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Data Goes with the Flow!

In healthcare organizations, the data goes with the flow of the patient. Every step a patient takes creates a data footprint. Data literally follows the patient through the patient pathway within the healthcare organization like bread crumbs in the forest. When data is collected over a length of time, predictive data exists that can actually predict where the bread crumbs will fall with 98% accuracy within a given day, month, and season!

The first question is: are you collecting this data? It is important to collect this data in order to optimize patient flow throughout the healthcare organization as it is essential to ensuring safe, high-quality, patient-centered care.

The second question is: do you know what to do with the data? When this data is applied, for example, to a current state value stream map clinicians can see where waste exists by assessing the problem areas and identifying major areas of opportunity for change. Or maybe you'd like to balance demand and capacity through load leveling?

The Infinitum Healthcare Transformation System is based on the lean Toyota Production System that provides the right care at the right place and at the right time. Waste is removed from the patient pathway by the people doing the work as lean methodologies are learned such as visual management. Employees learn to work as a collaborative team and individual QI experts resulting in innovative problem-solving. When data is collected, monitored, and analyzed through the lens of system thinking the healthcare organization can ensure that capacity can meet the demands for services, prevent overcrowding, create predictable scheduling, and calculate the return on investment.

Last question: would you like to go with the flow of your patient data? Contact Infinitum! We will customize a learning package that fits your healthcare organization size and implement actionable strategies, transferable knowledge, and ensure a data-driven work culture.

Blog Index

You don't know what you don't know!

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It's true, you really don't know what you don't know until you become aware of it. This is more than an amusing adage as it speaks to the need for information. Information that reveals factual data to create awareness. According to Google, awareness is the "knowledge or perception of a situation or fact." Ever wonder if something is really true? Your mind tells you one thing and your gut tells you another. Somehow the human heart negotiates between the two to make a decision. But how do you know if it's the right decision until you have all the information?

When data is collected and analyzed, it reveals truth and provides knowledge. What is something you'd like know? How about the demand and capacity of your healthcare organization? Would you like to know how many people in the population you serve need to be seen and how often? Would you like to know if these patients are being scheduled correctly? Would you like to know if your demand and capacity line up? Even if your gut had a crystal ball you would never be able to guess that information. What do you need? Data! And lots of it. Preferably a year's worth, and it can be pulled from your EMR. A year's worth of data to show the fluctuations from day to day, month to month, and season to season. For example, in the fall you know you're going to have a lot of flu vaccine appointments and sport physicals before school starts. Or maybe your data will show that Mondays are consistently over scheduled.

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Now that you have the data, what are you going to do with it? Here are some basic steps:

  • Sort the patient data by provider and appointment to create upper and lower control limits. You quite literally can see the demand over time; days, weeks, months, and seasons. (There is so much you can do with this information including the takt time of the practice. We will discuss this more later, but for now, let's stay focused on demand and capacity.)

  • Pull your EMR procedure list and sort them by time to create service families.

  • Perform a patient time study on procedure time.

  • Compare the appointment times against the actual visit time.

  • Perform a root cause analysis to determine why the appointment times and actual visit time do not match.

  • Create a countermeasure plan to address the service family deltas.

  • Complete another patient time study to confirm that procedures are now correctly organized within the service family.

  • Analyze how many clinical hours and compare against demand.

  • Perform a root cause analysis to determine why the schedule does not accommodate the population.

  • Create a countermeasure plan to address the demand and capacity deltas to adjust the work load and alleviate burnout.

We've all heard the term "data-driven decision making." Why has this become so popular in system thinking? Because without data you do not have the information you need to become aware of the situation and make the most informed decision. Data will back up any decision reliably. The numbers don't lie, but your gut can. Would you like to know what you don't know using data? Contact Infinitum, the healthcare transformation system that relies on data!

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References

Awareness, defined by Google. 26 February 2019. Web address: https://www.google.com/search?q=definition+of+awareness&rlz=1C1CHBD_en&oq=definition+of+awareness&aqs=chrome..69i57j0l5.4398j1j7&sourceid=chrome&ie=UTF-8#dobs=awareness

Love my work!

Have you heard yourself tell other people those three little words? If you haven't, have you taken the time to ask yourself why? Obviously, you're passionate about your patients, the work that you do, and the people you affect or you wouldn't be where you are. Right? So what are the items that fall under the "con" column in your work life?

