The 4 disciplines of execution

'I know what I need to do. I just don’t know how to do it'

We know that we want to bring strong leadership to our workplace. We have put thought into the strategies that we think will succeed. But how do we move forward? What principles do we need to put in place to ensure success?

I recently came across a discussion about a book called ‘The 4 Disciplines of Execution’. A book that builds on extensive case studies to describe 4 disciplines (abbreviated 4DX) that help organisations implement high level strategies. I believe there might be something in this for medical leaders who want to bring positivity, strength, purpose and direction to their own leadership. 

So what is the 4DX framework, and how can we adapt it to our goals?

Discipline #1: Focus on the Wildly Important
The more you try to do, the less you actually accomplish. Execution should be aimed at a small number of ‘wildly important’ goals. This simplicity will help focus energy (yours and your departments) to bring real results. As David Brooks wrote in ‘The Art of Focus’: ‘If you want to win the war for attention, don’t try to say ‘no’ to the trivial distractions you find on the information smorgasbord; try to say ‘yes’ to the subject that arouses a terrifying longing, and let the terrifying longing crowd out everything else’.

Pick a few challenges or new approaches that - when successful - will really turn around the way your team work together and provide care. Don’t be afraid to be ambitious, make them ideas that will produce profound, tangible rewards for your team.

Discipline #2: Act on the lead measures
Once you’ve chosen your wildly important goal, you need to measure your success. There are 2 types of metrics for this: lag measures and lead measures. Lag measures describe the thing you’re ultimately trying to improve. For example, you might choose to do some work on supporting your staff. You know that staff who are better supported will be both happier in the workplace and contribute to better patient care, for a whole range of reasons. The relevant lag measure for supported staff is improved feedback at their 6/12 monthly review; or improved patient outcomes if you look even further afar.

As the 4DX authors explain, the problem with lag measures is that they come too late to change your behaviour. Lead measures, however ‘watch the new behaviours that will drive success on the lag measures’. In the case of supporting our staff better, you might choose lead measures such as:

  • number of weekly teaching sessions that occur
  • monthly review of training log book or touch-base meetings staff have with their supervisor, consultant or head of department, just to see how they are doing, and if they need any additional assistance
  • number of update meetings or communications by head of department to keep team appraised of what is happening within the service
  • number of opportunities sought and taken to provide ad hoc positive feedback to members of the team

Of course there are many more activities that are involved in creating an engaged workforce, and these are just a few examples. As you improve the numerical quantity of your lead measures, your lag measures will improve as well. In other words, lead measures turn your attention to improving the behaviours you directly control in the near future, which in turn will ensure the success of your long-term goals.

Discipline #3: Keep a compelling scoreboard
The 4DX authors explain: ‘People play differently when they’re keeping score’. This means that it’s important to have a public scoreboard to drive your team’s engagement toward your wildly important goal. This not only creates a sense of competition, but once the team notices their success in the lead measure, they become invested in perpetuating the performance.

Turning to our example, you might keep a physical document that tabulates all the registrars and RMOs by month and the number of meetings that have taken place. Other lead measures are more personal, so the Director might alone keep a calendar on the wall and check off when she or he carries out a weekly communication with the team in some form or other. Finally, individuals may keep a note on their daily journal or have a recurring ‘To do’ item on their phone that reminds them to seek out individuals within their team to reward with some specific positive feedback.

For other wildly important goals, you might create a public scoreboard for the whole team: e.g. if you decide to do a piece of work focusing on reducing complication rates of some description, it’s important that you have a running score somewhere, so the team knows how it’s going.

Discipline #4: Create a cadence of accountability
To maintain focus on lead measures, this is the final step to put in place. ‘A rhythm of regular an frequent meetings of any team that owns a wildly important goal’. During these meetings, the contributors confront their scoreboard, commit to actions to further the cause and reflect on what happened to the numbers since the last meeting, reviewing their previous actions.

For individuals assessing their own scoreboard, this means a ‘weekly review and reflection’. Where the goals are owned by larger teams, it should include all who are committed to the cause, and be systematic in it’s approach. This might take place at a weekly or monthly team meeting, depending on which lead measures need review.

The 4DX framework is based on the fact that execution is fundamentally more difficult than strategising. For all of us. After reviewing hundreds of case studies, the inventors nailed it down to a few simple disciplines that can help. For most medical leaders, the idea of keeping and reviewing a scoreboard isn’t intuitive. And even if our goals aren’t wide ranging or desperately complex, the 4DX disciplines can help achieve success by aligning our practice with a method that is known to work. 

If you think this is important, join the positive leadership movement and talk about these issues. Share/like on social media, so others know you believe in it and the word spreads. Be the change you want to see in our health care systems.

Running a hospital like a business

Simon Sinek here highlights the medical profession as an example of poor leadership, and the consequences of this.

Hospitals are run like businesses, and the problem isn't the people giving the care - those people are highly trained. The problem is the way those people are cared for.

