Caring for the caregiver: Principles of leadership and change

Dr. Tony Briningstool is an emergency room physician and the senior vice president and chief medical officer at American Physician Partners.

A huge area of focus for Dr. Briningstool is on what we call caring for the caregiver – how to support clinical staff and build teams to reduce the incredible problem of burnout and moral injury among physicians.

Those issues, of course, are of even greater concern during COVID-19. And so Dr. Briningstool spoke with Jarrard Inc. chief innovation officer and founding partner Molly Cate about how he and the APP team approach positive, proactive leadership and what COVID-19 could mean for the future of healthcare as it relates to clinicians.

Read the transcript

Molly Cate: Well why don’t we start there. Give us some highlights from that conversation. Some takeaways.

Tony Briningstool: Well, perfect. So as you know, part of our leadership structure is that on every quarterly basis, I do a webinar with all of our leaders on our team. It’s a wonderful time for us to bring everyone together and really talk about exceeding expectations for our patients, our providers, our hospital partners. Really focusing on the power of positive, proactive leadership. And it’s a chance for us to bring in some guest speakers who have a chance to really be influential to our medical directors.

MC: You mentioned being a proactive and positive leader and that being an opportunity for emergency room physicians, given that they’re on the front lines of this. What does that look like?

TB: That’s a great question. So I think for us, it looks different at different times. But you know, the number one is taking ownership and making sure our teams are prepared. Our team has to know the game plan of how we’re going to keep our team safe. How we’re going to rally together and create a one team philosophy within our emergency department. How we’re going to create the right process or protocol secure for our COVID patients and our non-COVID patients. So to make sure that the department is structured, you’ve got to be able to meet the needs of all of our patients in an acute crisis.

And then, it’s managing the team over time. So, it’s one thing to create a game plan, but then you have to execute the game plan, and executing the game plan can change by the day. So you have to be an adaptive leader, an agile leader. You have to be a positive proactive leader from the standpoint of forecasting what the needs of your team and the needs of our patients in our department is at the given point in time. But also being able to make sure that each one on the team understands what their role or responsibility is, and that they’re supported, encouraged, and have the tools necessary to deliver that care at that time.

And I think one of the key elements around this whole part is, I think back to when we didn’t really have many COVID cases in America. You know, where was I in January with our teams thinking about this COVID-19 crisis and what’s coming. We saw what was happening in China and how that was moving into Europe. And as I was thinking about that, at that time I thought we were bracing for an overrun or an overload of patients.

We were bracing for high volumes. What we’re going to do to staff up and made sure that we had all the right resources in our departments to take care of a higher number of patients or an increased line of patients. And who would have thought in a worldwide infectious pandemic that our healthcare system in America would be facing volume shortages and the revenue impact of those volume shortages.

You think about social distancing. Think about cancellation of elective surgeries and the things that we did to prepare our hospitals to create capacity for this influx of patients. And in fact, the influx of patients is coming, but we have removed the other sort of standard population of patients we take care of.

So I think what we’ve seen over the last couple of weeks as we’re managing this pandemic, and certainly New York and Detroit and Louisiana are a little bit different than the rest of America. But I would say for most communities, our hospitals are full of COVID patients, but they’re not at max capacity.

And our emergency department volumes across the country are down anywhere between 10 and 30 percent. So when we talk about the power of proactive and positive leadership, it is managing to lots of things that we’re not foreseeing. Crises that arose, that we didn’t predict. But how can you be agile and adjust to that?

So what is our team doing? We’re adjusting our staffing to our volume. We’re trying to contract our resources so we can decrease exposure and protect our team, but also have a bench that allows us to be able to replenish our team when volumes do hit at unpredictable or at a future time. We’re making sure that we’re managing all of our resources well, both in the emergency department and in the inpatient arena to really match the volume of patients we’re seeing now. And then we’re doing that in conjunction with our hospital partners so that we can make sure that we’re doing everything we can to make sure our teams are equipped, our teams are supportive, but our teams are right size to the line of patients we’re seeing.

And then probably the other last piece I would talk about around positive, proactive leadership is sometimes when people hear positive leadership, they think of kind of you’re staring through rose colored glasses, or you’re thinking about a ‘pollyanna’ approach to leadership. It’s actually very much the opposite. Being a positive leader just means that you’re willing to lead by example. You’re willing to be an encouragement to your team, and you’re really looking to be optimistic. All crisis create opportunity.

So how can we help make sure that we’re rising to the challenge and creating the right environment of care so our patients get the best care experience possible. Our hospital and teams are working in the best environment as possible. And we’re working through an optimism, a belief and a hope that we know that we can deliver great care despite the challenges that we’re facing.

MC: I think universally, across the country right now, everyone is looking to be supportive to physicians and engage with them in a meaningful way that honors the incredible work that they’re doing.

Take us inside the mind of emergency room physicians and what’s important to them right now. What’s on their mind and how do we meet them where they’re at?

