Military Medicine

Woo, Jason J, Y

doi: 10.1093/milmed/usaa209pmid: 32754729

ABSTRACT The transformation to health and readiness for individuals and organizations, while structured in common strategies, metrics, and process improvement frameworks used throughout healthcare, will not be achieved or sustained without a shift in mindset. Health and healthcare face increasingly complex—and similar—challenges across the federal and civilian sectors. These challenges range from the high-level organizational efforts to improve financial solvency and creating high reliability organizations, to the inpatient and outpatient administrative and clinical teams’ focus on patient safety and quality outcome cultures, to the individual provider and patient needs for health, readiness, and resilience. Increasingly there is greater convergence of these challenges as the Military Health System merges under the Defense Health Agency and the collaborations this transformation is driving with other federal, Tribal, state, local, and private sector health and healthcare organizations. How to lead this transformation to health and readiness is the primary concern for most healthcare leaders and practitioners. The science of leadership, or the practice, is often seen as the strategies, competencies, ideas, tools, and metrics used to achieve individual, team, and organizational goals. The Department of Defense and private sector healthcare invest heavily in teaching and training these practices, often relying on assessments, competencies, and testing for progressive awareness and expertise in applying them. These competencies and frameworks provide critical structure to the initiatives and behavioral changes desired to achieve healthcare leadership needs and objectives. Successful healthcare system transformation or improvement has become less reliant on applying the right strategy or framework. Healthcare is full of smart, dedicated, accomplished, and hardworking executives, practitioners, and providers. However, success in addressing these challenges remains inconsistent despite the consistent preparation and strategies applied across the healthcare spectrum. An analogy is that the pursuit of the right strategy, technique, framework or behaviors is the pursuit of the best seed. The soil in which that seed is planted represents the culture of each organization or individual. And every organization’s and individual’s culture is unique. In the pursuit of the best seed, the soil in which that seed is planted is often left untended, its uniqueness being justification to ignore its cultivation. The endeavor to find the right strategy, technique, or approach to leadership is founded in the good intentions of improved efficiency and effectiveness. Yet with every leadership situation being a unique opportunity and experiment, lessons from successes can be dismissed: “well that may have worked for them, but our situation (soil) or culture is different.” Addressing this resistance to change and transformation is the challenge health leaders must overcome, or the best strategies, frameworks, and intentions will be futile. Military and federal healthcare have a long history and unparalleled reputation of leader development, innovation, agility, and success. What many military and federal healthcare practitioners have discovered is that the problems and challenges in healthcare—like financial insolvency, conflict, low morale, quality and safety deficiencies, provider burnout, poor performance, prejudice, and lack of accountability—are not problems separate from themselves. These all represent symptoms of a much deeper issue—the driving force behind these problems that makes it not only difficult to find true solutions to these problems but also creates these problems in the first place! This driving force is mindset. It underlies every behavior—and therefore every result—that we experience and feel in our lives. An inward mindset, where I am focused on only my own results and not seeing the humanity of others, is the core of the resistance to change that inhibits the success of the best strategies and frameworks applied to healthcare challenges. Conversely, an outward mindset, where I am focused on the collective result and where I see others as people with needs, objectives, and challenges of their own, is the core, the soil, for effective change and success. With the understanding that addressing mindset is the foundation for leading the transformation to health, readiness, and improved individual and organizational results, the authors of the articles in this Supplement Issue of Military Medicine share their experiences and success in shifting mindset across the spectrum and levels of the challenges in healthcare. These challenges include the organizational level and cross-organizational DHA transformation of the army prototype market construct led by COL John Melton, Commander of Womack Army Medical Center; COL David Gibson, USA (Ret.), former Commander, Carl R. Darnall Army Medical Center, Fort Hood, Tx, leading the financial transformation of CRDAMC from a $20 M shortfall to a $36 M surplus; COL Teresa Roberts, USAF (Ret.), former Commander, USAF 7th Medical Group, leading the downsizing of that clinic under the same DHA transformation; and Dr. Cynthia Foslien-Nash, Associate Chief of Staff of the VA North Texas Health Care System, helping set the conditions for successful transformation for their hospitals to become high reliability organizations. These examples also include team issues of readiness, conflict, and unit performance beginning with CPT Austin Otocki and MAJ Brian Turner sharing the particular challenge of mid-level leaders in healthcare caught in the middle of aspirational metrics from the top and the reality of frontline constraints. LTC Eric Weber describes how the conflict that naturally arises in deployment units can be successfully addressed in the field with attention to mindset. And addressing the core challenge of increasing the readiness of our military forces, CDR George Howell, Commander of the nuclear-powered submarine USS Missouri, shares how readiness and performance is improved by the preventive maintenance of the human operating system provided by shifting mindset. At the individual level, RADM Sarah Linde, MD, USPHS (Ret.) and former Chief Public Health Officer for the Health Resources and Services Administration (HRSA) in the Department of Health and Human Services, describes how attention to mindset is key for provider self-awareness and resilience in the chaotic healthcare environment and even more so under the provider challenges brought by Covid-19. ENS Noah Nevo, a first year medical student at Uniformed Services University, and Dr. Laura Lambert, Residency Director at the University of Utah, describe the challenges of medicine driving students and providers away from the human connection that first drew them to medicine and where shifting mindset can help re-establish that connection. And Dr. James Hayden, Clinical Psychologist for the Bureau of Prisons, and Major Chip Huth, Division Commander for the Kansas City Police Department Traffic Division, consider how shifting mindset has and can help heal and bridge the divide between officers and the populations they serve, the foundation for truly addressing the nation’s needs for seeing and engaging with each other in the wake of the death of George Floyd. There are no randomized controlled trials that can provide the evidence of the leadership approach that most effectively implements the right strategy, metric, or framework for achieving the desired health and organizational outcomes. Leading people is an art. Each of these examples represent only a single perspective or experience, a case study where N = 1. But taken together these case studies become a case series demonstrating why shifting mindset matters at every level. With each successful shift to an outward mindset and resulting transformational results, the evidence base increases for leaders to focus on addressing their own and their organization’s mindset as the foundation for reducing resistance and the barriers to change. The transformation to health and readiness for individuals and organizations, while structured in common strategies, metrics, and process improvement frameworks used throughout healthcare, will not be achieved or sustained without a shift in mindset. Funding/COI LearningCoreLeadership is the sole U.S. affiliate of the Arbinger Institute. The views expressed are solely those of the authors and do not reflect the official policy or position of the U.S. Army, U.S. Navy, U.S. Air Force, the Department of Defense, the Department of Veterans Affairs, the Department of Health and Human Services, the Bureau of Prisons, the Kansas City Police Department, the Department of Justice, or the U.S. Government. © Association of Military Surgeons of the United States 2020. All rights reserved. For permissions, please e-mail: [email protected] This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Melton, John, J;Quick, Jeffrey, W