We all have to own this, by looking after our teams, and guiding them in doing the same for each other.

The video starts right at the relevant segment and lasts 2 minutes. The ongoing conversation about the human factors involved and how all organisations can create a workplace that inspires our teams is very important too.

Medical training: a curriculum for leadership?

Last week I came across some interesting research carried out by Google, looking at why some of their teams are highly productive and others, not so much. The results got me reflecting on our own teams and how relevant this research might be for healthcare professionals.

Thinking more widely, it brought me to the question: does undergraduate and postgraduate training prepare doctors for the leadership challenges they face for the rest of their working lives?

Most postgraduate programs have extensive curricula, challenging examination hurdles, and are many years duration. When I think about advanced specialty trainees as they approach the end of their training, almost unanimously their anxieties are about their level of practical skills or clinical knowledge. Are they going to be able to cut it as a boss, to be the all-knowing leader of a clinical team? They angst about whether they can do the procedures, if they have enough operations under their belt to be the slick consultant they want to be. A leader who is good enough, in turn, to mentor his or her own registrars.

Becoming the boss
But what does it actually take to be a leader? What skills are necessary to lead a successful team? What do clinical Directors look for when interviewing for a new consultant? Registrars are often surprised when I tell them that clinical or surgical expertise is rarely one of the differentiating values between candidates. It's actually taken as read that you can do the job if you fulfill the criteria to be shortlisted. You've done your time, you've got your Fellowship. I don't care if you've done 50 or 500 hysterectomies - the clinical expertise will come with time and support. What is most important is can I work with this person every day of my life? Are they going to bring value to the team? Are they emotionally intelligent? Or are they going to cause chaos and disharmony in the workplace that requires constant fire-fighting. When you bring a colleague into your team, you are selecting a new family member. So it needs to be a good one. 

Evidence-based leadership qualities
As I mentioned, Google found that some teams within their company were excelling, whilst others were poorly functioning, even though they all seemed to have members with similar technical abilities. So they looked to determine the characteristics of the leaders of the best functioning teams within their organisation. Google's Project Oxygen worked through exit interviews, team reviews and 360 degree ratings, amounting to over 10,000 observations of leaders' behaviours. There were 8 characteristics identified in leaders of high quality teams - and technical expertise was at the bottom of the list.

  1. Be a good coach
  2. Empower people - don't micromanage
  3. Be interested in the wellbeing and success of each of your team members
  4. Be productive and results-orientated
  5. Be a good communicator and listen to your team
  6. Help team members with their career development
  7. Have a clear vision and strategy for your team
  8. Have key technical skills

Think about what you look for in your leaders as you train, is it not all of the above? Teams want a leader who helps them to puzzle out problems themselves. Always giving the answers implies superiority and shuts down the conversation. Asking questions implies confidence in your team and sustains communication. People need constructive feedback, within a caring and supportive environment. Your team needs to know that you believe in them and to provide them with adequate mentorship for their growth. One of the most valuable things you can give your team is one-on-one time. We cannot lead from a distance.

Improved patient care
The most important consequence of this, is that it doesn't just produce happy workers, it builds teams that are highly functional. Leaders who focus on these characteristics will have teams that embody respect for each other and support one other in their day to day work. This means better patient care and fewer adverse events. Highly functional teams will go above and beyond the call of duty to get the job done.

But how to start? When to start?
You might not have explicitly thought about it, but all through postgraduate training (and often before, as a student), we are put in situations where we are expected to lead. These include:

  • Therapeutic relationships with our patients and their family relies on team work
  • When you're looking after a group of medical students
  • If you're the administration RMO or registrar
  • When you're the on-call registrar overnight
  • When you're the most senior doctor around for the day's ward duties
  • Senior registrars taking on increasing clinical team responsibilities

Notice that I'm not talking about only medical teams. If you're the registrar on duty, you are a member of more than one clinical team, and many of these are multidisciplinary: your ward team including the RMO and nurses responsible for your patients, the MET call team, the surgical team in theatre, the birth suite team, including the shift co-ordinator and all the midwives. Our responsibilities don't only lie with other medical staff. It's as much our role to provide all the 8 leadership qualities to the nurses, midwives and other health care workers within our wider MDTs.

So, when & where to start? Right here, right now. Think about how you can map the leadership qualities above to your own daily experience and responsibilities as a doctor.


If you think this is important, join the positive leadership movement and talk about these issues. Share/like on social media, so others know you believe in it and the word spreads. Be the change you want to see in our health care systems.

Discuss...

Mutual accountability: the holy grail of teams

Mutual accountability: the holy grail of teams. Where I feel that I can succeed, among people I know, trust and care for, why would I let them down?
— Margaret Hefferman

But what does this look like in practice? How can I have it in my workplace. What can I do?

