5 Frontline Leaders – Becoming the Change: Leadership Behavior Strategies for Continuous Improvement in Healthcare

Frontline Leaders

Here is the worst thing an organization can do when trying to adopt principle-based behaviors: go to the managers and directors with a list of behaviors and say, “Here, do this.”

It sounds tempting though, doesn’t it?

After all, frontline management is where change initiatives have traditionally aimed their energies. The managers who supervise one unit and the directors who have a portfolio of units are an easy target. If they adopt a new idea and bring all their frontline caregivers and support staff with them, the pendulum will swing, right?

This plan has a couple of problems. The experienced managers will see you coming from a mile away with your sparkling new initiatives that (in their experience) do little but cause more work, and they will smile and duck. Some managers will be happy to try something new and, perhaps, imagine that being an early adopter will get them noticed and advance their careers. And then battle lines form between the skeptics and the cheerleaders, and a tremendous amount of energy gets wasted in this divide.

But the bigger problem with this plan is that it misses the point of behavioral change. For managers and directors, adopting these behaviors is not add-on work; it is the way they will get their new jobs done.

In a continuous improvement organization, the functional role of managers and directors is very different than in a traditional one. In most organizations, managers and directors were talented clinicians or frontline support. These people were organized, experienced, and energetic. They got promoted because they knew the work well enough to tell others how to do it, or to jump in and fix any issues that arose. They are conduits for orders from above, making sure that executive directives are followed.

But in a continuous improvement system, the job of managers and directors is to teach and coach their teams to become problem solvers. In this role, managers are not carrying out direct orders from above, and this can cause some anxiety. No longer can managers seek “the right answer” from a boss. Executives and other bosses are still responsible for guidance and direction, of course. They just don’t have all the answers. Nor does the manager. The right answer to a problem is instead sought in the team’s scientific thinking and careful problem solving.

The key traits we will be highlighting for managers—curiosity and perseverance—exist to support these talented, energetic people as they make a difficult transition from doing to coaching.


“We started this journey with an idea board that Eric [Dickson]suggested we put up on the unit in 2013,” says Georgina Gardner, RN, manager of the pediatrics unit at UMass Memorial in Worcester, whom everyone calls Gina. “It was a dark time here. They had decreased bed capacity on the pediatric unit from 37 beds to 20. They were putting up walls and pushing us into a smaller area, and people would come to work feeling sick to their stomachs. In six months, the pediatric float pool was dissolved, and we lost all eight staff members.

“Still, we were going to start this huddle. We met at the idea board once a week, every Tuesday at 1:30. The mood on the unit was sad, though, and for the first six months, it was often just me and my physician partner, Neil Tyrell, at the meeting. We would ask people what they wanted done—anything—and then go do it,” Gina says.

Gina and Neil had a coach from the UMass performance improvement office, and they knew it was not the ideal way to run a huddle—making little fixes and holding those lonely two-person meetings. But they were not going to force people to come, either. They wanted an atmosphere of respect. So, Gina took requests and then installed coat hooks, moved laundry hampers—just about anything people suggested.

When wait times in the pediatric ED got dangerously high due to a lack of beds to transfer patients into, the unit expanded again to 30 beds. And every Tuesday, she and Neil were there at the idea board, looking for things to fix. Eric, the CEO, showed up and asked if they had one wish, what it would be. They asked for more computers and got four new workstations on wheels, so the doctors no longer had to share computers with the nurses.

Tentatively at first, people started showing up to the Tuesday meeting with ideas and requests. Perseverance was paying off. Gina and Neil used some of that time in the huddle to talk about what they had learned about problem solving with an A3, and about looking upstream and downstream of a process to see what effects their solutions might have on other people—passing on the knowledge they learned from their coach.

More people attended the meeting; Gina went from acting manager to manager, and that same year, pediatrics was awarded innovator of the year for UMass Memorial, a distinction that came with a big cash award to work on an idea.

