William C. "Bill" Waters IV, MD, joined Carrollton, Ga.-based Tanner Health System in 2002 as an intensivist and medical director of the intensive care unit. Four years later he was named CMO, a role that gives him responsibility for patient safety, quality, clinical integration and other areas. Here, he describes how building high-performance teams is one of the key strategies to achieving success in a hospital or health system.
Q: What is the most important lesson you have learned as CMO of Tanner Health System?
Dr. Waters: The most important lesson I've learned as chief medical officer is that everybody in the organization — whatever their jobs are and their daily frustrations or goals, especially in a not-for-profit hospital — in their heart very much wants to provide exceptional care for the community. Sometimes things happen in the course of the day that distract us from that, but the most important task is to motivate people to excellence. To accomplish this, we keep the patient as the centerpiece of everything that we do. Everybody in the organization responds to [patient-centeredness] if you are able to unite them around that cause.
Q: How did you learn this lesson?
BW: Before I left the ICU and accepted the chief medical officer job — I visited five or six places across the nation that had chief medical officers working. None of them told me, but I observed at their facilities, just as I've observed at ours, that concern for the patient seemed to be the thing that suddenly turned everybody's lights on. Upon my return, I interviewed our administrative staff here, and it became apparent to me that the same thing that motivates doctors also motivates our administrative staff and workers here. If you make everything come back to "What's the best thing for the patient?" and get everybody to rally around that cry, it's an unimpeachable standard that nobody wants or can say no to.
Q: How do you think your original position as medical director of the ICU at Tanner Medical Center/Carrollton contributed to your leadership style and the decisions you make?
BW: My experience in medicine, culminating in ICU leadership, taught me a valuable lesson, and it is very important to take what I learned there and expand it to the rest of the organization: The most successful care in the ICU — the most successful programs with the best outcomes — are those in which people work as a team rather than individuals with solely individual responsibility. Putting together nursing leadership, the patient's nurse, the patients' family, the case manager, nutritionist, physician, nurse practitioner, pharmacist, respiratory therapist and other administrative staff as a team in the environment of care is a night and day difference compared to everybody working separately as individuals. Nothing is more powerful than that. Getting everybody to work as teams and not in separate silos was a pivotal realization for me and one I tried to share with the rest of the institution.
As chief medical officer I understand the clinical realm. The hardest leadership realization one must have is that even though you work as a team in the ICU or other setting like that, in leadership in general, the more you have responsibility for, the more you need to be able to delegate to build a truly effective team. You have to be able to trust individuals to do the job for you. You might be the one responsible for everything, but you can't possibly do everything. The second tier in my career has been building a high-performance team and supporting them through their mistakes and victories.
Q: What has been your biggest challenge as CMO?
BW: My biggest challenge has been getting people in the environment of care to accept and adapt to change and to work as a team. You read all the time about how difficult it is to get physicians to change. In my experience that's not at all true. Everybody has difficulty with change. I think there is at least as much and probably more difficulty getting administrative and other staff to change as there is getting physicians to change.
Q: How do you persuade people to change and work together?
BW: You need to have everybody as much as possible feel secure about the [change] process so you can work as a team. People work in silos, and in my experience, people work in silos not necessarily because they want to but because they have certain insecurities. It's the same reason a doctor might want to control everything in [his or her] environment. The ability to trust and delegate responsibilities is not something the American healthcare industry is used to doing. To build a team, you have to create an environment in which everyone is a team member, has an active role in their field, is empowered as part of the team and feels like they have ownership in the process. To do that you have to figure out what the group's and individuals' insecurities are and do your best to do away with those. To me, that's a key strategy in team building of any type. Insecurity is what keeps us working with ourselves and not with others.
Q: How do you eliminate people's insecurities?
BW: One of my colleagues observed recently that in a [health administration] master's program, you get trained to lead and manage, but there is no training on how to work with doctors. I think my colleague was right, but not because we lack the skill set. I think it is because we lack the perspective that physicians need, like everyone else, to be a respected partner and stakeholder in all our processes. Few places know how to do that.