doi: 10.1093/milmed/usaa164pmid: 33002144

ABSTRACT The transition of authority to manage and administer all DoD Medical Treatment Facilities from the Military Department Services to the Defense Health Agency is an extremely complex challenge involving multiple stakeholders and systems in an effort to achieve greater force readiness while reducing cost. Womack Army Medical Center at Fort Bragg served as the U.S. Army’s sole prototype for the initial phase of the transition of authority. Starting with a foundational shift to an organizational outward mindset was essential in building effective relationships to exercise Mission Command at echelon to manage risks to mission during this period of uncertainty and ambiguity. This shift in mindset set the conditions for mobilizing Army Doctrine, elicited, and invited collaborative behaviors, and resulted in the improved organizational performance accomplished with velocity to successfully lead the transformation to Defense Health Agency. MAKING CHANGE AN OPPORTUNITY The U.S. Armed Forces seeks to cultivate effective strategic leaders who can develop, inspire, influence, and empower people and large organizations in driving and managing constant change toward achieving strategic objectives. The Department of Defense (DoD) 2018 National Defense Strategy cited three overarching priorities: increasing lethality for the war fighter, strengthening allies and partners, and reforming business practices. The U.S. Army’s vision is to innovate, reorganize, modernize, and field a multidomain operation capable force by 20281 as part of the joint force, ready for the complexities of the future global security environment and prepared to operate in large-scale combat operations. The Army recognizes that readiness of the joint force relies upon people—the soldiers, their families, civilians, retirees, and veterans. Foundational to the readiness of the joint force is that soldiers must be physically and cognitively optimal—ready and available for training and worldwide deployments—and proficient in their respective medical role skills. The Military Health System (MHS) is a critical enabler to realize the Army’s vision. FIGURE 1 Open in new tabDownload slide The Leadership and Customers of WAMC: U.S. Army Forces Command (FORSCOM), U.S. Army Reserve Command (USARC), Joint Special Operations Command (JSOC), U.S. Army Civil Affairs and Psychological Operations Command (Airborne) (USACAPOC), 1st Civil Affairs and Psychological Operations Training Brigade (1st CA/PO TNG BDE), Security Force Assistance Command (SFAC), II Security Force Assistance Command (II SFAC); XVIII Airborne Corps (XVIII ABN CORPS), 3RD Expeditionary Sustainment Command (3d ESC), 82nd Airborne Division (82nd ABN DIV), 16th Military Police Brigade (16th MP BDE), 18th Field Artillery Brigade (18th FA BDE), 20th Engineer Brigade (20th ENG BDE), 44th Medical Brigade (44th MED BDE), 525th Military Intelligence Brigade (525th E-MIB), 82nd Sustainment Brigade (82nd SUST), 1st Brigade Combat Team (1/82 BCT), 2nd Brigade Combat Team (2/82 BCT), 3rd Brigade Combat Team (3/82 BCT), 82nd Airborne Division Artillery Y (82nd DIVARTY), 82nd Combat Aviation Brigade (82nd CAB), U.S. Army Special Operations Command (USASOC), 1st Special Forces Command (1st SFC), 3rd Special Forces Group (3rd SFG), 4th Psychological Group (4th PSYOP GRP), 8th Psychological Group (8th PSYOP GRP), U.S. Army Special Operations Aviation Command (USASOAC), 95th Civil Affairs Brigade (95th CA BDE), 528th Sustainment Brigade (528th SUST(SO)), Military Information Support Operations Influence and Analysis Group (MIAG), U.S. Army John F. Kennedy Special Warfare Center and School (USAJFKSWCS), 1st Special Warfare Training Group (1st SWTG), Special Warfare Medical Group (SWMG), Special Warfare Education Group (SWEG), U.S. Army Installation Management Command (IMCOM Readiness), 43rd Air Mobility Operations Group (43rd AMOG), 18th Air Support Operations Group (18th ASOG), Dental Health Activity (DENTAC), Fort Bragg Garrison IMCOM, U.S. Army Security Assistance Training Management Organization (USASATMO), 4th ROTC Brigade (4th ROTC BDE), Airborne and Special Operations Test Directorate (ASOTD), 108th Air Defense Artillery Brigade (108th ADA BDE), 419th Contracting Support Brigade (419th CSB), 406th Army Field Support Brigade (406th AFSB), Army Golden Knights, 139th Infantry Regiment (139th INF RGT), Senior Executive Service (SES), and Executive Agent (EA). FIGURE 1 Open in new tabDownload slide The Leadership and Customers of WAMC: U.S. Army Forces Command (FORSCOM), U.S. Army Reserve Command (USARC), Joint Special Operations Command (JSOC), U.S. Army Civil Affairs and Psychological Operations Command (Airborne) (USACAPOC), 1st Civil Affairs and Psychological Operations Training Brigade (1st CA/PO TNG BDE), Security Force Assistance Command (SFAC), II Security Force Assistance Command (II SFAC); XVIII Airborne Corps (XVIII ABN CORPS), 3RD Expeditionary Sustainment Command (3d ESC), 82nd Airborne Division (82nd ABN DIV), 16th Military Police Brigade (16th MP BDE), 18th Field Artillery Brigade (18th FA BDE), 20th Engineer Brigade (20th ENG BDE), 44th Medical Brigade (44th MED BDE), 525th Military Intelligence Brigade (525th E-MIB), 82nd Sustainment Brigade (82nd SUST), 1st Brigade Combat Team (1/82 BCT), 2nd Brigade Combat Team (2/82 BCT), 3rd Brigade Combat Team (3/82 BCT), 82nd Airborne Division Artillery Y (82nd DIVARTY), 82nd Combat Aviation Brigade (82nd CAB), U.S. Army Special Operations Command (USASOC), 1st Special Forces Command (1st SFC), 3rd Special Forces Group (3rd SFG), 4th Psychological Group (4th PSYOP GRP), 8th Psychological Group (8th PSYOP GRP), U.S. Army Special Operations Aviation Command (USASOAC), 95th Civil Affairs Brigade (95th CA BDE), 528th Sustainment Brigade (528th SUST(SO)), Military Information Support Operations Influence and Analysis Group (MIAG), U.S. Army John F. Kennedy Special Warfare Center and School (USAJFKSWCS), 1st Special Warfare Training Group (1st SWTG), Special Warfare Medical Group (SWMG), Special Warfare Education Group (SWEG), U.S. Army Installation Management Command (IMCOM Readiness), 43rd Air Mobility Operations Group (43rd AMOG), 18th Air Support Operations Group (18th ASOG), Dental Health Activity (DENTAC), Fort Bragg Garrison IMCOM, U.S. Army Security Assistance Training Management Organization (USASATMO), 4th ROTC Brigade (4th ROTC BDE), Airborne and Special Operations Test Directorate (ASOTD), 108th Air Defense Artillery Brigade (108th ADA BDE), 419th Contracting Support Brigade (419th CSB), 406th Army Field Support Brigade (406th AFSB), Army Golden Knights, 139th Infantry Regiment (139th INF RGT), Senior Executive Service (SES), and Executive Agent (EA). On December 23, 2016, the President of the United States signed into law S. 2943, the “National Defense Authorization Act (NDAA) for Fiscal Year 2017.”2 Section 702 of the law mandates the creation of a single agency (Defense Health Agency [DHA]) responsible for the administration of all Medical Treatment Facilities (MTFs) to improve and sustain operational medical force readiness and the medical readiness of the Armed Forces, improve beneficiaries’ access to care and the experience of care, improve health outcomes, and lower the total management cost of the MHS. How this was to be accomplished was tasked to the DoD to be developed over time. Nested within the 2018 National Defense Strategy directive to organize for innovation, leaders were and are expected to adapt their organizational structures to best support the joint force for this objective. The Fort Bragg, NC, MHS (FBMHS) is a federated system that is centralized around Womack Army Medical Center (WAMC). The FBMHS is an employer-based provider and payer of care. At Fort Bragg, the Home of the U.S. Army Airborne and Special Operations Forces, the employer is an expeditionary Army whose most critical population health outcome is readiness of the force (Fig. 1). WAMC operates the FBMHS Medical Role 4 and integrates the health care delivery, public health, medical education, and research systems. In January 2018, the U.S. Army designated WAMC at Fort Bragg to serve as the first and only Army MTF to transition to the DHA with a dual-hatted Womack Commander (Fig. 2). In June 2018, the plan was further refined with the development of a regional market construct with WAMC serving as the first and only Army led prototype (Central North Carolina Market) among four regional areas selected for piloting the new market construct concept.3 To realize the transformational changes directed in the NDAA legislation and DoD priorities, WAMC cultivated collaborative relationships and regional integration with Federal, State, Local, Military, and Civilian systems. As the Army’s Pathfinder, in a period of uncertainty and ambiguity, WAMC’s organized efforts provides a path and end state for others to follow that meets congressional intent, supports DoD priorities, and enables the Army’s vision (Fig. 3). START IN THE RIGHT WAY As with many initiatives, while the “end state” is articulated, navigating the path to that state through the initial uncertainty and continuous evolution is the challenge. Army Leaders are expected to visualize that end state, communicate the vision, and set conditions for shared understanding and accomplishment of that vision. The Army provides an established framework for leading that is well-articulated in the Army Doctrine for Mission Command (ADP 6-0)4 and the Professional Leadership of the Army (ADP-22).5 How a leader chooses to organize for and model this framework determines the effectiveness of organizational efforts and performance. At WAMC, leadership set the foundation for accomplishing this transformation by developing and implementing an outward mindset6 and integrating this into the application of the Mission Command framework. FIGURE 2 Open in new tabDownload slide WAMC Dual-Hatted Commander: More than Two Hats! The Multiple Roles Delegated to the WAMC Commander for the Transition to DHA: (1) WAMC Commander, (2) Fort Bragg Director of Joint Health Services, (3) DHA MTF Commander, and (4) Army Medical Readiness Commander. FIGURE 2 Open in new tabDownload slide WAMC Dual-Hatted Commander: More than Two Hats! The Multiple Roles Delegated to the WAMC Commander for the Transition to DHA: (1) WAMC Commander, (2) Fort Bragg Director of Joint Health Services, (3) DHA MTF Commander, and (4) Army Medical Readiness Commander. FIGURE 3 Open in new tabDownload slide WAMC Framework for Strategic Execution and Managing Risk. Integrating the Art of Command (Building Cohesive Teams Through Mutual Trust, Creating Shared Understanding, and Providing a Clear Vision) with the Science of Command (Exercising Disciplined Initiative, Using Mission Orders, and Accepting Prudent Risk) to Implement Army Doctrine in the Operationalization of Healthcare Management and Delivery Frameworks. FIGURE 3 Open in new tabDownload slide WAMC Framework for Strategic Execution and Managing Risk. Integrating the Art of Command (Building Cohesive Teams Through Mutual Trust, Creating Shared Understanding, and Providing a Clear Vision) with the Science of Command (Exercising Disciplined Initiative, Using Mission Orders, and Accepting Prudent Risk) to Implement Army Doctrine in the Operationalization of Healthcare Management and Delivery Frameworks. The outward mindset framework was first introduced to WAMC in 2014 after the organization received several findings during their March 2014 (The) Joint Commission (TJC) Triennial On-Site Survey that resulted in a conditional accreditation. With a loss of confidence and subsequent relief of the WAMC Commander and the Senior Leader Team in May 2014, new leaders were positioned from other organizations to assume these duty positions. The current WAMC Commander previously served as the WAMC Deputy Commanding Officer from May 2014 to May 2016. Being an enthusiastic supporter and facilitator of the Arbinger Institute’s outward mindset framework and tools, he first introduced and applied these concepts to organize WAMC’s quality assurance reset and sustainment plan toward full accreditation. WAMC leaders at all levels were empowered to self-select and apply this approach amongst their teams—a bottom up approach that leveraged the innovators and early adopters—but did not require “compliance” across the organization or from WAMC Senior Leaders. This approach facilitated WAMC achieving full TJC accreditation in November 2014 and the inclusion of outward mindset internal facilitators into WAMC’s organizational learning team to offer continued instruction and adoption of these principles and tools.7 In January 2018, the current WAMC Commander was reassigned from commanding Irwin Army Community Hospital (IACH) at Fort Riley, KS, to rejoin WAMC and serve as its Commander. Two weeks after he assumed command at WAMC, the Army Chief of Staff selected WAMC to be the first and only Army MTF to transition to the DHA for Phase 1. At IACH this Commander had led a comprehensive, top down “waterfall” approach in shifting the organizational mindset to overcome 4 years of delays and occupy their new Community Hospital within 100 days of him assuming command. Building on that sense of urgency, this approach resulted in substantial improvement of IACH’s culture and performance, a rebranding as the “Big Red One” Hospital including a 9-fold improvement in patients’ “Overall Hospital Rating” compared to the average military hospital change.8 With this evidence of the value of shifting organizational mindset to set the conditions for successful organizational transformation, he initiated a similar top down, strategic approach that developed the supervisory chain three levels down from the WAMC Commander to adopt and apply outward mindset principles. Using the sense of urgency created by the DHA transition of authority, developing this awareness and practice amongst the supervisory chain provided a foundational vision and vernacular to systematically organize and synchronize individual, team, and leader efforts to realize the transformational changes directed in the NDAA legislation. Why Shifting Our Mindset Matters Though Army Doctrine expects leaders to be self-aware to effectively exercise relational authority and influence beyond their positional authority, there is variation in how Army leaders manage and evaluate performance that impacts their effectiveness. Both Federal Civilian and Military performance management programs invite competition instead of cultivating collaboration. These programs tend to reinforce individual behaviors to be the best ON the team, often at the expense of what is best FOR the team. Subsequently, without a systematic approach to counter this tendency, large military organizations can be inconsistent in their ability to develop sustainable cohesiveness, collaboration, and the culture needed to accomplish their mission. This is not a criticism of those systems or of the desire of staff and leaders to do their best; it is, though, recognition that the system that evaluates and rewards this motivation may not create effective collaboration and teamwork without the leadership and culture to channel individual efforts. This is particularly true for larger military organizations where the Commander at the top can, at best, only effectively influence two levels down from him or her through day to day interactions and leadership. The outward mindset framework clarifies how mindset drives behavior and determines outcomes and impacts. All behaviors can be done either from an inward mindset or from an outward mindset. When done from an inward mindset, an individual’s focus is on their own need or goal to perform their own task or responsibility. What is missed is the effect their action may then have on others beyond the immediate focus of their effort. From this mindset, then, negative collateral effects often occur which undermine the overall effectiveness of the team and the organization. Alternatively, the outward mindset workshop provides concepts and tools—such as S.A.M. (See others, Adjust my efforts, Measure my impact), Meet to Learn, Job Responsibility Mapping, 3A+ Development Framework, and the Influence Pyramid7—that shift the focus from one’s output to instead the impact of one’s efforts on the overall mission (Table S1). By shifting attention beyond individual output (the task) and to instead consider impact, an outward mindset invites performance and action that is helpful to others. This builds and sustains effective relationships by fostering trust and empowerment to better leverage Mission Command, the vision, at all layers of an organization. With every interaction comes an invitation to choose a mindset that helps one be the best FOR the team throughout the organization. MINDSET AMPLIFIES DOCTRINE With this foundational approach to shifting mindset established for the DHA transition at WAMC, key elements of Army doctrine were mobilized operationally from its strategic planning and execution framework (Fig. 4). These elements included: (1) Setting conditions for extending influence founded on a culture of operating with relational authority (ADP 6-22, leading, developing, achieving organization leadership and strategic leadership), (2) Mobilizing around change (ADP 6-0, subordinate decision making, decentralized execution, and levels of controls), (3) Accepting internal risk (ADP 6-0, disciplined initiative and risk acceptance), and (4) Measuring for impact (ADP 6-22, assessing to ensure mission success and organizational improvement and consistently assessing capabilities). FIGURE 4 Open in new tabDownload slide The Vision for the WAMC/FBMHS Transformation to DHA. The Fort Bragg MHS is at the Center of the System that Jointly Delivers and Demonstrates Value at a Lower Price, using a Population Health Management Approach Toward Value-based Care as a DoD-VA and Military-Civilian Integrated System of Readiness and Health. Integrated Elements in the FBMHS: Federal Health Organizations: WAMC-centered Shift to Population Health Care and Providing Didactic Instruction, Preceptor Teaching, Clinical Experience and Simulation for Individuals and Teams. Optimizing Existing Direct Care and Network Care Capacity Utilization to Adopt a Population Health Management Approach Toward Value-based Care. Create Capacity for Soldier Performance Readiness Centers. Pursuing a Bidirectional Clinical Integrated DoD-VA System to Effectively Manage the Health of Select at Risk Populations and Increase High Complexity Volume. Regional Health Organizations: Pursuing a Bidirectional Clinical Integrated Military-Civilian System Providing High Complexity Clinical Experience to Enhance Womack Scope of Practice. Public Health Departments: Pursuing a Bidirectional Clinical Integrated Military-Civilian System to Effectively Manage the Health of Select at Risk Populations and Increase High Complexity Volume. Educational and Research Institutions: Providing Didactic Instruction and Simulation to Sustain Condition Based Medical Role Skills Proficiency. FIGURE 4 Open in new tabDownload slide The Vision for the WAMC/FBMHS Transformation to DHA. The Fort Bragg MHS is at the Center of the System that Jointly Delivers and Demonstrates Value at a Lower Price, using a Population Health Management Approach Toward Value-based Care as a DoD-VA and Military-Civilian Integrated System of Readiness and Health. Integrated Elements in the FBMHS: Federal Health Organizations: WAMC-centered Shift to Population Health Care and Providing Didactic Instruction, Preceptor Teaching, Clinical Experience and Simulation for Individuals and Teams. Optimizing Existing Direct Care and Network Care Capacity Utilization to Adopt a Population Health Management Approach Toward Value-based Care. Create Capacity for Soldier Performance Readiness Centers. Pursuing a Bidirectional Clinical Integrated DoD-VA System to Effectively Manage the Health of Select at Risk Populations and Increase High Complexity Volume. Regional Health Organizations: Pursuing a Bidirectional Clinical Integrated Military-Civilian System Providing High Complexity Clinical Experience to Enhance Womack Scope of Practice. Public Health Departments: Pursuing a Bidirectional Clinical Integrated Military-Civilian System to Effectively Manage the Health of Select at Risk Populations and Increase High Complexity Volume. Educational and Research Institutions: Providing Didactic Instruction and Simulation to Sustain Condition Based Medical Role Skills Proficiency. The foundation for executing these elements in the right way relied on using the outward mindset workshop tools and vernacular to help all staff shift, from the top down, to a more outward focus on the impact of their efforts. The workshop material provides specific tools to insert into this strategic framework that operationalizes these concepts into the daily pulse and practices of the organization. Relational Authority: Leading, Developing, and Achieving Organization Leadership and Strategic Leadership with Outward Mindset Awareness Operationalizing relational authority is key for unleashing the full potential and energy of an organization’s people. Relational authority provides an environment where individuals, when directly serving the needs of a customer or colleague, have the authority to adapt their actions without needing to ask permission. The focus is on being responsive to the need of the stakeholder, which in turn addresses the mission of the organization. An outward mindset culture allows staff to be agile and responsive because it also inspires and creates accountability for more internal collaboration and communication. The staff member acting on relational authority to an external stakeholder understands that, with an outward mindset, accountability requires communicating about what he or she has done with the appropriate colleagues internal to the organization. The outward mindset framework helps staff connect to the impact of their efforts on others and understand how to continuously identify the gaps in the services or performance of the organization. Instead of unintentionally undermining the work of others, relational authority exercised with an outward mindset helps expand the impact of others’ efforts. The complexity of military and healthcare environments requires agility. Performance in these operative environments necessitates being alive to the current needs, challenges and goals of colleagues, partners, customers, and stakeholders. In today’s healthcare environment, those needs, goals, and challenges change daily—if not by the minute—depending on the immediate need of a patient. Creating an outward-focused culture that enables people to understand the impact they have on others and gives them the creative agility to respond with this awareness is the key to developing a dynamic, responsive organization. Mobilize Around the Change: Subordinate Decision Making, Decentralize Execution, and Lower Levels of Controls with Outward Leadership Tools Implementation of the WAMC/Central North Carolina “Market Construct” required engagement with a greater range of external partners to organize with and respond to. Internally, this meant the WAMC Senior Leaders needed to prioritize work to scale and scope for this focus on key external relationships, including: (1) Reorganizing for command and staff direct support relationships (assignment of areas of responsibility), (2) Refocusing on the value proposition supporting the better and best outcomes and skills proficiency, ie, readiness of the force (alignment on mission), (3) Establishing collaborative partnerships in health delivery, public health, research, and medical education with a focus on regional integration (aligning with external stakeholder needs), and (4) Developing staff estimates for migrating functions, defining processes, and delineating authorities from both the MTF and Market Director perspective (prioritization and collaboration across service lines for effectiveness and efficiency). Supplementing the outward mindset awareness with Outward Leadership9 provided the operational tools for addressing these priorities. The scope of relationships required delegating and mapping across the WAMC Senior Leaders “fields of fire,” or areas or responsibility while identifying synergies to eliminate redundancy and enhance collaboration. The outward mindset job responsibilities and clarify roles were critical tools to establish this understanding and collaboration across the WAMC Senior Leaders to be systematic and comprehensive for the market stakeholders (Fig. S1). Once areas of responsibility with understanding of cross service line impact were established, the major challenge for WAMC Senior Leaders was continuing to be adaptive and responsive to the complexity and rapid changes within the developing market construct environment. The primary focus during the transition and delegation was to discover the friction points across key activities. The WAMC Commander coached his people to solve or push the problem-solving down to the lowest levels possible and focus their own efforts at the strategic level. Once delegated, it was critical to be judicious about addressing the problem-solving challenges that others had been empowered to solve. The use of Outward Leadership tools for reporting down and reporting up provided regular means for clarifying and communicating in a way that maintained high trust and empowerment in these leaders and reduced the drama and trauma of addressing these friction points. WAMC Senior Leaders focused particularly on the friction points of the midlevel leaders. The midlevel leaders are usually the leaders most challenged within any organization, caught between the aspirations, goals and directions of upper leadership with the reality of managing the capabilities and capacities of the front-line resources. WAMC Senior Leaders focused on helping these leaders the most by addressing the challenge that the performance management system does not motivate them in the right direction. The periodic metric reports of the organization’s performance (Lean Daily Management) do not tell the story of what is needed to solve daily challenges. WAMC Senior Leaders instead focused their time and interactions with these leaders to model the outward mindset downward. This was accomplished by using the established Lean Daily Management activities, informed by the outward mindset and use of the Three Questions tool,7 to go beyond asking for just the identification of challenges. Rather, senior leaders demonstrated the tenacity and curiosity of an outward mindset to get clarity on the friction points and challenges of the midlevel leaders. It was this tenacity of outward mindset driven curiosity that modeled the process for the organization seeking to fix the problems and not just identify issues. Accepting Internal Risk: Disciplined Initiative and Trust of the Outward Mindset Culture to Deliver on External Stakeholder Needs There is a constant challenge to balance internal vs. external risk. Internally, the risk is the time and attention paid to ensuring operations and people are performing optimally; externally, the bandwidth dedicated to being responsive and collaborative with the stakeholders needed to deliver on the mission. With WAMC performing internally with an outward mindset culture setting the conditions and empowering staff, WAMC Senior Leaders were able to focus on making external changes by the opportunity brought on by the transition to the DHA market construct. The shift to an outward mindset organizationally helps to minimize internal risk. Internal change challenges are typically self-induced. There can be a tendency to focus on the immediate performance issues internally and not provide leaders with the time and space to deliver. Over the long run, though, this limits the capability of the organization and the opportunity to develop the external trust of partners where the investment and ROI (return on investment) generally does not show up immediately but over 6 to 12 months. To the extent that an outward mindset culture is established and supported, there is less volatility and less uncertainly around this internal risk and performance. WAMC Senior Leaders prioritized the “no fail” issues and set hard limits for delivery, with lack of performance being the invitation for more intensive internal engagement. The WAMC Commander’s challenge was to adequately focus on the external relationships and accept the limit on the time available to focus on additional internal coaching and mentoring by trusting the internal culture. To earn the trust and advocacy of partners, organizations must perform and deliver well. Performance is particularly important during times of external change. The more the Commander can push the resolution of stakeholder issues down to the front lines in the organization, the more those relationships and solutions empower organizational capacity and the goodwill of the external stakeholders. When external issues arose, investing in the teams sent out to figure out the stakeholder’s need was the key step and not in telling them what needed to be done. This investment involved having the team use the outward mindset framework’s Meet To Learn tool7 empowered with the mindset shift to generate real curiosity and awareness of the WAMC impact on others. The trust delegated to the team then empowered them to resolve the issue at the lowest level. This led to the timely addressing of the stakeholders needs by doing it right the first time instead of needing to take solutions up the chain and wasting time and space trying to solve it at multiple levels and multiple times. WAMC Senior Leaders reached out to external stakeholders and provided them with their direct contact information, including direct contact to the WAMC Commander. This sent the message that if a friction point arose, WAMC Senior Leaders were fully accountable and responsible for the response. WAMC Senior Leaders specifically sought notification on any challenges WAMC initiatives or activities were creating for these stakeholders. Then, by communicating these issues down and empowering WAMC Subordinate and Front-Line Leaders to resolve these issues, over time there was a progressive decrease in both the volume and, more importantly, the severity of issues. As WAMC internal teams became better in their responses to external stakeholders’ needs over time, what came to the WAMC Commander level was less frequent and less severe. This was clearly a measure of the improvement of the internal teams and the collaborative effort in moving to the market construct. Measuring for Outward Mindset Impact: Assessing to Ensure Mission Success & Organizational Improvement Externally: WAMC Impact Creating Advocacy From Others The market construct transformation relies on integration and collaboration among multiple regional stakeholders. The key to successful integration, collaboration, and finding efficiency is the alignment among stakeholder in achieving common goals and objectives. Metrics in healthcare often target patient visits, procedures done, patient satisfaction surveys, or simplistic monetary units. The WAMC Commander instead sought improvement in a metric dependent on feedback from external stakeholders; time and effort were invested to better understand their unique challenges, opportunities, goals, and objectives. This metric was the advocacy demonstrated and collaborative opportunities realized by and with those external stakeholders in support of WAMC. The outward mindset approach to focus on the impact on others leads to asking for feedback and doing work in a way that helps those stakeholders achieve their objectives. This naturally leads to measuring their positive feedback and advocacy as measures of the effectiveness of this effort. It was when staff levels at partner organizations begin to trust WAMC staff they interacted with that WAMC gained this external advocacy. WAMC also gained greater organizational understanding of what those stakeholders were doing by having its people spend time with them. This made it easier for WAMC Senior Leaders to go back to those other organizations’ leaders. When WAMC Senior Leaders met with partner organization senior leaders, it mattered little what they told them about WAMC performance. Rather, it was what those leaders heard from their own people that determined their sense of credibility about WAMC performance. When their leaders heard from their own staff that WAMC was responsive, helpful, and fully capable, this earned more time and space for the next issue. Every issue addressed helped to set conditions for gaining more partner engagement, more time and space to solve the issues together. This was the main metric of WAMC’s performance; the preference of partner organizations’ people to advocate for working with our people at the lowest possible levels to fix the problems without going up the chain or elsewhere to complain or try to solve their problems. Internally: MBWA—Seeing How Staff are in Relation with Each Other Internally, the key indicator of the culture is not what people say in response to organizational surveys or what is reported up the chain of command; rather, it is how they interact and engage with one another. The only way to see and measure this is to do MWBA: management by walking around. Leaders may speak directly to staff, but the key indicator of the outward mindset culture is not what they say to leadership but to see how they hold their meetings with each other and how they respond to each other, even in the presence of senior leadership. In the outward mindset framework the measure of internal success is not on paper or the reports coming up to Command, but how staff are actually engaged, reporting, and responding with each other—the accountability towards their relationships and the common objectives they are working together on. The primary way to measure this culture was in the feel of rounding at the front line—seeing firsthand the attitudes and processes, the engagement and participation of all members on a team, the communication and mannerisms that seek to understand and adapt to others’ needs rather than just getting one’s own work and goals completed. The teams and units where the leaders were not being as effective in shifting the culture outward did not show the same trust to delegate and support each other. In particular there were leaders who conveyed they had organized their teams in the right “way” but where it was clear how they had not truly adopted the shift when it continued to only be the leader who was allowed to “pull the trigger,” to attend upper level meetings and report, or simply send an email or approve the decision. The leaders who struggled “needing to be seen as” leaders or as the decision makers are those who Command helped the most with or eventually replaced. They were typically the ones who did not have the strategic patience to follow through with this approach of developing accountable people. At WAMC, there was heavy emphasis and deliberation in creating a complex schedule for the Commander and his direct reports to round throughout the organization in different places each week to gain a sense of the communication and teamwork. WAMC leadership worked with tenacity to continuously model the Three Questions down towards their direct reports to keep moving this curiosity down through the organization. Two areas that were leading indicators for the overall organizational mindset and culture were the operating room and emergency room work centers, the “canaries in the coal mine.” These two areas represented the most integrated process workflows with the greatest complexity and highest risk. When these teams and their workflows resulted in better or best performance outcomes because of the synergy of their team with other teams across the organization, WAMC Command had a strong indicator that the leadership culture was being effective in shifting the organizational culture outward. Table I WAMC Accomplishments with Stakeholders during the DHA Transition (October 2018 – March 2020) • Established accredited 20-week Paramedic Certification Program with Fayetteville Technical Community College enhancing Medical Role 1 critical care and prolonged field care skills to maximize close combat survivability. • Established the Fort Bragg Research Institute with the Geneva Foundation and Cape Fear Consortium focusing research on operational needs for close combat formations for better value-based outcomes. • Integrated WAMC Inpatient Pediatric Services at Cape Fear Valley Medical Center optimizing resources and increasing acuity volume for better value-based outcomes. • Integrated WAMC Surgical & Medical Services with Fayetteville VA Medical Center sharing resources and increasing acuity volume for better value-based outcomes. • Increased Medical and Dental Readiness Assessment capacity two weekends per month with the US Army Reserve Southeast Medical Area Support Group optimizing Army Total Force resources and maximizing Soldier availability for training for better value-based outcomes. • Integrated WAMC Medical Education & Training with the 82ABN Division Taylor-Sandri Medical Training Center enhancing Medical Role 1–3 skills for better valued based outcomes. • Integrated didactic instruction, preceptor teaching, simulation, and clinical experience with 44MED BDE-Ft. Bragg, 4MDG-Seymour Johnson AFB, 20MDG-Shaw AFB, & 43MDS-Pope AAF for medical role skills sustainment for better value-based outcomes. • Established resource sharing agreements to rotate WAMC Providers and Care Teams to UNC Medical Center, Duke University Hospital, and Wake MED for medical role skills sustainment to enhance WAMC scope of practice for higher acuity-volume. • Achieved American College of Surgeons verification and North Carolina Office of Emergency Medical Services designation for Trauma Center Level 3 status with UNC Medical Center optimizing resources and increasing acuity volume for better value-based outcomes. • Achieved national accreditation for Health Care Delivery with The Joint Commission optimizing resources for better valued based outcomes. [Only 26 findings out of 1417 elements of performance with zero findings in Leadership (LD), National Patient Safety Goals (NPSG), and High-Level Disinfection (HLD)] • Integrated public health functions with UNC Gillings School of Public Health, Region 6 South Central Public Health Departments, and the North Carolina Department of Health & Human Services improving quality and processes for better value-based outcomes. • Achieved national accreditation for Public Health and recognized by the United States Center for Disease Control & Prevention (CDC) for Public Health Quality & Process Improvement. • Established accredited 20-week Paramedic Certification Program with Fayetteville Technical Community College enhancing Medical Role 1 critical care and prolonged field care skills to maximize close combat survivability. • Established the Fort Bragg Research Institute with the Geneva Foundation and Cape Fear Consortium focusing research on operational needs for close combat formations for better value-based outcomes. • Integrated WAMC Inpatient Pediatric Services at Cape Fear Valley Medical Center optimizing resources and increasing acuity volume for better value-based outcomes. • Integrated WAMC Surgical & Medical Services with Fayetteville VA Medical Center sharing resources and increasing acuity volume for better value-based outcomes. • Increased Medical and Dental Readiness Assessment capacity two weekends per month with the US Army Reserve Southeast Medical Area Support Group optimizing Army Total Force resources and maximizing Soldier availability for training for better value-based outcomes. • Integrated WAMC Medical Education & Training with the 82ABN Division Taylor-Sandri Medical Training Center enhancing Medical Role 1–3 skills for better valued based outcomes. • Integrated didactic instruction, preceptor teaching, simulation, and clinical experience with 44MED BDE-Ft. Bragg, 4MDG-Seymour Johnson AFB, 20MDG-Shaw AFB, & 43MDS-Pope AAF for medical role skills sustainment for better value-based outcomes. • Established resource sharing agreements to rotate WAMC Providers and Care Teams to UNC Medical Center, Duke University Hospital, and Wake MED for medical role skills sustainment to enhance WAMC scope of practice for higher acuity-volume. • Achieved American College of Surgeons verification and North Carolina Office of Emergency Medical Services designation for Trauma Center Level 3 status with UNC Medical Center optimizing resources and increasing acuity volume for better value-based outcomes. • Achieved national accreditation for Health Care Delivery with The Joint Commission optimizing resources for better valued based outcomes. [Only 26 findings out of 1417 elements of performance with zero findings in Leadership (LD), National Patient Safety Goals (NPSG), and High-Level Disinfection (HLD)] • Integrated public health functions with UNC Gillings School of Public Health, Region 6 South Central Public Health Departments, and the North Carolina Department of Health & Human Services improving quality and processes for better value-based outcomes. • Achieved national accreditation for Public Health and recognized by the United States Center for Disease Control & Prevention (CDC) for Public Health Quality & Process Improvement. Open in new tab Table I WAMC Accomplishments with Stakeholders during the DHA Transition (October 2018 – March 2020) • Established accredited 20-week Paramedic Certification Program with Fayetteville Technical Community College enhancing Medical Role 1 critical care and prolonged field care skills to maximize close combat survivability. • Established the Fort Bragg Research Institute with the Geneva Foundation and Cape Fear Consortium focusing research on operational needs for close combat formations for better value-based outcomes. • Integrated WAMC Inpatient Pediatric Services at Cape Fear Valley Medical Center optimizing resources and increasing acuity volume for better value-based outcomes. • Integrated WAMC Surgical & Medical Services with Fayetteville VA Medical Center sharing resources and increasing acuity volume for better value-based outcomes. • Increased Medical and Dental Readiness Assessment capacity two weekends per month with the US Army Reserve Southeast Medical Area Support Group optimizing Army Total Force resources and maximizing Soldier availability for training for better value-based outcomes. • Integrated WAMC Medical Education & Training with the 82ABN Division Taylor-Sandri Medical Training Center enhancing Medical Role 1–3 skills for better valued based outcomes. • Integrated didactic instruction, preceptor teaching, simulation, and clinical experience with 44MED BDE-Ft. Bragg, 4MDG-Seymour Johnson AFB, 20MDG-Shaw AFB, & 43MDS-Pope AAF for medical role skills sustainment for better value-based outcomes. • Established resource sharing agreements to rotate WAMC Providers and Care Teams to UNC Medical Center, Duke University Hospital, and Wake MED for medical role skills sustainment to enhance WAMC scope of practice for higher acuity-volume. • Achieved American College of Surgeons verification and North Carolina Office of Emergency Medical Services designation for Trauma Center Level 3 status with UNC Medical Center optimizing resources and increasing acuity volume for better value-based outcomes. • Achieved national accreditation for Health Care Delivery with The Joint Commission optimizing resources for better valued based outcomes. [Only 26 findings out of 1417 elements of performance with zero findings in Leadership (LD), National Patient Safety Goals (NPSG), and High-Level Disinfection (HLD)] • Integrated public health functions with UNC Gillings School of Public Health, Region 6 South Central Public Health Departments, and the North Carolina Department of Health & Human Services improving quality and processes for better value-based outcomes. • Achieved national accreditation for Public Health and recognized by the United States Center for Disease Control & Prevention (CDC) for Public Health Quality & Process Improvement. • Established accredited 20-week Paramedic Certification Program with Fayetteville Technical Community College enhancing Medical Role 1 critical care and prolonged field care skills to maximize close combat survivability. • Established the Fort Bragg Research Institute with the Geneva Foundation and Cape Fear Consortium focusing research on operational needs for close combat formations for better value-based outcomes. • Integrated WAMC Inpatient Pediatric Services at Cape Fear Valley Medical Center optimizing resources and increasing acuity volume for better value-based outcomes. • Integrated WAMC Surgical & Medical Services with Fayetteville VA Medical Center sharing resources and increasing acuity volume for better value-based outcomes. • Increased Medical and Dental Readiness Assessment capacity two weekends per month with the US Army Reserve Southeast Medical Area Support Group optimizing Army Total Force resources and maximizing Soldier availability for training for better value-based outcomes. • Integrated WAMC Medical Education & Training with the 82ABN Division Taylor-Sandri Medical Training Center enhancing Medical Role 1–3 skills for better valued based outcomes. • Integrated didactic instruction, preceptor teaching, simulation, and clinical experience with 44MED BDE-Ft. Bragg, 4MDG-Seymour Johnson AFB, 20MDG-Shaw AFB, & 43MDS-Pope AAF for medical role skills sustainment for better value-based outcomes. • Established resource sharing agreements to rotate WAMC Providers and Care Teams to UNC Medical Center, Duke University Hospital, and Wake MED for medical role skills sustainment to enhance WAMC scope of practice for higher acuity-volume. • Achieved American College of Surgeons verification and North Carolina Office of Emergency Medical Services designation for Trauma Center Level 3 status with UNC Medical Center optimizing resources and increasing acuity volume for better value-based outcomes. • Achieved national accreditation for Health Care Delivery with The Joint Commission optimizing resources for better valued based outcomes. [Only 26 findings out of 1417 elements of performance with zero findings in Leadership (LD), National Patient Safety Goals (NPSG), and High-Level Disinfection (HLD)] • Integrated public health functions with UNC Gillings School of Public Health, Region 6 South Central Public Health Departments, and the North Carolina Department of Health & Human Services improving quality and processes for better value-based outcomes. • Achieved national accreditation for Public Health and recognized by the United States Center for Disease Control & Prevention (CDC) for Public Health Quality & Process Improvement. Open in new tab SUCCESSFULLY LEADING THE MHS TRANSFORMATION The transition to DHA consolidation of the MHS and creation of the market construct in the Central North Carolina Market is a complex, uncertain, and ambiguous endeavor, full of multiple stakeholder perspectives, needs, goals, and challenges. Success in this environment requires an outward mindset culture that is responsive to the complexity of the external healthcare market to fully serve the mission needs and ensure the health and readiness of the fighting forces of the Army, Navy, and Air Force units throughout this region. Only through enhanced collaboration can the system wide efforts across health care delivery, public health, research, and medical education be integrated to meet the efficiency and savings required by the DHA transition while advancing the health and readiness of military personnel. Adopting and applying the outward mindset in exercising Mission Command elements throughout WAMC has provided the foundation and culture to expand the scope of collaboration amongst various Federal, State, Local, Military, and Civilian stakeholders. In the past 15 months, during a period of uncertainty and ambiguity with a lack of predictability for staffing and financial resources, WAMC has successfully integrated and collaborated with partners across the Central North Carolina market on multiple elements that are leading to the successful consolidation under the DHA Market Construct (Table I). It has been the effectiveness of the relationships at the front line between organizations that has provided the basis to realize the opportunities of meaningful scale to reorganize resources and reform processes to generate readiness and build a more lethal force cost-effectively. Setting the conditions for change by instilling an outward mindset culture approach mobilizes the Army Doctrine strategies and maximizes the capabilities of WAMC staff to align, engage, and adapt to the new needs and requirements in creating the market construct and serving stakeholder needs. A metaphor for how outward mindset tools integrate and enhance the capacity and performance of the organization is how maximal lethal force is achieved in the field. To navigate uncertainty and ambiguity, leadership must organize at echelon teams and leaders with overlapping “fields of fire” to better manage risk and exploit opportunities (Job Responsibility, Clarify Roles).7 Each leader and team has shared understanding of the Commander’s Intent within their respective field of fire and those that overlap with them. Instilling mutual trust with an outward mindset, leaders are empowered to take disciplined initiative to engage targets (Meet To Learn, Meet To Give).7 As teams and leaders become more effective using the basic outward mindset tools, they became iteratively better at incorporating the more advanced tools such as the Influence Pyramid, 3A+ Accountability Conversations, and Impact Check-In from the Outward Leadership workshop. When conditions of mutual trust exist, the more leaders fire and engage, the better they get and the more lethality they bring to the engagement zones. These fields of fire extend beyond the chain of command, beyond Fort Bragg, and cover Federal, State, Local, Military and Civilian stakeholders amongst health care delivery, public health, research, and medical education systems. The key to establishing an outward mindset culture is the extent to which mindset is modeled from the top down, where Senior Leaders hold themselves accountable to their subordinates. To set these conditions Senior Leaders must own their own mindset and have the humility to see and speak the truth of the impact their own mindset may have, especially when they themselves are creating problems for others. An early example occurred in the first month of the current WAMC Commander’s tour. Several Executive Assistants (EAs) in the Headquarters had conveyed concerns to the WAMC Command Sergeant Major (CSM) on the impact of the new WAMC Commander’s communication approach. The WAMC CSM inquired whether they had been able to share this concern with the WAMC Commander. They responded that they had not. The very next day, the WAMC CSM scheduled a Meet To Learn between the WAMC Commander and the Headquarters EAs. The WAMC CSM invited the Commander to apply the Outward Mindset Pattern, aka S.A.M., by inviting him to meet with the EAs and be genuinely curious about their needs, challenges, and objectives (See Others). Given what he learned in that meeting, the Commander publicly committed to the EAs several things he would change in order to be more helpful (Adjust Efforts). Finally, he committed to a regular cadence of meetings with the EAs so that he could check in and hold himself accountable for his impact on their work (Measure Impact). This simple example of the Commander taking responsibility for his own mindset and impact had a cascading effect beyond the EAs as this story was told and retold—that the new WAMC Commander sought and appreciated feedback to be better aware of his own mindset so that he could shift and be more effective in his role and professional relationships with both internal and external stakeholders. This early vignette provided the power example and gave permission to other WAMC Senior Leaders and leaders to be more self-aware to be better FOR the team and organization. This outward mindset accountability creates the conditions for not just getting the job done but getting it done right: not just leading the transformation to DHA but leading in a way that achieves the objectives of greater health and readiness. The views expressed are solely those of the authors and do not reflect the official policy or position of the U.S. Army, U.S. Navy, U.S. Air Force, the Department of Defense, or the U.S. Government. Neither the author nor their family members have a financial interest in any commercial product, service, or organization mentioned in this article. REFERENCES 1. U.S. Army : The U.S. Army in Multi-Domain Operations 2028. TRADOC Pamphlet 525-3-1 , 6 December 2018 . Available at https://www.tradoc.army.mil/Portals/14/Documents/MDO/TP525-3-1_30Nov2018.pdf; accessed March 1, 2020 . 2. S. 2943—National Defense Authorization Act for Fiscal Year 2017. U.S. Congress . Available at https://www.congress.gov/bill/114th-congress/senate-bill/2943/text; accessed March 1, 2020 . 3. Final Plan to Implement Section 1073c of Title 10, United States Code : Office of the Under Secretary of Defense , June 30, 2018 . Available at https://webcache.googleusercontent.com/search?q=cache:UMez-7veKvYJ:https://health.mil/Reference-Center/Congressional-Testimonies/2018/06/28/Reform-of-Administration-of-the-Defense-Health-Agency-and-Military-MTFs+&cd=1&hl=en&ct=clnk&gl=us; accessed March 1, 2020 . 4. ADP 6-0 Mission Command : Department of the Army , July 2019 . Available at https://fas.org/irp/doddir/army/adp6_0.pdf; accessed March 1, 2020 . 5. Army Leadership and the Profession : Department of the Army , July 2019 . Available at https://fas.org/irp/doddir/army/adp6_22.pdf ; accessed March 1, 2020 . 6. The Arbinger Institute . The Outward Mindset . San Francisco , Berrett-Koehler Publishers , 2016 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 7. The Arbinger Institute : Developing and Implementing an Outward Mindset Workshop . Available at https://arbinger.com/Workshop/Publicdiom.html; accessed March 1, 2020 . 8. The Arbinger Institute : Arbinger Training Dramatically Improves Culture in Healthcare . Available at https://arbinger.com/registerWhitePaper.html?file=Whitepaper_Dramatically_Improving_Performance.pdf; accessed March 1, 2020 . 9. The Arbinger Institute : Outward Leadership Workshop . Available at https://arbinger.com/Workshop/PublicOMSL.html; accessed March 1, 2020 . © Association of Military Surgeons of the United States 2020. All rights reserved. For permissions, please e-mail: [email protected]. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Howell,, George

