Governance in an ASC
Administrators and ambulatory surgery center (ASC) leaders play a key role in ensuring that their organizations are properly governed....
By: Wayne M. Sotile, PhD
Ever since the COVID-19 pandemic hit in 2020, surgical leaders and their teams have dealt with unprecedented levels of stress, as well as exceedingly volatile staffing situations. Many of our surgical generals and their troops are beaten down, frustrated and exhausted.
I’ve studied, consulted and lectured on the topic of resilience (and the lack thereof) in health care for over 40 years. We’ve worked with over 12,000 physicians and surgeons as clients in our practice. Given the current state of things, resilience in surgery is more crucial than ever.
What is resilience? It’s the process of getting through difficult times and coming out stronger for having gone through them due to the choices we make about how we cope. Resilience isn’t simply being strong or optimistic — those qualities are ingredients, but they’re not enough. Rather, resilience is created through a set of tactics and strategies that can be taught and learned. Just as the U.S. Army now routinely provides pre- and post-deployment resilience training for soldiers and their loved ones, progressive healthcare organizations are following suit.
It’s important to impart the tactics and strategies of resilience before leaders and their teams get too far down the road of burnout, career dissatisfaction, interpersonal conflict, difficulty with retention, and a general erosion of attentiveness, detail and accountability that threatens not only quality and safety at work but also the quality of their own lives. Rather than waiting until providers are coming apart at the seams, it’s important to incorporate resilience into the overall job experience and workplace culture to foster supportive environments and productive collaboration with the utmost professionalism. It’s not only about each individual provider, either. Resilience involves working together on how we work together in the OR or more broadly within the surgical facility.
No matter what role an employee or leader plays at your facility, part of the definition of professionalism is to take appropriate care of yourself — in mind, body and spirit — so you can also manage your relationships appropriately. In doing so, we build resilience.
Three vital variables must be managed to drive resilience: energy, attitudes and relationships.
Managing energy. Coping (and thus resilience) takes energy. In the field of resilience, which has been studied since the early 20th century, we have long noted that a disproportionate number of episodes of disruptive workplace behavior occur late in or after shifts because people are sleep deprived. If you’re depleted of energy, you likely won’t cope with stress very well, struggle to solve problems and possess much less grace in tolerating people who irritate you.
Imagine you and every person who works at your facility each has an internal tank of biological, spiritual and emotional energy. Every choice you make throughout the day is a deposit or withdrawal from that tank. Resilient people, intuitively or through intentionality, learn to counter the withdrawals with deposits. Specifically, they counter daily hassles with daily uplifts. These uplifts are what leaders need to dispense to their troops regularly.
None of this comes naturally. Resilience is like having a loving marriage. It’s not a given. It needs to be practiced. One way to practice and engender resilience is to learn to scan for and harvest uplifts that help reenergize you, that make you feel good. The science behind this is that positive and negative health behaviors among leaders and their teams co-vary.
If you’re in a good mood, you’re more likely to eat reasonably healthy, wear your seatbelt, floss your teeth, take medicines as prescribed, work out. It’s when you are depressed, stressed, anxious, angry, or feel unappreciated or devalued that you are more likely to strike out at others while not taking very good care of myself.
If you focus on training people how to generate and harvest positive emotional experiences, everything you want more of — patient satisfaction, teamwork, the quality of your leadership — tends to follow. The more positive emotion, the more positive energy and the more positive coping.
Leaders of stressed or depleted workforces need to be ambassadors of uplift. They need to show gratitude, energize people, orchestrate moments of joy, celebrate achievements.
Lousy leaders fall into two dysfunctional categories: cynical pessimists and rose-colored-glasses optimists.
One uplift is interest. What did we learn today — even if we learned about something we didn’t want to learn about? By acknowledging what we learned, even if it’s bad, the topic becomes less toxic to us. Consider the pandemic, and all the uncertainty and fear that came with it. We had to train masked providers how to conduct rapport-generating conversations with masked patients and caregivers. We learned to smile with our eyes, use more words, be more attentive than we typically would be when facial expressions are visible. It was difficult, but we made the adjustment and learned to work around unforeseen obstacles. That’s something to celebrate, because we know we did what was necessary and it improved a difficult situation for all involved.