TB: What a great question. And I think the number one thing to realize is physicians are human, and we have all the same emotions that everyone else does, even though we have an incredible job to serve and care and help promote healing for our patients. I would say, there’s an underlying fear in the mind of emergency physicians, all health care providers, all of our front-line providers, our nurses, our pretty therapists, our critical care physicians, emergency positions. Everybody who’s really caring for patients in the COVID-19 crisis.

I think all of them in the back of their mind think there’s a fear of, ‘What are the risks of me getting sick. How do I protect myself and manage this concern about shortage of PPE? Or is my organization supporting me? Does my hospital support me? Do I have the tools and resources necessary?’ So I’d say, think about what physicians are thinking. For emergency physicians, there’s this overwhelming sense of, ‘I’m going to charge the hill and take care of patients.’ Because we have an overwhelming desire that pulls us to helping provide care to patients. But we have to remember too, that we have to protect ourselves so that we can provide care to multiple patients.

And so if I was speaking to our administrative colleagues, I would say, what could you do to best support your team? Just be thoughtful, be visible, and I would ask two questions often. It’s to ask all of your physicians, how can I help you and what do you need? And then delivering that. Sometimes it might be, I just need to make sure we’ve got enough PPE for tomorrow. I need to make sure that I’ve got the right equipment, that I can go into the room safely and provide care and not put myself in harm’s way. Because if I don’t put myself in harm’s way, I can protect myself from getting sick.

And then the other reality that comes out of that is through a crisis, what a wonderful time to strengthen relationships. We talk often at APP about a one team philosophy. We want to bring a one team of culture to our hospitals where we’re all on the same team, striving to exceed expectations for each patient we’re privileged to serve. And I think in a time of crisis for our hospital partners, what an incredible opportunity to be visible, be present, but also realizing that in this crisis, through that visibility, through that desire to ask how I can help you and how I can serve you, what is it that you need? It will strengthen the relationships between maybe the medical team and the administrative team through this crisis together.

And I think what happens on the outside of that is home stress. Stress drives relationships one or two ways. It either can weld them together, strengthen them and solidify them, and they can become greater and tighter relationships over time. Or can create a division or a separation relationship when maybe a needs not been met or an expectation wasn’t realized.

And so I think this is just a terrific opportunity for us in healthcare together, to come together and embrace a one-team culture philosophy and really serve and lead well.

MC: As we move forward as an industry, we hear a lot of talk and read a lot about, that healthcare won’t ever be the same. You know as our nation and as our healthcare delivery system emerges from COVID-19, it will fundamentally change going forward. How do you see the role of physicians changing in a post COVID-19 universe?

TB: What a great question. I think about three different things that will change. I think one, we will shift our hospital structure to a more acute care setting. I think that what we’re seeing right now is with the shifting of elective and non-urgent or emergent procedures away from the acute care setting, we’re going to develop ways as a society and as a healthcare organizations of how to take care of lower acute patients in a different environment outside of the hospital. I think the stress of COVID-19 and what it’s created on the critical care units, I think our inpatient hospitals are going to expand the critical care capabilities. Whether it’s ICU beds, step-down beds or acute care, inpatient beds.

And certainly the emergency department. What we’re seeing happening already is an evolution of higher acute care, more acute care, but maybe compression and volumes. And so as you look at the post COVID state and what I think of is, maybe our ED volume, our visit volume may come down, but the acuity of patients will be taken care of, there will be a higher acuity of patients – which is probably appropriate for what we do in emergency medicine and how we’re trained. And lower acute patients will find other platforms of care whether they’re through telehealth or telemedicine solutions.

And I think we’re going to also expand outpatient platforms for transitions of care. So patients who don’t need, maybe the high intensity of services in the inpatient setting or even in the emergency department, will be able to find those all delivered through hospital organizations but outside the four walls of the hospital.

So I think there’s going to be some structural changes in healthcare of we will see going forward and all for the better. All for ways for us to provide better care for our patients, but maybe more cost effective and maybe a newer model.

MC: Thank you. Anything else on your mind that you feel would be important.

TB: No, I think about this in general, you know, with crisis comes great opportunity. And with opportunity, it’s a great time to lead well, and it’s a great time for us to maybe reinvent how we have done things in the past. I look at how hospitals are rapidly transforming to meet the need of our COVID-19 challenges, and I think about what’s happening within relationships. I think what’s happening within restructuring, I think what’s happening within the honoring and appreciation of what we do in medicine as physicians to really heal and care. And then I think the other part that, there’s a real awareness of something that I think is really important.

We had talked about maybe months ago, that there was this concept around physician burnout or healthcare caregiver burnout. There’s a thought around moral injury, and what does that mean?

And I think there’s no better opportunity than what the COVID-19 crisis has presented to us than for us to maybe have a deeper understanding of the emotional depletion that happens within our caregiver team.