And then, just as Gina was reading more broadly about leading with respect and humility and preparing to start coursework for a doctorate in nursing practice, she received the results of the civility survey that UMass conducts every year of medical students, volunteers, and visitors. It was like a slap. In pediatrics, 60 percent of residents said they felt threatened in a conversation with staff; 46 percent said communication was

“These were our residents. They were showing up and trying to do their best and they were feeling bullied,” Gina says. “I had to look hard at how we behaved. Every year, we have something like a dozen new med students, interns, and residents show up to learn and work with us, and to be honest, I didn’t even bother to learn their names. It was not uncommon to hear people talking badly about their own staff members. We seriously needed to change.”

Gina took the survey results to the Tuesday huddle and presented them with a question: How could they address this problem? By this time, the pediatrics team was accustomed to thinking in terms of better engagement leading to better work processes and better patient outcomes. So they created an interdisciplinary work group and attacked the issue with interest.

Some ideas the team came up with were simple and quickly implemented. They began greeting each incoming group of medical students with ice-breaker games. They went bowling. They learned one another’s names.

But then they needed to look at why medical students might feel bullied or get yelled at. They created a working group from the larger team to dig deeper into the issues. Sometimes, the group learned, tempers flared because mistakes were made or because the medical students seemed like they did not know simple things. A resident or intern would change something in a patient’s 101room that should not be touched, or ask a patient or family questions that had been answered 10 minutes earlier. But whose fault was it that a medical student was in
the dark?

It used to be that patient rounds—where each case was discussed and updated by caregivers—were conducted in a closed conference room and involved only physicians and a few nurses. Members of the working group asked each other, what would it look like if lots of people were privy to that information?

To include more people into vital information, the team in pediatrics moved the patient status reports to an open space at the nurses’ station and invited medical students, therapists, pharmacists, social workers, psychiatric staff, and anyone else who needed to consult on patient care. Everyone was hearing the same information at the same time.

“We needed to change the mindset of staff, and that required structural changes to get us all working together,” Gina says.

This work toward a more respectful environment was not just happening on the patient floors, either. Kathleen Hylka, director of strategic space planning at UMass Memorial, was selected to help roll out the Standards of Respect program.1 An architect by training, she is detail oriented and thorough. She began her new role by googling “workplace respect” and reading everything she could find. Her leadership team decided that their first job—before they asked anything of anyone—would be to model the behavior.

“You have to be the change,” Kathleen says. “Leaders need to walk the talk, and then they need to bring everyone along. Everyone. We can’t say, ‘Well, that person is the chair of such and such and brings in a lot of grant money every year, so he’s allowed to be rude.’ ”

Members of the team were the subjects of some of the first Stepping Up Respect 360-degree reviews, which provided each person with feedback on three things they did well and three things they needed to work on. Then, each person created a personal plan with countermeasures to improve their behavior. Think of this as crowdsourced coaching.

“I got feedback on my first 360 review that it doesn’t always seem like I’m paying attention to people when they talk to me. I’m a multitasker. So now, I close my computer when I’m talking to someone,” Kathleen says. She admits that she is not scoring 100 percent on this action, but she’s trying.

Back in pediatrics, focusing on the right behaviors and being more inclusive have had a significant impact. In 2019, three years after Gina was shocked by the civility survey results, her team had reason to celebrate. People who reported feeling threatened during a conversation with staff had dropped from 60 percent to 16.7 percent. And those who complained of poor communication dropped from 46 percent 103to 8 percent. Respondents who felt threatened by family members of patients actually rose a point, however, from 78 percent to 79 percent. So, the team has a new gap to address.

Here we should highlight two important elements of the behavioral change work at UMass Memorial that have enabled the spread of these ideas. First, it was led and modeled by leadership. Senior leaders determined what good behaviors were, specifically, and then modeled those behaviors and coached direct reports. If Eric Dickson had not been instrumental in setting up that first huddle board and attending the meeting in pediatrics to offer his help, the meetings might not have continued. Even in the months when it was just Gina and Neil at the board every Tuesday, it was leaders who were there, keeping the flame lit and inviting others to participate.