Hope is another uplift. It’s not enough for a leader to simply show empathy and compassion to beleaguered troops. You also need to issue a call to the noble mission you’re all on. We renew resilience and stamina through meaning and wonderment, and through reminders that we’re all members of an elite corps. Feeling purpose builds resilience.
Another uplift is pride — pride of affiliation, pride of survivorship. If, on a scale of one to 10, we’re at a five, a resilient leader will point out that we’re not at a three, so let’s celebrate where we are now. A resilient leader also creates a shared, articulated vision of a desired future that energizes themselves and their team.
Uplifts are key to renewing energy reserves. If a patient screams at you, take strength from the other patient who thanked you for your help with tears in their eyes. Harvest that other more positive experience and relish it.
As a leader, you not only need to be compassionate, but also a positive motivator: “OK, team, it’s time to get it up and do it again, let’s kick it.” Remember, if anybody could do what you and your staff do, everybody would. Everyone at your facility should feel proud of what they do and where they do it. Remind them of the nobility, importance and specialness of what you all do. A sense of mission, pride and good fortune fuels energy renewal.
Managing attitudes. What are you thinking about and mentally spreading in the workplace? Attitudes, emotions and behaviors are contagious, and bad ones — especially from leaders — can sicken entire organizations. To build resilience, you need to shape attitudes, including your own.
This isn’t an easy process. Leadership is complicated and resilience is complicated because people are complicated. However, if you start this process by focusing on vital variables, you’ll be at least halfway there. Four specific attitudes correlate with resilience: meaning, wonderment, incorporation and realistic optimism.
Meaning. Meaning is the antidote to distress, so you and your team need to be reminded of why you do what you do. Meaning both reenergizes and motivates, and resilient leaders are its spokespersons. “I’m grateful to you, thank you for what you did this morning because it relates to the meaning of what we’re about in this facility.”
Wonderment. Familiarity can be an extension of meaning. When we first join an organization, everything we do is filled with meaning, but then we start taking it for granted. Wonderment, however, means seeing both the familiar and unfamiliar ways. The pandemic was a key driver for wonderment; we suddenly saw many familiar and unfamiliar ways. What a privilege it was when we used to go to restaurants without a mask, pop into a neighbor’s house or go to conferences in person. With all of those things and many more suspended, we viewed them with wonderment.
Resilient people excel at practicing wonderment. They see joy and uplift wherever it resides. They say things like, “Look at what we’re doing at this surgery center on our worst days. In the history of the human race, we are doing something that a micro-percentage of people learn to do.” Just expressing such a thing can be both powerful and empowering for you and everyone in your care.
Incorporation. The psychology of incorporation opposes the psychology of discontinuity. People who burn out, drop out or grow dissatisfied tend to focus on discontinuity. “My life was good, now it stinks.” “Things were great when we first got together, but now we realize we’re not the first perfect couple in the history of the world.” “My health was great and then I got heart disease, and now I’m miserable.” This all-or-nothing thinking is destructive and demotivating.
Those who embrace the psychology of incorporation understand that life is about a lot of things, and now it just happens to be about this new bad thing too. Instead of feeling discouraged and impotent, these people take a more holistic view of their existence and learn to live and thrive with heart disease, orthopedic problems, menopause or a difficult situation at work.
Work teams tend to be enthralled and attached with each other when they’re new or when things are going smoothly. Resilient leaders keep those positive feelings going through crises. By coming together and realizing you are all more seasoned than you were before, you can better overcome obstacles together. Resilient leaders and teams incorporate current realities into their overall mission, rather than fixate on the bad and let themselves and their staff fall into grievance and despair.
Realistic optimism. As a leader, you must realistically acknowledge the challenges you face, but maintain an attitude of hope.
Lousy leaders fall into two dysfunctional categories: cynical pessimists and rose-colored-glasses optimists. The cynical pessimist believes there’s no sense in trying to change because it wouldn’t make a difference anyway. The rose-colored-glasses optimist believes there’s no reason to change because the bad thing will eventually go away and everything will turn out okay. The realistic optimist avoids these traps, and they and their teams thrive as a result.