Lack of joy at work affects everyone in healthcare, but let's look at what a physician might have in their "con" column. According to Medscape's National Physicians Burnout, Depression & Suicide 2019 Report, 44% of the physicians surveyed in October 2018 reported that they felt burned out. And what were the top three biggest contributors? Too many bureaucratic tasks, spending too many hours at work, and "increasing computerization of practice." According to the Advisory Board's 2019 survey report, 21% of a physician's work hours are spent on non-clinical paperwork, and 54% stated they were emotionally exhausted. Sadly, this data confirms what you already know: we have a national crisis in American healthcare.

So, how is this crisis being addressed? Physicians were also asked how they cope with burnout and the top three answers were: exercise, talk with family members and close friends, and "isolate myself from others." Can you see how the root cause of the problem is not being addressed and the coping tactics are just a bandage for the real problems? There are people working together across the healthcare industry to try and find a solution for the future, but what about right now?

Infinitum can offer you a "right now" solution: assessment, transference of lean knowledge, root cause analysis, countermeasure projects, and implementation. The Infinitum Healthcare Transformation System begins with an assessment by an Infinitum Consultant, a lean healthcare expert, who will evaluate the healthcare organization for:

  • Current improvement methodology.

  • Strategic alignment of the board of directors, executives, management and frontline staff with respect to the organization's goals.

  • Alignment of overall priorities in the adoption of a lean management system.

  • Behaviors and policies that demonstrate implicit or explicit principles and expectations of leaders and staff that can accelerate or impede the adoption of a lean healthcare management system.

  • The consistency of the day-to-day approach of implementing process improvements that will provide sustainable growth and benefits to future growth strategies.

  • Enable a multidisciplinary group of stakeholders as participants to envision, simulate and co-create a future-state vision for implementation.

After the assessment, the Infinitum Consultant will customize a learning and training package for the healthcare organization based on the desired level of implementation. Infinitum offers lean healthcare methodology through the Infinitum University online education modules; on-site or virtual workshops, training, and certification for your quality improvement people or the organization as a whole; and consultant support at every level of the chosen learning and training package. Infinitum consultants are experienced multidisciplinary transformation experts who will assist a healthcare organization to design and promote a consistent day-to-day approach to implementing process improvement across the healthcare organization; achieving a sustainable culture of change and collaboration, and operations fine-tuned to deliver value to your patients while improving work relationships and reducing the mental load.

At Infinitum we help people address their "con" column by addressing the root causes within a given healthcare organization. Would you like to hear yourself say, "Love my work?!" What are you doing "right now" to improve your joy at work? Contact Infinitum!

Graphs provided by Medscape's National Physicians Burnout, Depression & Suicide 2019 Report:

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References

Hasan, Hamza Hasan. Research Division Practice Manager of The Advisory Board Company. 18 January 2019. Web address: https://www.advisory.com/daily-briefing/2019/01/18/burnout-report

Kane, Leslie. "Lifestyle Burnout and Depression. Medscape. 16 January 2019. Web address: https://www.medscape.com/slideshow/2019-lifestyle-burnout-depression-6011056

Love My Work

For the love of Lean!

Organizations love lean because it works when properly implemented. This implementation requires that the whole team be willing to look at healthcare through the lens of data and become reliant on data-driven decisions. Yes, this process improvement methodology came from car manufacturing, however, it is transferable when it comes to reducing inefficiencies and improving patient value with their healthcare being the end product. Lean has three key goals:

  1. Eliminate waste

  2. Value employees

  3. Continually improve

What is interesting about the three goals is that they work synergistically. You cannot meet one goal without meeting the other goals. Through the inclusive process of eliminating waste by focusing on non-value added activity; keeping inventory low by only storing what is needed when it is needed; embracing technology to provide data and reduce manual labor, valuing employees by developing people, and continuously improving by focusing on the root causes the synergy happens. Healthcare organizations across the country are learning to love lean as their awareness of the transformation in the way they look at the patient flow via data grows.