I think doctors are in some ways different, but by and large not that much different from anybody else. One way or another they have undergone the transformation from feeling like the emperors of medicine to feeling like commodities. We in organized medicine are then surprised when they respond to us like commodities. Get physicians involved as core members of the team and make sure they're not treated like commodities. That is one of the ways to get rid of physicians' insecurities.
For other people's insecurities, it's a matter of using emotional intelligence and other skills to figure out what motivates and frightens them. Things that are not readily apparent can cause insecurity. We all have insecurity about the future of medicine. The group realization they need to have is that they're best equipped to handle things as a team, not as individuals. A key realization is that there's never been a worse time to be a standalone physician than now. But there has never been a better time to be a physician as a member of a high-performance team than right now.
Q: What are the biggest challenges hospital CMOs in general face?
BW: The central problem chief medical officers face is that people do not understand their job or what their role is in it. People in a hospital environment and outpatient environment intuitively understand what an operational leader does. But they are often unsure, even when it is carefully explained, what the role of the chief medical officer is. This inhibits [the CMO's] ability to create the trust and the cohesiveness that comes from understanding their appropriate involvement. For example, most chief medical officers should have responsibility for patient safety. Patient safety permeates every aspect of the operational environment. Without the proper expectations and knowledge of how to work as a team with the chief medical officer as an ally, it's extremely difficult to work together on patient safety because of the resistance of people in the environment from what is otherwise perceived as an intrusive presence.
Understand each other's roles. If you don't, it makes the job of chief medical officers, if not impossible, so inefficient that they are not able to accomplish what they need to accomplish.
Q: How do you recommend CMOs approach and overcome these challenges?
BW: Teaching others about one's role can create trust when working with teams. You need to create a structure in your organization that accommodates the team. The point is that we get to have mistakes and victories together. Sometimes you want to take the bull by the horns and get things going, but as much as possible relegate core missions to teams. It is really helpful in that situation to utilize proven strategies like Lean Six Sigma to facilitate team building and performance improvement.
Q: How would you describe a hospital or health system CMO's role?
BW: That's difficult to answer because the job descriptions across the nation are so varied. Understanding that, let me try: The jobs that are central to a chief medical officer are having operational responsibility for patient safety and quality improvement; care management/case management/utilization review; health information management; medical staff processes such as credentialing and peer review; infection prevention and risk management. It is important for physicians to be involved in these. These are becoming more important as a way to unite people toward common goals in patient care with [accountable care organizations] and bundled payments on the horizon.
For those of us who hold the reins in healthcare institutions, one of our jobs is to create an environment that offers physicians the resources to do what is necessary. So many places use the term "partnership" when referring to their relationship with physicians. But what they mean by that is they have gotten physicians to go along with certain directives because [the physicians] don't have an option. But a true partnership is where everybody has input as to how everything will work and the decisions made. You have to build an environment of trust through sharing responsibility and decision making and understanding what gratifies individual physicians. Money alone is not what motivates most physicians. They want to feel good about the contributions they made that day. It's up to us to construct that team structure and make them part of it.
Q: What accomplishment as CMO are you most proud of?
BW: Whatever role I might have had in uniting physicians, hospital staff and administrative staff in working together to try to achieve some of the goals we have had to achieve. We tremendously reduced mortality rates, we have an outstanding record in infection prevention and we were named one of the top 15 health systems in the nation by Thomson Reuters and one of the top five for small hospitals in the nation. In my opinion, we achieved that through teamwork. It's not my accomplishment, but I am proud of whatever role I had in facilitating the team effort.
Q: What advice do you have for other health system CMOs?
BW: I have several pieces of advice: Be sure that you have a well-developed sense of humor. You have to be able to see humor in everything or any intense job will wear you out. Never be directive with medical staff. Facilitate them and make sure that you are doing everything you can to make it true that they are never treated as a commodity. Understand the way that you're perceived by hospital staff and be sensitive to that. Be respectful of non-physician administrative colleagues, many of whom may not exactly understand your role but nonetheless have made a significant contribution to the organization themselves.
