and liability problems for organizations, limiting effectiveness and innovation. One goal of healthcare reform is to increase the engagement of the patient, the health system, and the community in preventive measures. Hospitals must begin to model the way forward through the support they provide to their own people. Employees are most productive and committed to their organization when they are engaged emotionally, mentally, and physically. Without a proactive focus on employee engagement and well-being, the challenges of the next few years have the potential to create new levels of burnout within the rank and file. Healthcare organizations cannot afford for patient care to suffer due to lack of ideas, skills, time, and talent. They have no choice but to adapt, change, and innovate. Organizational leaders must take an integrated approach to helping employees maintain health, maximize their energy, and feel both connected with their work and aligned with the organization. Energy is a special concern in healthcare, with around-the-clock needs and high-intensity work in an emotionally charged setting. Human energy is essential for full employee engagement and satisfaction, both personally and professionally. Lack of energy cannot be resolved through time-management efforts alone, though. The problem is often systemic. For example, adequate staffing can be a critical component so patient-care teams are not stretched too thin. Energy is optimized when both leaders and organizations value the whole person, linking individual health and wellbeing to organizational health and well-being through purpose, integrity, and accountability. The ultimate goal is for the organization to create a culture in which people care as much for themselves and each other as they do for their patients. This type of culture has true bottom-line impact by increasing retention, reducing grievances, and minimizing costly errors. Leadership Practices • Creating an integrated approach to engagement and well-being • Maximizing human energy and potential in service of the organization’s mission • Fostering a culture in which the people who work in the organization are treated as well as the people they serve (Includes encouraging a healthy work/life balance, sustainable staffing models) ©2016 enter for Creative Leadership. All rights reserved. 9 The Payoff: A Culture of Collaboration Collaborative leadership is the collective activity of setting direction, seeking alignment, and building commitment (Drath, McCauley, Palus, Van Velsor, O’Connor & McGuire, 2008). We use the word “collective” because leadership does not reside within the individual, but rather is the shared responsibility of all required to fulfill the mission. CCL’s leadership model for healthcare transformation focuses on the development of six organizational capabilities that can help to create a collaborative leadership mindset. It is based on the ultimate goal of developing an interdependent leadership culture that will lead to quality, compassionate patient care in the face of the adaptive challenge. The culture must be experienced and the values must be practiced at every level in the system, from frontline care providers to top-level executives. In hospitals and health systems, there are two key areas in which collaboration is especially critical. The first is the relationship among caregivers at the bedside, which impacts patient care and health outcomes. The second is the relationship between clinical services and business operations, which is critical to the overall sustainability of the entity. Successful health systems must strive toward bridging the divide and work toward a more collaborative and equal relationship among caregivers in service of the patient. At the organization level, leaders must manage and bridge the paradoxical relationship between the business and clinical forces involved in fulfilling the mission of each healthcare organization. While these two strategies can often be at cross purposes, system leaders must be dutiful about minimizing the negative impact that the paradox can have on the patient experience. They must take on and internalize the charge of managing both the mission and the margin. Rather than making patchwork, incremental changes, innovative thinking is needed to find ways to transform how work is done. Culture is a hidden power in all organizations and rooted in traditional roles, hierarchies, and systems. A hospital’s culture is often created out of managing the tensions between the clinical and business sides of the organization. Culture is also inextricably linked to business strategy and drives outcomes. When the business side changes and new strategies are required, the organizational culture needs to shift as well. If it does not, the traditional culture—the beliefs, the practices and “the way things are done around here”— will override the new direction and prevent innovation and positive change. Leadership Practices • Enacting the tasks of leadership: Direction-Alignment-Commitment • Working interdependently to achieve the mission of healthcare • Creating a culture of collaboration and mutual respect 10 ©2016 Center for Creative Leadership. All rights reserved. Conclusion The US healthcare system is considered by many to be broken, fractured, and unsustainable. Yet, the system holds examples of what works well and what the future will look like. Some hospitals, healthcare systems, and innovative organizations are showing tremendous success in transforming their cultures and providing efficient, quality care, and superior patient outcomes. At CCL, we see collaborative leadership as a powerful lever for change, transformation, and sustainability. By clarifying organizational