doi: 10.1093/milmed/usaa162pmid: 33002143

ABSTRACT Improving the readiness and lethality of the U.S. fighting forces has always been a key priority, and it received renewed emphasis in the National Defense Authorization Act of 2017. A major rearrangement of the Defense Health Agency and the Military Health System is ongoing with this emphasis. Although revising features to improve our military health service is essential, the health, well-being, and readiness of our people will also rely on the culture created at the Command level where soldiers, sailors, airmen and civilians operate daily. In alignment with our military health care community and in support of our renewed emphasis on warfighting readiness, USS Missouri began a journey to address foundational mindset that drives the core behaviors, training, and procedures of the submarine force and Naval Nuclear Propulsion Principles leading to enhanced readiness, resilience, and accountability. MAINTENANCE AND OVERHAUL OF THE HUMAN OPERATING SYSTEM Substantial resources are committed to the U.S. Navy submarine overhaul and maintenance period to ensure the readiness and technical superiority of the U.S. Navy warfighting machine. During these extended periods of dry dock operations, the overhaul period provides an opportunity to implement preventive maintenance and enhancement of the human operating system alongside technical improvements to the naval arsenal. Throughout training pipelines within the submarine community, the Navy teaches leadership, ethics, and methods to maximize individual leader performance. The overhaul period provides a unique opportunity to expand on this foundation by advancing the collaborative mission-driven mindset to an entire crew—to invite a shift in mindset whereby each shipmate takes greater ownership of his/her impact on the mission. Enhancing the human operating system by shifting mindset is critical to achieving maximum readiness and lethality. As the modern warfighting environment grows faster, more complex, and technical, the speed and complexity of the combat environment has increased the need for a greater focus on the human network and collaborative response.1 The technical advantage of U.S. fighting forces persists, yet the rest of the world is closing the gap.2 Readiness is the key objective.3 Having a deliberate method to improve the culture of accountability, resilience, and collaboration can augment and support established submarine training. Command leadership sought to establish a strong cultural foundation for both the leaders and crew of the Missouri to accelerate readiness and improve effectiveness by introducing a shift in mindset. THE USS MISSOURI EXPERIENCE The USS Missouri completed an Atlantic deployment at the end of 2017 and a scheduled change of home port at the beginning of 2018. USS Missouri commenced a major extended maintenance period requiring dry dock after arrival in its new home port of Pearl Harbor, Hawaii. During this transition, there were multiple indicators of declining crew morale, accountability, and performance. Traditional disciplinary and performance improvement methods to curb this trend were ineffective. With the status quo being unacceptable and the ability to focus on the warfighting mission at increasing risk, the Command opted to institute a process to address the underlying mindset4 driving the behaviors and conduct. Command leadership was familiar with the outward mindset workshop and framework implementation by Navy Recruit Training Command Great Lakes, Navy Region Mid-Atlantic, and Naval Criminal Investigative Service to successfully lead through similar performance and behavior issues.5 ADDRESSING THE MINDSET, NOT THE BEHAVIOR Addressing mindset is different from established approaches to performance improvement because it focuses on shifting the underlying driver of behaviors. The intellectual foundations of the outward mindset material6 indicate that people operate at any given time from one of two mindsets: an inward mindset or an outward mindset (Fig. 1). All behaviors manifest from one of these two mindsets. From an inward mindset, people focus only on their own personal goals and objectives, without consideration for their impact on others. From an outward mindset, we see others as people who matter like we do, and as a result, take into account their needs, challenges, and objectives. The outward mindset focuses on collective results. Figure 1 Open in new tabDownload slide Two Mindsets. The effectiveness of all my behaviors is determined by my mindset. From an inward mindset, I see others as objects, so I do not see them as having needs or objectives. Therefore, my efforts can only focus on achieving my results. From an outward mindset, I see others as people and see they have needs and objectives. From an outward mindset, I can adjust my efforts to achieve my goals and objectives in a way that is helpful to others in achieving their goals and objectives. Only from an outward mindset can my efforts be collaborative and helpful to the collective result. Copyright 2020 Arbinger Properties, LLC. All Rights Reserved. Used with permission. Figure 1 Open in new tabDownload slide Two Mindsets. The effectiveness of all my behaviors is determined by my mindset. From an inward mindset, I see others as objects, so I do not see them as having needs or objectives. Therefore, my efforts can only focus on achieving my results. From an outward mindset, I see others as people and see they have needs and objectives. From an outward mindset, I can adjust my efforts to achieve my goals and objectives in a way that is helpful to others in achieving their goals and objectives. Only from an outward mindset can my efforts be collaborative and helpful to the collective result. Copyright 2020 Arbinger Properties, LLC. All Rights Reserved. Used with permission. Conflict is typically at the root of poor conduct or performance issues. When individuals are focused on their own needs rather than the collective result, conflict is likely to occur.7 Furthermore, behavioral solutions such as implementing or requiring compliance with process often fail to eliminate conflict. In fact, individual focus on achieving one’s own performance objectives can become the justification for undermining or disparaging the objectives and goals of others. Achieving lasting performance improvement requires more than compliance to new behavior and process standards; it requires commitment to performing those behaviors and processes in a way that helps others achieve their objectives. IMPLEMENTING A CULTURE SHIFT The opportunity to initiate the culture shift began early in the preparation for the change of the Missouri’s homeport and transition to an extended maintenance period. The implementation strategy followed the “waterfall” approach effectively utilized in other military organizations to shift culture.8 An initial workshop to introduce the material to the Missouri’s leadership (Chiefs and Officers) was conducted during the Missouri’s relocation from Groton, Connecticut to Pearl Harbor, Hawaii from January 4 to 28, 2018. This culture transformation process typically begins with a 2-day workshop5 to develop the use of self-awareness and accountability tools followed by a sustainment period where additional materials are integrated into an organization’s standard operational schedule. After the initial training for the Missouri leaders, there were a few areas of immediate improvement in leadership collaboration. Sustained performance improvement, however, was not achieved. Education and training were not sufficient to achieve a cultural shift. After arrival in Pearl Harbor, the Command leadership team began in late April to implement a sustainment battle rhythm by deliberately scheduling and using specific tools provided in the workshop, “Start In the Right Way,” “Meet to Learn,” “Biggest Headache,” and “3A+ Impact Assessment.” Additional reinforcement was provided in the routine fireside chat discussions with the review of sustainment videos and exercises available in the workshop materials. With the subsequent sustainment program and integration of outward mindset tools into the regular day-to-day rhythm, the shift in culture and performance became palpable and discernible in the performance metrics. With Missouri leadership using the vernacular of the outward mindset framework, some of the crew became progressively interested in the mindset materials. At the end of the 2018 fiscal year, additional materials and training time were committed for the rest of the 140-member crew to participate in the traditional 2-day workshop and further inject the vernacular and rhythm of an outward mindset shift into the Missouri’s daily operations. GETTING RESULTS: ENHANCING BEHAVIOR AND READINESS Before establishing the leadership shift in mindset, there were several key indicators of a crew struggling with the transition from a successful deployment to an extended overhaul period. Specifically, in the first nine months of 2018, there were 12 Captain’s Masts (nonjudicial punishment). Eight were integrity-related, one was for performance problems, one was for driving under the influence, and two were for illegal substance use. Two incident reports were submitted for significant issues that occurred during this period, and there were 31 near-miss events requiring command level attention. In addition, there were 17 formally declared test program problems (TPPs) due to watch standing errors and seven unplanned personnel losses (UPL) of crew members resulting in gaps in manning. Electrical division work practices were unsafe and resulted in an electrical shock to a Sailor. Electrical division’s maintenance accomplishment report that tracks on time completion of required maintenance highlighted 1 of multiple divisions unable to keep up with the routine maintenance demand. Shifting the mindset of the Missouri improved personal accountability and performance. From October 2018 to June 2019, after the entire crew participated in a workshop, only one nonjudicial punishment proceeding was conducted. No crew members tested positive for illegal substance use. Reported liberty incidents decreased by 70%. During this period, the Missouri had not a single significant issue that required reporting via incident report. Over the same time, there were only seven near miss events requiring a command level critique, an 80% reduction. Only six test program problems were declared due to watch standing error. Unplanned personnel losses, retention, and attrition improved (Table I). TABLE I Before and After Results Key Indicators . Before . After . . Implementing Mindset Change (January–September 2018) . Implementing Mindset Change (October 2018—June 2019) . Number of Captain’s Mast (misconduct) 12 1 Number of UPL’s 7 1 Number of Illegal drug use incidents 2 0 Number of incident reports 2 0 Number of critiquable events 31 7 Number of TPPs due to watchstanding 17 6 Number of liberty incidents (alcohol) 7 2 Key Indicators . Before . After . . Implementing Mindset Change (January–September 2018) . Implementing Mindset Change (October 2018—June 2019) . Number of Captain’s Mast (misconduct) 12 1 Number of UPL’s 7 1 Number of Illegal drug use incidents 2 0 Number of incident reports 2 0 Number of critiquable events 31 7 Number of TPPs due to watchstanding 17 6 Number of liberty incidents (alcohol) 7 2 UPL, unplanned personnel losses; TPPs, test program problems. Open in new tab TABLE I Before and After Results Key Indicators . Before . After . . Implementing Mindset Change (January–September 2018) . Implementing Mindset Change (October 2018—June 2019) . Number of Captain’s Mast (misconduct) 12 1 Number of UPL’s 7 1 Number of Illegal drug use incidents 2 0 Number of incident reports 2 0 Number of critiquable events 31 7 Number of TPPs due to watchstanding 17 6 Number of liberty incidents (alcohol) 7 2 Key Indicators . Before . After . . Implementing Mindset Change (January–September 2018) . Implementing Mindset Change (October 2018—June 2019) . Number of Captain’s Mast (misconduct) 12 1 Number of UPL’s 7 1 Number of Illegal drug use incidents 2 0 Number of incident reports 2 0 Number of critiquable events 31 7 Number of TPPs due to watchstanding 17 6 Number of liberty incidents (alcohol) 7 2 UPL, unplanned personnel losses; TPPs, test program problems. Open in new tab A continuous theme of USS Missouri mindset training is to shift focus from a sailor’s individual results to instead view the impact of his/her efforts on others. Each sailor performed critical preventive maintenance work using self-accountability tools with primary emphasis on: (1) capability and skills, (2) impact on others, and (3) level of effort (Fig. 2). Using these tools, all divisions achieved performance standards for mission readiness. The improved performance of Electrical division was particularly remarkable. By planning, collaborating, and working as a team, they eliminated their entire backlog of maintenance items. Figure 2 Open in new tabDownload slide Outward mindset accountability tool. The outward mindset accountability framework helps shift self-accountability by creating a focus on impact on others. Individuals identify when they may need assistance in their capability or in adjusting their diligence and focus, and then seek feedback on the impact of their efforts. Individuals now focus beyond doing their job (effort) to their impact on others, the unit, and the mission. Copyright 2020 Arbinger Properties, LLC. All Rights Reserved. Used with permission. Figure 2 Open in new tabDownload slide Outward mindset accountability tool. The outward mindset accountability framework helps shift self-accountability by creating a focus on impact on others. Individuals identify when they may need assistance in their capability or in adjusting their diligence and focus, and then seek feedback on the impact of their efforts. Individuals now focus beyond doing their job (effort) to their impact on others, the unit, and the mission. Copyright 2020 Arbinger Properties, LLC. All Rights Reserved. Used with permission. SUSTAINING IMPROVED PERFORMANCE Education about mindset is not enough. Only after the effort to be more deliberate in operationalizing the material into the crew’s daily practices is when the Missouri’s culture and performance began to change and more importantly sustain. From the Command leadership perspective, the constant focus on the core watch standing principles of the Naval Nuclear Power Program in combination with the additional effort on shifting underlying mindset yielded the desired trend in performance and readiness metrics. Improved performance was sustainable for longer periods with the addition of mindset change tools into the daily routine. Ownership and self-correction became more evident with an increase in the frequency and quality of self-monitoring. Small problems and mistakes certainly still occurred; however, daily utilization of outward mindset tools via sustainment efforts provided the awareness of inward mindset red flags that guided self-correction before small problems became bigger. It is important to recognize that Missouri’s problems, while improved, did not drop to zero across the board. The knowledge of mindset is not a magic pill or panacea for perfection. Each member of the crew, now armed with the knowledge and awareness of their impact on others, has a choice. Once trained and aware of this option, the ignorance of the choice is not an option—you cannot “unsee” the material. Once aware of the ways one may be contributing to a negative impact on shipmates or the mission, one may continue to make poor deliberate choices; however, leadership will honor that person’s choice to not work in an accountable way, and provide the subsequent consequence. On the Missouri, the approach is to develop accountable Sailors, so leadership spends less time holding Sailors accountable. More than just the tracked measures of crew performance and readiness is the palpable shift in culture from adopting mindset awareness. One particular example where the mindset shift likely contributed to a positive outcome was for a nuclear-trained Sailor significantly behind his due dates in qualifications. The mindset shift tools5 were utilized by the Command to outwardly invite this Sailor to come up with his own plan of action, execute his plan, and hold himself accountable for his results in alignment with the needs of the Missouri. With his plan (not the Command’s plan for him), this Sailor regained track and earned his Submarine Dolphin Warfare insignia in front of 1,300 people at the Submarine Birthday Ball. Before outward mindset adoption, the correction process would likely have included counseling chits, Letters of Instruction, Captain’s Mast, or Naval Enlisted Classification removal, and could have resulted in an unplanned loss to the ship and the Navy. Instead, the application of the outward mindset materials invited this young man to choose a path to remain a contributing crew member who is confident, proud, and holds himself accountable to the team and the organization’s results. In addition, the confidence in the outward mindset culture of the Missouri led the Command leadership to accept nine second chance Sailors from other submarines, including a department head, one junior officer, two chief petty officers, two first class petty officers, and three junior Sailors. All these Sailors, including the one mentioned above with the qualification challenges, faced a significant uphill battle due to past performance problems. They all had a prior trail of counseling, Letters of Instruction, and adverse evaluations that are typically insurmountable and inconsistent with continued service. Supported by the outward shift in the Missouri and the self-awareness learned from the workshop, all but one of these Sailors improved and demonstrated satisfactory performance aboard Missouri. They learned to own their past mistakes to show initiative in holding themselves accountable instead of the Command holding them accountable and came to see truthfully why their performance to support the established standard operating processes and procedures is so vitally important to the readiness of the Missouri to meet its warfighting mission. The mindset shift of Missouri had an additional positive impact on the effectiveness of its relationship and collaboration with the shipyard project team. The shipyard project superintendent noticed a significant difference from the performance of the Missouri crew and approached the Command to inquire how this difference came about. After an explanation of the accountability and ownership methods on Missouri, the project superintendent and 50 of his leaders attended the outward mindset training. The two collective teams (Missouri’s leaders and civilian shipyard leaders) collaborated, planned, and worked with enhanced effectiveness completing the submarine maintenance period early at a savings of $25 million dollars. WHY SHIFTING MINDSET MATTERS Understanding that mindset drives behavior, the Missouri Command and crew now have tools that provide a framework for the preventative and corrective maintenance of the human operating system that is as essential to the readiness and lethality of our force as the technical and mechanical tools and systems. These tools help shift awareness toward a collaborative focus of one’s impact on others and help drive behaviors in a way that make them more helpful, impactful, and beneficial to the organizational efforts. This mindset shift improved operational safety as more time is spent focused on ensuring things go right rather than reacting to things going wrong. Mindful of numerous naval leadership objectives from the Secretary of Defense, the Secretary of the Navy, the Chief of Naval Operations, the Commander of the Pacific Fleet, and the Commander of the Submarine Force of the Pacific Fleet to increase lethality in a near-peer competitor environment, the Missouri strives to achieve the full potential of the human network in fighting and winning together. The U.S. Navy invests heavily in resources to maintain our technical and mechanical advantage. A commensurate investment in our human operating network can help us maintain and expand our unparalleled, asymmetric fighting advantage. The experience of Missouri using this mindset shift demonstrates our existing training is enhanced, renewed, and more meaningful by addressing the mindset that drives behavior. We are using our existing training and executing the behaviors we desire in a safer and more efficient way resulting in faster and more sustainable, improved results. Mindset awareness tools provide a framework and common language to execute the submarine training and do not counter the current process improvement framework. It lays a foundation for greater collaboration and communication. The focus on important connections to both our mission and our shipmates provide the critical element that makes readiness and collaborative teamwork possible. It is possible to misinterpret mindset shift as a Pollyannaish belief or hope that everything will work out, or as another description of the power of positive thinking. What this interpretation fails to understand is that significant work and effort are required; shifting mindset does not assume everything just works out. Rather, it is a shift in seeing each other, the humanity, and personhood of each shipmate. This shift provides clarity on the source of one’s own contribution to a conflict or challenge, as well as the understanding of a broader array of options for resolving the issue within one’s own efforts and sphere of control. The efficiency and effectiveness of this material are the reduction in valuable time, manpower, and mental energy figuring out how to address the same problems that arise time and time again. The investment in training and executing a sustainability program creates huge dividends in the time to focus on mission, enables an understanding of the big picture down to the deck plate level, and provides a sustainable culture where day-to-day business is executed not just in service to the mission but with the understanding of “how” it serves the mission. Shifting to an outward mindset is a journey, not an end state. Every day, there are opportunities to see inwardly or outwardly, and the goal is to be a little more outward each day. In shifting mindset for leadership and crew, the Missouri was able to shift time and resources away from addressing conflict, misbehavior, and poor performance. When focus can instead spotlight each sailor’s capability and skills, their impact on others, and level of effort, mission readiness can only improve. With the toolkit to invite an outward mindset, Missouri leadership and crew increased collaboration, improved conduct, and maximized mission readiness during the extended overhaul period. The views expressed are solely those of the author’s and do not reflect the official policy or position of the U.S. Submarine Force, U.S. Navy, the Department of Defense, or the U.S. Government. REFERENCES 1. Razma G : A modern warfare paradigm: reconsideration of combat power concept . J Security Sustain Issues 2019 ; 8 : 435 – 52 . Google Scholar Crossref Search ADS WorldCat 2. Lague D , Lim BK: China’s vast fleet is tipping the balance in the Pacific. Reuters Investigates , 2019 . Available at https://www.reuters.com/investigates/special-report/china-army-navy/; accessed March 1, 2020 . 3. Nindl BC , Billing DC, Drain JR, et al. : Perspectives on resilience for military readiness and preparedness: report of an international military physiology roundtable . J Sci Med in Sport. 2018 ; 21 : 1116 – 24 . Google Scholar Crossref Search ADS WorldCat 4. The Arbinger Institute . The Outward Mindset . San Francisco , Berrett-Koehler Publishers , 2016 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 5. The Arbinger Institute : Developing and Implementing an Outward Mindset Workshop . Available at https://arbinger.com/Workshop/Publicdiom.html; accessed March 1, 2020 . 6. The Arbinger Institute : The Intellectual Foundations of the Arbinger Institute . Available at https://arbingerinstitute.com/whitepapers.html; accessed March 1, 2020 . 7. The Arbinger Institute . Leadership and Self-deception , Ed 3rd. San Francisco , Berrett-Koehler Publishers , 2018 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 8. The Arbinger Institute : Arbinger Training Dramatically Improves Performance . Available at https://arbinger.com/registerWhitePaper.html?file=Whitepaper_Dramatically_Improving_Performance.pdf; accessed March 1, 2020 . © The Author(s) 2020. Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States. All rights reserved. For permissions, please e-mail: [email protected] This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Gibson, David, R