Second, UMass Memorial was also organized by a daily management system that acted like a kind of superhighway for ideas. In departments such as pediatrics and strategic space planning, leaders were consistently using team huddles and one-on-one coaching sessions to solve problems and discuss how the work was being done. There was a time and place to talk about respectful behaviors as part of the problem-solving process.


Across the Atlantic Ocean in Berkshire country—in England’s southwest, home to Windsor Castle—the management team at Berkshire Healthcare NHS had also discovered that the management system was a natural conduit for behavioral change.

This is a community physical and mental health provider with several hospitals, about 100 clinics and 4,500 employees serving a population area of not quite a million souls. The system offers mental health care, treats learning disabilities in adults and children, specializes in dementia and memory care in the elderly, and offers home-based healthcare. It is a diverse portfolio with many sites spread over several towns.

Julian Emms, chief executive, began introducing the concepts of continuous improvement to Berkshire in 2017 with rapid improvement events. Very quickly, teams trying to implement change found that they had a hard time making improvements stick and decided to focus on a two-pronged strategy: implementing a daily improvement system to solve lots of problems at the front line, while also introducing and practicing principle-driven behaviors.

Senior leaders, in partnership with a local consulting company, developed training in A3 thinking, establishing standard work, and setting up and supporting huddles. Then they brought together leaders and introduced the principles of quality improvement—QI, in their vernacular—including leadership behaviors, how to coach others as they solved problems, and how to enable a culture of problem solving.

One of the people in those first training sessions was Rosemary Warne, a nurse consultant who was relatively new to Berkshire. She had decades of experience in clinical care, teaching, and leading projects, but she had not come across a management system quite like this before, where the quality improvement work was part of the work of day-to-day managing. It was unnerving at first. And then, it suddenly made sense.

“When the penny dropped for me, I incorporated more teaching into my regular work, helping others understand A3 thinking, huddles, standard work, and status reports,” Rosemary says. Soon, she was named a clinical director, supervising and coaching the work of four matrons, who are each responsible for two ward managers.2

On units throughout the system, managers began using daily one-on-one status reports and team huddles to conduct their work. Problems uncovered in status reports were often addressed by the frontline teams, in daily huddles, where everyone was learning to use PDSA cycles and Shingo principles such as thinking systemically and assuring quality at the source to find local solutions.

Berkshire leaders also developed a clear escalation process for problems. When problems uncovered in a status report or huddle needed to be addressed fast or with additional resources, they were swiftly reported to the next level up in a clearly outlined manner. Meanwhile, strategic goals critical to Berkshire’s True North were communicated down the chain of command. If top leadership chose to focus on patient falls as a quality metric, for instance, all units were asked to track and report on patient falls and daily status report meetings included questions about which patients might be at risk of falling.

Leaders like Rosemary all began developing standard work. Her calendar included attending one or two huddles on a unit every week, as well as regular gemba walks that she identified by subject matter. For instance, she would do safety walks with a ward manager to discover any lingering concerns at the front line of care. Rosemary would time staff walks to begin toward the end of a team huddle so she could connect with caregivers and listen to their experiences on the ward. Patient walks, likewise, were also about connecting with people and listening.

“I like the phrase ‘Big ears, big eyes, small mouth.’ When I am connecting with people, I really try to go without an agenda. I want to hear what they want to talk about,” Rosemary says.

Like most of her leadership colleagues, however, many of Rosemary’s days are consumed with meetings. Many of the meetings are good and useful, but there are too many to attend if one also wants to spend time at gemba, like Rosemary did.

So, she and a few colleagues worked out a schedule for attending some meetings in relay. One of their group would attend and type up meeting notes afterward for the others. The little bit of extra work for one meeting ended up freeing Rosemary from several others, adding hours to the week, which she can spend at gemba.