If you’re the RMO, build trust and strong relationships by looking after your colleagues; ask what you can do to make their day easier if you’re having a quiet one. Get to know others on a personal level and ask them about the important things in their life. Relationships are about the small stuff. Take your medical students under your wing, acknowledge the stress of short attachments, constant change & disorientation (you know about that too). Enthuse them with your excitement for being a doctor - you’re their inspiration. Let them do things, give them responsibility, and show you trust them to complete it. Touch base with everyone, often.

If you’re the registrar, remember what it was like being an RMO, they will appreciate your empathy. Relationships and communications are key to happy teams, and your role as a middle grade doctor is central. You carry much more power in team dynamics than you realise - especially in wider MDT relationships. Keep your ears to the ground for the general mood of your team - if there are frictions, consider why and what you can do to help solve them. Ask for help if you’re not sure. Team trust is built through reciprocity - share knowledge, ideas and concerns, contribute to each others problems, acknowledge and talk about your shared goals of excellent patient care. Teach your RMOs and medical students about the importance of efforts devoted to creating a strong workplace culture. When your RMOs or registrar colleagues are busy, offer a hand to help. They will never forget the feeling of being well supported and will return the favour. Ironically, when we help others, we have more to gain, because it makes us feel great too.

Consultants understand that the key to a strong, happy team is a combination of trust, social connectedness and empathy. They support members who are in difficulty, but most importantly, are constantly looking for opportunities to reward positive behaviours in others. Make it a rule to acknowledge at least one person in your team for something good they did, every single day. Heartfelt, specific and in public if appropriate. The more senior you are, the more important it is to listen properly. People look to you for sage advice, but you will never learn anything new unless you are listening. Demonstrate humility, acknowledge your own imperfections, model the behaviours you want to see in others and you will lift your team higher than you could imagine. And earn the respect of those around you. 

Discuss...

Deep work: Shawn Blanc vs Cal Newport

I've followed Shawn's blog for some time - he's a design-centric, techy kind of guy. A writer who's always looking for productivity and efficiency gains in his life. Recently he interviewed someone I hadn't heard of before: Cal Newport.

Cal is 34 year old Assistant Professor of Mathematics in Georgia, US. Apart from his mathematics research, about which I know nothing, he has spent his life writing articles and books about how to learn efficiently - for school kids, university students, and anyone looking for ways to be more efficient with their time. And specifically looking to be more productive with their learning.

His most recent books are 'So Good They Can't Ignore You' and his newly launched 'Deep Work'. He has some fascinating and sensible ideas around how we can all learn more efficiently and spend our days being a ton more productive - leaving us more time for family, friends and all the other things that sit on the other side of work/life balance.

I've ordered his two books, so will do more of an in depth review of these, and his ideas, in another post. Meanwhile, check out Shawn's interview with him (link here) for a summary of some of his ideas. It's on a SoundCloud link, so you can put it on your phone and listen while you're getting dressed or on the way to work. Recommended.

 
 

The heart of a good leader

I came across two acronyms for what makes a strong leader, and they both embody the attributes we must aspire to:

H E A R T

Hunger for wisdom
Expect the best
Accept responsibility
Respond with courage
Think: others first

Human - we are all human and if you want to lead others effectively, you must be willing to be vulnerable and let people see that. We all make mistakes and have weaknesses, and if you think they don't see them anyway, you're kidding yourself. When they see the real you, they are more likely to follow. Check out Brian Goldman's TED talk about doctors making mistakes and the pitfalls of a denial culture in medicine.

Empathy - I'll write a separate article about the huge importance of empathy as a doctor, as a leader, and to succeed in life in general. I'm sure you recognise the difference between empathy and sympathy so I won't labour that point. You will connect with people and lead more effectively if you can 'put yourself into the shoes of others' and consider their position when dealing with difficult situations. Here's a wonderful 3 minute animated short about empathy and the qualities that are ingrained in this simple word.

Attitude - attitude isn't about how clever or logical you are, it's 100% emotion. Sometimes we play down the important of attitude, until our team members have a bad one! Attitude is as contagious as herpes and as a leader, you have the highest viral load. OK, so bad analogy there, but spread the good attitude widely. It's fine to be occasionally disappointed or frustrated in front of your team, and in small doses it reveals your humanity. But they need to see your positive passion for medicine, for patient care, human interactions and the rewards of our work as often as possible.

Relationships - people want to be led by someone they know and like. Find ways to connect with your team. A large part of Emotional Intelligence is about human relationship management and I'll definitely be writing more about the huge importance of EQ. Lead from the heart and work on building stronger and more lasting working relationships with others.

Trust - your team needs to know they can rely on you. That your word is good and you follow through on your promises. They want to follow someone they can trust, and that can be you. 

These two acronyms aren't that different when you look at them and ultimately, leaders must bring their heart to work. You can't lead from a distance. Your team will respect you for it and the reward will be their loyalty and commitment to your shared goals.

Discuss...