doi: 10.1093/milmed/usaa190pmid: 33002147

ABSTRACT Resolving major challenges for health care organizations is a constant challenge. Each military service provides its leaders with superb education and training to lead the constant needs and changes of the mission requirements. The primary trap we leaders may fall into, though, is when we mistake our own expertise and perspectives as the solutions to our organizational challenges. To fully unleash the potential of our people and organizations, we must be deliberate in setting a culture that leverages all the diversity within our organization. At the Carl R. Darnall Army Medical Center, Fort Hood, TX, our leadership team initiated an effort to shift the organizational mindset to create this cultural soil. The seeds of our education, training and strategic initiatives then were able to flourish and address our organizational challenges, but only after we addressed our own leadership mindset gap. By establishing and modeling a foundational outward mindset to ensure our team focused on the impact of our actions, we nurtured a culture that was inquisitive, collaborative, and without blame. In doing so, we eliminated negative financial and safety outcomes that threatened our institution and transformed it into a leading Army Medical Center. STANDARD PREP The military has a very regimented framework to develop and prepare leaders as part of a continuous learning enterprise (Fig. 1).1 This framework is defined by three domains that further shape training curriculums for military members, civilians, and even contractors across the Department of the Army. Each domain can be further defined for schools, courses, individual learning experiences, and institutional training opportunities based on one’s specialty and career path. For example, someone board-selected to command a medical facility would be expected to have had appropriate leadership development opportunities, educational opportunities, and have demonstrated success in prior roles based on their performance evaluations. The Army promotion process has a board of directors (i.e. Department of the Army Senior Leaders) review a candidate’s files to ensure selectees for a Chief Executive Officer position have appropriately demonstrated leadership competencies to be successful in these coveted roles. FIGURE 1 Open in new tabDownload slide The Army Learning Enterprise (TRADOC Regulation 350–70)1. The matrix framework of the Army Learning Enterprise addressing the Self-development, Operational, and Institutional Domains supported by Systems, People, Policies, Resources, Processes, and Organizations. FIGURE 1 Open in new tabDownload slide The Army Learning Enterprise (TRADOC Regulation 350–70)1. The matrix framework of the Army Learning Enterprise addressing the Self-development, Operational, and Institutional Domains supported by Systems, People, Policies, Resources, Processes, and Organizations. The Department of the Army has also published a Handbook for Leadership Transitions2 that provides methodologies distilled into best practices, proven techniques from military and civilian sources, and helpful tips and checklists that leaders should consider when assuming new leadership roles. The handbook includes the courses that these leaders should have attended before assuming key positions. For example, in addition to a master’s level education, Army Medical Department leaders are expected to have completed the Command and General Staff College or Intermediate Level Education, a Senior Service or War College, the Basic Healthcare Administration Course, the Army Medical Department Executive Skills Course, a Pre-command Course, and other training on topics such as best practices, enterprise metrics, current programs, and process improvement methodologies. The handbook provides a solid basis for addressing the preparation leaders should get from each of the three domains listed above. This breadth of preparation is essential for helping leaders implement key competencies for performance in their new role. Upon assuming command, the Army has formal and informal performance expectations for each commander. For example, as part of an Army program, each unit will undergo a variety of anonymous surveys that will be returned to the new commander as well as the new commander’s supervisor. The most notable survey is the Defense Equal Opportunity Management Institute Organizational Climate Survey (DEOCS).3 This in-depth assessment is focused on apprising the new leadership team of the organizational climate, the multiple facets of equal opportunity, and organizational perspectives by different individuals and groups across the enterprise (ie, military, civilian, by grade, etc.). This survey, coupled with other assessments such as the Army Readiness Assessment Program (ARAP),4 interviews with internal and external stakeholders, in-briefs and meetings, collectively provides invaluable insights regarding what is working as well as problem areas for the organization’s climate. This information is important to incorporate into a larger environmental scan focused up and out of the organization to address operational challenges and shape, respond, or exploit strategic opportunities. With this background and preparation, the next challenge for the new commander is the art of execution. STANDARD EXECUTION FRAMEWORKS The military places great emphasis on the use of checklists to produce better outcomes and prevent disasters. In Atul Gawande’s book, The Checklist Manifesto,5 Gawande distinguishes between errors of ignorance and errors of ineptitude—mistakes made because what was known was not appropriately or correctly applied. Gawande describes how brilliant and accomplished surgeons can improve their success in complex, clinical cases by using checklists for simple tasks that often become errors because of the volume, stress, and effect of other contributing factors competing for the surgeon’s attention. In the medical arena, surgeons and others throughout the health care environment are encouraged to adopt checklists and standardized approaches to think through a series of possible outcomes and plan to mitigate those risks. However, checklists are not enough.6 Despite compliance with procedures and following the checklist, the tasks on a checklist still can be performed incorrectly or missed, resulting in compounded and undesirable, to sometimes tragic, outcomes. The military health system (MHS) has embraced the 5 tenets of a high-reliability organization (HRO) across the global Army Medicine enterprise.7,8 These tenets include: (1) preoccupation with failure, (2) reluctance to simplify, (3) sensitivity to operations, (4) commitment to resilience, and (5) deference to expertise. The Army recognized that all HROs are fundamentally organizations and industries whose success is inextricably linked to human endeavors and that the experts for most operations are on the front lines of patient care. This drove senior Army Medicine leadership to leverage a variety of programs and tools by which to improve people, processes, systems, and strategy.9 Inculcating these tenets to address safety and chase zero preventable harm goes beyond traditional messaging, training, and preparing for The Joint Commission Survey. To get at the root necessitates engaging and connecting with people. Many would assume that in the military and in military health care, orders or directives would be issued, subordinates would comply, and everything would run like a fine Swiss watch. Although commanders do have authority to issue directives, policies, and orders, leadership at its core is about influence. This is especially important since most health care systems are highly matrixed. For example, at the Carl R. Darnall Army Medical Center (CRDAMC) in Fort Hood, Killeen, Texas, the governance structure included 42 committees that reported into an Executive Committee—cooperation and collaboration in the course of coordinating, synchronizing, and integrating these groups can only be achieved with influence. The Army Handbook for Leadership Transitions is a great tool filled with best practices and numerous checklists; however, successful leadership depends on executing influence to leverage the efficiencies and synergies from collaboration and innovation across these groups. GETTING TO EXECUTION—ADDRESSING THE GAP BY SHIFTING MINDSET In command positions, we mostly do not lack the key knowledge, strategy, or resources to succeed. The key resource, though, that is often underutilized is the human operating system. When people in organizations are asked what the challenges to improving the organization are, they often cite common challenges including: poor communication, poor collaboration, siloes, lack of transparency, and lack of teamwork.10 The Arbinger Institute has researched thousands of organizations and identified the source of these challenges. Their work describes this challenge on a scale of an inward mindset, where individuals are focused on their own goals, needs, and objectives, versus an outward mindset, where individuals are focused on the collective results by doing their jobs in a way that takes into account the goals, needs and objectives of others. Invariably when asked to rate their organization’s mindset score on a scale from 0 to 10, individuals will rate their organization as about a 4.6, whereas they rate their own mindset at a 6.8.11 This result varies slightly depending on where individuals sit within the overall management hierarchy of the organization, but invariably individuals score themselves about 30–50% better than their organizations. How can this be? How can an organization where everyone thinks of themselves as a 6.8 be a 4.6? Arbinger describes this as the “self-deception” gap. In other literature, it has been defined as the “above-average effect,” as in “I may not be perfect, but there are a whole lot of other people in this organization that have to improve before I have to do.”12 And because of this gap, change waits—not because people do not perform the things they are asked to, but because they perform them in a way that does not necessarily help the collective outcome. There may be some slight improvement, but never the chance to achieve “the opportunity” until this gap, this challenge, is addressed (Fig. 2).11 FIGURE 2 Open in new tabDownload slide Arbinger Data on The Self-Deception Gap, Opportunity, and Challenge. Why Change Waits: Organizations are full of individuals who rate themselves more outward than their colleagues. Although all organizations want to shift and become more outward overall (The Opportunity), efforts to shift tend to wait while individuals wait for “the ones who need it” to change first, not realizing they themselves are the ones who need to shift (Self-deception). The Arbinger Institute framework helps organizations address this gap (The Challenge). Copyright 2020 Arbinger Properties, LLC. All Rights Reserved. Used with permission. FIGURE 2 Open in new tabDownload slide Arbinger Data on The Self-Deception Gap, Opportunity, and Challenge. Why Change Waits: Organizations are full of individuals who rate themselves more outward than their colleagues. Although all organizations want to shift and become more outward overall (The Opportunity), efforts to shift tend to wait while individuals wait for “the ones who need it” to change first, not realizing they themselves are the ones who need to shift (Self-deception). The Arbinger Institute framework helps organizations address this gap (The Challenge). Copyright 2020 Arbinger Properties, LLC. All Rights Reserved. Used with permission. The key to addressing this challenge is to help individuals shift to an outward mindset, thus allowing the organizational culture to shift as well.13 This shift reduces the “self-deception” gap, enabling efficiencies to be found by leveraging greater collaboration and teamwork and allowing innovation to flourish. What is at first seen as a major challenge becomes minor in the face of what can be accomplished when leaders are able to identify and address this gap within themselves. CRDAMC SITUATION AND CHALLENGES For CRDAMC in 2017 the dynamics described above were no different. At that time, the CRDAMC’s 95 building campus was fortunate to have a new $600 M facility for the main hospital. Yet despite having a new facility, the medical center still had an enormous list of challenges as might be expected of any organization of its size. CRDAMC’s challenges included: working through a long punch list of new facility deficiencies; the pending modernization of many long-lead time capital investment and equipment systems; renovation or replacement of buildings across the campus and in the community; and building relationships with key stakeholders on and off the installation. Of even more concern were challenges of the basic sustainability and performance of the medical center including addressing the center’s $20 M financial deficit; low patient care and satisfaction scores; and addressing the morale, engagement and professional development of the workforce. At the same time, the Department of Defense (DoD) was undergoing the single-greatest change to the MHS in a generation by implementing a multiyear plan to meet congressionally directed mandates of the 2017 National Defense Authorization Act.14 This legislation required the MHS to consolidate the Army, Navy, and Air Force medical systems into one integrated system of health with a new headquarters, the Defense Health Agency (DHA). The uncertainty around what changes would be required by MHS and DHA throughout this transition added to the complexity of the challenges and relationships that needed to be addressed to resolve these challenging organizational issues. CRDAMC COMMAND APPROACH Starting by addressing mindset and culture, the CRDAMC command team developed a shared vision and charted a strategy for evolutionary—and revolutionary—changes to address the initial shortfalls. Although “culture trumps strategy,” strategy and performance management systems are still important for tracking and guiding successful implementation. CRDAMC implemented Lean Six Sigma practices as the framework for developing and tracking the process improvement strategy and execution. This framework was applied by and across service lines. Well-performing service lines are critical for health care delivery. High-performing health care requires cross-service line collaboration. Every issue developed an appropriate A3 to document and track efforts to achieve goals and objectives. However, the cooperation and collaboration necessary to move the projects forward was enabled by the climate (Fig. 3). The implementation and tracking proceeded as follows: FIGURE 3 Open in new tabDownload slide CRDAMC Comprehensive Strategic Elements for Change. Outward Mindset Training sets the conditions for success of the preparation, tools, and strategies used to execute organizational transformation. Army Leader Transitions: standard elements in the education, preparation, and resources for executive leaders. Assess Current State: standard tools and data sources for organizational assessment [7S Mckinsey Model, Equal Opportunity and Equal Employment Opportunity data, PASBA, ARAP, DEOCS]. Set Conditions: Using the Outward Mindset Training and Tools as the foundation for cultural change. Develop and Implement Strategy: standard goals and concepts in the Lines of Effort for organizational transformation. FIGURE 3 Open in new tabDownload slide CRDAMC Comprehensive Strategic Elements for Change. Outward Mindset Training sets the conditions for success of the preparation, tools, and strategies used to execute organizational transformation. Army Leader Transitions: standard elements in the education, preparation, and resources for executive leaders. Assess Current State: standard tools and data sources for organizational assessment [7S Mckinsey Model, Equal Opportunity and Equal Employment Opportunity data, PASBA, ARAP, DEOCS]. Set Conditions: Using the Outward Mindset Training and Tools as the foundation for cultural change. Develop and Implement Strategy: standard goals and concepts in the Lines of Effort for organizational transformation. Phase 1: Leader Preparation This phase included: environmental scanning, data collection, and personal preparation. This phase provided the transitioning leadership perceptions and insights that were further refined after assuming the Chief Executive Officer role. The Army Handbook for Transitions provides a collection of checklists to ensure new leaders are planning and preparing for actions that assist with their transitions in alignment with the framework described in “The First 90 Days” by Michael Watkins.15 Phase 2: Assess the Current State This phase focused on significant data collection, sharing that data with key leaders, and enabling them to articulate their assessments and recommendations in the framework of the McKinsey 7S model.16 The key aspect of this phase was the enabling of the “guiding coalition” to make their own assessments of the data and begin formulation of feasible solutions. This approach incorporated broader staff engagement as part of the strategy development and solution process. In addition to the DEOCS and ARAP surveys, The Patient Administration and Biostatistics Activity (PASBA)17 collects data that can provide leaders insights into coding practices, encounter management, encounter opening and closure practices, and much more by clinic. These insights directly impact data quality, records management, relative value unit, Medical Severity-Diagnosis Related Group (MS-DRG), and Current Procedural Terminology (CPT) Code-level assessments billing, and more. Understanding the implications of these insights is key to resolving the underlying issues (eg, staffing adequacy, clinical documentation and coding, and cost structures, etc.). These surveys were administered to the employees and provided to the executive team at CRDAMC. Phase 3: Outward Mindset Development and Implementation The 2-day “Developing and Implementing an Outward Mindset” workshop18 was intentionally provided after the initial assessments in order to shape how leaders approached developing their strategies before charting the course. As with all behaviors, strategic planning and execution can be done from an inward mindset or an outward mindset. When starting from an inward mindset, the strategy generally becomes “all the things we need to get other people to do in order to help us” versus, from an outward mindset, where the objective becomes “how can we help others achieve the things they are capable of accomplishing?” It was essential that senior leaders received the training first, to model and set the conditions for inviting the shift to an outward mindset by their direct reports, followed by midlevel managers, then frontline staff.19 The outward mindset material changes how people see challenges as individuals, teams, and organizations. More than empathy that attempts to just understand another’s feelings through the context of one’s own experience, an outward mindset creates collaboration by acceptance of another’s perspective without a justification of one’s own experience to verify that other’s perspective. By seeing differently, leaders change how they lead and develop their subordinates.20 They change how they approach problems and challenges; for large, highly matrixed organizations, this is key to collaboration and innovation. Failure to see other’ individual, team, or departmental needs, goals, and challenges creates a much greater risk of suboptimizing solution sets. Proliferating this mindset awareness throughout an organization addresses the self-deception gap and shifts the culture. Phase 4: Develop and Operationalize the Strategy This phase required bringing key leaders together to discuss their greatest challenges, possible solutions, and development and championing of action plans and associated metrics with input from stakeholders and the appropriate subject matter expertise. This part of the process was executed and modeled consistently well by the CRDAMC leadership team. The Deputy Commanders (executive staff such as Executive, Senior, and Vice Presidents) actively listened to their colleagues’ challenges and how they could best collaborate to assist in delivering solutions. Many of the biggest challenges were addressed in the room and resulted in identifying executive sponsors among different medical center departments. The outward mindset culture created efficiency in addressing solutions, freeing time, and space for addressing additional challenges. START WITH LEADERSHIP—THE RESULT The CRDAMC leadership team valued the outward mindset tools and the intellectual diversity they cultivated. Collectively, the leadership team focused on setting the conditions for organizational change that led to a rapid creation of a shared vision, goals, and strategic priorities. Most training and enterprise leadership tools lack the emphasis on addressing culture and mindset—two pillars that underpin an organization’s ability to implement change. The multistage approach to shifting mindset provided a framework to improve organizational culture that started with leadership and allowed for a rapid shift in the organization’s mindset. The 3-stage approach started with (1) shifting mindset, followed by (2) outward leadership development, and then (3) systems outward transformation.13 This process emphasized the value of having leadership understand what an outward shift entailed and the cost of not addressing their own gap, then providing the means to help lead others to make the shift to working more outwardly, followed by a deliberate revision of systemic practices to invite outward shift throughout the organization. This approach resulted in a consistent framework for implementing mindset change and addressing organizational barriers to meet the ongoing missions and address newly evolving requirements. Advancing the organization required leveraging talent internally and externally. Sometimes, the best solutions to problems come from external sources. These solutions are useless if those in the organization are not in a mindset to accept them. At CRDAMC, the hospital leadership team focused on shifting their own perspectives outward to invite a similar commitment and willingness of staff to shift outward and be more open to diverse ideas and solutions. Engaging the executive committee first, followed by rolling the outward mindset tools out across the medical center, established the mindset conditions with key staff to address: staffing adjustments, improve data quality, validate cost structures, improve clinical performance, improve operating room utilization, increase cycle time of the revenue cycle, and improve morale of patients and staff. The strategic goals, initiatives, and associated metrics were secondary to focusing on the most important component of developing a dynamic organizational strategy—the outward mindset culture of the organization. MINDING THE GAP Critical to implementing this outward mindset shift organizationally was for leadership to model and actively identify when they may be slipping toward an inward mindset and adjust accordingly. An example in our implementation included our own outward mindset implementation and communication plan. We thought we had a good plan. Leaders who want to rapidly implement change must address the environment and culture to create the conditions necessary for organizational evolution. Influencing the culture for a large and geographically dispersed organization requires more than reliance upon a waterfall of information flow. Leaders must communicate strategically to reach, connect to, and resonate with their organization’s staff and stakeholders. Communications must be tailored for specific stakeholders.21 The CRDAMC leadership team worked extensively on communicating and executing the strategy for outward mindset training for the needs of the complex medical center with three primary work shifts, functioning 24 hours a day, seven days a week, 365 days a year. There are many barriers to reaching all members of the clinical and administrative staff in this type of environment. Command used multiple methods and forums to communicate the overall plan and strategy—townhalls, waterfall messaging, newsletters, etc. We thought we did a good job: but we had missed a critical element. The sequence of providing outward mindset training as planned with an approach of cascading was not executed well, particularly regarding the expectations for midlevel leaders. Although command staff completed the workshop and assumed midlevel leaders and so on would do so as well, many required subordinates to attend the training even if their respective supervisors had not. We had mistaken knowledge of the requirement with understanding of the expectation. When this challenge surfaced, leaders initially shifted inward, seeing the midlevel management as a problem. Yet identifying their own frustrations with the implementation process allowed the executive level leadership to consider the challenges of midlevel management in meeting the expectations. Often in organizations, it is the midlevel management team that is most stressed between the performance requirements and metrics expected from the top—with the reality of time and space limitations of human performance and capacity. The midlevel leaders are instrumental to driving all strategic efforts and must be adequately engaged to achieve desired results. In fact, engaging midlevel leaders is instrumental to achieving organizational momentum.22 What became clear on seeing the midlevel leadership challenges was the mistake on the Command team’s part to understand the challenge for midlevel leaders—even with an aggressive communication plan and efforts to model the significance and importance of the training. The leadership team committed to helping the midlevel managers by ensuring their own presence and speaking at the beginning and ending of all training sessions to demonstrate their support for these subordinate leaders. By sharing their own commitment and practice of the material and how it could be integrated in the culture and values of the organization, the Command leaders supported the midlevel leaders’ concern for helping their reports see this was not something done “to” them by leadership but as a practice for all of them to adopt. By minding the gap and recognizing the “blaming” inward shift, the Command team was able to shift outward to see the challenge for midlevel leaders caught between the requirements of senior leaders with the time and resource limitations of the midline and frontline. Seeing our own “gap” and adjusting to support the efforts of the midlevel leaders provided substantial credibility and support to the overall organizational transformation effort. MINDING THE GAP PAYS CRDAMC experienced the success of the cultural mindset shift in many areas. First and foremost was in resolving the financial insolvency that was an existential threat to the viability of CRDAMC within the overall DHA assessments and planning. The $20 M deficit was resolved and an additional $36 M was realized over the planned performance target. In addition to achieving financial targets, CRDAMC improved service line operations, population health, patient satisfaction, and employee morale, receiving multiple awards for the accomplishments in these areas (Table 1). These accomplishments validated the attention focused on addressing the culture of the organization as the first priority. Quality, performance, and reducing cost were all achievable improvements when the culture promoted two key elements that came from transforming the organizational mindset. Table 1 CRDAMC Accomplishments and Recognitions 2017–2019 • Improved customer satisfaction from beneficiaries as measured in many areas and multiple survey instruments; most notably the Interactive Customer Evaluation system operated by the installation garrison • Achieved #1 in DoD for American College of Surgeons National Surgical Quality Improvement Program and #7 of 718 of nationally participating military and civilian hospitals • Recognized as the 2nd best DoD teaching facility by Uniformed Services University • 2019 Passed The Joint Commission Accreditation Survey with lower than expected findings from like-sized medical centers nationally (The Joint Commission) • 2019 EMS Lifeline Mission Silver Plus Award (American Heart Association) • 2018 and 2019 Top 25 Environmental Excellence Award (Practice Greenhealth) • 2018 Environmental Leadership Award (State of Texas Alliance for Recycling) • 2018 Gold Standard Accreditation (College of American Pathologists) • 2018 Army Safety and Occupational Health Star (The Army Safety Center) • 100% American Society for Clinical Pathology (ASCP) Pass Rate • Dean’s List of Institutional Training • Only DoD Facility to Earn Simulation Center 5-year Accreditation • Urology Top Service in DoD • West Killeen Medical Home Opened • The Bennett Clinic Remodeled • 120,000 Soldiers Processed for Deployment and Redeployment • Improved customer satisfaction from beneficiaries as measured in many areas and multiple survey instruments; most notably the Interactive Customer Evaluation system operated by the installation garrison • Achieved #1 in DoD for American College of Surgeons National Surgical Quality Improvement Program and #7 of 718 of nationally participating military and civilian hospitals • Recognized as the 2nd best DoD teaching facility by Uniformed Services University • 2019 Passed The Joint Commission Accreditation Survey with lower than expected findings from like-sized medical centers nationally (The Joint Commission) • 2019 EMS Lifeline Mission Silver Plus Award (American Heart Association) • 2018 and 2019 Top 25 Environmental Excellence Award (Practice Greenhealth) • 2018 Environmental Leadership Award (State of Texas Alliance for Recycling) • 2018 Gold Standard Accreditation (College of American Pathologists) • 2018 Army Safety and Occupational Health Star (The Army Safety Center) • 100% American Society for Clinical Pathology (ASCP) Pass Rate • Dean’s List of Institutional Training • Only DoD Facility to Earn Simulation Center 5-year Accreditation • Urology Top Service in DoD • West Killeen Medical Home Opened • The Bennett Clinic Remodeled • 120,000 Soldiers Processed for Deployment and Redeployment Open in new tab Table 1 CRDAMC Accomplishments and Recognitions 2017–2019 • Improved customer satisfaction from beneficiaries as measured in many areas and multiple survey instruments; most notably the Interactive Customer Evaluation system operated by the installation garrison • Achieved #1 in DoD for American College of Surgeons National Surgical Quality Improvement Program and #7 of 718 of nationally participating military and civilian hospitals • Recognized as the 2nd best DoD teaching facility by Uniformed Services University • 2019 Passed The Joint Commission Accreditation Survey with lower than expected findings from like-sized medical centers nationally (The Joint Commission) • 2019 EMS Lifeline Mission Silver Plus Award (American Heart Association) • 2018 and 2019 Top 25 Environmental Excellence Award (Practice Greenhealth) • 2018 Environmental Leadership Award (State of Texas Alliance for Recycling) • 2018 Gold Standard Accreditation (College of American Pathologists) • 2018 Army Safety and Occupational Health Star (The Army Safety Center) • 100% American Society for Clinical Pathology (ASCP) Pass Rate • Dean’s List of Institutional Training • Only DoD Facility to Earn Simulation Center 5-year Accreditation • Urology Top Service in DoD • West Killeen Medical Home Opened • The Bennett Clinic Remodeled • 120,000 Soldiers Processed for Deployment and Redeployment • Improved customer satisfaction from beneficiaries as measured in many areas and multiple survey instruments; most notably the Interactive Customer Evaluation system operated by the installation garrison • Achieved #1 in DoD for American College of Surgeons National Surgical Quality Improvement Program and #7 of 718 of nationally participating military and civilian hospitals • Recognized as the 2nd best DoD teaching facility by Uniformed Services University • 2019 Passed The Joint Commission Accreditation Survey with lower than expected findings from like-sized medical centers nationally (The Joint Commission) • 2019 EMS Lifeline Mission Silver Plus Award (American Heart Association) • 2018 and 2019 Top 25 Environmental Excellence Award (Practice Greenhealth) • 2018 Environmental Leadership Award (State of Texas Alliance for Recycling) • 2018 Gold Standard Accreditation (College of American Pathologists) • 2018 Army Safety and Occupational Health Star (The Army Safety Center) • 100% American Society for Clinical Pathology (ASCP) Pass Rate • Dean’s List of Institutional Training • Only DoD Facility to Earn Simulation Center 5-year Accreditation • Urology Top Service in DoD • West Killeen Medical Home Opened • The Bennett Clinic Remodeled • 120,000 Soldiers Processed for Deployment and Redeployment Open in new tab First of these was the development of people who held themselves accountable and did not need to be held accountable. Every leader wants to build high-performing teams and all high-performing teams are constructed of committed, high-performing team-members operating in learning environments. A favorite saying of mine is that “when it comes to a bacon and egg breakfast, the chicken is involved, but the pig is committed.” The point of this saying is that we need commitment over compliance, and commitment only comes from an environment that engenders trust and safety. Trust and commitment, the development of people who hold themselves accountable, are essential to high-performing teams and organizations. This is critically important in creating HRO qualities where employees must feel safe surfacing and reporting near-misses for mistakes that could lead to harm. We all want employees to feel safe in reporting preventable mistakes without fear of retribution. It is only when these concerns are shared that they can be addressed and communicated enterprise-wide to fully reduce the risk. Shifting the mindset of an organization, particularly starting with leadership, creates a true “servant leadership” culture, where those above see their work as helping those reporting to them to do their work, not holding them accountable for organizational metrics. This engenders the trust and commitment of those staff who are naturally committed to being valued for their work. Secondly, with an organizational transformation, staff see the value of listening and learning and truly cultivating the diversity of the organization. Henry David Thoreau is quoted as saying, “Could a greater miracle take place than for us to look through each other’s eyes for an instant?” His question is a powerful lesson in how to connect with others and how to “see” people as people. Plato was quoted as stating, “Be kind, for everyone you meet is fighting a harder battle.” Seeing others goes beyond being kind and trying to understand the many battles in others’ lives. Seeing someone as a person requires not just understanding or appreciating their point of view. Seeing someone as a person requires you to put yourself in their shoes, see the world through their eyes, based on their circumstances, and internalize their perspective. When you see their perspective, consider how you would think, feel, and act if you were them. If you arrive at that point, you will now have a broader, more diverse set of mental maps, models, frameworks, and perspectives to achieve a common understanding. Our perspectives are shaped by our background, training, experience, and mental models we reference on a given issue. This is referred to as cognitive bias and everyone brings a cognitive bias to the challenges they face. Although this bias can create obstacles, it also provides diversity of thought. When this diversity is embraced and leveraged, the results are clear—performance that leverages diversity is better.23 Understanding the impact of an inward or outward mindset unleashes this appreciation for the perspective of others and the additional knowledge or information that expands the alternatives and options to better address the challenges of the organization. THE ART OF EXECUTION: MINDING THE GAP Outward mindset training is only the first step to improving awareness and appreciation of one’s impact on others. The training provides insights, tools, and practices that enable people of all specialties and education levels to improve how they see themselves and others. The training does not serve as an inoculation to ensure empathetic tendencies, but rather initiates the beginning of a journey that helps consider what others may be thinking or experiencing. This journey experiences successes and failures, but when people commit to the practices individually, transformational change can be achieved in both their personal and professional lives. Practice is essential. We all have the standard preparation and frameworks. These are essential and critical elements in and part of the strategy for execution and performance achievement. An analogy to see where this is not enough is comparing the seed and soil. These frameworks and strategies are the seeds. Sometimes they grow well, sometimes they do not. When considering our preparation or the strategies we implement, it is like we are looking for the best seed. What this does not address is the soil. The soil is the culture that we cultivate and grow our results from. Our organization is only as good as all our people and the culture, the soil, we collectively operate in. The 3-step process to organizational transformation by shifting mindset, developing outward leaders, and then systematically shifting the standards processes and practices cultivates the diversity, engagement, and accountability of everyone in the organization. That soil then allows not only a seed to germinate but also becomes a fertile foundation for growth of many other seeds coming from the accountability of the people in our organization. We can only cultivate it by tending our own “gap,” our awareness that we may be contributing to the health or toxicity of the soil. When leadership eliminates the gap by seeing outwardly and truthfully, we initiate the process that fertilizes that soil. CONFLICT OF INTEREST The views expressed are solely those of the authors and do not reflect the official policy or position of the U.S. Army, U.S. Navy, U.S. Air Force, the Department of Defense, or the U.S. Government. Neither the author nor their family members have a financial interest in any commercial product, service, or organization mentioned in this article. REFERENCES 1. Army Learning Policy and Systems : TRADOC Regulation 350 – 70 , July 10, 2017 . Department of the Army . Available at https://adminpubs.tradoc.army.mil/regulations/TR350-70.pdf; accessed March 1, 2020 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 2. Army Handbook for Leadership Transitions . Department of the Army . Available at https://usacac.army.mil/sites/default/files/documents/cal/LeadershipTransition.pdf; accessed March 1, 2020 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 3. Defense Organizational Climate Survey . Defense Equal Opportunity Management Institute . Available at https://www.deocs.net/public/index.cfm; accessed March 1, 2020 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 4. U.S. Army Combat Readiness Center , Army Readiness Assessment Program . Available at https://arap.safety.army.mil/; accessed March 1, 2020 . 5. Gawande A . The Checklist Manifesto . New York , Metropolitan Books , 2009 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 6. Raman J , Leveson N, Samost AL, et al. : When a checklist is not enough: how to improve them and what else is needed . J Thorac Cardiovasc Surg 2016 ; 152 ( 2 ): 585 – 92 . Google Scholar Crossref Search ADS PubMed WorldCat 7. Chassin MR , Loeb JM: High-reliability health care: getting there from here . Milibank Q 2013 ; 91 ( 3 ): 459 – 90 . Google Scholar Crossref Search ADS WorldCat 8. Malish RG , Sargent P: High-reliability uncaged: safety lessons from army aviation . Mil Med 2019 ; 184 ( 3/4 ): 78 – 80 . Google Scholar Crossref Search ADS PubMed WorldCat 9. Wolf RW : Becoming a high reliability organization: Army medicine Foundation for Patient Safety . Army Med January 14, 2015 . Available at .https://www.army.mil/article/141122/becoming_a_high_reliability_organization_army_medicine_foundation_for_patient_safety accessed March 1, 2020 . Google Scholar OpenURL Placeholder Text WorldCat 10. Gentry WA , et al. The Challenges Leaders Face Around the World . Center for Creative Leadership . 2016 . Available at https://www.ccl.org/wp-content/uploads/2015/04/ChallengesLeadersFace.pdf; accessed on March 1, 2020 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 11. The Arbinger Institute : Mindset Assessment Illustrates Self-Deception Gap (New Data) . June 13, 2017 . Available at https://arbingerinstitute.com/BlogDetail?id=22; accessed March 1, 2020 . 12. Kim YH , Kwon H, Chiu CY: The better-than-average effect is observed because “average” is often construed as below-median ability . Front Psychol 2017 ; 8 : 898 . Available at . https://www.frontiersin.org/articles/10.3389/fpsyg.2017.00898/full#h10 accessed March 1, 2020 . Google Scholar Crossref Search ADS PubMed WorldCat 13. The Arbinger Institute : Our Approach . Available at https://arbingerinstitute.com/approach.html; accessed March 1, 2020 . 14. S. 2943 - National Defense Authorization Act for Fiscal Year 2017 . U.S. Congress . Available at https://www.congress.gov/bill/114th-congress/senate-bill/2943/text; accessed March 1, 2020 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 15. Watkins M . The First 90 Days: critical success stories for leaders at all levels . Boston , Harvard Business Review Press , 2013 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 16. Waterman RH , Peters TJ, Philips JR: Structure is not organization . Bus Horiz 1980 ; 23 ( 3 ): 14 – 26 . Google Scholar Crossref Search ADS WorldCat 17. Patient Administration Systems and Biostatistics Activity . U.S. Army Medical Department . Available at https://www.pasba.amedd.army.mil/History.html; accessed March 1, 2020 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 18. The Arbinger Institute . Developing and Implementing an Outward Mindset Workshop . Available at https://arbinger.com/Workshop/Publicdiom.html; accessed March 1, 2020 . 19. The Arbinger Institute : Arbinger Training Dramatically Improves Culture in Healthcare . Available at https://arbingerinstitute.com/registerWhitePaper.html?file=Whitepaper_Dramatically_Improving_Performance.pdf; accessed March 1, 2020 . 20. The Arbinger Institute . The Outward Mindset , Ed 2nd. San Francisco , Berrett-Koehler Publishers , 2019 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 21. Katzenbach JR , Steffen I, Kronley C: Cultural change that sticks . Harv Bus Rev, July-Aug, 2012. Available at: https://hbr.org/2012/07/cultural-change-that-sticks; accessed March 1, 2020. OpenURL Placeholder Text WorldCat 22. Gutberg J , Berta A: Understanding middle Manager’s influence in implementing patient safety culture . BMC Health Serv Res 2017 ; 17 : 582 PMID: 28830407 . Google Scholar Crossref Search ADS PubMed WorldCat 23. Simons SM , Rowland KN: Diversity and its impact on organizational performance: the influence of diversity constructions on expectations and outcomes . J Technol Manag Innov 2011 ; 6 ( 3 ): 171 – 83 . Google Scholar Crossref Search ADS WorldCat © Association of Military Surgeons of the United States 2020. All rights reserved. For permissions, please e-mail: [email protected]. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Hayden,, James;Huth,, Charles