A realistic optimist acknowledges that the world changed when COVID arrived: “Now we have a new normal, so let’s rock and roll in that new normal.” They acknowledge new challenges, like staff shortages and more discerning job hunters — and they understand that they need to learn from them and adapt. “Let’s not wait for things to go back to the way they were. Let’s use this opportunity to build a better workplace.”
People love working in places where leaders are inquisitive about what they need more or less of.
Healthcare providers have been telling us for decades what they need more of and what they need less of — especially what they consider is not meaningful. Truly dynamic and creative organizations breathe a new kind of meaning into teamwork by couching such dialogue in realistic optimism.
In the process, those organizations are becoming retention magnets. The message needs to be: “We’re getting through this, and we’re going to keep getting through it. We’re going to envision and shape a better and better workplace as we go.” A shared vision of a desired future should drive dialogue.
Managing relationships. As go your relationships, so will go your resilience. The quality of your relationships is the most powerful predictor of wellbeing or ill-being, of resilience or burnout.
There are no perfect relationships, but the distinguishing characteristic of a thriving one is not the absence of hassles. It’s the presence of uplifts, which create a positive emotional bank account, if you will — interactions that are affirming, appreciative, caring, acknowledging.
Of course, being nice is intuitive and not too difficult for most people. But there’s a counterintuitive aspect that also drives thriving relationships — the courage required to drive accountability. Dynamic leaders don’t just “manage up.” They also “manage out” those who either should have changed or been fired years ago. Tolerating these employees’ bad attitudes, backbiting and cliquish behavior sucks the energy out of everyone who works with them, poisoning the culture of a workplace.
The tone you should set is, “Let’s all call on our better angels to be nice and appreciative and caring to one another, but also, let’s be courageous.” If someone is acting out, everyone on the team should feel empowered to say, “That’s not how we treat each other here.” Your team should be the silent majority who is always nice but stands up and speaks out when necessary. Otherwise, the disruptors become malignant deviants, when in fact it should be made clear that they should either shut up, change or leave. All three of those outcomes are more desirable then allowing them to ruin the culture of your workplace.
This goes for leaders as well. If the leader commits infractions, they’re actively promoting those behaviors as acceptable, and they shape your workplace.
Leaders and staff should manage themselves and their interactions among each other with emotional intelligence. Don’t go numb and wait for the difficult times to pass. Instead, everyone should resolve to grow continuously through bad times by managing their energy, attitudes and relationships.
As always, it starts with leadership. If you have 10 people who report to you, do you know what each of them most wants and/or needs right now to feel a greater sense of wellbeing? Most people answer that question based on either recent conversations they had or a generalized, compassionate understanding that more staff or money or effort is needed to fix things.
But here’s the reality, backed by social support literature. If you ask someone, “What do you need?” their answers fall into four different categories. To drive this concept home, imagine you are dealing with a recovering patient.
Here’s the big point: If you take those same people and ask the question again in three months or three years, people who were in one of those groups could be in another group at that time. That’s why dynamic leaders need to have dynamic conversations — frequent and to-the-point conversations asking, “How are you doing?” “What do you need?” What someone needs today might not be what they need next month, or further down the road, so it’s important to stay connected to your people and listen to their feelings and concerns, while also dispensing uplifts.
It’s all about inquisitiveness. People love working in places where leaders are inquisitive about what they need more or less of. This is crucial, however — follow through on these conversations. The message should always be, “You spoke and we listened, and here’s what’s happening.” At the very least, follow up with a “stoplight report” at staff meetings or with individuals:
This simple process of acknowledgment and accountability is powerful. It fertilizes relationships. It drives home the point to each staff member that they work at a place where their voice matters, where there are supportive interactions. To reenergize your workforce, it starts with conversations and continues with accountability and transparency.
Some leaders who consider themselves introverts might feel these tactics and strategies are beyond their social capabilities. But introverts have as much to offer, and as much to gain, from a culture of resiliency as extroverts do.