Recently the Infinitum Transformation Team was conducting a Value Stream Map Workshop, also known as the Transformation Acceleration Program or TAP Workshop. At the table was a representative from each work area discussing delay area 2 on their current state value stream map. One of the delays was that the "providers were running late." Through the 5-why root cause analysis it came down to the providers being late because the previous appointment took longer than expected. This happens, but upon further investigation, it was discovered that this happens frequently as in more than 50% of the time. The Infinitum Transformation Team walked them through the data mining process of figuring out their demand and capacity so that they are now scheduling patients within the appropriate time slots by creating service families; processes were reconfigured to meet the time limitations; and they learned how to create a demand chart from their data showing upper and lower control limits to address the patient demand variations with 98% accuracy.

Lean on lean; it's reliable! Contact us to learn how your organization can transform for the love of lean.

References

Dunn, Lindsey. "5 Key Principles for Hospitals from Toyota's Lean Production System." Becker's Hospital Review. 17 Sept, 2009. Web address: https://www.beckershospitalreview.com/news-analysis/5-key-principles-for-hospitals-from-toyotas-lean-production-system.html

The Heart of the Matter!

The heart of lean healthcare is to create value by eliminating waste. It's hard to imagine that there is any waste when all efforts are for the patient. After all, where would the human race be without medicine and the professionals that care for us? So let's define waste within the framework of patient flow. Waste is the non-value added activities or the inefficiencies within a given process or workflow of a system; in this case, healthcare. Gain or value-added services are what the patient is willing to pay for. Every step in a process is either value added or it non-value added. Non-value added activities fall within these eight categories:

  • Defects: Poor labeling of tests, incomplete referral instructions or missing information in patient charts.

  • Excess Inventory: The cost to store, manage, and maintain (e.g., monitor expiration dates) is greater than the savings of buying in bulk (e.g., latex gloves).

  • Excess Transportation: Moving patients back and forth, moving information, and moving lab tests.

  • Excess Motion or Movement: Lifting, bending, and reaching more than is necessary. Not having the things that are used most often closest to your work; this includes equipment.

  • Overproduction: By producing in excess, faster, or earlier than needed (e.g., producing “just in case” IV solutions, or batching lab samples).

  • Over Processing: Re-testing, extra labels on charts, multiple insurance claim forms.

  • Unused Talent or Creativity: Sharing of knowledge and ideas, working to the top of a license or skill level, and a safe culture that respects creativity.

  • Waiting or Reoccurring Delays: Waiting to be roomed, waiting to see the provider, or waiting for an x-ray are a few examples.

According to Maureen Bisognano, President Emerita of the Institute for Healthcare Improvement and a Senior Fellow, the top reason to improve patient flow is to reduce patient that feels disrespectful to patients and families. This stress on the patient is also stressful on the clinicians and staff because it negatively affects them and creates burn out. Lean provides a way to create a more effectively designed and managed process that supports clinicians and staff morale resulting in increased joy at work, reduced stress, and increased productivity and job satisfaction.

There are opportunities to remove non-value added activities within the interconnected processes in any and all healthcare systems. Lean is a multi-faceted methodology that requires a simultaneous application within a healthcare organization in the micro, meso, and macro work levels. The Infinitum Healthcare Transformation System is designed to work with and integrate all three levels:

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Some lessons from the field have taught the Infinitum Transformation Team:

  • It starts with leadership. Employees look to leadership for permission to be innovative, autonomous, and collaborative within a team.

  • Purpose (sets the direction), Process (how people do it), and People (organizational values that drive action). A shared vision is a co-created story that everyone plays a part in. Sustainable change happens when everyone moves in the same direction while aligning their actions to a shared vision.

  • The vital few must be identified. A system-wide transformation requires representation from each work area. It was Italian economist Vilfredo Pareto that reported in 1906 that 80% of the land was held by 20% of the people. He also noticed that 20% of the pea pods in his garden produced 80% of the peas. This principle of factor sparsity or the law of the vital few is known as the Pareto Principle. This statistical distribution of data states that 80% of a specific event can be explained by 20% of the total observation, or 20 percent of an activity will account for 80 percent of the results. Therefore, the 80-20 rule is a very helpful concept for life, time management, and work. A modern day example, Microsoft observed that 80% of the operating system crashes were eliminated by fixing 20% of the most reported bugs.

  • Identify issues through learning rather than blame. Learning is a curiosity rather than an assumption. The Infinitum Transformation Team asks "why" rather than "who."

  • Customer satisfaction through patient flow is the patient's perspective on how they move through a healthcare system.

  • Methods matter as much as results.

  • Back to the data; always back to the data. Not only the average, minimum, and maximum, but how often and within what control limits?