doi: 10.1093/milmed/usaa125pmid: 32633325

ABSTRACT Bottom Line Up Front: Prison, for most incarcerated persons, can be a harsh and oftentimes dehumanizing environment. The U.S. criminal justice system has become more punitive than rehabilitative since the 1970s. In a reversal of this trend, newly passed legislation has charged prisons with preparing incarcerated persons for reentry into society, reducing recidivism, and providing rehabilitation programs targeting individual needs and risk. At the same time, prison staff delivering these services are faced with the challenge of burn-out, fatigue, depression, PTSD, suicide, and substance abuse at higher rates than individuals in other professions. To sustainably deliver the newly mandated prison-based services with an emphasis on the health and wellbeing of both the staff and the incarcerated population, prisons and the criminal justice system must change dramatically. The key to accomplishing this change is a foundational shift in mindset, from a self-focused “inward mindset” to an in impact-focused “outward mindset.” The purpose of this article is to hypothesize the potential for increased safety, security, and human wellbeing when a prison culture adopts an outward mindset. INTRODUCTION Prison reform movements have been observed since the Reconstruction era. Historically, prison reform has focused on reduction of cruel and unusual punishment, the rights of incarcerated persons and improved living conditions. The Reformatory movement in the early 20th century started an era rooted in the belief that incarcerated persons could be rehabilitated and returned to society as law-abiding citizens. Despite a shift in the 1970s in favor of a more punitive criminal justice system, recent analysis reveals that prisons have actually continued with rehabilitative efforts under the name of “reentry programs.”1 Reentry-based programs appear to garner public and policy maker support because of the emphasis on increasing public safety. Recent legislation, namely the First Step Act (FSA),2 has codified a requirement for prisons to provide reentry and self-improvement services for incarcerated persons. This law provides incentives for incarcerated persons to engage in rehabilitative programs to prepare them for release and decrease their risk of recidivism. Helping incarcerated people learn, grow, and make changes to improve their lives is the desired outcome of the FSA. Overall, these incentives and objectives should create a culture and environment that helps both the incarcerated and prison staff be healthier, happier, and collaborative. Yet, despite the desire for better outcomes, there continue to be many challenges for not only the incarcerated3 but also those responsible for their care, the corrections officers. Suicide, depression, and PTSD rates continue to be reported higher in correction officers than average.4 Similarly, mental health, substance abuse, and the rate of recidivism continue to be areas of concern for the incarcerated. Why are the efforts and changes in the corrections systems not producing the desired results? What may explain this is a framework that sees these efforts and changes as failing to address the foundational element that determines the impact of behavior: mindset. The Arbinger Institute uses the term “outward mindset” to describe a way of “seeing” others that is characterized by an awareness and curiosity to understand their challenges, objectives, and concerns (Fig. 1).5 Alternatively, it describes an “inward mindset” as a focus on one’s own goals, challenges, and objectives. An inward mindset sees others as “objects,” vehicles to help oneself, obstacles that get in the way of one’s own needs, or irrelevancies that have no impact at all. The key insight of this framework clarifies that behaviors, even if intended to be noble and helpful, can be done from either an inward mindset or an outward mindset. When done from an inward mindset, the behaviors tend to undermine their intended impact. Hence, strategies and efforts to improve the health of the incarcerated and corrections officers, without attending to the mindset that drives how those efforts are delivered, have failed to achieve the desired outcomes. To truly transform the health outcomes for the incarcerated and the corrections officers, a shift in mindset must first occur to better deliver on the design and implementation of wellintentioned reform initiatives for the health of all. FIGURE 1 Open in new tabDownload slide Seeing With an Inward Versus an Outward Mindset. FIGURE 1 Open in new tabDownload slide Seeing With an Inward Versus an Outward Mindset. THE INCARCERATION CULTURE Culture has been defined as a shared set of beliefs, assumptions, values, and attitudes, which are expressed, maintained and re-enforced through communication and actions within a group of people.6 Liebling has looked at prison cultures and found that the viewpoint of staff and their attitudes toward incarcerated persons has an influence on the prison’s moral climate.7 Further, Liebling and Price have concluded that the heart of prison work lies at the nexus of staff-prisoner relationships.8 These relationships create the possibility for equal relational and cultural influence. Analysis and definition of the staff culture in a prison setting is complicated by the obvious impact of the culture of the incarcerated population. By nature of the criminal behavior, thinking patterns, criminal values, criminal beliefs, and the often-pathological antisocial personalities of convicted felons, the incarcerated culture is inundated with criminogenic factors. The correctional officer faces the tide of the incarcerated person prison culture daily. Thus, the literature acknowledges that correctional officers develop camaraderie and an “us versus them” mindset to survive in the often-harsh incarceration cultural environment. Byrne and colleagues suggest that the nature of prison work often leads officers to exhibit qualities that are rigid, brash, macho, and suspicious.9 The authors describe the taking on of these characteristics as acculturation with the incarcerated person culture. Unfortunately, these confrontational characteristics undermine effective, safe, and secure delivery of human services in the correctional environment. The need to counter these negative, unhealthy, unsafe, and self-preserving dynamics in the prison environment is evident. Clearly, the potential for correctional staff to become influenced by the negative aspects of the incarcerated person culture can change the values and norms of staff culture. From a self-preservative, inward focused perspective, staff can become hardened in their work with incarcerated people, and the resulting cynicism permeates their relationships with each other. When operating from an inward mindset, a person can interpret the slightest perceived mistreatment or neglect as provocative and threatening, which can, in turn, invite defensiveness and blame. The Arbinger Institute labels this type of toxic interaction “collusion,” which can be understood as a semi-tacit collaboration between two or more persons or groups in which the participants behave in a matter that unwittingly invites the very mistreatment from others that they claim to resent (Fig. 2).10 The impact of this collusion and the culture of the prison community has a negative impact on not just the health of the incarcerated but also on the providers and staff of the prison community. FIGURE 2 Open in new tabDownload slide Collusion—Inviting the Blame We Claim to Resent. FIGURE 2 Open in new tabDownload slide Collusion—Inviting the Blame We Claim to Resent. EFFECT ON PRISON WORKERS Though studies have only been able to provide correlative evidence, the effect the prison environment and culture have on the correctional worker’s wellbeing is staggering. In a room with 100 randomly selected correctional officers, approximately 34 out of 100 will have Post-Traumatic Stress Disorder (PTSD).11 In comparison, the Centers for Disease Control (CDC) found PTSD rate for adults in the general population to be 3.5 percent.12 For male correctional officers, that rate was 35.8%. Like PTSD, in a room with 100 randomly selected correctional officers, approximately 31 out of 100 will be diagnosed with severe depression. The CDC found the depression rate for adults in the general population, with similar income, to be 3.5 percent.13 For the male correctional officer, it was 33.5%. Clinical concern exists that the comorbidity of PTSD and depression may increase the risk for suicide among correctional officers. THE CHANGE THAT NEEDS TO HAPPEN In large prisons, housing and caring for thousands of incarcerated persons is a monumental task. Thousands of meals are prepared and dispensed three times a day. Clothing must be provided, routinely laundered, and changed out because of seasonal requirements. Educational, occupational, recreational, and religious services programs must be offered. Health care and psychological services, routine and emergent, must be provided. In summary, prison work is delivery of human services. From ensuring incarcerated persons have enough toilet paper to maintaining their physical safety, communication and the maintenance of working relationships are key. The quality and nature of these working relationships are central to maintaining effective human service delivery systems. The safety and security of staff, the incarcerated population, and the public community are a chief concern when conducting this complex work. Providing these services and ensuring safety and security can be done with either an inward, self-focused mindset or an outward, others-aware mindset. The challenges of providing humane delivery of human services in a prison setting, while maintaining the health and wellbeing of staff and incarcerated persons are evident in a culture of mutually re-enforcing inward mindsets. Working to overcome these stark challenges requires significant change in the staff, incarcerated persons, and ultimately the prison culture. As stated in the Arbinger whitepaper, Resolving the Heart of Conflict, “When I choose to see people as objects, I become invested in seeing them poorly, which investment invites them to respond poorly to me, which mistreatment I then count as justification. I end up valuing problems more than solutions and conflict more than peace.”14 Unfortunately, the very nature, context, and setting of the prison environment and culture condone and support the continuance of this conflict dynamic, the “collusion” of an inward mindset where an individual is inviting the very response he or she claims she doesn’t want from the other person. Much of the challenge for staff in providing high quality, humane, and effective care of incarcerated persons, while maintaining their own wellbeing is self-generated. As noted earlier, the environment and the clientele present inherent invitations for staff to be focused on their own self-preservation and needs. This mindset, seeing the clientele and the environment as threatening or dangerous, invites the negativity and reinforcing behaviors from the incarcerated persons that staff do not want to have to contend with in the first place. Those who work in prisons and enforcement feel and hear the results of an inward mindset firsthand, from the histories and lives of the incarcerated population to the stories and views of the staff. The experiences and stories of everyone create a repository of reasons to blame, justify, and not see others as people first. As eloquently stated by Phillip Adams, the incarcerated brother of the current U.S. Public Health Service Surgeon General Jerome Adams, “Please see me as a person, same as you, and not a file number.”15 A staff member’s own inward mindset orientation, or not seeing others as people, creates a cycle of justification for that individual, which invites an inward mindset response from others. The effect is contagious. An incarcerated person does not merely respond to the behavior he or she experiences from a staff member; he or she responds to how they feel seen and valued by that staff person during an interaction. When an incarcerated person senses a staff member is regarding them as a person with intrinsic value and worth, he or she is more likely to reciprocate. Conversely, feeling unseen and devalued, an incarcerated person may leverage this perceived mistreatment at the hands of another as a rationalization for mistreating them in kind, which serves to perpetuate the cycle of blame and justification. This dynamic cycle becomes a trap leading to the building of inner, mental prisons for the people who work in the prison eight hours per day. The “mentally incarcerated” staff feel incapable of breaking free even though the metaphorical bars and cells of their negative and stressful emotions are completely self-generated. The bars of negativity and stress feel completely real and unchangeable. When this dynamic of inward thinking takes hold, the likelihood of staff burnout and a reduction in resiliency is increased. This can result in staff having less tolerance, patience, and concern for the incarcerated population when delivering services. This inevitably leads to the incarcerated population experiencing a general decrease in respect from and, subsequently, for the staff. In the end, neither group views the members of the other group as people. When this dynamic is prevalent, the potential for violence and manifold safety concerns increase. To break this cycle, a foundational shift in how prison staff and providers see the incarcerated is available in order to deliver human services in a way that is actually helpful to the incarcerated population and relieves the prison staff of their self-inducing stress and negativity. A shift to an outward mindset has the potential to increase safety and improve conditions. SHIFTING TO AN OUTWARD MINDSET Creating a culture of safety, a common theme in health care,16 is more likely to be achieved when built on an outward mindset foundation that establishes critical qualities of trust, transparency, and collaboration. The outward mindset shift has been successful in shifting culture in this way.17 Implementing an outward mindset in a prison environment may seem counterintuitive. Yet, the adoption of an outward mindset on the part of corrections and enforcement officers could lead to a reduction in violence, a decrease in the number of emergency responses, and an increase in staff safety. This type of result was realized in Kansas City, Missouri when a high-risk warrant service team collectively adopted an outward mindset.18 The team, once the most complained about unit in the agency, enjoyed a three-fold increase in productivity as measured by the standard metrics (weapons, currency, and drug seizures) while concurrently eliminating community-generated complaints and substantially reducing use of force incidents. High incidents of violence and emergency responses are known to contribute to a decrease in staff welfare.11 Reducing the frequency of these negative factors will likely improve the overall wellbeing of the staff. There are numerous low-risk opportunities for prison staff to begin to shift their mindset outward without concern for their immediate safety or need to be in a “self-preserving” mode. For example, a frequent complaint staff must respond to is when incarcerated persons complain of compatibility issues with their cell mates. This is often seen as just a way of complaining and creating a problem for the prison staff to have to deal with. Rather than seeing this as a problem and seeing the complainant as causing this problem, if the staff person could shift to seeing the incarcerated person as a person, this may create the space to truly listen to the concerns and better understand the complainant’s challenges. This true listening then becomes a collaborative relationship that allows work toward improving the living conditions of the individual.19 The shift to an outward mindset is what allows the “doing” of the listening to become effective. Incarcerated individuals are often powerless and rely upon staff assistance for phone calls, visits, appointments, jobs, education, health care, religious services, recreation, and psychology services. In each of these disciplines, the incarcerated person must work with staff to obtain desired services. When the staff in these disciplines view the incarcerated person as a person with needs, concerns, and goals, they are more likely to listen and try to understand the conditions that drive the incarcerated individual to act how they do. With this insight, it may then become easier to consider other ways to assist that are truly helpful as opposed to just complying with standard policies or procedures. Another example is in the impact of the discipline of the prison environment on the health of the incarcerated person. Incarcerated persons, like all people, experience health challenges. These are often compounded by the mental stressors of the prison environment.20 When a health care provider sees their patient as a person rather than just another “inmate,” the quality of the services and the interventions is likely to improve. Rather than a superficial effort to address the professed need of the patient, a conversation on underlying causes may become available. Subsequently, the patient and the provider may experience an increase in positive interaction and rapport, thus reducing stress for both. Finding ways to shift to an outward mindset is possible in a correctional environment even when faced with the most difficult scenarios. For example, when a staff member is confronted by an irate inmate, there is an instinct to try to control the behavior and eliminate the problem. This inward mindset generally results in the inmate escalating their behavior to try to get their perceived needs met. An outward mindset, conversely, would enable staff members to view the inmate as a person who is upset and apparently trying to solve a problem. This mindset helps the staff member to stay calm, stay engaged, listen, and attempt to de-escalate the situation. This helps shift collaboration toward a common goal, as usually neither the staff nor the inmate want the situation to escalate into an unsafe and dangerous scene. Among all these examples, a basic yet easy-to-overlook approach to help providers view incarcerated persons as people rather than an object, is to change the language and terminology we use when talking about or in addressing them. The labels “inmate” and “offender” immediately invoke a sense of “other” and can begin the inward mindset dynamic. From the incarcerated person perspective, the term “inmate” is viewed as a term of contempt.21 In this article, we have purposely chosen to utilize the terminology of incarcerated person or incarcerated individual. This terminology avoids the deprecating and stigmatizing label. It moves away from describing people as something other than a person. When put into practice, the use of this language may result in staff remembering the humanity of the incarcerated individual. This may result in the staff softening their approach to the people they serve. It also results in incarcerated persons experiencing others viewing them as a person, rather than as an object. The language we use often reinforces the views and beliefs we hold that ends up being a self-fulfilling prophesy of our justification for the way others view themselves. HELPING INDIVIDUALS AND INSTITUTIONS BY ENDING THE COLLUSION The shift to an outward mindset starts with awareness by the individual and the recognition that seeing others as objects is not only a false perception of reality (people are people) but is actually detrimental to oneself and the goals we often claim to be pursuing. The cultural shift of an organization toward an outward mindset can support the individual shift and can be accomplished efficiently and effectively when beginning from the top down. When the executive leadership of an organization adopts the mindset shift, it provides the foundation for organizational culture change that struggles to happen without them. As identified and encouraged to all leaders by W. Edwards Deming in his 14 Points for Management, “Adopt the new philosophy.”22 Unlike sloganistic and propaganda-based initiatives, shifting mindset requires personal change from an organization’s leaders. This change is experienced and observed by all staff surrounding these leaders. These staff model this change for those in their leadership circles, and those staff model this change for line staff. The line staff then model this change for the incarcerated population, with whom they have direct daily contact. This top-down approach has been proven to result in positive cultural change without even having to train all levels of the organization or staff.17 An outward mindset invites an outward mindset in others. Ultimately, the correctional organization may find that it needs to reassess its core values, objectives, and mission statement to incorporate the concept of shifting mindset. As Deming also noted, “Eliminate slogans, exhortations and targets for the workforce.”22 As noted, safety and security are job one for everyone within the correctional environment. However, the stated values and beliefs concerning how to achieve this objective, “the slogans and exhortations,” may benefit instead by incorporating and promoting person-focused, outward mindset human relationships and connectivity as a means to achieve the overarching objective of safety. More than just words in a document or posted on a wall, core values and mission statements only become actualized when those trying to achieve them see the people these values and objectives are oriented toward. Only by incorporating an outward mindset as the foundation that drives the behaviors and activities of the human service delivery efforts in the prison environment will a healthier culture and outcomes be achieved for both the staff and the incarcerated. Demonstrating the correlation between an outward mindset and an increase in staff wellbeing in prison continues to be an area ripe for research. With few exceptions, the lives and wellbeing of correctional officers have been excluded from academic research and are absent from policy discussions about correctional programs and reform.23 It is welldocumented, however, that when people begin to see one another as people and work together, rather than against each other, positive outcomes are achieved.24 Knowing that shifting to an outward mindset is achievable for individuals, groups, and organizations provides hope for change even in prison and the correctional culture where we continue to struggle with improving the health, safety, and wellbeing of all. The views expressed are solely those of the authors and do not reflect the official policy or position of the Bureau of Prisons, the Kansas City Police Department, The Department of Justice, or the US Government. Neither the authors nor their family members have a financial interest in any commercial product, service, or organization mentioned in this article. REFERENCES 1. Phelps MS : Rehabilitation in the punitive era: the gap between rhetoric and reality in U.S. prison programs . Law Soc Rev 2011 ; 45 : 33 – 68 . Google Scholar Crossref Search ADS PubMed WorldCat 2. Public Law 115-391, First Step Act . United States Government Publishing Office , 2018 . Available at https://uslaw.link/citation/us-law/public/115/391; accessed March 1, 2020. 3. Massoglia M , Pridemore WA: Incarceration and health . Annu Rev Sociol 2015 ; 41 : 291 – 310 . Google Scholar Crossref Search ADS PubMed WorldCat 4. Lerman A. Officer Health and Wellness: results from the California correctional officer survey . Goldman School of Public Policy , UC-Berkley . Nov 2017 . Available at: https://gspp.berkeley.edu/research/selected-publications/officer-health-and-wellness-results-from-the-california-correctional-office; accessed March 1, 2020 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 5. The Arbinger Institute . The Outward Mindset , Ed 2nd. San Francisco , Berrett-Koehler , 2018 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 6. Schein EH . Organizational Culture and Leadership , Ed 3rd. San Francisco , Jossey-Bass Publishers , 2004 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 7. Leibling A . Prisons and their Moral Performance: a study of values, quality and prison life . New York , Oxford University Press , 2004 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 8. Leibling A , Price D. The Prison Officer . Prison Service Journal , Leyhill , 2001 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 9. Byrne J , Hummer D, Taxman FS. The Culture of Prison Violence . Boston , Allyn and Bacon , 2008 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 10. The Arbinger Institute . Leadership and Self-deception , Ed 3rd. San Francisco , Berrett-Koehler , 2018 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 11. Denhof M , Spinaris C: Depression, PTSD and comorbidity in United States corrections professionals: prevalence and impact on health and functioning . National Institute for Corrections 2013 . Available at . https://nicic.gov/depression-ptsd-and-comorbidity-united-states-corrections-professionals-prevalence-and-impact-health accessed March 1, 2020 . Google Scholar OpenURL Placeholder Text WorldCat 12. Jaimie L. Gradus. Epidemiology of PTSD . Available at https://www.ptsd.va.gov/professional/treat/essentials/epidemiology.asp; accessed March 1, 2020 . 13. Debra J Brody, Laura A Pratt, Jeffery P Hughes. Prevalence of Depression Among Adults Aged 20 and Over: United States , 2013-2016 . Available at https://www.cdc.gov/nchs/products/databriefs/db303.htm; accessed March 1, 2020 . 14. Ferrell J. Resolving the Heart of Conflict . The Arbinger Institute Whitepaper , Available at https://arbinger.com/registerWhitePaper.html?file=Whitepaper_Resolving_The_Heart_of_Conflict.pdf; accessed March 1, 2020 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 15. Joseph A : The surgeon general and his brother: a family’s painful reckoning with addiction . STAT 2017 . Available at . https://www.statnews.com/2017/12/07/surgeon-general-and-his-brother/; accessed on March 1, 2020 . Google Scholar OpenURL Placeholder Text WorldCat 16. Weaver SJ , Lubomksi LH, Wilson RF, Pfoh ER, Martinez KA, Dy SM: Promoting a culture of safety as a patient safety strategy: a systematic review . Ann Intern Med 2013 ; 158 : 369 – 74 . Google Scholar Crossref Search ADS PubMed WorldCat 17. The Arbinger Institute . Arbinger Training Dramatically Improves Culture in Healthcare . Available at https://arbinger.com/registerWhitePaper.html?file=Whitepaper_Dramatically_Improving_Performance.pdf; accessed March 1, 2020 . 18. The Arbinger Institute . Averting a Collective Bargaining Conflict and Transforming Leadership - Kansas City Police Department Case Study . Available at https://arbinger.com/caseKCPD.html ; accessed March 1, 2020 . 19. Zenger J , Folkman J. What Great Listeners Actually Do . Harvard Business Review . 2016 . Available at https://hbr.org/2016/07/what-great-listeners-actually-do; accessed March 1, 2020 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 20. Massoglia M , Pridemore WA: Incarceration and health . Annu Rev Sociol 2015 ; 41 : 291 – 310 . Google Scholar Crossref Search ADS PubMed WorldCat 21. Hickman B. Inmate. Prisoner. Other. Discussed. The Marshall Project , 2015 . Available at https://www.themarshallproject.org/2015/04/03/inmate-prisoner-other-discussed; accessed March 1, 2020 . 22. Deming WE . Out of the Crisis . Boston , MIT Press , 2000 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 23. Brower J . Correctional Officer Wellness and Safety Literature Review . Washington, DC , US Dept of Justice. Office of Justice Programs Diagnostic Center , 2013 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 24. White K . The Shift: how seeing people as people changes everything . San Francisco , Berrett-Koehler Publishers , 2018 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC © The Author(s) 2020. Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States. All rights reserved. For permissions, please e-mail: [email protected]. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Otocki, Austin C; Turner, Brian F

doi: 10.1093/milmed/usaa134pmid: 32602551

Abstract In most organizations, middle managers are expected to meet goals and expectations passed down from above while also connecting with and inspiring the frontline employees doing the work of the organization. Caught in the middle, they often receive training on competencies intended to help them manage issues that arise from this situation. Yet this training tends to be temporarily helpful at best—and harmful at worst. Competency training, because it focuses on changing behavior, fails to address a foundational element necessary to consistently and effectively resolve their challenges. That foundational element is mindset. Providing training and tools to shift their mindset regarding their management objectives better prepares mid-level leaders to be more effective in their challenging positions. MIDDLE MANAGERS HAVE IT HARDEST Middle managers bear the brunt of organizational challenges, pinned between management goals such as performance metrics, and the responsibility to integrate the organization’s human “resources” into those performance metrics. In a typical hierarchical structure, these mid-level leaders are expected to interpret the prescribed strategies passed down from their supervisors and implement those strategies with the direct reports working beneath them. The traditional military hierarchal management and command system expects two different behavioral modalities. By nature of their roles, middle managers are the leaders of some and followers of others. When interacting with direct reports, they are expected to adopt a more assertive behavioral style, but when interacting with supervisors, they may adopt a more deferential behavioral style. “Failure to conform to these role-based expectations can lead to social conflicts and confusion”; however, it is “psychologically challenging to disengage from a task that requires one mindset and engage in another task that requires a very different mindset.”1 This back and forth role switching may disrupt cognitive performance or lead to increased stress and anxiety. The complexity of healthcare delivery adds to the burdens of middle managers.2 Within the typical matrix system of military medicine, middle managers often find themselves stuck between a complex rank structure and conflicting guidance, adding to their managerial burdens. Additional challenges for middle managers may include a siloed command structure that creates barriers to collaboration across departments, directives for process, and safety improvements that fail to address the collaborative nature of these initiatives, and a performance evaluation system that focuses on individual “accountability” that does not consider the actual impact on others, particularly patients and colleagues, in the healthcare system. For these reasons, it is critical to understand and ease the burdens of these essential mid-organization workers. HOW THE SYSTEM TRIES TO HELP The Army strives to foster a culture of continuous learning in hopes of transforming young soldiers and officers into professionals. This is accomplished through “training” focused on teaching and instilling the correct behaviors that demonstrate competence in the situations they frequently encounter in their day to day challenges. Mid-level Army officers are expected to acquire many technical and professional skills in their continuous growth.3 At this point in their career, the mid-level leader will have typically completed multiple professional development programs focused on personal and professional growth, work efficiency and lean processes, equal opportunity (EO) and sexual harassment awareness, and soldier warrior tasks and drills. In FY18 the Department of Defense spent nearly $9.4 billion on training-related costs and increased their budget request for FY20 to over $10.1 billion.4 This represents a tremendous investment and commitment to improving the human performance factor of military and health efforts. NECESSARY, BUT NOT SUFFICIENT Most training and education programs tend to focus on conveying and demonstrating “correct” behavior for the various challenges and issues that arise when leading people. Nevertheless, problems with conflict and collaboration continue to arise and persist despite this investment to address “people” problems. There is a big assumption that effective implementation follows once education and training is completed. Experience over and over suggests this assumption is fundamentally wrong. Both the leadership and medical training literature identify this deficiency in the education process.5,6 The impact of a behavior is not just in the doing; it is in the how and why the behavior is performed in relation to the person or patient it is expected to help. Education and training fall short when they become the standard of performance for an individual. Without instilling the awareness and accountability for impact in the individual, the team, or the unit, the training system that focuses on education and then “holding accountable” after the fact fails to resolve underlying conflict. Worse, it relegates additional time and resources to investigate and identify new corrective actions. WHAT MORE IS NEEDED: MINDSET DRIVES BEHAVIOR There is a very clear explanation for why behavioral modification is not as effective as desired: behaviors are driven by an underlying mindset. Carol Dweck first addressed “mindset” in her book in 2006. Dweck’s research approached the idea of two mindsets from the lens of growth and development. Dweck found that “with a fixed mindset, there are feelings of powerlessness and learned helplessness.”7 Over time, these thoughts can lead to the development of a self-defeating identity and may discourage people from growing and acting. Contrary to a fixed mindset, a growth mindset is likely to “encourage people to develop feelings of empowerment – people begin to see how they might take action to positively influence their community and their learning.” Along with Dweck there has been a surge in the “mindset” movement, with many other contemporary concepts of what it is.8,9,10,11 Typically, these concepts offer various assessments to help identify the “mindset” of an individual in attempts to classify one’s underlying worldview or belief system.12 The typical “mindset” approach starts with a personality or preference styles “assessment” that provides some process for classifying one’s perspective, strengths, or beliefs. Once armed with this knowledge and awareness, the theory is that one is better prepared to engage with others to improve collaboration and outcomes. However, in most cases, these assessments simply become a way to justify one’s approach to others. Rather than improving collaboration, they become a barrier, a justification, for why others are to blame for the conflict.13 A different approach to “mindset” is described by the Arbinger Institute: rather than looking at mindset as a belief or established set of attitudes, it identifies mindset as a way of “seeing” others. More specifically, “It is the lens through which we see our work, our relationships, and our world. It is at the foundation of all that we do and shapes how we do it.”14 This approach to mindset is unique because of the critical fact that actions and behaviors do not occur in a vacuum; all goals, challenges, and needs occur in relation to others. Additionally, there is always a choice in how one chooses to see others. On one hand, one can choose to see others as “objects”—this framework refers to this as an “inward” mindset, where concern is largely focused on one’s own personal behaviors and needs. On the other hand, we can choose to see others as “people,” or act with an “outward” mindset, being attuned to how one’s behavior can have a helpful or hurtful impact on others. “Without a change in mindset, newly adopted behaviors will not stick, and results will suffer. Organizations that foster the right foundational mindset are able to ensure that employees sustainably adopt those behaviors that drive the desired results.”15 The same behavior performed from an objective-focused outward mindset will greatly differ in results from one performed by a self-focused inward mindset. This distinction is critical and can be detrimental to an organization if overlooked. The outward mindset approach differs by identifying the dynamic, moment-by-moment choice that exists in all relationships, helping remove blame, and judgment for a situation with honest clarity that differences between people exist. Rather than attribute justification when seeing objects from an inward mindset, the outward mindset approach of inviting oneself to “see others” leads to a sense of curiosity and seeking of understanding. This changes everything in the way one then approaches differences, creating time and space for other options and solutions. AN EXAMPLE OF THE TYPICAL MIDDLE MANAGEMENT CHALLENGE IN THE MILITARY Without addressing the underlying mindset, implementing new training as a solution to a problem will not likely have the desired, lasting results. Training to “check a box” will certainly not get the right result no matter how intensive and resource-draining the training effort may be. A situation at a small duty station several years ago highlights this issue. In early 2011, there was a heavy focus on EO and combatting discrimination within the ranks. In attempts to tackle the problem, the unit put together an active campaign of messaging and training: all soldiers were sent through a two-hour EO refresher where they learned the legal definitions of words like “discrimination” and “bullying,” and then were drilled with up-to-date reporting procedures. Soldiers also learned about the Army’s campaign plan and the recommended ways to address EO issues in the workplace. After three months of twice-weekly training sessions, the entire unit was marked “complete.” From the military plan’s perspective, 100% of the soldiers were trained and the mission was a success. Never-the-less, one month following the training, an EO altercation and soldier-on-soldier dispute arose. An investigation of this incident identified the following: (1) At the installation coffee shop, a soldier made inappropriate comments and gestures toward another member in his unit. While attempting to break away from the environment, the offended soldier was pushed into a wall as he left the premises. The incident was reported later that day by one of the other patrons who witnessed the event. All soldiers involved in the dispute and present at the time had received the two-hour EO workshop the month prior. (2) The soldiers involved could correctly define the terms used in the training and understood why the actions during the incident were wrong. (3) No witnesses stepped up to stop the escalating exchange of offensive comments despite knowing the steps to do so. The EO workshops were successful in educating soldiers, but they failed to tackle the root cause of the problem—these workshops did not address the underlying mindset that drives behavior. When we discriminate against others, we are not seeing them as people, and we are placing our needs, objectives, and goals above those we discriminate against. Educating soldiers on how they should treat others will not have lasting effects unless we help them change the way they see others. ANOTHER WAY: ARMY MEDICAL EDUCATION AND DEVELOPMENT DEPARTMENT (AMEDD) SHIFTING ORGANIZATIONAL MINDSET Since 2012, the AMEDD Training and Organizational Development Branch has contracted training addressing mindset awareness development both individually and organizationally. Since 2016, the Self-Awareness Training, Executive Coaching, and Supplies contract (W81K04-16-D-0035) has developed over 635 trainers within AMEDD to deliver a foundational two-day outward mindset self-awareness workshop followed by additional sustainment and implementation materials to ~33,000 people across the AMEDD at over 41 different facilities, including 8 of the 9 AMEDD tertiary care medical centers. A Georgetown and Cornell University study conducted at one of these facilities found that this mindset awareness training increased employee cooperation and collaboration by 12% and increased employee personal investment in their work by 11%.16 On top of the primary participant results, the study also found that untrained employees working in the same facility felt more psychologically safe, more empowered, and were more focused on how they impacted others. Over the same time period, the “outward” focused facility saw more than a 30% increase in the percentage of their patients giving the hospital an overall rating of 9 or 10 (of 10) compared to only a 4% of near-pear facilities, while it also saw a 21% increase in the percentage of patients recommending the hospital compared to just a 3% increase for near-pear facilities. This study demonstrates that outward mindset principles can shift the culture of an organization in a way that delivers on the outcomes and impact most important to senior leadership—the overall performance of the organization in improving patient outcomes. This shift in mindset has been helpful to middle managers in two examples we can share. HOW SHIFTING MINDSET OF MIDDLE MANAGERS HELPS IMPROVE HEALTHCARE AND HEALTH The healthcare industry faces a similar challenge as the military management, example cited above, as process improvement is largely centered on behavior regarding patient safety, quality, and care issues. Military medicine has had a goal to become a High-Reliability Organization (HRO) for more than a decade. As organizations strive to become HROs, there are 5 principles they focus on: (1) addressing failures immediately and completely, (2) finding complex solutions for complex problems through data analytics and root cause analysis, (3) remaining sensitive to operations by listening to every voice, (4) being resilient and recovering swiftly, and (5) encouraging deference to expertise.17 As with most strategic frameworks for organizational improvement, these principles are behavior based and as such, by the outward mindset framework, are dependent on underlying mindset. Organizations will not become an HRO by simply “checking the box” on training or instilling procedures to achieve the patient outcome goals if they do not address the underlying mindset of their people. Within an organization, each department, each team, and even each individual may have competing responsibilities regarding their commitment to patients, which makes it easy to lose sight of their impact on other departments and services. When one of our hospitals recently opened, our pharmacy department found themselves in a shared space with the laboratory. Concerned about providing a comfortable environment for the patients, a Staff Sergeant (middle manager) responsible for the management of the pharmacy organized the waiting room chairs to face the pharmacy counters. FIGURE 1 Open in new tabDownload slide The cycle of collusion between departments—instigating what we claim to resent. Step 1: I see someone I blame for creating a problem for me. Step 2: I do something even if done “to be helpful” that carries my blame, toward them. Step 3: they see me treating them as an object. Step 4: they respond in a way that, even if done “to be helpful” carries blame. Toward me for treating them as an object. Step 5: I gather allies to help me in my blame of the other. Step 6: that person does the same. The cycle of blaming is consistently perpetuated between two people and two groups in collusion, blaming the other for blaming them. The next morning, an administrative assistant from the laboratory noticed the new waiting room layout and promptly resituated the chairs to meet the needs of patients waiting on labs. The following day, the pharmacy rearranged the chairs, and this cycle continued day after day. Along with the time cost associated with rearranging the chairs each morning, there were additional costs to this negative cycle of behaviors. The following are some of the negative outcomes that were building within the departments. (1) The departments began disparagingly talking about each other. They made comments like, “this is what pharmacy tried to do today…” , sometimes in the presence of patients. (2) The behaviors began to escalate beyond the simple rearrangement of chairs: “Oh yeah, you’re going to do that?! Well we’re going to do this…” (3) Supervisors were called into the situation, taking their time away from department needs and patient care. (4) These behaviors halted collaboration between the departments and inevitably led to behaviors that were no longer focused on patients’ needs and were solely focused fulfilling the grudges held by the staff involved. “Instead of being the proponent for the patient, they began to be the defender of the department.” (5) Lastly, patient experience and satisfaction were negatively affected within both departments. What initially started as a sincere concern for the wellbeing of patients quickly transformed into a cycle of self-satisfying behaviors without patients’ needs being addressed. These departments were spending hours each day literally moving chairs, creating more work for both teams, and confusing patients in the process. Mindsets matter and ultimately drives the success or failure of behaviors. A single primary care visit to a hospital may involve over a dozen patient touchpoints, all of which are opportunities to improve the impact of patient care. Most of these touchpoints are with nonclinical staff, but most initiatives to improve outcomes look toward the providers for solutions, placing the burden of the outcome on them. It is essential that all staff members embody the HRO principles through an outward mindset since every employee, not just the provider staff, either touches a patient, or enables those that do. After weeks of this chair rearrangement cycle continuing, one of the laboratory managers had the opportunity to attend two-day “Developing and Implementing an Outward Mindset” workshop.18 It was in this workshop that she finally recognized the self-fulfilling cycle of behaviors that one department was instigating and the other was reciprocating. She and her team realized that they had to break the cycle. (Fig. 1) In order to do so, they applied a tool from the workshop, the “SAM” model, to their situation—see others, adjust efforts, and measure impact. This initiative set the conditions for a collaborative meeting. The result was hearing the needs of each department and working together to find a solution that met the patients’ needs as well as the needs of both the pharmacy and the laboratory. The teams even took the solution one step further by addressing the concerns of facilities, safety, health insurance portability and accountability act, infection control, and the frontline staff. Once the underlying mindset was shifted outward, the two departments were able to both stop the spiral of negative behavior and simultaneously address other patient needs. The outcome was a decrease in interactive customer evaluation complaints across both departments, an increase in the amount of time devoted to patient care, and an increase in customer satisfaction leading the pharmacy to be one of the highest rated in their region. This example demonstrates the role of organizational mindset, not just of providers, that impacts the patient experience and outcomes. A second example is the impact mindset awareness has for “informal” middle managers. At many healthcare institutions, advanced practice providers (APPS) are delegated responsibility for coordinating patient care within a team while often having informal management authority in relation to the other members of those teams. At Brooke Army Medical Center (BAMC), the Department of Defense’s largest and only Level 1 Trauma and Quaternary Medical Center, there was an alarming turnover rate of the APPs. Surgical services at BAMC was comprised of 8 department teams each with their own leaders and staffs of interdisciplinary healthcare professionals separated by silos created not only by the traditional medical hierarchy but also complicated by those within the military. Although there are mutual goals between the individual departments, the efforts to achieve those goals as a coordinated team were being met with limited success. This threatened the facility’s trauma designation and compounded already tense relationships between neurosurgery and the rest of the facility. The APPs bore the brunt of the stress in coordinating across the surgical services teams and were leaving at an alarming rate, impacting both the quantity, quality, and safety of BAMC’s surgical operations. An intensive rollout of the outward mindset material with the APPs resulted in an immediate benefit. The service became fully staffed within two months, with all current APPs renewing their service agreements while patient safety reports because of poor or no communication decreased by >42% within that time. Shifting mindset helped create a focus for these middle managers on clarifying the impact of their efforts and better identifying what they could control or influence and how they could be more helpful and effective in their relationships. The impact on their morale and ability to improve performance within this challenging condition appeared directly tied to their ability to focus beyond their daily tasks and more on the impact of their relationships within and among the surgical services staff by shifting outward in their mindsets. WHY UNDERSTANDING MINDSET HELPS MIDDLE MANAGEMENT Providing mid-level leaders with this foundational understanding of mindset is essential to enable greater collaboration and effectiveness of all the process improvement and performance development initiatives and efforts in the military and military health. There are multiple ways in which this material addresses challenges of mid-level leaders: (1) First and foremost, it helps remind every leader that in every moment they have a choice in how they see those above them in the military or hospital hierarchy or those reporting to them. This reminder of control is the key to empowerment, resilience, and agility irrespective of how direct the behavior order or requirement may be from above or what is needed below. There is always this choice and empowerment that drives how they will respond. (2) Mindset reframes the work of the leader beyond their to-do list. Instead of holding people accountable, the work of the middle manager is to develop accountable people. Instead of just getting their own to-do lists done, it reframes their work objective to be getting it done in a way that helps others. Again, the behavioral requirement may be clear, but the freedom to achieve that in a way that better impacts others provides awareness of one’s own choice and greater understanding of others, connecting mid-career leaders in their direct relationships better. (3) Because impact on others becomes a greater focus when operating from an outward mindset, lateral engagement across departments and silos becomes essential for the work of the mid-career leader (Fig. 2). Seeking understanding of the needs, challenges and goals of other department leaders now becomes a routine process for understanding the intent and impact of requirements or metrics from above, thus improving the likelihood those objectives will be effectively addressed. (4) Performance management is routinely recognized as unhelpful.19 In most cases, they typically invite an inward mindset by focusing on individual’s goals and achievements in a way that is independent of the impact on others. Providing awareness of the choice to achieve individual objectives in a way that is more helpful to others helps reduce the collusion most performance management creates. Shifting to an outward mindset empowers greater proactivity and accountability in the mid-level leader, enhancing the awareness and alignment to be effective leaders and not just managers of the people resource, “objects,” they have. FIGURE 2 Open in new tabDownload slide Seeing my impact on others, not just my outputs, the inside triangles represent my goals, responsibilities and activities, my “work.” The “outside triangles” represent the needs, objectives and challenges of those I am working with. Shifting outward means performing my work in a way that actually helps those I am working with achieve their needs, objectives, and challenges, and not just in a way that I think or hope I am helping, ie, according to my “job” description. Being helpful cannot be a formulaic process or activity done without awareness of impact on others; it must be done with understanding and awareness of other’s needs. When mid-level leaders are empowered and engaged in shifting their own mindset, the improvements in culture and morale create a work environment that engenders commitment and teamwork. Empowering all staff, from the front door greeters to our nurses and physicians, with the awareness of their mindset choice improves engagement in daily operations and greater collaboration and resilience. A nursing leadership study on work engagement and burnout found that “engaged professional nurses and empowering nurse managers are critical to preserving the quality of our healthcare delivery system.”20 A separate study by the Department of Healthcare Management at Hacettepe University in Turkey found that “similar to improving physical health with medical treatments, healthcare providers and their patients are now also working together to improve quality of life by changing thoughts and attitudes, and boosting emotions.”21 The practice of medicine is evolving to better incorporate mindset awareness and seeing patients as both people and active participants of their healthcare is the way ahead. Helping mid-level leaders gain this awareness and ability to see how they can shift their focus on the impact of their efforts helps improve everything. Expanding access and integration of the outward mindset materials across the military health system should be prioritized to improve the impact and effectiveness of all our current training, development, and process improvement efforts. The views expressed are solely those of the authors and do not reflect the official policy or position of the US Army, US Navy, US Air Force, the Department of Defense, or the US Government. Neither the authors nor their family members have a financial interest in any commercial product, service, or organization mentioned in this article. References 1. Anicich EM , Hirsh JB: Why being a middle manager is so exhausting . Harv Bus Rev 2017 ; 2 – 5 . Google Scholar OpenURL Placeholder Text WorldCat 2. Embertson MK : The importance of middle managers in healthcare organizations . J Healthc Manag 2006 ; 51 ( 4 ): 223 – 32 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 3. Commissioned Officer Professional Development and Career Management. Department of the Army . 2014 . Available at https://api.army.mil/e2/c/downloads/376665.pdf; accessed March 1, 2020 . 4. Operation and Maintenance Overview Fiscal Year 2020 Budget Estimates. Office of the Under Secretary of Defense Chief Financial Officer . Digital Report , 2019 . Available at https://comptroller.defense.gov/Portals/45/Documents/defbudget/fy2020/fy2020_OM_Overview.pdf; accessed March 1, 2020 . 5. Beer M , Finnstrom M, Schrader D: Why leadership training fails—and what to do about it . Harv Bus Rev 2016 ; 94 (10): 50 – 7 . Google Scholar OpenURL Placeholder Text WorldCat 6. Yazdani S , Momeni S, Afshar L, Abdolmaleki M: A comprehensive model of hidden curriculum management in medical education . J Adv Med Educ Prof 2019 ; 7 ( 3 ): 123 – 30 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 7. Dweck C : Carol Dweck revisits the growth mindset . Educ Week 2015 ; 35 ( 5 ): 20 – 4 . Google Scholar OpenURL Placeholder Text WorldCat 8. Sinek S . The Infinite Game . London , Portfolio/Penguin , 2019 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 9. Cernovich M . Gorilla Mindset . Scotts Valley, CA , CreateSpace , 2015 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 10. Schnurman D . The Fast Forward Mindset . Jersey City , Highpoint Executive Publishing , 2019 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 11. Couros G . The Innovator’s Mindset: empower learning, unleash talent, and lead a culture of creativity . San Diego , Dave Burgess Consulting, Inc , 2015 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 12. Reed BN , Klutts AM, Mattingly TJ 2nd.: A systematic review of leadership definitions, competencies, and assessment methods in pharmacy education . Am J Pharm Educ 2019 ; 83 ( 9 ): 7520 . Google Scholar Crossref Search ADS PubMed WorldCat 13. Berger JG , Achi ZG: Understanding the Leader’s ‘identity Mindtrap’: personal growth for the C-suite . Mckinsey Quarterly 2020 . 14. The Arbinger Institute . Mindset and the Basics of Arbinger’s Work , 2017 . Available at https://arbingerinstitute.com/BlogDetail?id=48; accessed March 1, 2020 . 15. The Arbinger Institute , "Difference: The Arbinger Institute," 2019 . Available at https://arbinger.com/difference.html; accessed March 1, 2020 . 16. The Arbinger Institute . Research Results: arbinger training dramatically improves culture in healthcare . Arbinger Properties/LLC , Salt Lake City , 2019 . Available at https://arbinger.com/whitepapers.html; accessed March 1, 2020 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 17. Chassin MR , Loeb JM: High-reliability health care: getting there from here . Milbank Q 2013 ; 91 ( 3 ): 459 – 90 . Google Scholar Crossref Search ADS PubMed WorldCat 18. The Arbinger Institute . Developing and implementing an outward mindset . Available at https://arbingerinstitute.com/Workshop/Publicdiom.html; accessed March 1, 2020 . 19. Aguinis H , Joo H, Gottfredson RK: Why we hate performance management—and why we should love it . Bus Horiz 2011 ; 54 ( 6 ): 503 – 7 . Google Scholar Crossref Search ADS WorldCat 20. Greco P , Laschinger HK, Wong C: Leader empowering behaviours, staff nurse empowement and work engagement/burnout . Nurs Leadersh 2006 ; 19 ( 4 ): 41 – 56 2006 . Google Scholar Crossref Search ADS WorldCat 21. Top M , Dikmetas E: Quality of life and attitudes to aging in Turkish older adults at old people's homes . Health Expect 2015 ; 18 ( 2 ): 288 – 300 . Google Scholar Crossref Search ADS PubMed WorldCat Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2020. This work is written by (a) US Government employee(s) and is in the public domain in the US. This work is written by US Government employees and is in the public domain in the US. Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2020. This work is written by (a) US Government employee(s) and is in the public domain in the US.