And I think that’s for health care providers of all specialties. But if you think about, I’ll just take you into the minds of an emergency medicine provider right now. You know, they show up to work every day. They make sure to have the right amount of PPE there, and their entire shift they’re faced with doffing, or putting on, or donating their PPE equipment and making sure everything is ongoing into the room to deliver great care, delivered in a compassionate and thoughtful way. Then they’ve got to doff this equipment, take it all off, wash their hands, sort of sanitize themselves and move into another set of gear into another patient room to take care of another patient in.

Each one of those patients has a unique dynamic to them. One might be an elderly patient who’s there alone and dying from the COVID-19 crisis and has to die alone because of our isolation in our infectious precautions that we’re having. But there’s a human connection, there’s an emotional component there, where I think our team… your hearts break day after day, shift after shift, where we’re trying to deliver the best-in-class care.

If you step away from that example of the COVID-19 crisis, look at healthcare as a whole, You know, in emergency medicine or in our inpatient acute care world, we’re managing high risk patients.

Time after time, patient after patient, encounter after encounter, we’re managing busy departments. We’re managing BMRs and challenges of that. We’re managing the desire to achieve best practice metrics. But there’s a human connection that happens at the patient care experience, and there’s a human investment that happens and there’s an emotional, deposit and withdrawal that occurs in every single one of those encounters, and I think, hopefully, when we come through this, there’ll be a greater appreciation of two things.

One – The incredible privilege that our healthcare team has, that we get to provide care and we get to care for patients in their time of need – what an incredible privilege that is. But also, with that privilege comes great responsibility. Not only the responsibility of the caregiver to deliver high quality clinical care in compassionate, courteous way, but the responsibility of our healthcare organizations, our healthcare administrators, our hospitals, and all of the support structure around our caregiver team to have a deeper appreciation and understanding that there’s an emotional connection, and there’s an emotional depletion. It happens hour after hour, shift after shift, time after time, as we manage this.

And I think just understanding that, having a compassionate appreciation for that, and then being able to realize how do we as organizations, as healthcare leaders, keep that in the forefront of our mind as we’re leading our teams, so we can continue to encourage our teams, continue to support our teams, provide the resources necessary for them to manage that emotional depletion and be able to restore, or give them the opportunity to restore, and replenish and recharge so that as they come back in again for their next shift, for their next month, for that next year, that we can work on healthcare preservation of our healthcare team or healthcare resources as they continue to meet the needs of our patients.

And nothing like this COVID-19 crisis has been better to create a reset in healthcare. Healthcare doesn’t happen without caregivers. Healthcare doesn’t happen without doctors. It doesn’t happen without nurses. It doesn’t happen without the respiratory therapist. It doesn’t happen without people who go to the bedside with all the expertise, knowledge, and training, but with a caring and compassionate heart and say, how can I take care of you?

MC:  So right now, our industry is focused on the crisis of COVID-19 and how to lead through this significant moment in time. It’s an unprecedented crisis in our industry. What principles of change and in leadership and change can we apply from this, that we take with us on the other side of COVID-19.

TB: We know about positive leadership and the value of that. Certainly, about our servant leadership cultural and other things there, but what are the concrete principles that we want, that I want our leaders to be equipped with? Sort of the six basic things. That is how you effectively lead through change, because that’s what we’re doing every single day.

We have this crisis in front of us, and what does that look like? And you could replace change for crisis, whatever it would turn out to be, but you’re leading through crisis. But it’s really about communicating the facts and speaking truth.

We have to make sure that we define the problem or the challenge to our team very well. And then we have to communicate our plan and what our solution is to solve the problem or overcome the challenge. And then it’s about communicating our expectations, how our leaders lead by example, and share how through executing our plan and through each person embracing what the plan is and doing their part to create consistency in the execution of the game plan, we realize what we can achieve together.

It’s the power of teamwork, and clarifying that or communicating that, and our expectations led by our leader, but communicating each person’s role within X and the game plan to achieve the outcome together. And then I think these last ones are the most important.

It’s communicating a belief in our team that we’ll conquer the crisis at hand. And how do we reiterate that plan through optimism and desired communication? That through our collective teamwork and the plan we’ve created, that if we execute this together, I believe, or we believe, that we will achieve the end result that we desire to achieve together.

So really communicating the power of our belief and optimism in our team that we’ll achieve a desired outcome together.

And then lastly, it’s about servant leadership and relationships. It’s about leading by example, the power of teamwork, and then as our leader modeling for our team what it should look like for them.

And then it’s about building relationships with every single person that you’ll lead. And I think those are the powerful things. And if we’re thinking about how do we navigate through a crisis? How do you lead for change? How do you lead to effectively overcome any type of challenge or obstacle in our way?

We think about communicating the facts, communicating the plan, communicating our expectations, leading by example, communicating our beliefs, communicating our desired outcome through optimism and encouragement. And then really leading by example through servant leadership and tight relationships is how we’ll do that.

I think if you ask, how are we doing it as a company, that is the foundational principles we as a team are following as we are navigating the COVID-19 crisis. But also, we’re helping each of our hospital departments really successfully navigate the challenges that we’re facing so that we can deliver better care experiences for our patients and create better work environments for our team.

David Shifrin