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Q: What is the most important lesson you have learned as CMO of Tanner Health System? Dr. Waters: The most important lesson I've learned as chief medical officer is that everybody in the organization — whatever their jobs are and their daily frustrations or goals, especially in a not-for-profit hospital — in their heart very much wants to provide exceptional care for the community. Sometimes things happen in the course of the day that distract us from that, but the most important task is to motivate people to excellence. To accomplish this, we keep the patient as the centerpiece of everything that we do. Everybody in the organization responds to [patient-centeredness] if you are able to unite them around that cause.
Q: How did you learn this lesson?
BW: Before I left the ICU and accepted the chief medical officer job — I visited five or six places across the nation that had chief medical officers working. None of them told me, but I observed at their facilities, just as I've observed at ours, that concern for the patient seemed to be the thing that suddenly turned everybody's lights on. Upon my return, I interviewed our administrative staff here, and it became apparent to me that the same thing that motivates doctors also motivates our administrative staff and workers here. If you make everything come back to "What's the best thing for the patient?" and get everybody to rally around that cry, it's an unimpeachable standard that nobody wants or can say no to.
Q: How do you think your original position as medical director of the ICU at Tanner Medical Center/Carrollton contributed to your leadership style and the decisions you make?
BW: My experience in medicine, culminating in ICU leadership, taught me a valuable lesson, and it is very important to take what I learned there and expand it to the rest of the organization: The most successful care in the ICU — the most successful programs with the best outcomes — are those in which people work as a team rather than individuals with solely individual responsibility. Putting together nursing leadership, the patient's nurse, the patients' family, the case manager, nutritionist, physician, nurse practitioner, pharmacist, respiratory therapist and other administrative staff as a team in the environment of care is a night and day difference compared to everybody working separately as individuals. Nothing is more powerful than that. Getting everybody to work as teams and not in separate silos was a pivotal realization for me and one I tried to share with the rest of the institution.
As chief medical officer I understand the clinical realm. The hardest leadership realization one must have is that even though you work as a team in the ICU or other setting like that, in leadership in general, the more you have responsibility for, the more you need to be able to delegate to build a truly effective team. You have to be able to trust individuals to do the job for you. You might be the one responsible for everything, but you can't possibly do everything. The second tier in my career has been building a high-performance team and supporting them through their mistakes and victories.
Q: What has been your biggest challenge as CMO?
BW: My biggest challenge has been getting people in the environment of care to accept and adapt to change and to work as a team. You read all the time about how difficult it is to get physicians to change. In my experience that's not at all true. Everybody has difficulty with change. I think there is at least as much and probably more difficulty getting administrative and other staff to change as there is getting physicians to change.
Q: How do you persuade people to change and work together?
BW: You need to have everybody as much as possible feel secure about the [change] process so you can work as a team. People work in silos, and in my experience, people work in silos not necessarily because they want to but because they have certain insecurities. It's the same reason a doctor might want to control everything in [his or her] environment. The ability to trust and delegate responsibilities is not something the American healthcare industry is used to doing. To build a team, you have to create an environment in which everyone is a team member, has an active role in their field, is empowered as part of the team and feels like they have ownership in the process. To do that you have to figure out what the group's and individuals' insecurities are and do your best to do away with those. To me, that's a key strategy in team building of any type. Insecurity is what keeps us working with ourselves and not with others.
Q: How do you eliminate people's insecurities?
BW: One of my colleagues observed recently that in a [health administration] master's program, you get trained to lead and manage, but there is no training on how to work with doctors. I think my colleague was right, but not because we lack the skill set. I think it is because we lack the perspective that physicians need, like everyone else, to be a respected partner and stakeholder in all our processes. Few places know how to do that.