Linde,, Sarah

doi: 10.1093/milmed/usaa135pmid: 32728732

ABSTRACT Today’s healthcare environment is predictably unpredictable and increasingly complex, thus challenging the intellectual, emotional, physical, and spiritual limits in all of us, and resulting in real consequences such as provider turnover, burnout, shortages, and poor patient health outcomes. Strengthening our resilience results in part from reclaiming hold on our most powerful gift, the ability to choose how we see things. Identifying and shifting our mindset, and especially to an outward mindset in which we clearly see and connect with others around us, will restore the healing in healthcare. LAY OF THE LAND—THE VUCA WORLD Healthcare today is a chaotic conglomeration of practices, payment, people, and pandemics. Advances in science, communication, technology, informatics, and other fields outpace a single brain’s ability to master older bodies of knowledge before new ones emerge. Conflicting standard practice guidelines issued by professional organizations, electronic health record implementation, insurance eligibility and enrollment, marketplaces, navigators, networks, premiums, co-pays, deductibles, approvals, referrals, billing and reimbursements, essential health benefits, non-covered services, separate coverage for vision or dental needs, the alphabet soup of acronyms to include Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), Independent Practice Association (IPA), and Value Based Care (VBC) contribute to the chaotic mix.1 Personal protective equipment, testing, social distancing, telehealth reimbursement, politics interfering with public health, ethical dilemmas, unemployment, and many other issues related to the emergence of COVID-19 in our lives have created even more challenges. An environment of volatility (V), uncertainty (U), complexity (C), ambiguity (A), or VUCA for short. Healthcare is undeniably a VUCA environment. Is it any surprise providers are overwhelmed, stressed, exhausted, and burning out?2 Is it any wonder patients may not be experiencing optimum health?3 In the VUCA healthcare environment, we may feel a loss of control, discouraged by our inabilities to overcome obstacles, resentment toward the forces that are preventing us from achieving our true potential, resignation that we are stuck in the status quo or anxious about what lurks around the next professional corner. From this perspective, it is easy to identify things that must change in the system or by others for things to improve. If only the government, patients, staff, office manager, department chair, CEO, board of directors, insurers, or numerous others would—fill in any activity—then, we could think, feel, or act differently, see more patients, get work done more efficiently, leave work earlier, have more time to spend with family, take better care of ourselves, feel more safety, security, peace, and joy in our lives. We may not be able to simplify, change, or escape the VUCA environment in which we live and work. How then, as individuals, can we reclaim the healing part of healthcare, build resilience in ourselves as providers, and improve health in our patient populations? EFFORTS TO IMPROVE RESILIENCE THROUGH SELF-AWARENESS Resilience has been described as a dynamic, evolving process of adapting well in the face of adversity and stress and adopting positive attitudes and effective strategies including developing self-awareness, positive personal relationships, effective professional relationships, and good communication.4 The literature is replete with meta-analyses and studies on provider burnout and cultivating resilience highlighting promising approaches with cognitive, behavioral, and mindfulness-based interventions that may include psychoeducation, cognitive behavioral therapy, interpersonal communication, building social connections and support, skills training for coping with stressful situations, and professional coaching.5–8 At the core of these approaches is cultivating greater self-awareness and self-regulation. Self-awareness enables our mind to focus on the moment-to-moment experience of life including our values, aspirations, beliefs, thoughts, feelings, behaviors, strengths, and weaknesses, and the impact we have on others. The benefits of self-awareness and efforts to cultivate it have been around since ancient times and preoccupied philosophers and poets and, in modern times, psychologists and the neuroscientists.9 Self-awareness is associated with higher job and relationship satisfaction and effectiveness, personal and social control, and happiness, and is inversely related to anxiety, stress, and depression. Self-awareness is seen as particularly critical in the development and ability of healthcare providers to maintain and sustain our own mental health and resilience in the stresses of the healthcare environment.10,11 As a seasoned family physician and public health professional, and a comparatively new executive and leadership coach, I can say with stability, certainty, simplicity, and clarity (the opposite of VUCA) that “thinking and feeling about how you think and feel” is a skill I wish I learned much earlier in my professional career. Whether from one’s natural inclination, self-study, formal training program, and/or the help of an executive and leadership coach, being able to challenge ourselves to notice and explore our thinking, and in so doing, create opportunities to reframe or change not only our thinking but also the resulting feelings and actions, and who and how we are in relation to others and the world around us is a critical element in building our resilience and putting the healing back in healthcare. PUT ON YOUR OUTWARD MINDSET MASK FIRST BEFORE HELPING OTHERS In today’s VUCA and COVID infected world, we must put our own “oxygen” or face masks on first. For cultivating self-awareness and building resilience, our oxygen mask is our mindset. In simple terms, mindset is an attitude or inclination. In more sophisticated terms, mindset includes our thought habits and may include cognitive, emotional, and behavioral components. Several “kinds” of comparative mindsets have been described: for example, abundance versus scarcity, positive versus negative, and growth versus fixed.12–14 One particularly helpful and practical approach to mindset comes from Terry Warner and is carried on by the Arbinger Institute: outward versus inward.15 TURNING INWARD An inward mindset focuses only on personal goals and objectives, and sees other people as objects, either as vehicles through which goals can be achieved, as obstacles that need to be removed to achieve goals, or as irrelevant and therefore able to be ignored. Inward mindsets do not allow us to see others as people with their own goals, objectives, challenges, and needs. In this mindset, one is not engaged in human-to-human interaction, and connection to people and humanity is lost. The relationship between oneself and others is positioned for the purpose of advancing one’s own needs and ignores the impact on others and can result in frustration, conflict, lack of innovation, decreased engagement, and ineffectiveness. Warner suggests that these negative feelings are self-induced based on a choice to see others as objects rather than as people and in convincing and deceiving ourselves that the solutions lie external to ourselves, by using, removing, or ignoring these objects.16 LOOKING OUTWARD In contrast, an outward mindset sees others not as objects but as people who matter and whose goals, needs, and challenges also matter just like our own goals, needs, and challenges matter. An outward mindset takes into account the impact one has on others, the connection between self and other, and how one may be helpful to and collaborative with others. The outward mindset shifts the essential focus from one’s own goals to one’s relationships and collective results with others. Outward mindsets create different choices; challenges transform from threats to opportunities; unexpected outcomes result in learning not failing; and others shift from critics to contributors and from competitors to colleagues. THE CHALLENGE As service-oriented healthcare providers, we are likely to consider this framework and assume we must have outward mindsets. In fact, we may even congratulate ourselves for how amazing we are in maintaining an outward mindset considering the chaos and complexity that surround us. Herein lies the challenge. As humans our mindset is dynamic and never completely inward nor completely outward. Our challenge is to identify when we have shifted inward. When we find ourselves blaming, justifying, defending or disregarding our mistreatment of others, we are likely inward. How this manifests in practice varies for each of us. For example, as a clinician with an inward mindset, I might see the “shoulder pain” in room 1 or the “Pap smear” in room 2, or the “tired all the time” in room 3 as “obstacles” or problems to my day. With an inward mindset, I see the burdens that make my day difficult, the symptoms that I need to remedy or the procedures I need to do. From this mindset, we may see our patients as vehicles that satisfy our sense of competence as healthcare providers, or as obstacles that frustrate us for failing to follow advice or directions. We may see colleagues as vehicles who help us get our work done or as obstacles who slow us down with administrative burdens keeping us from being more productive. However, when I can catch myself and shift to an outward mindset, I reconnect with the fellow human beings who have those symptoms, inquire about the impact of the symptoms on their life and well-being, and am curious about what else is going on in their lives and, what mattered to them. By seeing them as people, I am alive to what unarticulated struggles they may be contending with and am mindful about my impact as I offer solutions, care, comfort, and healing. Whether or not I can cure what ails them, with an outward mindset I can make patients, staff, and colleagues feel seen and heard, and let them know that they mattered to me. In this human connection, I can lighten the burden of my challenges and reenergize from the ability and influence to positively impact their day. During the current Covid-19 pandemic, there is no shortage of additional challenges that invite us inward. These include fears of being infected by our own patients, or carrying the virus home and contaminating our own families; the need to practice social isolation and distancing from those we are caring for and those we care for; the challenge of blame directed at insufficient institutional and governmental resources for protective personal equipment, testing, or even good information. Shifting inward is not an indictment of a self-focused or self-preservative desire; yet it is a shift toward being less effective in our efforts, less connected, and finding more stress in our own situation. Finding ways to shift outward help relieve the anxiety and stress and build and sustain our resilience. HELP WITH SHIFTING OUTWARD: SAM The outward mindset framework has a simple tool to help us shift our perspective: SAM (See others, Adjust our efforts, and Measure our impact (Fig. 1).17 When we remember to see that others are people, that they have needs, objectives and challenges of their own, and when we seek to learn about those, we begin to shift our mindset outwardly. When we adjust our efforts by engaging in the process of understanding why others are acting as they do, the negative feelings generated from our inward thoughts dissipate. When we measure our impact by seeking direct feedback from and connecting to those we strive to impact, we find the value, meaning and purpose in our efforts. FIGURE 1 Open in new tabDownload slide The SAM Model: Coach SAM. Creating connection means being alive to and interested in the people with whom we interact. Coach SAM reminds us to “see” others by seeking understanding of their needs, objective and challenges, “adjust” our efforts to be more helpful, and “measure” the impact of our efforts on them. Copyright 2020 Arbinger Properties, LLC. All Rights Reserved. Used with permission. FIGURE 1 Open in new tabDownload slide The SAM Model: Coach SAM. Creating connection means being alive to and interested in the people with whom we interact. Coach SAM reminds us to “see” others by seeking understanding of their needs, objective and challenges, “adjust” our efforts to be more helpful, and “measure” the impact of our efforts on them. Copyright 2020 Arbinger Properties, LLC. All Rights Reserved. Used with permission. In a world of volatility, uncertainty, complexity, ambiguity and other temptations to turn inward, if we can remember a simple tool to see ourselves in relation to those around us, adjust our efforts, and measure our impact, then we reconnect to the people we serve and serve with in health, strengthen our resilience as providers, better meet the needs of our patients and colleagues, and help put the healing back into the healthcare system. The views expressed are solely those of the authors and do not reflect the official policy or position of the U.S. Army, U.S. Navy, U.S. Air Force, the U.S. Public Health Service, the Department of Defense, the Department of Health and Human Services, or the U.S. Government. Neither the author nor her family members have a financial interest in any commercial product, service, or organization mentioned in this article. References 1. NEJM Catalyst . Physician burnout: the root of the problem and solutions . NEJM Group 2017 . Available at https://moqc.org/wp-content/uploads/2017/06/Physician-Burnout.pdf; accessed March 1, 2020 . 2. Patel SP , Bachu R, Adikey A, Malik M, Shah M: Factors related to physician burnout and its consequences: a review . Behav Sic (Basel) 2018 ; 8 ( 11 ): 98 . Google Scholar OpenURL Placeholder Text WorldCat 3. Reith TP : Burnout in unites states healthcare professionals: a narrative review . Cureus 2018 ; 10 ( 12 ): e3681 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 4. Jensen PM , Trollope-Kuma K: Heather water, Jennifer Everson building physician resilience . Can Fam Physician 2008 ; 54 ( 5 ): 722 – 9 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 5. Robertson HD : Resilience of primary healthcare professionals: a systemic review . Br J Gen Pract 2016 ; 66 ( 647 ): e423 – 33 . Google Scholar Crossref Search ADS PubMed WorldCat 6. Nemeth C , Wears R, Woods D, et al. Minding the Gaps: creating resilience in health care. Advances in Patient Safety: new directions and alternative approaches (Vol 3: Performance and Tools) . Rockville (MD) , Agency for Healthcare Research and Quality (US) , 2008 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 7. West CP , Dyrbye LN, Erwin PJ, Tait D: Shanafelt interventions to prevent and reduce physician burnout: a systematic review and meta-analysis . Lancet 2016 ; 388 ( 10057 ): 2272 – 81 . Google Scholar Crossref Search ADS PubMed WorldCat 8. Gazelle G , Liebschutz JM, Riess H: Physician burnout: coaching a way out . J Gen Intern Med 2015 ; 30 ( 4 ): 08 – 13 . Google Scholar Crossref Search ADS WorldCat 9. Longhurst M : Physician self-awareness: the neglected insight . CMAJ 1988 ; 139 ( 2 ): 121 – 4 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 10. Rasheed SP , Younas A, Sundus A: Self-awareness in nursing: a scoping review . J Clin Nurs 2019 ; 28 ( 5–6 ): 762 – 74 . Google Scholar Crossref Search ADS PubMed WorldCat 11. Thompson T : Self-awareness: behavior analysis and neuroscience . Behav Anal 2008 ; 31 ( 2 ): 137 – 44 . Google Scholar Crossref Search ADS PubMed WorldCat 12. Howell E . How to Eliminate Your Scarcity Mindset so You can Enjoy Abundance . Scotts Valley , CreateSpace Publishing Company , 2016 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 13. Dweck C : Carol Dweck revisits the growth mindset . Educ Week 2015 ; 35 ( 5 ): 20 – 4 . Google Scholar OpenURL Placeholder Text WorldCat 14. Sinek S . The Infinite Game . London , Portfolio/Penguin , 2019 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 15. The Arbinger Institute . The Outward Mindset . San Francisco, CA , Berrett-Koehler Publishers , 2016 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 16. The Arbinger Institute . Leadership and Self-deception . San Francisco, CA , Berrett-Koehler Publishers , 2000 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 17. The Arbinger Institute . Developing and Implementing an Outward Mindset Workshop . Available at https://arbinger.com/Workshop/OnsiteDIOM.html; accessed March 1, 2020 . © Association of Military Surgeons of the United States 2020. All rights reserved. For permissions, please e-mail: [email protected]. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Weber, Eric, D