Healthcare organizations are businesses providing a service, and like all businesses, they need to focus on achieving a positive ROI (return on investment) to stay in business. The lean process can give you between 20%-60% cost savings and more work capacity which equals more profit. Lean methodology provides evidence that quality improvements are sustainable in the long term and are culture changing. The Infinitum Healthcare Transformation Team can help you get at the heart of the matter!


References

Bisognano, Maureen. "Flow Failures are Disrespectful to Patients." Institute for Healthcare Improvement. 25 Aug, 2016. Web Address: http://www.ihi.org/communities/blogs/flow-failures-are-disrespectful-to-patients

Teich, Sorin T and Fady F Faddoul. “Lean Management-the Journey from Toyota to Healthcare” Rambam Maimonides medical journal vol. 4,2 e0007. 30 Apr. 2013, doi:10.5041/RMMJ.10107. Web Address: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3678835/

Tracy, Brian. "The 80-20 Rule Explained." No date. Web Address: https://www.briantracy.com/blog/personal-success/how-to-use-the-80-20-rule-pareto-principle/

Kenton, Will. Reviewed 80-20 Rule. 29 May, 2018. Web Address: https://www.investopedia.com/terms/1/80-20-rule.asp

The Heart of Experience!

The Infinitum Transformation Team is passionate about their work. They have witnessed firsthand how lean methodologies such as value stream mapping works to increase capacity at healthcare organizations. In addition to removing waste, creating efficient processes, boosting staff morale, and addressing provider burnout, lean methodology also helps people to see how their work in interconnected to the work of others within the system of care. This self-awareness is a catalyst for change not only in the work they do, but in the relationships between the team members.

Within the Infinitum Healthcare Transformation System we have a value stream mapping workshop that we call TAP (Transformation Acceleration Program). The TAP workshop is one of many lean methodologies used by the Infinitum Transformation Team. The Infinitum Transformation Team has observed that the TAP Workshop has an effect on relationships in many ways:

  • TAP looks at processes and not people. TAP is a non-judgmental workshop that creates a safe space for people to think about how their work fits into the value stream without feeling judged. (Depending on the number of people the workshop can usually be done in 4 hours with additional pre-work and post-work hours with one designated contact.)

  • TAP creates a shared view of the patient pathway which puts the team members on the same mission to find waste and improve the patient experience by problem solving together.

  • TAP instills a shared knowledge of a quality improvement lean technique that the team members can continue to use long after the Transformation Team is gone.

In addition to the improved team member relationships and employee satisfaction, the patient relationships are improved also as they will move more efficiently through the practice system of care by having better scheduling management and less waiting.

Recently the Infinitum Transformation Team was contracted to deliver a TAP Workshop to a primary care practice. There was tension between two of the providers because one provider consistently saw more patients each day. The cause was that the other provider talked longer with each of her patients. The provider seeing more patients considered this a problem because the other provider wasn't staying within the allotted appointment time which then cascaded through the patient pathway making each consecutive patient wait longer for their appointment. The provider seeing less patients believed that taking more time with the patient meant giving them more care. They wondered how to fix the problem, and didn't know how to avoid a conflict. Does any of this sound familiar?

It was a beautiful thing to witness the two providers become aware of each other's view, and the provider who saw less patients shared how she now saw how she was holding up the patient flow in the name of care. This new shared awareness created the non-judgmental space to talk about the situation and brainstorm about how to keep the system moving on time and provide the best possible care. This is part of the IDEAL state we teach in the TAP Workshop.

We spend more time with the people we work with than our family and friends. Work relationships matter that much. We all want healthy relationships where we are respected and can work collaboratively within a non-judgmental or safe space. The TAP Workshop provides the awareness and process to support that goal. Additionally, the patient relationship has as much importance. They trust the people within a healthcare organization to provide them with the care they need. A healthcare system is complex because of the different relationships interconnected processes. Every person within that system touches the patient from the front desk that makes the appointment to the checkout desk that might schedule a test or a follow up appointment.

The Infinitum Transformation Team, like the healthcare industry we serve, are passionate about our work because we see how lean methodologies like the TAP Workshop affect relationships and the processes within a healthcare system. It is from the heart of our experience that the Infinitum Transformation Team wants to support your relationship goals and quality improvement programs. Contact us and tell us about the relationships that matter to you.

