The Art & Science of Leadership and Followership in Preventing Infection

1. The Art & Science of Leadership and Followership in Preventing Infection Sanjay Saint, MD, MPH Professor of Medicine Ann Arbor VA Medical Center University of Michigan Medical School

2. Leadership: Definitions • Leadership is “a process whereby an individual influences a group of individuals to achieve a common goal” (Northouse in “Leadership: Theory and Practice” 2010) • “Assigned” leadership = leadership that is based on occupying a position in an organization • “Emergent” leadership = leadership that emerges from an influential member of a group regardless of the person’s title or position

3. Leadership vs Management • “Leadership” has been studied since Aristotle • “Management” only emerged in the last century with industrialization • Primary functions of management: planning, organizing, and staffing(H. Fayol, 1916) • Both “management” and “leadership” are essential to a successful organization (J.P. Kotter, 1990)

4. Leadership Research 101: A Brief History • Traits • Style • Situational and Contingent • Transactional and Transformational

5. Leadership Research: Traits • The “great person” approach to leadership • Compare leaders with non-leaders: identify key traits • Summary of 6 studies from 1948-2004: 5 key traits • Persistence • Intelligence • Integrity • Self-confidence • Sociability

6. Leadership Research: Traits • Strengths: Easy to understand, studied extensively, appeals to those who like to see their leaders as gifted • Out of favor among academicians for several reasons: • No definitive list distinguishing leaders from non-leaders • The list of traits is rather subjective • Focus only on the leader (not the follower or situation) • Not terribly helpful in self-improvement (Northouse, 2010)

7. Leadership Research: Style • Focuses on the leader’s behavior towards followers • 2 main behaviors: “task” and “relationship” • Task: facilitate goal attainment • Relationship: help followers feel good • “Concern for Production” vs “Concern for People”

8. Leadership Research: Style • Strengths: Highlights the tension between task vs relationships; behaviors are easier to change than traits; extensive research (from both Ohio State and Michigan) • Criticisms: • Unclear how styles are associated with outcomes • Unable to identify universal behaviors associated with effective leadership • Unclear if high-high (9, 9) is the best style (Northouse, 2010)

9. Leadership Research: Situational & Contingent • Different situations require different leadership styles • Situational approach: The leader should match their style to the follower’s needs • “Directive” behaviors: Task-oriented • “Supportive” behaviors: Relationship-oriented • Contingent approach: The leader should adapt their style (task vs relationship) also to the organizational context

10. Leadership Research: Situational & Contingent Criticisms: • Not a “one-size-fits-all” strategy • Cumbersome in real-life • The leader must constantly adapt Strengths: • Makes intuitive sense • Some empiric support • Can be applied to family members

11. Leadership Research: Transactional vs Transformative Transformational: • Inspires followers to see beyond their self-interest • Adapts to the needs and motives of followers • Behaves in a way that engenders great trust • Various politicians who rely on charisma Transactional: • Specifies roles and tasks • Reward & punishment used as motivation • Transaction (or exchange) of something leader has that the follower wants • “One-size-fits-all” • P4P

12. The 5 Key Practices of Transformational Leaders (Kouzes and Posner) • Model the Way: explicit about their values and act as role models by always following through on their commitments • Inspire a Shared Vision: create a compelling vision which challenges the status quo to do something for another • Challenge the Process: behave like pioneers by experimenting and innovating • Enable Others to Act: teamwork and cooperation are core values; followers feel good about their work environment • Encourage the Heart: reward others for their accomplishments…and it is authentic

13. Question: What is the Secret to Good Leadership?

14. Followership • Follower: “a person who accepts the leadership of another” • An understudied area: Book search on Amazon revealed… • >95,000 titles on leadership • 792 titles on followership (mostly spiritual or political) • 120:1 in favor of leadership (Bjugstad, 2004) • Unfortunate asymmetry since leadership and followership are intertwined • Most leaders are also followers! (Kelley, Harvard Business Review, 1988)

15. Followership: 4 Key Types(Kelley: The Power of Followership, 1992) • Alienated followers: mavericks with a healthy skepticism of the organization; capable but cynical • Conformist followers: the “yes people” of the organization; will do the organization’s work and actively follow orders • Passive followers: rely on leaders to do the thinking for them…and require constant direction • Exemplary followers: independent, innovative, and willing to question leadership; critical to organizational success

16. Followership: “Speak Up!” (Bennis: Managing the Dream, 2000) • Good followers speak up and disagree with leaders • Ineffective followers fail to give honest opinions, and become “yes people” • If a group is going down the wrong road, it will get there faster if followers remain silent • Effective leaders respect followers who speak their minds rather than withhold key information

17. Putting it All Together • Leadership • Followership + Infection Prevention

18. Understanding Why Some Hospitals are Better than Others in Preventing Infection • Interested in overarching qualitative themes • These themes spanned the hospital-acquired infections studied (UTI, CLABSI, VAP) • Specifically interested in identifying barriers to and facilitators of the use of preventive practices • Much of the variability between hospitals is related to the people who work in those hospitals

19. Findings: Key Barriers • _____________________: people who prefer doing things the way they have always done them • _____________________: passive-aggressives who undermine change without active resistance (Saint et al. Joint Comm Journal Qual Safety 2009)

20. Key Facilitator

21. Leadership… At All Levels • Applies not only to the CEO… • Getting the right people on the bus and in the right seats: identify and support “champions” • Examples: Infection preventionists, hospital epidemiologists, CMOs, etc

22. Key Behaviors of Effective Infection Prevention Leaders(Saint et al. Infect Cont Hosp Epid. Sept 2010) • Cultivated a culture of clinical excellence • Developed a clear vision • Successfully conveyed that to staff •  Inspired staff • Motivated and energized followers • Some, not all, were charismatic

23. Key Behaviors of Effective Infection Prevention Leaders(Saint et al. Infect Cont Hosp Epid. Sept 2010) • Solution-oriented • Focused on overcoming barriers rather than complaining • Dealt directly with resistant staff • Thought strategically while acting locally • Planned ahead leaving little to chance; politicked before crucial issues came up for a vote in committees • Worked well across disciplines and kept their eye on the goal: improving patient care

24. What about the Future? • 21st century: what should be the role for those of us who want to improve the quality and safety of hospitalized patients?