doi: 10.1093/milmed/usaa189pmid: 33002146

ABSTRACT Preparation is the key to performance. The Army invests substantially in team and unit preparation prior to deployments. However, despite the time and training to build camaraderie and confidence in one another, conflict still arises within units. Most training does not address the underlying mindset that is the source of conflict. Army medicine has utilized training material that addresses the mindset source of conflict to improve team and organizational collaboration and outcomes in hospital settings. We adapted this current Army training to conditions in a deployment environment and improved the culture and reduced the conflict in the unit. TEAM PREPARATION FOR DEPLOYMENT The Army prepares its soldiers and teams extensively before deployments. Typically, units are organized and train together for almost a year in advance of scheduled deployments. Within the Medical Service Corps, hospital units often have about 80% of the team preparing as an intact unit.1 Attributable to limited availability, physicians are typically substituted in and out, and end up receiving a condensed version of the predeployment training in preparation for their roles.2 For both groups, the training runs the gamut from people to practical needs, from language skills, cultural awareness, and theater policies, to donning chemical protective gear or escaping from an armored vehicle if it flips over. Training helps individuals and the unit to be better together in handling challenges and completing the mission in the deployed environment. Yet even with the time spent together in training to build camaraderie and confidence with one another, deployment brings new challenges that make even the best of buddies find issues that challenge their ability to work together.3 Conflict occurs whenever you bring people together in a new environment with a common goal. Life experiences are all different; teammates come from different parts of the world, from different cultures and experiences, and have different ways of responding to changes in the field that impact the approach to achieving the mission. All have different personalities and approach change and challenges differently. Conflict then arises because individual expectations of what others should do to help adjust to change differ from person to person. The ability to address conflict, even with training on conflict resolution and best practices, is then difficult because of the different biases, perspectives, and experiences each person brings to a challenging situation. The greatest barrier to resolving conflict, although, is the failure to see or understand the impact of mindset on the situation.4 Providing better understanding of this unseen problem is needed to reduce conflict and improve deployment team collaboration and performance. THE MINDSET THAT MATTERS Although there are many approaches to mindset, the Army Medical Department (AMEDD) has used contracted material from the Arbinger Institute that identifies mindset not as a fixed belief system but rather a way of seeing others.5 In this framework (Outward Mindset), I am not of one mindset but rather I am always on a spectrum: seeing more “inwardly,” where I sense others more as objects, versus “outwardly,” where I have a better sense of the humanity or personhood of others.6 From an outward mindset, I value the quality of my relationship with that person and not just the role that brings them into connection with me. This material is inherently different than other personality or perspective assessment materials in that instead of focusing on me as an independent unit for evaluation, it assesses the way I see myself in relation to others. This distinction provides a foundation for approaching conflict differently than standard personality, preference, or conflict resolution frameworks. The outward mindset framework was introduced to Army medicine in 2012 and has spread rapidly since 2015, with over 30,000 AMEDD staff trained and over 600 internal facilitators. I was first introduced to the material in 2016 by our Chief Nursing Officer, who was a facilitator of the material. I subsequently volunteered to become a facilitator and started a program at Fort Bliss’ William Beaumont Army Medical Center to provide regular workshops and trainings for our own staff. Initially, we trained several hundred staff using master facilitators from the Arbinger Institute before using our own internal facilitators to create a sustained culture and continuous development of an outward mindset organization. Arbinger had previously conducted a study at a similar-sized Army hospital and showed marked improvement in the culture, including in measures of employee engagement, job satisfaction, and sense of psychological safety.7 At Fort Bliss, although not yet able to conduct a similar study pending our own Institutional Review Board (IRB) approval, we anecdotally have had similar improvements in collaboration, better conflict resolution, and teamwork. Mindset drives behavior. By helping our staff understand the choice of mindset they have in any situation, we have helped provide an understanding of why differences can be seen as either a basis for conflict or a basis for collaboration. This insight provides every individual a means of resolving a perceived conflict by shifting their own mindset and not being left feeling a victim of their situation or that an issue is beyond their own ability to resolve. DEPLOYMENT CONFLICT HAPPENS With this background, I felt confident in my ability to address the challenges of my deployment to Iraq with an Army hospital unit in 2019. Like many physicians, I did not have the opportunity to train with my unit in advance, but I did get the typical situational and process briefings to get me up to speed with the unit. Additionally, I expected my experience facilitating this material would help our unit adjust to the challenges of being in the field and be better at addressing the conflicts that arise. Conflict rarely fixes itself and can often simmer until boiling into a hostile environment. Within a few weeks of arriving, it became apparent that my unit was not unlike most health care units stateside—there was conflict, and the vast majority became increasingly interpersonal attributable to the increasing failure to effectively address initial smaller conflicts. Senior leadership was struggling to hold the unit together in a tense environment; more time was spent mediating conflict within the unit than on patient care or unit readiness. What can be particularly challenging in resolving conflict is the perspective of all involved that they are doing their best to “get the job done.” In our unit, different sections focused on accomplishing their own goals would take supplies from other areas to have the supplies they needed. Later, when the “donor” unit needed those supplies, they found themselves unable to complete the mission. Conflict would result because of the competing senses and needs to get “the job” done. From an inward mindset, the belief that one is doing the right thing to get one’s own “job” done to serve the unit’s mission justifies one’s own actions. The sense of victimhood, resignation, anger, or frustration from these conflicting perspectives often leads to worsening of a unit’s challenges. At the very least, there is significant wasted time and energy on dealing with the negative emotions that also leads to less productivity. This conflict in our unit ranged from nurses competing for a good evaluation to surgeons being disrespectful to other staff. Captains and Majors were sabotaging each other, to the point that one officer, an important member of the team, needed to be removed from the unit. Even worse, careers were at stake. In our unit, several nurses faced disciplinary action that could have ruined an otherwise stellar career. We all needed each other to get our work done; the problem is that we were focused on achieving our own goals rather than helping each other. No one was free of this trait - the inward mindset tendency to see others as objects - including those with grounding in the outward mindset material. SEEING MY ROLE IN CONFLICT When I say, “even those with a grounding in the outward mindset material,” I certainly had my own blind spot, despite being aware of the role my mindset played in creating conflict. A situation occurred early in my deployment where I simply did not see myself as creating a problem. We were notified that a service dog was injured in a fight and needed facial reconstruction. A veterinarian had assessed the dog and determined that both otolaryngology and ophthalmology were required. The dog was on his way and would be at our location within an hour. I alerted part of the head and neck team to include the otolaryngologist, the scrub tech, and the nurse anesthetist. The dog arrived, and we quickly got him into the operating room, explored his orbit, and determined that he had a hematoma and eyelid laceration, which we fixed in short order despite our lack of experience with canines. We were feeling pretty good about what we did and retired for the night. The next morning, I was quickly confronted with the conflict my actions created. The chief of the operating room, a very well-organized nurse, was beside himself that he was not made aware of the surgery. I had completely neglected to inform the team leader, an operating nurse by training, and commander of the head and neck detachment. I also neglected to alert the operations section. Our team lead was clueless when asked by the Unit Commander and Deputy Commander what took place the prior night. From an inward mindset, I might have been ready for conflict. I had reacted in what I considered the best way for the team, providing us with an opportunity to practice a surgical response while providing for the real need of a canine member of the service. It was my call to take advantage of the training for my team that would better prepare us for the “real” casualty scenarios that would likely come our way, when performance would be critical to saving human lives and conditions. At least this is how I justified neglecting parts of my team. In fact, my initial reaction was to feel indignation that they did not understand the importance of the opportunity, or to even congratulate me on being so resourceful and helpful to the team. Yet shifting to an outward mindset, I realized the confusion, conflict, and stress created by a lack of communication on my part. Freed me from my justification and rationalizations for the righteousness of my actions, I could see the concerns of the leadership team. They all had every right to be upset. Had we taken fire or received unexpected casualties, my lack of communication could have severely hindered our ability to care for those patients. In my enthusiasm for the team training opportunity I had viewed all these other leaders as objects—if I did not need them that night for my surgery, I did not bother calling them. Here I was, a certified facilitator of this material, and yet I had found myself shifting inward. I implemented and oversaw the mindset shift training at a 4,000-employee military facility. I try to live and breathe an outward mindset, also known as an “out-of-the-box” mentality. I practically had an influence pyramid8 tattooed on my forearm (Fig. 1). But on that night, I was “in the box”9 of an inward mindset and not alive to the full impact of my actions on others in my command. FIGURE 1 Open in new tabDownload slide Arbinger Influence Pyramid—How to help others change and the lessons of the pyramid: The influence pyramid is a structure to organize all of your leadership efforts. It is particularly helpful whenever you would like to influence change in another person. There are three lessons about the pyramid as depicted. Copyright 2020 Arbinger Properties, LLC. All Rights Reserved. Used with permission. FIGURE 1 Open in new tabDownload slide Arbinger Influence Pyramid—How to help others change and the lessons of the pyramid: The influence pyramid is a structure to organize all of your leadership efforts. It is particularly helpful whenever you would like to influence change in another person. There are three lessons about the pyramid as depicted. Copyright 2020 Arbinger Properties, LLC. All Rights Reserved. Used with permission. DEBLAMING CONFLICT The outward mindset framework’s success for resolving conflict is in its ability to help people quickly “deblame” situations. Every conflict invariably begins with both participants thinking and feeling he or she did the right thing (or is in “the right”) and it is the other party who is in the wrong. The outward mindset framework helps an individual identify that, from the perspective of each participant in a conflict—they are both “seeing” their own right and righteousness. Both want to be helpful, to do what is helpful to the unit or the mission. In most cases, conflict arises irrespective of the approach to systematic approaches, i.e. root cause, cause–effect analysis (Ishikawa), critical event analysis, or any other term, because those do not account for the initial sense and acknowledgment of the individuals who see themselves as trying to “do the right thing” in the moment. What the outward mindset helps us recognize is that people are people. It “deblames” the intent by allowing a participant to engage without blaming the other or seeing them as the source of one’s problem. Once an individual can see the other, letting go of his or her own preconceived assumptions, judgments, and emotional ties to his/her own “ego,” the opportunity and space for learning and curiosity are opened. In the outward mindset framework, an empowering key factor is that only one person needs to be aware of their mindset and shift. The willingness to make this shift is the essence of leadership. It is easy to be inward toward others who blame me and to simply blame them back. It is also easier to be outward toward those who are outward toward me, working together in a culture that honors each person. What is hard is shifting to an outward mindset when I am invited into an inward mindset by my sense that others are blaming me. An insightful tool in the outward mindset shifting material is the tool called “Deblaming Collusion” (Fig. 2).7 In this exercise, participants learn how to see their “problem” not as the people who they sense as the cause of the problem, but rather as people who have their own needs, challenges, and objectives. The material invites inquiry into the impact one’s actions may have had on others, not in the light of one’s own goals but with an understanding that, despite best intentions, there may be collateral impacts that hinder someone else from accomplishing their goals and challenges. In this light, the ability to adjust and offer some alternative approach that will be more helpful is the shift that deblames the conflict and opens a path to resolving or improving the situation. FIGURE 2 Open in new tabDownload slide Deblaming Collusion Tool: The steps of the Deblaming Collusion Tool are: Step 1: What things are they doing that bother me when I am in the box—things I wish they would change or quit doing? Step 2: When I’m in the box, how do I see them and what they’re doing? How do I see myself? What kinds of emotions do I experience? Step 3: When I’m seeing and feeling in the ways listed in quadrant 2, how do I respond or react to this person/group—what kinds of things do I do? Step 4: When they are in the box toward me, how do they likely see me and the things I am doing? How might they see themselves? What kinds of emotions might they experience? Deblame collusion by then considering: Step A: List the other person or group’s objectives, challenges, headaches, and concerns. Step B: If I/we weren’t in the box, how would I/we see them and what they are doing? Step C: How have I/we made things harder for them? What could I/we do differently to be more helpful? Implement what you feel to do differently from Step C. Step D: Follow-up with this person to see how what you are doing in Step C is helpful or not. Copyright 2020 Arbinger Properties, LLC. All Rights Reserved. Used with permission. FIGURE 2 Open in new tabDownload slide Deblaming Collusion Tool: The steps of the Deblaming Collusion Tool are: Step 1: What things are they doing that bother me when I am in the box—things I wish they would change or quit doing? Step 2: When I’m in the box, how do I see them and what they’re doing? How do I see myself? What kinds of emotions do I experience? Step 3: When I’m seeing and feeling in the ways listed in quadrant 2, how do I respond or react to this person/group—what kinds of things do I do? Step 4: When they are in the box toward me, how do they likely see me and the things I am doing? How might they see themselves? What kinds of emotions might they experience? Deblame collusion by then considering: Step A: List the other person or group’s objectives, challenges, headaches, and concerns. Step B: If I/we weren’t in the box, how would I/we see them and what they are doing? Step C: How have I/we made things harder for them? What could I/we do differently to be more helpful? Implement what you feel to do differently from Step C. Step D: Follow-up with this person to see how what you are doing in Step C is helpful or not. Copyright 2020 Arbinger Properties, LLC. All Rights Reserved. Used with permission. SHIFTING MINDSET IN THE FIELD Ironically, just before this “emergent surgical” event occurred, the leadership approached me and asked me to put a plan together to share the outward mindset principles, in some form, to the unit. A few members of the senior leadership had taken the 2-day Developing and Implementing an Outward Mindset course offered throughout AMEDD and believed it would be helpful to the unit in the field. With the help of the team at Army Medical Command (MEDCOM) that ran the AMEDD contract, we were able to secure the necessary materials for a team training in our field environment. This type of training had never been attempted in a deployed environment. Ideally, you need a comfortable room with round tables that facilitates group discussions. You need easels with space to write down ideas from the group. You need name cards and stickers. All we had was a small conference room that was part of a modular hospital, and a chapel that was made from trailers. Neither was particularly comfortable, and neither was designed to facilitate group discussion. We found one easel with a battered white board on it, and about 10 sticky note pads. The preference would be to have these items in advance of deployment. Operationalizing for our situation required adjusting the delivery. The current AMEDD workshop entails 2 consecutive days of training. Given our situation and the challenge of taking people off-line from their deployment responsibilities, we broke up the 2-day course into four blocks; each week we taught the same 4-hour block to four different groups. Conducting the workshop in this manner, despite the challenge of being in the field with extended work shifts and constant operational matters to attend to, was very effective. I found myself having frequent sidebar conversations with soldiers throughout the weeks and the participants’ understanding of and engagement with the material was better at subsequent sessions when compared to the 2-day workshops I have usually conducted. Unit members recognized the value of taking the time to better understand the source of the conflicts which were coming up daily and find a better way to approach resolving them. Spacing the sessions out also gave some participants the opportunity to engage with the material within their personal lives by using the exercises to call home between sessions and address “domestic” conflicts. These “domestic” issues, even though far away geographically, remained an integral part of the deployed soldier’s daily existence. Helping address these issues improved morale and the ability to address the unit’s internal conflicts as well. Within a month’s time, we had provided the unit a common language it could use to avoid or resolve conflict. It became routine to hear someone reference the material by saying something like “before we get into this, I think I’ve been thinking about this with an inward mindset” or something similar. In the canine example above, I was able to use this language when I failed to inform the OR staff about our case, and we were able to have a frank discussion and quickly identify solutions for better communicating when such an opportunity might arise in the future. The vernacular helped my colleagues hear me owning my own role in the communication problem, and that invited their engagement to focus on how we could improve the situation going forward and not have to focus on convincing me that I had contributed to the problem. It became evident how valuable this training could have been if our unit had this common language and insight in advance of our deployment. An additional example of how this training affected unit morale and performance occurred after I left the unit. There were two inspector general investigations that were launched because of some infighting that occurred prior to the workshops. As part of their investigation, they questioned both unit members and leadership. In some of these interviews, they quickly learned that the mindset of the unit had already shifted. The complainants admitted that the problem was partly of their own making; leadership agreed that they had a blind spot and the outward mindset material allowed them to see the challenges that their soldiers faced. The inspectors were so impressed with the implementation of the outward mindset shift that they dismissed the complaints without any adverse findings. PROVIDING MINDSET AWARENESS TO DEBLAME THE CONFLICT THAT HAPPENS The Deblaming Collusion Tool is so valuable because we know conflict will happen when we get into the operational environment. This conflict happens not because anyone is trying to create problems but simply because it is the nature of having different perspectives looking at the same issue differently.10 This tool helps by moving you to see and understand what and why you are feeling and to analyze what and why the person you are in conflict with is feeling. With this, you are invited to shift your own mindset, see other people as people, and identify what their needs, challenges, and goals are. When you see what other people need, you see them as human, not as objects. In my experience, this step of identifying others’ needs helps you appreciate that almost no conflict is based on one’s desire to harm you; instead, almost all conflict develops from someone’s desire to do the right thing, just from their perspective.11 They just fail to identify your needs in the process, and conflict develops. The outward mindset workshop is unique in that it does not focus on changing your behavior—it asks you to consider and shift your mindset first, which ultimately drives your behavior. Over my 20 year Army career, I have been exposed to several behavior-modification programs that the Army purchased—you leave feeling good but the behavior is quickly forgotten because your underlying mindset is the same—namely, that I matter more than others and others are just objects to help me get where I am going. Without understanding the role of mindset and my choice of mindset in every interaction, behavior modification efforts fail to help me escape the self-focused justifying emotions of an inward mindset. Subsequently, when circumstances change in the field and I do what I think is best to serve the mission, anyone challenging my efforts instinctively becomes an adversary. The outward mindset framework and tools help break that all down and get past the negative feelings. Then problems are just issues that you are both working to solve together rather than battles to prove who was “right” in the first place. By incorporating some aspect of this material into the predeployment training, units will be better prepared for addressing the conflict that invariably arises in an operational environment. The views expressed are solely those of the authors and do not reflect the official policy or position of the U.S. Army, U.S. Navy, U.S. Air Force, the Department of Defense, or the U.S. Government. Neither the author nor their family members have a financial interest in any commercial product, service, or organization mentioned in this article. REFERENCES 1. Riojas C : Semper Gumby: team and leadership training for deployed trauma teams . Milit Med 2017 ; 182 : 1752 – 6 . Google Scholar Crossref Search ADS WorldCat 2. Holloway MD : Predeployment medical training for providers . US Army Med Dep J 2016 ; ( 2–16 ): 192 – 4 . Google Scholar OpenURL Placeholder Text WorldCat 3. Adler AB , Adrian AL, Hemphill M, et al. : Professional stress and burnout in US military medical personnel deployed to Afghanistan . Milit Med 2017 ; 182 : 1669 – 76 . Google Scholar Crossref Search ADS WorldCat 4. Kleiman T , Enisman M: The conflict mindset: how internal conflicts affect self-regulation . Soc Personal Psychol Compass 2018 ; 12 : e12387. Google Scholar OpenURL Placeholder Text WorldCat 5. Federal Contract IDV Award . Indefinite Delivery Contract W81K0416D0031 . Available at https://govtribe.com/award/federal-idv-award/indefinite-delivery-contract-w81k0416d0031, June 16, 2016 ; accessed March 1, 2020 . 6. The Arbinger Institute . The Outward Mindset , Ed 2nd. San Francisco , Berrett-Koehler Publishers , 2018 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 7. The Arbinger Institute . Arbinger Training Dramatically Improves Culture in Healthcare . Available at https://arbingerinstitute.com/whitepapers.html; accessed March 1, 2020 . 8. Arbinger Institute . Developing and Implementing an Outward Mindset Workshop . Available at https://arbinger.com/Workshop/Publicdiom.html; accessed March 1, 2020 . 9. The Arbinger Institute . Leadership and Self-deception: Getting Out of the Box , Ed 3rd. San Francisco , Berrett-Koehler Publishers , 2018 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 10. Warner CT . Bonds That Make Us Free . Salt Lake City , Deseret Book Company , 2009 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 11. The Arbinger Institute. The Anatomy of Peace . San Francisco , Berrett-Koehler Publishers , 2006 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC © The Author(s) 2020. Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States. All rights reserved. For permissions, please e-mail: [email protected]. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Nevo, Ofir Noah; Lambert, Laura

doi: 10.1093/milmed/usaa161pmid: 32776105

ABSTRACT Bottom Line Up Front: In this perspective essay, ENS Ofir Nevo and Dr Laura Lambert briefly discuss the concept of an outward mindset and how they have applied it in the context of medical education. ENS Nevo shares his story of deciding to attend medical school at the Uniformed Services University, as part of his desire and commitment to serve others. Early on, the requirements of medical school created intense demands that began to disconnect him from the commitment and connection that first drew him to a medical career. ENS Nevo describes how an awareness of the choice of mindset helped him address these challenges and stay better connected to his purpose and calling. A case analysis by Dr Lambert further explores how the awareness and practice of an outward mindset may help students, residents, and attendings see how they can improve their own well-being and connection to the people that brought them to medicine in the first place. Their experiences demonstrate how outward mindset principles can be a valuable tool for empowering students and physicians with a perspective that invites new solutions for the challenges of life and work. TRUE SERVICE IS AN OUTWARD MINDSET I started medical school at the Uniformed Services University (USU) as the next step in my journey in a career of service. Beginning with my years as a soldier in the Israel Defense Forces, then as a pharmacist, and most recently as a U.S. Public Health Service officer, I have seen my service as a commitment to a life of purpose; a path that should provide me with a strong sense of community, connectedness, and self-actualization. Yet despite this commitment and service career path, I found myself struggling with stress, anxiety, and frustration, often at those I was serving with and sometimes directed toward those who I believed I was serving. Before entering medical school, I was introduced to a concept that helped me understand why these emotions still occur in me despite my honorable intentions. Along with several colleagues interested in leadership development, I participated in a book club that read “Leadership and Self-Deception”,1 and learned how “self-deception” permeated much of my self-image. The book defines self-deception as, “the inability to see that one has a problem,” in the context of interpersonal relationships.1 When in a state of “self-deception” we are narrowly focused on our own self-interest without considering our impact on others. We blame other people for our own behavior, and do not recognize how our perception of ourselves in relation to others is part of the problem. The key notion that resonated for me was that my “service,” although perhaps noble on the surface, can also really be self-serving. My journey with this material continued through leading other book clubs for “Leadership and Self-Deception”, and later for another book, “The Outward Mindset”.2 This second book describes how we are always on a spectrum of an inward versus an outward mindset, and I always have a choice in how I am “seeing” others (Fig. 1). All behaviors, even those supposedly done to help others, can be done either with an inward self-focus or an outward focus on the impact on others. From an inward mindset, I do not perceive others as people who matter as much as I do, and therefore only focus on my own goals. In contrast, with an outward mindset I see others as people and recognize they have needs, goals, and challenges that matter as much as my own. Therefore, when serving, if I am not truly seeing others and considering their goals, I am actually doing the “service” for myself. I may become fixated on doing or getting the service done the way I think is right, giving myself credit for “being right”. Service from this mindset is called an “outwardly nice, inward mindset”.2 Figure 1 Open in new tabDownload slide The spectrum of inward versus outward mindset and self-deception. Self-deception: failing to see that I am more focused on my own needs, objectives, and challenges than I think I am. An “outwardly nice, inward mindset” believes I am serving the needs of others when I am actually doing things which are self-satisfying and self-focused. Reprinted by permission from Arbinger Institute: Developing and Implementing and Outward Mindset program, copyright 2020. The philosophy of an outward mindset connected with my core values in a way that no other leadership development training ever had. Most of my experience with prior leadership trainings focused more on behaviors or skills, which although important, did not emphasize the more fundamental concept of how our mindset shapes our behavior. Eager to learn more about the outward mindset, I sought out other resources, including the book, “The Anatomy of Peace”,3 the two-day Developing and Implementing an Outward Mindset (DIOM) workshop,4 and the one-day Outward Leadership workshop.5 Lastly, I completed the DIOM Train-the-Trainer workshop to enhance my understanding of this material and learn to facilitate outward mindset trainings for others. What compelled me to continuously engage with this material was experiencing how effectively it could help me regulate my emotions when consciously shifting to an outward mindset. The concept of “self-deception” is the basis for helping me understand the source of my emotions. The language and tools I acquired from my exploration of the outward mindset enabled me to reclaim a sense of control over situations I previously felt powerless over. By choosing to shift outward, and truly see people as people who matter as much as I do, I could better recognize the impact my feelings and behaviors had on my professional and personal relationships. When I am outward focused, I am no longer stuck in “self-deception”. Instead of blaming others, I am able to take accountability for my feelings and behavior. Integral to this material is the understanding that I, as a person, am never completely “inward” or “outward:” all human beings are constantly somewhere on a spectrum between the two. The challenge is not that I am not perfectly outward; rather, the challenge is that I do not always realize when I am being more inward. “Self-deception” occurs not because I am intending to be self-focused; rather it occurs when I do not realize I have turned inward and I believe that I am being outward when I actually am not. In the midst of “self-deception”, I am convinced that my goals are more important than the goals of the people around me, and so I turn inward. As I pursue my goals without considering the impact I have on people I interact with along the way—my family, fellow classmates, attending physicians, patients, staff, and so on—I am unwittingly telling them that I do not see them as people who matter as much as I do. My behavior could still be nice and polite while operating with an inward mindset, but it may not be well-received if people sense I am being nice to them because I want something from them, rather than because I genuinely see and care about their needs and goals. The tendency to turn inward always exists. I perceive it as a self-justification that may provide some temporary sense of vindication or relief. Although when I am inward, I am much less effective in building relationships with other people, and subsequently less effective in fulfilling my goals of being of service to others. My frustrations, anxieties, and stresses generally come from when I am more focused on myself and not seeing others. Understanding the foundational material of an outward mindset has helped me see that just being in a “service” role or position is not necessarily truly serving. True service, that is actually helpful, is about seeing people as people who matter as much as I do, and not just having good intentions, the technical knowledge, or skills to do what I think is helpful. To meet my goals, I need to have a sincere interest for the needs, challenges, and goals of others—to be alive to what is truly helpful to them. THE OUTWARD INVITATION AND APPEAL OF USU Although I have had an interest in serving others as a physician for several years, I was also cautious about the many challenges a career in medicine can have.6 I was apprehensive about how ultracompetitive medical students seemed to be and the “inwardness” that it can invite. I was also mindful of the particular concerns related to physician resilience and burnout increasingly discussed in the literature.7,8 However, when I discovered the existence of the USU,9 I felt I had little excuse to not apply. Although many medical schools have made changes to their curriculum to attempt to increase collaboration among medical students, I saw nothing that compared with USU for the camaraderie, commitment to service, and general support for one another. By design, USU promotes a model of success based on collaboration.10 Because all students are commissioned officers in either the US Public Health Service, U.S. Army, U.S. Navy, or U.S. Air Force, USU students have already succeeded in securing employment and can focus more on working together rather than competing against each other. There are no tuition costs to worry about, which helps reduce some of the stress of medical school. If a student does not match to a specialty of their choice the first time around, they still have a viable career and opportunities to match in following years. Another unique aspect of USU is that most classmates will be coworkers later in their careers, and one day may even provide care to each other and their family members. There is a unique motivation to work together and encourage each other to become the best physicians possible. Beyond these structural incentives to collaborate, medical students who are attracted to USU tend to have a mentality of putting the mission first and sacrificing for the greater good.11 The more I learned about USU, the more convinced I was that this was the best path for me to become a physician. In August 2019, at the young age of 33, I began the exciting journey of studying medicine. THE INWARD INVITATIONS OF MEDICAL EDUCATION AND MEDICINE In many ways, becoming a physician—particularly a military or public health physician—seems like it would naturally align with developing an outward mindset, a way of seeing the needs, challenges, and objectives of others so that I can adjust my own efforts in pursuit of my own goals that is more impactful and helpful to others. After all, as a physician, my objective is to learn about the medical needs and goals of my patients and determine how to best help them. However, despite my familiarity with the outward mindset material, I quickly found no shortage of invitations to turn inward in medical education. Even with the supportive environment USU strives to create and all the characteristics I described earlier, I still found many “inward invitations” popping up in my day-to-day interactions: I could resent my classmates for being smarter or more talented; I could become upset with faculty for making my life more stressful than I thought necessary because of the expectations they set; I could doubt my ability to successfully graduate and feel a sense of helpless despair. From one perspective, many of these invitations arise out of the need for more time, an issue that seems ubiquitous in medicine.12 In the book “Scarcity: Why Having Too Little Means So Much”, the authors demonstrate how people respond in ways that often make their situations worse when they reach a critical shortage. “Scarcity reduces all the components of bandwidth – it makes us less insightful, less forward-thinking, less controlled.”13 Despite the quality of the USU education and my supportive classmates and colleagues, I too found myself challenged by the time demands of medical school itself. Initially I coped with this challenge by falling into the lure of “self-deception”, turning inward and blaming others. It was all too easy to believe that my frustrations, anxieties, and stresses were caused by others rather than myself. This became prevalent even with the person I care the most about. I became keenly aware of the demands medical school had on my relationship with my spouse. To ensure my success in medical school, I became very limited in my ability to show up to events that were important to my spouse, and more generally spend quality time together. I began to feel more and more resentment in our relationship during my first few months in medical school, blaming him for not understanding my needs as the justification for my not attending those events in the first place. Everywhere I went I carried that resentment, along with feelings of victimization, convinced I deserved a more understanding and supportive partner. Thankfully, I eventually recognized the reminders of my inward mindset, my “red-flags” (Fig. 2). Instead of staying stuck, I was able to recognize I was in an “I deserve” box, where I viewed myself as mistreated and unappreciated, and my reality was skewed to fit that perception. I was suffering from “self-deception”. There are many emotions that are indicative of this condition—in my case it was feelings of resentment and indignation. The outward mindset material helped me recognize that my emotions are connected to ways of seeing myself in relation to others, and that these emotions were doing little else than serving my need to feel justified about how I was seeing my spouse. Figure 2 Open in new tabDownload slide Inward mindset styles and red flag emotions. My emotions reflect different styles of an inward mindset. When I am inward, my self-view and feelings are driven by how I am seeing myself in relation to others. Irrespective of how I am seeing and judging myself in the moment and the emotions that are reflective of this, the red flags can help me recognize that I am seeing others from an inward mindset. Reprinted by permission from Arbinger Institute: Developing and Implementing and Outward Mindset program, copyright 2020. The outward mindset material also helps me recognize I always have a choice: I can continue to blame and judge—all hallmarks of an inward mindset—or I can stop judging my spouse and shift my mindset outward, considering what his goals and challenges might be. Instead of blaming my spouse and seeing him as unappreciative, I can choose to see him as a person who has his own needs and goals. I started to think more about how my being in medical school was impacting him, and how I could be more present for him while keeping up with my responsibilities as a medical student. Although there is no simple solution to the strain that the time demand of medical school has put on my marriage, I was not helping my marriage by blaming my partner for my woes. By recognizing that I can choose to see differently, in particular my spouse, I am better able to focus on what I can do to be helpful to my spouse and engage in a more effective way during the scarce time we do have together. By not carrying the inward mindset box I had around with me, I began to feel less burdened and was better able to be present at school, at home, and in all my other interactions. With an outward mindset the need to justify many of those negative emotions disappears. I know I will continue to experience inward invitations throughout this career path and also in my journey through life. These invitations may be the demands of medical school, residency, or practicing as an attending physician; they may be the needs of serving in an underserved area, on deployments, or anywhere within the continuing complexity of the healthcare delivery system and the needs of patients. All these challenges that starve me of my time or feel like barriers to my service will be invitations for me to turn inward. The main goal of the outward mindset material is not to be perfectly outward at all times. Rather, it is to improve my self-awareness and recognize when I may be operating more inwardly than outwardly. When I can see this, I then have the ability to choose. Victor Frankl is credited with saying something to the effect of, “Between stimulus and response there is a space, and in that space is a choice. And in that choice is my growth and my freedom.”14 By having awareness of my mindset, I have the ability to choose, and in doing so choose what is important, and effectively cope with the stresses of medical school. START THE RIGHT WAY: AWARENESS IS THE FIRST STEP In the DIOM workshop one of the first collaboration tools that is shared is called “Start the Right Way”. The objective of this tool is to help an individual or a team identify how they would approach some interaction, such as a phone call or a meeting, first from an inward mindset—what they would be thinking or doing as they prepared or engaged for the interaction—and then from an outward mindset. What becomes evident with this tool is how much more collaborative, curious, engaging, productive, and positively impactful the interaction will be if they are able to shift toward being more outward. For example, before approaching a classmate about a disagreement we had on how to move forward on a group project, I asked myself, “How would I act if my mindset was inward? That is, focused only on my goals?” and wrote down my response, and then asked myself, “How would I act if my mindset was outward? That is, if I also considered my classmate’s goals?” and again wrote down my response. After completing this quick exercise, it was easier to let go of judgmental thoughts, and became apparent to me that we would have a more productive and positive interaction if I approached our conversation with a curiosity for my classmate’s challenges and a desire to help. As I experience the demands of my medical education and learn more of the challenges I will face as my career in medicine progresses, I see this tool as a framework for helping my classmates and future medical students prepare for the increasing demands of the medical profession. Many of the current trends in healthcare talk about helping physicians needing to reconnect to their purpose that started them on the path to being a physician, or of the need for developing better resilience among physicians, or to even begin to screen for better indicators of “true” empathy and commitment to others.15 Instead of dealing with the symptoms that develop over time from the pressures of the system, we may prevent them by preparing earlier with an awareness that will help us see all these challenges differently. An article by Harvard Business Review highlighted this critical deficiency in that people start learning leadership skills too late in their careers.16 There are many ways that medical students, and even premedical students, can begin their journey with learning about the outward mindset. I have found the books I mentioned previously to be approachable and thought-provoking just by reading them on my own.1–3 A group of students interested in exploring the material further can form a book club to discuss the material, which can serve to improve their understanding of the concepts while also building connections with each other. One of the things I appreciated about the book clubs I participated in before medical school was the connections I developed with coworkers as we coached each other on how to apply the outward mindset to different professional and personal challenges we were experiencing. Many of the concepts in the books are intuitive and do not require an expert facilitator to navigate, as well as student-led book circles allow for flexibility with time commitment. Additionally, the philosophy of an outward mindset complements any leadership skill or behavior, and the books could fit well within a medical school’s existing leadership development curriculum. As we progress in our training, gain more clinical experience, and face new challenges and invitations to turn “inward”, we may find it beneficial to revisit the books and participate in more advanced in-person workshops.4,5 Consistent and on-going engagement with the material can help not just ourselves, but it can help our peers and all those engaged in healthcare to better serve our patients and each other. Before entering medical school, I had helped fellow colleagues by introducing them to the book “Leadership and Self-Deception” and facilitating book clubs with the other titles I have mentioned. I hope to help myself and my classmates continue this journey, reminded of the way of seeing others that inspired us in the first place to seek this profession and commitment. CASE ANALYSIS: LAURA LAMBERT, MD, FACS ENS Nevo’s experience as a new medical student is not surprising, even at a medical institution dedicated to mission and service. In my own experience as a medical student, resident, fellow, and surgical attending, I have seen the stress of medical education and practice constantly shift the focus of students and providers from helping and healing through connection with patients and their families to checking boxes and meeting productivity expectations. This is particularly challenging for medical students on clinical rotations, as the clinical learning environment does not provide clear learning objectives and they are always “under the microscope” with regards to knowledge, technical skill, and performance as a “team” member. People who hold the keys to their future are watching and grading everything they do and say. And, because of the demands of the profession, they are most often dealing with people who are predominantly inward focused—especially in surgery. Under these demanding conditions, students often perceive that they are being treated like objects, which invites them to pass that same feeling along to their colleagues and patients. Over the course of the two years of clinical rotations, the constant stress of competitive classwork, continual critique, and often condescending remarks from professors and residents, results in many students losing sight of the humanity that originally drew them to medicine. A DEEPER DIVE INTO THE ANATOMY OF HUMANISM Seeing people as people is a seemingly straightforward concept that is the absolute epitome of humanism. One of the books ENS Nevo mentioned in his learnings on the outward mindset, “Leadership and Self-Deception”, teaches about what it means to be “in the box”—seeing people as objects rather than as people and the impact that our way of seeing has not only on the other person, but also on ourselves. I felt an immediate connection with the book’s teachings, and I recognized the essential role that our way of seeing others plays in our ability as physicians to help others heal. I also recognized the impact that our way of seeing others has on the meaning that we find in the work of medicine and thereby our resilience against depression and burnout, both of which are major concerns among medical students and physicians. Another book ENS Nevo mentions, “The Anatomy of Peace”, explains that when we are “in the box” we create a distorted image of both ourselves and others. We can tell that these images are distorted, because they create within us a need to justify how we are seeing—a need that is most often met by blaming either the other person or ourselves. When we blame others to justify our distorted image of them, we feel as if our heart is at war—with others, with the world, and with ourselves. Whereas, when we are “out of the box”, we see both ourselves and others as we truly are and we have no need for justification. “Out of the box” our heart is at peace—with others, with the world and with ourselves. As a faculty advisor to the third-year medical students, I created a series of group training sessions during the surgical rotation called “The Anatomy of Humanism”. In it, my students and I explore how we can help our patients and their families heal by applying the principles from “The Anatomy of Peace” to medicine, and to the challenging experiences our medical students are experiencing in the moment. These sessions give the students an opportunity to reflect on their experiences in surgery and other clinical rotations and some of the challenges they have faced. During these sessions, the students and I are able to reconnect with our original purpose for getting into medicine: to help PEOPLE. Through these sessions, students learn how to get “out of the box” and relate to patients as people to be healed—not problems to be solved—especially when students feel like they have limited knowledge, limited skill, and no power as the lowest person in the medical hierarchy totem pole. We help them see that even though they may have limited medical knowledge, they actually have a greater capacity to help others heal, as they are often more humanistic than many seasoned physicians. Unfortunately, because of the shadow of the current medical environment, the easing of suffering through human connection is often not seen as scientific, professional, or productive (ie, “valuable”). This can be a very hard thing for students witnessing the reality of the environment of medicine for the first time. I believe that sharing these humanistic principles with the medical students is more important than anything I can teach them about surgery. How these students see others will affect who they are for the rest of their lives and help them to become not just a doctor, but more importantly, a healer. HUMANISM AS AN ANTIDOTE TO BURNOUT Finding meaning in the work of medicine by learning to see patients as people is a powerful antidote to depression and burnout.17 With new requirements to use electronic medical records and complex billing procedures, physicians actually spend more time on administrative work than they do with their patients. Dictating and billing can feel like a second job.18 Medicine is big business now. The doctors in a hospital are the people who bring in the money. Management is constantly pressuring them to see more people in less time, with added responsibilities to go through mandated checklists in addition to the problem that the patient wants addressed. On top of that, if there is a complication with a procedure, or if something does not go right, doctors are subject not only to the emotional stress of a patient not doing well, but also the possibility of being sued. The key to combating all these pressures, to retaining one’s humanity and a heart at peace, is to see people as people. That is the one thing that can provide the most meaning and satisfaction with the work of medicine. It is the best preventative measure against burnout. When we close the door to an exam room or to a hospital room and we are face-to-face with a patient and their family, we can remember that, that is why we went into medicine—to be present, and to help, and to serve. That is when humanistic doctors experience the most joy in medicine. Being a provider should be an “out of the box” space that lets our hearts be at peace—no matter what the circumstances are. We can help prepare medical students better with this foundational awareness as early as possible. ENS Nevo identifies a simple approach for instilling this awareness early in the medical education process. With greater awareness of our own mindset, we can provide better care to patients and families, decrease student and provider depression and burnout, and change the culture of the profession to reflect that which draws people to medicine in the first place. The opinions and assertions expressed herein are those of the authors and do not reflect the official policy or position of the Uniformed Services University, the Department of Defense, or the Department of Health and Human Services. Neither the authors nor their family members have a financial interest in any commercial product, service, or organization mentioned in this article. The authors do not endorse any entity or product. References 1. The Arbinger Institute. Leadership and Self-Deception , Ed 3rd. San Francisco , Berrett-Koehler , 2018 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 2. The Arbinger Institute. The Outward Mindset , Ed 2nd. San Francisco , Berrett-Koehler , 2016 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 3. The Arbinger Institute. The Anatomy of Peace . San Francisco , Berrett-Koehler , 2006 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 4. Available at https://arbinger.com/Workshop/Publicdiom.html; accessed June 1, 2020 . 5. Available at https://arbinger.com/Workshop/PublicOMSL.html; accessed June 1, 2020 . 6. Warman SA : The role of the physician in 21st century healthcare. Nota Bene: ideas for thought leaders . Assoc of Acad Health Centers 2017 December. Available at . https://www.aahcdc.org/Portals/41/Series/Nota-Bene/v2n1/Nota-Bene-12-17.pdf; accessed June 1, 2020 . Google Scholar OpenURL Placeholder Text WorldCat 7. Yates SW : Physician stress and burnout . Am J Med 2019 ; 133 ( 2 ): 160 – 4 . Google Scholar Crossref Search ADS PubMed WorldCat 8. Patel RS , Bachu R, Adikey A, Malik M, Shah M: Factors related to physician burnout and its consequences: a review . Behav Sci (Basel) 2018 ; 8 ( 11 ): 98 . Google Scholar Crossref Search ADS WorldCat 9. Willis S : Uniformed Services University of the Health Sciences . Acad Med 2003 ; 78 ( 4 ): 380 . Google Scholar Crossref Search ADS PubMed WorldCat 10. LaRochelle J , Durning SJ, Guilliland W; et al. : Developing the next generation of physicians . Milit Med 2018 ; 183 ( 11/12 ): 225 – 32 . Google Scholar Crossref Search ADS WorldCat 11. DeZee KJ , Durning SJ, Dong T; et al. : Where are they now? USU School of Medicine graduates after their military obligation is complete . Milit Med 2012 ; 177 ( (9) Supp ): 68 – 71 . Google Scholar Crossref Search ADS WorldCat 12. Konrad TR , Link CL, Shackelton RJ; et al. : It’s about time: physicians’ perceptions of time constraints in primary care medical practice in three national healthcare systems . Med Care 2010 ; 48 ( 2 ): 95 – 100 . Google Scholar Crossref Search ADS PubMed WorldCat 13. Mullainathan S, Shafir E. Scarcity: Why Having Too Little Means So Much . New York, NY: Henry Holt and Company , 2013 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 14. Victor Frankl . Available at https://www.goodreads.com/quotes/tag/frankl; accessed June 1, 2020 . 15. Hemmerding J , Stoddart S, Lilford R: A systemic review of test of empathy in medicine . BMC Med Ed 2007 ; 7 ( 1 ): 24 . Google Scholar Crossref Search ADS WorldCat 16. Zenger J : We wait too long to train our leaders . Harv Bus Rev 2012 . Posted Dec 18, 2012. Available at . https://hbr.org/2012/12/why-do-we-wait-so-long-to-trai Accessed June 1, 2020 . Google Scholar OpenURL Placeholder Text WorldCat 17. Schattner A : An antidote to burnout? Developing broad-spectrum curiosity as a prevailing attitude . QJM 2019 . (epub ahead of publication available at . https://doi.org/10.1093/qjmed/hcz322; accessed June 1, 2020 . Google Scholar OpenURL Placeholder Text WorldCat 18. Patel RS , Bachu R, Adikey A; et al. : Factors related to physician burnout and its consequences: a review . Behav Sci 2018 ; 8 ( 11 ): 98 . Google Scholar Crossref Search ADS WorldCat Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2020. This work is written by US Government employees and is in the public domain in the US. This work is written by US Government employees and is in the public domain in the US. Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2020. This work is written by US Government employees and is in the public domain in the US.