Leading by Example

"Quality is everyone's responsibility."

—Dr. W. Edwards Deming

Dr. W. Edwards Deming is one of the Infinitum Transformation Team's favorite lean leaders. He was a business consultant, statistician, engineer, author, and professor. As a leading management thinker in the field of quality, he played a major role in the post-war WWII recovery in Japan and worked closely with leaders of Japanese industry. Dr. Deming is credited for launching the Total Quality Management movement.

In his book "Out of Crisis" Dr. Deming writes about his "System of Profound Knowledge" which contained four points of views: appreciating a system, understanding variation, psychology, and the theory of profound knowledge. The theory of profound knowledge is a management philosophy grounded in systems theory. It is based on the principle that each organization is composed of interrelated people and processes that are the components of a system. His 14 point Total Quality Management Principles are:

  1. With the aim to be competitive and to stay in business, create jobs and consistency of purpose toward improvement of product and/or service.

  2. Adopt the new management philosophy because the times have changed and America needs to wake up to the challenge, learn their responsibilities, and take on leadership for change.

  3. Stop dependence on inspection to achieve quality. Eliminate the need for inspection and build quality into the product/service.

  4. Cease the practice of awarding business on the basis of the purchase price of a product/service, and instead minimize total cost. Business relationships are long-term and are built on loyalty and trust.

  5. Constantly improve the system of production and service and drive down cost.

  6. Institute training on the job is a must.

  7. Leadership should aim to help people and machines and gadgets to do a better job.

  8. So that everyone may work effectively for the company, drive out fear.

  9. Break down barriers between departments to create cross-functional teams to foresee problems of production/service.

  10. Eliminate slogans and targets for the work force asking for zero defects and new levels of productivity as they create adversarial relationships because the main cause of low quality and low productivity belong to the system and beyond the control of the workforce.

  11. Remove barriers that rob hourly people of their right to have pride in their work. It is the responsibility of leaders to provide focus on quality first.

  12. Remove barriers that rob salaried people of their right to have pride in their work. This means the termination of annual or merit rating and of management by objective.

  13. Institute a robust education and self-improvement program.

  14. Everyone should be working on accomplishing transformation as it is everybody’s job.

In addition to the above philosophy and management principles, Deming is the creator of the Deming Cycle, also known as a PDCA (Plan-Do-Check-Act) or PDSA (Plan-Do-Study-Act). This lean methodology is a continuous quality improvement tool consisting of four repetitive steps in a logical sequence for continuous improvement and learning. This lean tool is best used for small rather than complex problems.

Dr. Deming was certainly a leader in the quality management field. He led by example over a lifetime of teaching others that there is a better way to lead. We believe that part of his success was that he understood people and how they worked. We recommend watching the Red Bead Experiment. The Infinitum Transformation Team understands people and how they connect to the complexities of a healthcare system and their required involvement in quality.

"All anyone asks for is a chance to work with pride."

—Dr. W. Edwards Deming

References

  • Brainy Quote. W. Edward Deming, "Quality is everyone's responsibility." Web Address: https://www.brainyquote.com/quotes/w_edwards_deming_378714

  • Brainy Quote. W. Edward Deming, "All anyone asks for is a chance to work with pride." Web Address: https://www.brainyquote.com/quotes/w_edwards_deming_380787

  • Dr. Barbara Berry. 2011. Web Address: http://www.berrywood.com/wp-content/uploads/2011/08/DemingPaper.pdf

  • Mind Tools. 14 point Total Quality Management Principles. Web address: https://www.mindtools.com/pages/article/newSTR_75.htm

  • Wikipedia. Last updated January 18, 2019. Web address: https://en.wikipedia.org/wiki/W._Edwards_Deming

Fact: System Changes Need Collective Heroes!

Heroes are not born, they are developed by collective leaders. But what exactly is a collective leader? Sebastian Salicru, business psychologist, leadership development expert, executive coach, facilitator, researcher and author for The Professional Training Services (PTS) defines collective leadership as:

"Collective leadership is a social process aimed at accomplishing collective rather than individual goals and it requires collective and coordinated action. Terms such as 'collective', 'shared', 'distributive' or 'emergent' leadership are often used to describe very similar concepts."