I think doctors are in some ways different, but by and large not that much different from anybody else. One way or another they have undergone the transformation from feeling like the emperors of medicine to feeling like commodities. We in organized medicine are then surprised when they respond to us like commodities. Get physicians involved as core members of the team and make sure they're not treated like commodities. That is one of the ways to get rid of physicians' insecurities.
For other people's insecurities, it's a matter of using emotional intelligence and other skills to figure out what motivates and frightens them. Things that are not readily apparent can cause insecurity. We all have insecurity about the future of medicine. The group realization they need to have is that they're best equipped to handle things as a team, not as individuals. A key realization is that there's never been a worse time to be a standalone physician than now. But there has never been a better time to be a physician as a member of a high-performance team than right now.
Q: What are the biggest challenges hospital CMOs in general face?
BW: The central problem chief medical officers face is that people do not understand their job or what their role is in it. People in a hospital environment and outpatient environment intuitively understand what an operational leader does. But they are often unsure, even when it is carefully explained, what the role of the chief medical officer is. This inhibits [the CMO's] ability to create the trust and the cohesiveness that comes from understanding their appropriate involvement. For example, most chief medical officers should have responsibility for patient safety. Patient safety permeates every aspect of the operational environment. Without the proper expectations and knowledge of how to work as a team with the chief medical officer as an ally, it's extremely difficult to work together on patient safety because of the resistance of people in the environment from what is otherwise perceived as an intrusive presence.
Understand each other's roles. If you don't, it makes the job of chief medical officers, if not impossible, so inefficient that they are not able to accomplish what they need to accomplish.
Q: How do you recommend CMOs approach and overcome these challenges?
BW: Teaching others about one's role can create trust when working with teams. You need to create a structure in your organization that accommodates the team. The point is that we get to have mistakes and victories together. Sometimes you want to take the bull by the horns and get things going, but as much as possible relegate core missions to teams. It is really helpful in that situation to utilize proven strategies like Lean Six Sigma to facilitate team building and performance improvement.
Q: How would you describe a hospital or health system CMO's role?
BW: That's difficult to answer because the job descriptions across the nation are so varied. Understanding that, let me try: The jobs that are central to a chief medical officer are having operational responsibility for patient safety and quality improvement; care management/case management/utilization review; health information management; medical staff processes such as credentialing and peer review; infection prevention and risk management. It is important for physicians to be involved in these. These are becoming more important as a way to unite people toward common goals in patient care with [accountable care organizations] and bundled payments on the horizon.
For those of us who hold the reins in healthcare institutions, one of our jobs is to create an environment that offers physicians the resources to do what is necessary. So many places use the term "partnership" when referring to their relationship with physicians. But what they mean by that is they have gotten physicians to go along with certain directives because [the physicians] don't have an option. But a true partnership is where everybody has input as to how everything will work and the decisions made. You have to build an environment of trust through sharing responsibility and decision making and understanding what gratifies individual physicians. Money alone is not what motivates most physicians. They want to feel good about the contributions they made that day. It's up to us to construct that team structure and make them part of it.
Q: What accomplishment as CMO are you most proud of?
BW: Whatever role I might have had in uniting physicians, hospital staff and administrative staff in working together to try to achieve some of the goals we have had to achieve. We tremendously reduced mortality rates, we have an outstanding record in infection prevention and we were named one of the top 15 health systems in the nation by Thomson Reuters and one of the top five for small hospitals in the nation. In my opinion, we achieved that through teamwork. It's not my accomplishment, but I am proud of whatever role I had in facilitating the team effort.
Q: What advice do you have for other health system CMOs?
BW: I have several pieces of advice: Be sure that you have a well-developed sense of humor. You have to be able to see humor in everything or any intense job will wear you out. Never be directive with medical staff. Facilitate them and make sure that you are doing everything you can to make it true that they are never treated as a commodity. Understand the way that you're perceived by hospital staff and be sensitive to that. Be respectful of non-physician administrative colleagues, many of whom may not exactly understand your role but nonetheless have made a significant contribution to the organization themselves.
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Leading Through Unprecedented Change: 6 Behaviors CMOs Must Master