“I love going to a huddle and then staying behind after and chatting with people. Just by being open to a conversation to see where it goes, I hear things about safety and quality that I wouldn’t otherwise,” Rosemary says. “And really, I’m just making connections. I’m not in a QI role. I’m a clinical director using QI to do the job, which includes facilitating investigations into serious incidents. The more I know, the better.”

Rosemary also changed the format of the monthly safety and quality meeting with matrons and ward managers, asking everyone to bring updated information about the countermeasures currently being implemented or tracked in their areas. This allows Rosemary a few minutes of coaching with everyone as they discuss the link between root causes and countermeasures.

And for the learning review panels3 that follow a serious incident, Rosemary begins with a brief introduction that includes talking about the behaviors expected in that meeting. She offers a few ground rules and reminds people that they need to be curious, that the root cause answers they seek will be in the process, not the people.

“We’re all working hard not to be reactive. We know that we don’t need heroes. We need good, consistent processes. It’s still a struggle for all of us, really,” Rosemary says.

Another early adopter at Berkshire, Nikola Pollard, head of financial transformation, found that she needed to work at saying less in her huddles. An enthusiastic supporter of QI, Nikola was first introduced to organizational excellence 10 years ago and was in the first wave of green belt training4 in 2017.

Immediately, she began advocating to overhaul the finance function at Berkshire, and she has been experimenting with getting rid of the old budget system in favor of rolling forecasts in two units.5 At the same time, she began practicing daily status meetings with her own team and weekly huddles with the whole finance office—25 to 30 people—and all five of her fellow managers.

Not everyone was enthusiastic. Still, she pressed forward, quite certain that this was the right path.

“My management style involved a lot of telling rather than coaching. I needed to recognize when I was doing that. Now, instead of me talking through a ticket [an improvement idea or problem], I’m having people talk through their own,” Nikola said.

To do this required some planning. Before a huddle, Nikola began looking at the improvement tickets to be discussed and then meeting individually with the authors. She talked them through their problem statement and asked the kind of questions that would likely come up in the huddle, helping the often nervous team member prepare to present.

During those prep sessions, Nikola was careful to ask open-ended questions instead of drilling the person on presentation. It was a slower process and did not always feel very productive, she admits.

“The coaching style felt really unnatural at first. Sometimes, I still find myself interrupting and directing and I check myself,” Nikola says.

Becoming the coach she wanted to be was, Nikola knew, not a two-week endeavor. Sometimes her own ability to change seemed maddingly slow. Telling people what to do was so much quicker than listening and asking questions. But she kept at it because she knew that her real goal was even bigger—to break free of the constraints of her traditional role.

As a finance manager, Nikola was one of those people that operations managers love to hate, and who have considerable clout. All of the support functions—HR, IT, marketing, and finance—have people like this that they send out to do business with operations on a regular basis. The people from support services usually have closer contact with top leadership and are viewed as being the voice of “corporate.” The power dynamic often leads to more private grumbling than open dialogue.

Leaders at Berkshire NHS had a different vision for this interaction. Support specialists like Nikola had expertise that could be of real value to operations. They just needed to speak the same language and have a common set of behavioral expectations.

So, Nikola was preparing not just to be a better leader in finance, but to be a partner to clinical teams and administrative offices—to assist anyone who could use the particular skills of a financial analyst. Let’s see how that went.

1. A complete description of this program, with illustrations, follows in Chapter 6.

2. A ward manager is responsible for the work of a single unit. A matron in the United Kingdom is much like a director in the United States, supervising the work of multiple unit managers.

3. These learning review panels are small, cross-functional teams that gather to investigate the circumstances around a serious incident involving safety or quality, look for root causes, and decide on next steps.

4. Green belt training is an introduction to the behaviors and tools of organizational excellence, and it is often given as a series of workshops culminating in student projects.

5. Rolling forecasts are described more fully in Management on the Mend (ThedaCare Center for Healthcare Value, 2015), pages 131–141.