Collective leadership sounds a lot like lean leadership. Like lean leadership, collective leadership breaks down silos; increases knowledge sharing across organizations; power structures change direction; team identification with team responsibility and accountability; greater utilization of talent, higher levels of engagement and commitment; improved inclusion and acceptance of multiple voices; rapid acceptance of change and implementation of innovation; and greater coordination of action and performance outcomes which all lead to better business results. The difference between the two is that lean leadership originated from the business world while collective leadership originated from the social world.

Cassandra O'Neill and Monica Brinkerhoff of The Nonprofit Quarterly (NPQ) wrote that collective leadership looks at an organization as part of a system instead of a machine. While Western leadership functions from hierarchy, the lean and collective leadership functions as a connected network. Decision making is shared as there is an assumption that people are inherently capable and can be trusted to do the right thing. The focus moves from the individual super hero to the team of super heroes and the belief that success comes from the diverse perspectives and skills of the many. Furthermore, collective leaders empower people to work with multi-steak-holders by collaborating with cross-sectors within community initiatives that have a shared vision. These transformed heroes on the ground, according to the NPQ article, benefit from collective leadership by:

  • Better decision and increased effectiveness can be accomplished with multiple perspectives provide better decisions.

  • Increased self-direction and internal motivation is the best way to eliminate resistance to change.

  • Removing barriers to internal motivation is needed for growth and development through forming a partnership toward a shared goal.

  • Shared responsibility makes the workload lighter and feels more successful.

  • Realizing potential is important for people as it leads to job satisfaction and better job performance.

  • Increased engagement and investment happens when leadership is shared and it energizes people to create.

  • Sustainability is maintained in the knowledge of the many, and change is supported by the knowledge.

Whether within the organization's system or without as part of a larger system of organizations, according to Reem Rahman, et all, of the Social Innovation Journal, collective approaches to system changes can be seen as having five major motivations:

  1. "an effective way to tackle the nature of complex social problems. Certain social problems have the qualities of being large-scale, multi-sector, interconnected, and constantly changing, so they require solutions that have those same qualities as well;

  2. designed to remain accountable to having impact that reaches the entire community served;

  3. a more efficient way to optimize resources to overcome fragmented, "service delivery chaos11" by leveraging resources outside of just a single organization;

  4. an essential way to keep up with the hyper-pace of innovation and change and ensure sustainable value chains; and

  5. a more realistic way to ensure sustained impact because they pay deliberate attention to diversifying the stakeholders as co-owners."

Rahman and his co-authors of the Social Innovation Journal further believe there needs to be two major mindset shifts in order for collective leadership to be fully accepted:

  1. Top-down or hierarchical leadership is no longer effective; and acceptance that a few people making key decisions is now spread to many different people and organizations to lead a collective approach to leadership is a better way.

  2. The methodology of change from strategic planning to emergence. By tackling the root cause of problems through the knowledge that many factors affect every problem within a system. This wider thinking for problem solving looks at the problem as a symptom that is created by interactions within many system loops. Beyond strategic plans is asking the right questions, listening for what matters, and involving all that are involved so that the direction to move emerges from the chaos.

Imagine what would happen if collective and lean leaders were ubiquitous? What if every organization embraced collective and lean leadership? What would it be like if people from all areas of an organization functioned collectively with the organizations they interact with? What would it look like if we empowered all people to be collective heroes? If the healthcare system were to change over to a collective and lean leadership style, how many heroes would be made? This is, after all, the next evolution in healthcare: create the greatest value possible for the patient while connecting the community resources to the patient for the best health outcome.

Let Infinitum show you how to make heroes in your organization. Contact us to find out how!

Work Cited

Rahman, Reem, and Michela Fenech, Nadine Freeman, Kris Herbst, Dani Matielo. Social Innovations Journal: "Let's Bust the Lone Hero Myth: The Role of Collective Leadership in Systems Change." November 30, 2018. Web Address: https://socialinnovationsjournal.org/editoins/issues-52/75-disruptive-innovations/2908.

Salicru, Sebastian. The Professional Training Services (TPS): "Collective Leadership: What, How, and Why." August 18, 2015. Web Address: http://www.pts.net.au/collective-leadership-what-how-and-why.

O'Neill, Cassandra and Monica Brinkerhoff. Nonprofit Quarterly: "Five Elements of Collective Leadership." February 1, 2018. Web Address: https://nonprofitquarterly.org/2018/02/01/five-elements-collective-leadership/