needs and leadership challenges and by developing these capabilities with a collaborative mindset, we are helping our healthcare clients understand the interconnections between their business strategy and their leadership strategy. When organizations strengthen individual leaders and expand their collective leadership capability, they begin to pry loose some of their most intractable, resistant problems and uncover new directions, solutions, and opportunities. Collaborative leadership has the power to transform hospitals and healthcare organizations, improving the system today and for the future—to the benefit of patients, families, and caregivers. Why Care about Culture? In its most basic form, culture is a mechanism for sustainability and survival. It also has the hidden power to derail strategic change initiatives. In fact, research shows the majority of strategic change initiatives ultimately fail because they don’t address culture. • A culture is formed by beliefs that drive behaviors. • New beliefs lead to new behaviors and new possibilities emerge. • Change the leadership mindset and you change the organizational culture. ©2016 enter for Creative Leadership. All rights reserved. 11 About the Model: CCL’s Research and Experience For more than 40 years, CCL’s leadership development research and practice have helped healthcare organizations address their most pressing leadership challenges. In the past decade alone, more than 400 health service organizations have turned to CCL to develop leadership skills and transform their ability to achieve desired business results. In some instances the work has been short-term or has involved individual leaders who have benefited from our programs. In other instances we have been involved in long-term, indepth partnerships that have yielded significant results for client organizations. This work and related research conducted by our CCL team have informed the creation of the leadership model described in this white paper. 12 ©2016 Center for Creative Leadership. All rights reserved. We have seen firsthand the impact when health systems focus on and invest in the transformation of their leadership. Individuals gain communication, influencing, and conflict-resolution skills. Groups and teams improve performance and respond more effectively to change. Senior teams work more effectively to align the organization and drive strategic change. Developing individual leadership skills and organizational leadership capabilities creates a more collaborative culture that can have a direct impact on patient-care outcomes and organizational practices. Clients have reported that CCL-facilitated leadership development programs have helped improve clinical effectiveness, patient safety, and patient satisfaction and have contributed to strong gains in employee satisfaction and engagement. We have also observed that high-performing hospitals and healthcare systems share several key characteristics: • Physicians, nursing leaders, and staff at all levels are engaged in their work. Communication is clear, direct, honest, and open. • Innovative practices flow throughout systems. • Collaboration is proactive and effective; organizational silos do not get in the way of the work. • Leaders and employees act strategically and decisively in times of chaos and ambiguity. • Recruitment and retention processes result in a staff that is highly committed to compassion, quality, and safety. • Continuous learning is encouraged and rewarded. • A high-energy environment helps employees manage stress and maintain healthy lifestyles. Of course, achieving these high-performance outcomes is difficult, and maintaining them is equally challenging. To supplement our experiential knowledge within hospitals and healthcare organizations, CCL conducted in-depth, multiyear needs assessments between 2006 and 2009 with five diverse hospitals and health systems. The goal was to understand their current leadership challenges and future leadership needs based on their respective business strategies. The organizations included one community hospital and four large health systems, including an academic medical center, a nonprofit multistate system, a nonprofit regional organization, and a large for-profit multistate healthcare system. The needs assessments involved 164 leaders. Data on key challenges were gathered via surveys and interviews and then vetted and refined through facilitated dialogue. Several clear themes emerged through this work. Organization-level challenges were primarily strategic and operational: • Market forces (economy, healthcare reform, etc.) • Strategic issues • Resource management (budgets, people, processes, technology) • Decision making • Managing priorities, clarifying roles and responsibilities • Talent management processes • Planning and execution • Business process management Healthcare leaders also recognized the need to strengthen leadership and communication, improve organizational culture, and help employees find a better work/life balance. ©2016 enter for Creative Leadership. All rights reserved. 