I’ve coached thousands of healthcare executives who are all along the spectrum, and you don’t need to be a raving extrovert to practice and engender resiliency. Consider this: No matter how introverted you are, no matter how data-oriented you are in your approach to life, do you interact in certain ways that endear you to people you love? Surely you do. Don’t leave those tools and skills in your car trunk when you enter your workplace.
There’s tremendous power in introverted leadership. Part of emotional intelligence is honestly recognizing your strengths and your challenges, and then learning to self-regulate your feelings and emotions to generate positive outcomes and influence a diverse set of people across a wide range of circumstances. Put people at ease in your presence and engage them so you can influence them.
Effective leadership is about that capacity to influence people, which requires flexibility. Not everyone wants a hug, and you don’t need to gladhand people all day. Instead, as science suggests, chunk it down. Spend 20 to 30 minutes a day managing relationships in one- or two-minute spurts.
The science of team building hinges on the effective (or ineffective) behaviors of leaders. Effective behaviors almost always require charismatic connection. You personally don’t need to be charismatic, but you need to spread your connections around. The more irrational and introverted a leader, the fewer people they interact with, and less and less accurate information rises to leadership.
As a leader, you need to “round for resilience.” Get out of your office regularly and just talk to people. Ask how they’re doing, how their family is doing. Ask them what they need. Thank them for something they did this morning. Break positive reinforcement down into immediately administered, digestible chunks.
It’s fine to give someone a $200 bonus at the end of the year and celebrate their achievements, but it’s far more effective to give them $5 gift cards throughout the year as thanks for achieving smaller things, like covering a shift. One hundred years of motivational psychology says the only thing that creates sustained motivation and engagement is positive reinforcement frequently dispensed and relevant to something that just happened.
I’m not saying go out there and sing “Kumbaya” with everybody, but if you’re protecting your comfort zone by saying you’re not “touchy feely,” you’re making a big leadership mistake. If you’re not putting a wide range of types of people across a wide range of circumstances at ease in your presence, you’re putting a ceiling on your effectiveness as a leader.
You also need to mandate to the people in your organization that we all need to work on how we work together. In this industry, people are often thrown together to do incredibly complicated work, and are expected to somehow just get along. It’s ridiculous. We must work — with intention, with honesty, with transparency, with vulnerability, with emotional intelligence, with courage — on how we work together if we are to grow more effective as a team. Let them know that it’s not enough to show up and be technically competent, or just do your front office job or your nursing job. You’re expected to do that. We need to work on how we work together.
Three out of four of both healthcare workers and patients have developed psychosocial distress through the pandemic. The surgeon general recently presented data saying that eight out of 10 health professionals in the last calendar year reported being abused in the workplace by patients, family members, by visitors — verbally, emotionally or in some instances physically. It’s a human resource crisis, so we need to provide protection to our troops. Health professionals are hyper-focused on patient satisfaction, but what about staff safety? By applying the principles of resilience, you and your team will be better equipped to handle these unpleasant interactions.
Making mental health services and information available to your staff, especially now, will help them build resilience as well. Creative leaders let staff know that their wellbeing matters and provide resources so they can perform
self-checks or receive psychoeducational information or personal counseling.
Measuring things makes us better able to change them for the better. The best way to measure the resilience of your staff is to talk about it. Make talking about wellbeing and resilience part of your facility’s vernacular. Start every meeting with a connective purpose that imparts: “This is our mission, these are our values.” Make a brief wellness check part of every meeting. It’s kind of hokey at first, but then it becomes part of what you routinely talk about. “You said you were going to eat healthier. How many healthy foods did you eat this week?” “You said you wanted to exercise more. Did you take that yoga class I recommended?” Pretty soon, you and your staff will be playfully holding each other accountable, in the process creating social support for everyone’s wellbeing.
People want to belong to things they can be proud of. They crave organizational identification. When you impart that they are part of an elite group that always responds with professionalism and quality to any situation or crisis, your facility has a fine package of resilience.
As a leader, operate with some fire in your belly, manage your energy, screen staff comments through the four attitudes that shape resilience, and build positive relationships with a combination of compassion and accountability.
Emotionally intelligent leaders who create and maintain resilient workplace cultures are distinguishing themselves to jobseekers and patients alike. All it takes is a commitment to self-awareness, understanding and initiative. OSM
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