Foslien-Nash,, Cynthia;Reed,, Brady

doi: 10.1093/milmed/usaa143pmid: 33002145

ABSTRACT Health care and the Veterans Health Administration have adopted many initiatives to improve patient care, including efforts to create a “Just Culture” environment for patient safety and quality outcomes. Despite significant resources and efforts on these initiatives and some temporary improvements, we continue to struggle to make significant and sustainable improvements. At the Veterans Administration North Texas Health Care System, we see that our efforts have addressed the wrong thing. By focusing our efforts to shift the underlying mindset that drives behavior, we expect to create the foundation that will help us truly achieve a High Reliability and Just Culture organization that provides the care and outcomes our patients and staff deserve. NATIONAL HEALTH CARE CHALLENGES Since the publication of “To Err is Human” almost 20 years ago, the U.S. health care system has been focused on improving patient outcomes.1 One focus has been the development of “Just Culture (JC)”2 defined as “a learning culture that is constantly improving and oriented toward patient safety.”3 The primary appeal of creating such a culture is to encourage individuals to report mistakes so that the precursors to error can be better understood in order to fix the system issues. In this concept, individual practitioners should not be held accountable for system failings over which they have no control. A JC is one that has fair and just systems for holding people and the system accountable for quality and safety. Many efforts to achieve this culture have focused on improving relationships and teamwork.4 For example, the Veterans Health Administration (VHA) has been employing programs to help create better means of communicating and improving relationships through storytelling.5,6 The Department of Defense and Agency for Healthcare Research and Quality led implementation of TeamSTEPPS7 to improve teamwork and communication in an effort to reduce risks. TeamSTEPPS provides a variety of tools, techniques, and vocabulary to model, often through simulation practice first, and then apply in the health care work environment. This framework has also been employed in some corners of the VHA. Numerous other health care organizations and associations have also developed their own frameworks and techniques for ways to build the desired culture into an organization.8 Yet despite the efforts to adopt and implement these frameworks, patient safety and quality outcomes continue to be a challenge throughout the U.S. health care system.9 A recent study published by the American Journal of Medical Quality noted multiple challenges in the adoption of a JC, including no reduction in the reluctance to report or change in the culture of blame it targets, and no correlations between measures of safety beyond chance alone. In particular, the report noted that in over 90% of hospitals self-reporting is still not a top source of case finding.10 Challenges in adoption included: confusion and concern about job security, with widespread variation in standards hampering hospitals’ efforts to make improvements; perception of JC as a stand-alone program, as well as physician perception of it as a set of principles to be applied to nurses; and even simple resistance to adopting the program without understanding its goals. This failure to increase self-reporting is particularly undermining to this initiative. Without staff willing to report their challenges or near misses, there is no way organizations can learn from them and address the system issues that may have allowed harm. Staffs, focused on doing their own role with prescribed behaviors consistent with the JC standards, miss the impact that failing to report has on future outcomes. VETERANS ADMINISTRATION NORTH TEXAS HEALTH CARE SYSTEM (VANTHCS) CHALLENGES The VANTHCS has sought to optimize and utilize all available training and leadership techniques to improve the health care system culture and improve service to veterans. Success in the overall culture and performance has included improvements in scores for being a VHA regional “best places to work”, having improved from 18th up to 2nd from 2015 to 2019; continuing to improve access to care by increasing outpatient visits and appointments; and compliance with and attainment of the metrics and requirements of all the Congressionally mandated legislation and commitments to improving Veterans’ health.11 Yet, despite these improvements in metrics, there continues to be a challenge in achieving a breakthrough in sustaining and continuously improving the culture of accountability and the impact on veterans’ health. Patient satisfaction scores (Veterans Administration [VA] Survey of Healthcare Experiences of Patients) still have not significantly improved.12 On the annual VA All Employee Survey, staffs continue to identify “communication” and “accountability” as the 1 and 2 areas, respectively, and “coworker relationships” as 5 of key areas in need of improvement. Multiple training efforts, although often showing some initial improvement, fail to sustain cultural change and after a few months teamwork and cultural measures slide back to the prior underperforming levels. WHY JC INITIATIVES HAVEN’T WORKED One factor that contributes to the lack of success of culture change initiatives is the focus on prescribing behaviors. A consistent theme among the various frameworks is the emphasis on “appropriate” behaviors for the different situations and scenarios that arise in health care. Although much time, effort, and focus are placed on building awareness and then training in the appropriate tools and techniques, thus prescribing the desired behaviors, this approach still relies on a system of classifying the fault after the fact. The heavy emphasis on clarifying the distinct roles, responsibilities, and subsequent behaviors for each individual naturally creates an environment where each individual is focused on doing what is their “right behavior” rather than a focus on how their behavior will impact those around them. This focus on behavior misses the role of mindset on the impact of the behavior. Behaviors are driven by underlying mindset or personality type. Much of the current human development literature recognizes this and has placed a greater emphasis on assessing an individual’s belief system or worldview rather than behaviors.13–15 These approaches recognize the impact mindset has on how behaviors are performed and the subsequent outcome from that belief or personality type. Although the focus on JC has emphasized teaching the “right” behaviors, those behaviors can be at odds with an individual’s self-view or mindset. This may be at the heart of why the desired culture does not manifest even as employees intellectually support it or align with its goals. A different perspective on the role of mindset is presented in “The Outward Mindset (OM).”16 Rather than describing mindset as an individual’s choice of a belief system or worldview that can be classified, this work describes mindset as a dynamic choice in how an individual “sees” themselves in relation to others at any moment. The choice that then drives the impact of behaviors is not an individual’s preferred worldview or “style,” but rather the focus of the impact the individual seeks from their own behavior. This nuance in the perception of mindset as a choice rather than a preference is critical in understanding why culture change initiatives targeting correct behavior have not successfully shifted culture and patient safety outcomes. Rather than a focus on choosing the right “behavior” that most culture change initiatives seek by using training and assessments, the “OM” framework guides individuals to choose the focus of their impact. In this framework, all behaviors can be done from one of two mindsets: one is called “inward,” where the individual’s focus is on his or her tasks or job rather than the impact of that work. In this self-focused mindset, others are seen as objects, not people with needs, hopes, and challenges as important and equal to one’s own. This does not mean an individual intentionally looks down upon others, has only self-centered interests, or has any malicious intent. Rather, an inward focus can simply be just focusing on doing what one thinks they are supposed to do: i.e. doing the right behavior that one has been trained to do or told is the right thing to do. In effect, this is what most culture change training initiatives focus on teaching, the “right” behavior. However, from an inward mindset it is difficult to see near misses or systemic mistakes when one’s own efforts have been “behaviorally correct.” From this mindset it is easier to justify not sharing mistakes, near misses, etc. with the risk and potential impact on one’s workload, income, or opportunities. Unfortunately, the impact of not sharing will likely impact other peoples’ workload, income, and certainly that of the organization, and in particular patient safety. From an inward mindset, an individual simply does not see this impact. Another aspect of an inward mindset that prevents achieving a JC or any other improvement is “self-deception.” Research on organizational mindset shows a particular pattern—people routinely view themselves better than their organization.17 This research and data show people assess their organization, when measured on a scale from 0 (low) to 10 (high) in terms of collaboration, transparency, trust, engagement, etc., at an average of a 4.5 out of 10, while rating themselves at an average of 6.2 out of 10. This difference, which an organization made up of individuals on average at a 6.2 sees itself as a 4.5 overall, is termed the “self-deception gap.” Culture change waits in these organizations because individuals, although not seeing themselves as perfect or without room for improvement, see others in their organization as the “real” problem. Rather than fully engaging in how they can help improve culture or outcomes themselves, they find ways to justify why they are not at fault for the less than optimal culture. Within the culture change literature, this self-deception gap seems to be a significant indicator of the challenge for organizational change. Research has shown that organizations that have the least improvement in patient safety outcomes tended to have leadership that rated their organizations higher on the JC spectrum. Additionally, it showed that it was the frontline assessment of the culture of the organization that was more predictive of the actual patient safety outcomes. The organizations with the better patient safety outcomes were those where leadership’s assessment of the culture of the organization was much closer to those of the frontline staff.18 To create the desired JC, there needs to be a deliberate effort to address this leadership gap—not just at the individual staff level, but starting with senior leadership teams. A third aspect of culture change initiatives that may contribute to their failure is the “dehumanizing” nature of prescribing correct behaviors. At their core, organizational efforts to induce the “right” behavior may be seen by individuals as requiring them to be conformant, an effort by the organization to shape them into the right “tool” to serve the organizational goals for patient safety and quality. In health care, where many providers have taken oaths to serve their patients and spent years devoted toward their professional development as experts in that service of patient safety and quality outcomes, additional efforts that say “you must be this way” may create resistance to change. When organizations are telling providers to change and prescribing what they are expected to do, the providers are essentially being “seen” as objects, as tools, by the organization, which invites additional resistance from those providers to the changes they are being “required” to make. Although organizations often accept this dehumanizing quality as acceptable to the strategy for achieving organizational goals, research indicates there is little evidence to suggest this is effective.19 Most change initiatives try to force creation of changed culture by prescribing behaviors, a system where the fault is classified after the fact. Creating any improvement culture means working on the front end to prevent the problems, not by focusing on just being great at your job and doing the right behaviors but, in the complexity of health care, doing your job and the behaviors in a way that actually helps others achieve the outcomes desired. Training people in behaviors does not address this. What does address this are training experiences that help people see their work in relation to others and looking for the impact of their actions. WHY SHIFTING MINDSET MATTERS With an inward mindset, where individuals and organizations see others as objects, it is easy to blame others for problems that arise. An organization where the approach to improvement is based on judging the appropriateness of behavior creates an environment that, despite the intention, is still foundationally determining blame for adverse actions. This invites individuals to be self-focused and accountable only for their actions, not the outcome of their actions. When blame is commonplace it is difficult to establish the psychological safety necessary for change. The opposite of an “inward mindset” is an “outward mindset.” With an OM, individuals see others as people who matter like they matter—regardless of race, color, creed, rank, or position. The focus shifts from not only doing their job well but doing it in a way that seeks to have a positive impact on how well others are able to accomplish their goals and objectives. Success is measured not just in “my” results, but the degree to which one’s behavior helped achieve “our” results. If a culture change is to be achieved that successfully integrates the complexity of health care services to improve patient safety and outcomes, individuals must focus not just on what to do but how to do it. Shifting mindset becomes foundational to doing the right behaviors in a way that leads to the right impact. Army medicine has utilized the OM framework for over 5 years with significant improvement in their levels of staff engagement and psychological safety, key factors in the foundation of a JC environment, leading to improved patient safety and satisfaction outcomes.20 JC becomes achievable not by creating standards to hold people accountable to but instead by creating and developing people who want to be accountable for their impact on others. Caring in health care is not only about doing one’s job but also about the impact of one’s work on the team, the organization, and patients as a whole that creates the actions and behaviors that embody a JC without the need to prescribe the desired behavior. LAYING A NEW FOUNDATION FOR JC AND MOVING TOWARD HIGH RELIABILITY JC has been a goal for almost 20 years in health care to improve patient safety. More recently, the creation of a High Reliability Organization (HRO) has become the goal for health care improvement, including adoption of this goal by the VHA.21 Although there are additional principles that define an HRO, a preoccupation with failure is step 1, and a culture that promotes reporting of mistakes and errors is foundational for achieving that principle.22 Shifting organizational mindset is then the first step in the journey to achieving high reliability. The OM framework identifies that changing organizational culture requires addressing the “self-deception” gap with the executive or senior leadership team of an organization first before introducing it to “lower” levels of the organization, a “waterfall” approach (Fig. 1). Based on the success of Army medicine and this implementation approach to shifting organizational culture and performance, VANTHCS embarked on shifting its organizational mindset. Starting with its new executive team, VANTHCS leadership has completed two Arbinger workshops: the outward mindset workshop then followed by the outward leadership workshop, and further augmented its leaders’ awareness and deliberative practice with outward mindset implementation coaching.23–25 This investment to leverage the impact of the shift in the executive leaders had immediate and profound influence. With every executive conducting a “Report Down” (Fig. 2) to their direct reports—an exercise in holding themselves accountable for how well they are leading—there was an expedited response and demand from the next level of leaders to complete their own participation in the OM workshop. With over 30% of 430 supervisors having participated in the initial outward mindset workshop, the “waterfall” OM implementation framework is ahead of schedule to complete the initial outward mindset workshops for all VANTHCS supervisors by the middle of 2020. FIGURE 1 Open in new tabDownload slide Common training vs Outward Mindset training approach to shift culture. FIGURE 1 Open in new tabDownload slide Common training vs Outward Mindset training approach to shift culture. FIGURE 2 Open in new tabDownload slide OM Reporting Down tool. Copyright 2020 Arbinger Properties, LLC. All Rights Reserved. Used with permission. FIGURE 2 Open in new tabDownload slide OM Reporting Down tool. Copyright 2020 Arbinger Properties, LLC. All Rights Reserved. Used with permission. A benefit of the waterfall framework has been the anticipation and interest of staff at the lower levels of the organizational structure for the OM material. This is an atypical response from the more standard reluctance of frontline staff for new trainings, which has accompanied past initiatives for change. To expedite engagement and understanding of this shift in mindset in the challenging time and financial resource constraints of a health care delivery organization, rather than training the remaining 5,700 staff with the full 2-day DIOM workshop, VANTHCS internal facilitators will utilize a revised approach to the standard 2-day workshop, OM Fundamentals, which can be delivered over several weeks in 15–20 minutes snippets arranged within a lunch-n-learn schedule.26 It is anticipated that by not taking frontline staff away from their primary work serving our veterans, there will be less reluctance and resistance to the material and the change effort overall. For staffs who demonstrate continued interest and growth with this material, the VANTHCS internal leader development program will have the foundational DIOM workshop embedded in it to continue the organizational growth and culture shifting to an OM. THE ROAD AHEAD With this organizational shift in mindset, the VANTHCS will continue its pursuit of HRO and a JC environment. Already the VANTHCS has seen its Strategic Analytics for Improvement and Learning rating (similar to the Centers for Medicare & Medicaid Services rating) improve from 1 to 4 stars. However, different from prior efforts, results are thought to be significantly better and more sustainable because relations between people will be genuinely better at a deep, foundational level. By addressing the underlying factor that sets the conditions for cultivating the right behaviors up front, the organization will invite the natural inclinations of our people to connect and serve each other and our veterans better, achieving the true collaboration and innovation necessary to succeed in the complex health care environment. Effective introduction of VANTHCS culture and mindset to new employees must occur in New Employee Orientation. During the first days and weeks of experience with VANTHCS, new staff will learn the facility workplace culture. The learned culture must include overlapping and synergistic practices of those within an HRO and JC with an underpinning of the OM. The principles of HRO, JC, and OM are the building blocks of a healthy health care organization workforce (Fig. 3). FIGURE 3 Open in new tabDownload slide VANTHCS synergistic integration of HRO, JC, and the OM. FIGURE 3 Open in new tabDownload slide VANTHCS synergistic integration of HRO, JC, and the OM. Health care is filled with people who instinctively sought a career and profession that helps serve the needs of others. In many ways, with progressively more training, checklists, procedures, and competencies with which staff are expected to comply, health care creates an environment inviting individuals to focus on their own job, their own compliance with the required, prescribed activities. The connection to others, including patients, and the impact of one’s work on those is lost in the ever-increasing new “patient safety and quality improvement” initiatives and tasks one is expected to complete. To achieve a JC and achieve the safety, quality, and patient satisfaction goals of health care, we have recognized that JC cannot be just the behaviors we prescribe and want to see; it has to be the shift in mindset that allows those behaviors to flourish naturally. CONFLICT OF INTEREST Brady Reed is a full-time Strategy Consultant for the Arbinger Institute. He serves in the U.S. Army Reserves as the Commander for an Army Reserve Hospital Unit. The views expressed are solely those of the authors and do not reflect the official policy or position of the U.S. Army, U.S. Navy, U.S. Air Force, the Department of Defense, the Department of Veterans Affairs, or the U.S. Government. REFERENCES 1. Institute of Medicine (US) Committee on Quality of Health Care in America . In: To Err is Human: Building a Safer Health System . Edited by Kohn LT, Corrigan JM, Donaldson MS. Washington (DC) , National Academic Press (US) , 2000 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 2. Marx D. Patient Safety and the “Just Culture”: A Primer for Health Care Executives . Available at https://psnet.ahrq.gov/issue/patient-safety-and-just-culture-primer-health-care-executives, April 17, 2001 ; accessed March 1, 2020 . 3. Boysen PG : Just culture: a foundation for balanced accountability and patient safety . Ochsner J 2013 ; 13 ( 3 ): 400 – 6 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 4. Frankel AS , Leonard MW, Denham CR: Fair and just culture, team behavior, and leadership engagement: the tools to achieve high reliability . Health Serv Res 2006 ; 41 ( 4 Pt 2 ): 1690 – 709 . Google Scholar Crossref Search ADS PubMed WorldCat 5. Gallo C : A novel program at VA hospitals uses an old-world tradition to advance patient care . Forbes . Available at August 25, 2019 . https://www.forbes.com/sites/carminegallo/2019/08/25/a-novel-program-at-va-hospitals-uses-an-old-world-tradition-to-advance-patient-care/#668887ae5165 accessed March 1, 2020 . Google Scholar OpenURL Placeholder Text WorldCat 6. Roy J. VANTX group therapy uses storytelling and dragons. VA North Texas Health Care System . Available at https://www.northtexas.va.gov/NORTHTEXAS/features/Group_therapy_uses_storytelling_and_dragons.asp; accessed March 1, 2020 . 7. Henricksen K , Battles JB, Keyes MA et al. (editors). Advances in Patient Safety: New Directions and Alternative Approaches . Agency for Health Care Research and Quality (US) , 2008 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 8. Leading a Culture of Safety: A Blueprint for Success . Boston , American College of Healthcare Executives and Institute for Healthcare Improvement , 2017 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 9. Bates DW , Singh H: Two decades since To Err is Human: an assessment of progress and emerging priorities in patient safety . Health Aff (Milwood) 2018 ; 37 ( 11 ): 1736 – 43 . Google Scholar Crossref Search ADS WorldCat 10. Edwards MT : An assessment of the impact of just culture on quality and safety in US hospitals . Am J Med Qual 2018 ; 33 ( 5 ): 502 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 11. S.2921 - Veterans First Act. U.S. Congress Available at https://www.congress.gov/bill/114th-congress/senate-bill/2921/text, 2016 ; accessed March 1, 2020 12. VA Survey of Healthcare Experiences of Patients (SHEP) – Experience of Care Measures . Available at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/VA-Data; accessed March 1, 2020 . 13. Dweck C : Mindset: The New Psychology of Success . New York , Ballantine Books , 2008 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 14. Sinek S : The Infinite Game . London , Portfolio Penguin , 2019 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 15. Stein R , Swan A: Evaluating the validity of Myers-Briggs type indicator theory: a teaching tool and window into intuitive psychology . Soc Pers Psychol Compass . Available at 2019 . https://onlinelibrary.wiley.com/doi/abs/10.1111/spc3.12434 accessed March 1, 2020 . Google Scholar OpenURL Placeholder Text WorldCat 16. The Arbinger Institute : The Outward Mindset . San Francisco , Berrett-Koehler Publishers , 2016 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 17. The Arbinger Institute : Available at https://arbinger.com/MindsetWeb.html; accessed March 1, 2020 . 18. Vogelsmeier A , Scott-Cawiezell J, Miller B: Influencing leadership perceptions of patient safety through just culture training . J Nurs Care Qual 2010 ; 25 ( 4 ): 288 – 94 . Google Scholar Crossref Search ADS PubMed WorldCat 19. Christoff K : Dehumanization in organizational settings: some scientific and ethical considerations . Front Hum Neurosci 2014 ; 8 : 748 . Google Scholar Crossref Search ADS PubMed WorldCat 20. The Arbinger Institute : Arbinger Training Dramatically Improves Culture in Healthcare . Available at https://arbinger.com/whitepapers.html; accessed March 1, 2020 . 21. VA National Center for Patient Safety : VHA’s HRO Journey Officially Begins . Available at https://www.patientsafety.va.gov/features/VHA_s_HRO_journey_officially_begins.asp, March 29, 2019 ; accessed March 1, 2020 . 22. Chassin MR , Loeb JM: High-reliability health care: getting there from here . Milbank Q 2013 ; 91 ( 3 ): 459 – 90 . Google Scholar Crossref Search ADS PubMed WorldCat 23. The Arbinger Institute : Developing and Implementing an Outward Mindset Workshop . Available at https://arbinger.com/Workshop/Publicdiom.html; accessed March 1, 2020 . 24. The Arbinger Institute : Outward Leadership Workshop : Available at https://arbinger.com/Workshop/PublicOMSL.html; accessed March 1, 2020 . 25. The Arbinger Institute . Implementation Coaching : Available at https://arbinger.com/coaching.html; accessed March 1, 2020 . 26. The Arbinger Institute . Outward Mindset Fundamentals : Available at https://arbinger.com/OutwardMindsetFundamentals.html; accessed March 1, 2020 . © The Author(s) 2020. Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States. All rights reserved. For permissions, please e-mail: [email protected]. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)