13 When study participants were asked to identify high-priority organizational capabilities and leadership development needs, several common themes emerged: • Big-picture thinking. System-level planning and thinking, and strategic thinking. • Collaboration. Leading across boundaries, collaborative problem-solving, and consensusbuilding. • Commitment. Being accountable for results. • Communication skills. Sharing and communicating vision, transparency, and specificity. • Developing talent. Mentoring, coaching, and giving feedback. • Managing change. Adapting to changing needs, systems, and processes. Managing paradox. • Engagement. Empowering employees and generating follow-through and commitment. • Culture change. Creating an environment of trust, continuous learning, and support. • Organizational knowledge. Understanding healthcare best practices. • Leading teams. Building effective teams, providing clear direction, and creating alignment. • Stewardship of resources. Ability to address power and politics. This research provided much of the rationale for a model that could transform healthcare systems through collaborative leadership. The model was further informed by additional CCL research, including a Leadership Gap study that analyzed a sample of 34,899 leadership-effectiveness evaluations conducted between 2000 and 2009. These data came from people working across the healthcare sector, including employees of large hospital systems, regional providers, insurance firms, state and federal healthcare agencies, pharmaceutical firms, and medical device manufacturers. Respondents had been asked to evaluate the leadership competencies of a boss, peer, or direct report using CCL’s Benchmarks® 360-degree feedback survey. Key findings of the CCL Leadership Gap Study: • Adapting to change and meeting business objectives are strengths of healthcare leaders. They are resourceful, straightforward and composed, fast learners and willing to “do whatever it takes.” • The top priorities for leadership development in the healthcare sector are to improve the ability to lead employees and to work in teams. • Healthcare organizations also need to create strategies to provide current and future leaders broad, cross organizational experiences and learning. • Healthcare leaders have gaps in several areas that are essential for learning and long-term success: having a broad functional orientation, self-awareness, and career management. 14 ©2016 Center for Creative Leadership. All rights reserved. Details of this study are described in CCL’s 2010 white paper, Addressing the Leadership Gap in the Healthcare Sector: What’s Needed When it Comes to Leader Talent? Additionally CCL reviewed data from 1,000 leaders in healthcare organizations who participated in our open-enrollment and custom programs from 2006 through 2008. The participants were asked to identify the three most important challenges they face as leaders. We looked at responses that reflected challenges specific to the healthcare sector and then coded and analyzed a random sample of 300. The final sample included leaders at the middle, upper-middle, and executive levels, with 61% working in upper-middle to executive leadership roles.The following top five challenges emerged: • Leading teams and individuals • Culture change/organizational transformation • Talent management • Leading across boundaries • Building effective relationships Collectively, these studies confirmed what we learned through our direct experience with healthcare organizations about the themes and pressure points faced. Furthermore, the model is supported by a broader body of CCL’s most current research on organizational leadership development. ©2016 enter for Creative Leadership. All rights reserved. 15 Impact Stories Catholic Health Partners: Creating a Results—Focused Leadership Academy Catholic Health Partners (CHP) is one of the largest nonprofit healthcare organizations in the United States. In partnership with CCL, the organization aligned its strategic priorities with five critical leadership factors needed to meet them: a passion for the mission and values, a commitment to servant leadership, the ability to handle complex mental processes, a bias for action, and the ability to develop others. Together, CCL and CHP created the Leadership Academy, a 14-month process that combines classroom time, individual and team coaching, and action learning projects. Improvements were seen in clinical effectiveness, patient safety and patient satisfaction as a result of action learning projects. Cape Fear Valley Health: Collaborating to Manage Growth Cape Fear Valley Health (CFVH) is among the largest and busiest health systems in North Carolina. The organization experienced rapid growth over the previous decade, propelling it from a small county hospital to a full-fledged health system. CFVH’s executive team collaborated with CCL to design and deliver a five-day leadership skills-building and collaborative leadership development process for five cohort groups made up of the top 125 leaders in the health system. CFVH’s senior VP for Human Resources described the impact of this initiative: “As a large regional healthcare system, we face new challenges every day. Working with CCL helped us strengthen a strong leadership team by providing the leadership tools to perform our jobs more effectively. As a result, we are more agile in dealing with tough challenges like patient satisfaction and other operational issues. We are now faster at getting to the root of problems and developing creative solutions to solve them. That makes a real impact on our bottom line!” National Association of Community Health Centers: Coaching for Impact The National Association of Community Health Centers (NACHC) administers a year-long EXCELL leadership development program for executives of member facilities—not-for-profit health centers across America that provide care for poor, migrant, and homeless communities. More than 140 individuals have graduated from EXCELL since its inception in 1999. To ensure application of what participants were learning to the realities of the workplace, the Center for Creative Leadership worked with the EXCELL faculty and leadership to build a coaching component into the program. Participants judge coaching among the most beneficial elements in their development, and retention rates are very high among graduates of the program. Lenoir Memorial Hospital: Revitalizing Leadership When Lenoir Hospital set a goal of becoming the “provider of choice” in its competitive eastern North Carolina marketplace, the not-forprofit medical center recognized that success would require a huge commitment to change as well as a new leadership model. The desire was to create a leadership process capable of bringing about an organization-wide culture shift. The Kinston, NC hospital worked with CCL to create a two-year process for 65 executives, directors, managers, and supervisors, built around a framework of a shared vision, a leadership strategy, and a capability of connected leadership needed to continue moving forward. As a result of this process, leaders at Lenoir reported a marked sense of openness and engagement in the organization’s day-to-day operations. Scores on both the hospital’s employee-satisfaction survey and the customer satisfaction survey soared. As a result of the initiative’s emphasis on the concept of “distributed leadership,” Lenoir Memorial established a leadership academy to retain top young talent and imbue them with the strong professional leadership skills the hospital will need in generations to come. References Buerhaus, P. I. (2009). The recent surge in nurse employment: Causes and implications. Health Affairs, 657–667. Committee on the Robert Wood Johnson Foundation on the Future of Nursing, a. t. (2011). The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press. Dolon, T. C. (2010, September/October). Leadership skills for healthcare reform. Healthcare Executive, p. 6. Jarousse, L. (2010). Leadership in the era of reform. H&HN: Hospitals & Health Networks, 84(11), 32. McAlearney, A. S. (2010, May/Jun). Executive leadership development in US health systems. Journal of Healthcare Management, 55(3), 206–222. Regan, L. C., & Rodriguez, L. (2011, Winter). Nurse empowerment from a middle-management perspective: Nurse managers’ and assistant nurse managers’ workplace empowerment views. The Permanente Journal, 15, 1–6. Wilfred, H. D., McCauley, C. D., Palus, C. J., Van Velsor, E., O’Connor, P. M. G., & McGuire, J. B. (2008). Direction, alignment, commitment: Toward a more integrative ontology of leadership. Leadership Quarterly, 19, 635–653. 16 ©2016 Center for Creative Leadership. All rights reserved. About the Authors Henry W. Browning is a senior faculty member at the Center for Creative Leadership (CCL®) with expertise in individual, group, and organizational performance development. Henry focuses on helping individuals improve their impact in leadership roles and processes, developing high-performing management and project teams, and working with senior executive teams leading organizational change. He has led numerous leadership development initiatives with hospitals and healthcare systems in his faculty role with CCL. Deborah J. Torain is a senior account manager with CCL’s Business Development Group and leads the CCL healthcare sector team. Deborah serves as a relationship manager who gains insight into the business and leadership needs of clients and helps to customize the appropriate leadership development solution. She has managed a number of the Center’s top client relationships with a focus in health and healthcare services and a client base that includes Catholic Health Partners, Medtronic, St. Joseph’s Health System, WellPoint, Trinity Health, and Bon Secours Health System. Tracy Enright Patterson is director of CCL’s Evaluation Center, a group responsible for developing knowledge, methods, and approaches to the evaluation of leadership development. She has designed and implemented program evaluations for the leadership development initiatives of several of CCL’s healthcare clients, including Catholic Health Partners, WellPoint, Medtronic, Cape Fear Valley Health, Trinity Health, and two programs funded by the Robert Wood Johnson Foundation: “Ladder to Leadership” and “Executive Nurse Fellows.” Contributors: Heather Champion, CCL Senior Research Faculty; Joan Gurvis, CCL Managing Director; and Courtney Harrison, Former CCL Senior Faculty Adknowledgements: The authors would like to thank the following people for their review and feedback on the paper as it was developed: Jon Abeles, Senior Vice President, Operations Excellence, Catholic Health Partners; William Pryor, Senior Vice President, Cape Fear Valley Health; Rick Vanasse, Senior Vice President and Chief Learning Officer, Bon Secours Health System; Cindy McCauley, CCL Senior Fellow; Nancy Probst, CCL Adjunct Faculty; Amy Martinez, CCL Senior Faculty; Kelly Hannum, CCL Senior Research Faculty; Elizabeth Gullette, CCL Senior Faculty. To learn more about this topic or the Center for Creative Leadership’s programs and products, please contact our Client Services team. +1 800 780 1031 +1 336 545 2810 info@ccl.org ©2016 enter for Creative Leadership. All rights reserved. 17 The Center for Creative Leadership (CCL®) is a top-ranked, global provider of leadership development. By leveraging the power of leadership to drive results that matter most to clients, CCL transforms individual leaders, teams, organizations and society. Our array of cutting-edge solutions is steeped in extensive research and experience gained from working with hundreds of thousands of leaders at all levels. Ranked among the world’s Top 5 providers of executive education by the Financial Times and in the Top 10 by Bloomberg Businessweek, CCL has offices in Greensboro, NC; Colorado Springs, CO; San Diego, CA; Brussels, Belgium; Moscow, Russia; Addis Ababa, Ethiopia; Johannesburg, South Africa; Singapore; Gurgaon, India; and Shanghai, China. 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