I was asked to speak at a multi-state health system retreat in Oklahoma1 where I sat at the senior leaders’ table for lunch. There, I was pulled into a conversation between a CNO and a CMO about an event that had happened the previous night. Apparently, a nurse had a care question about a patient and called the patient’s doctor-of-record. The doctor refused to take the nurse’s call, feeling like she should call the doctor-on-call instead. The CNO said that it was outrageous that the doctor would not take the call. The CMO said that it was outrageous that the nurse would not follow protocol and call the appropriate doctor. I simply asked, “what happened to the patient?” While we understand the importance of teamwork in operations, sometimes our collective histories get in the way of practicing teamwork in our daily deeds. Since this story was recounted by the senior leaders of a hospital system, this spoke not just about how those at the bedside forget this lesson, but also how our own leadership forgets this lesson, in their effort to be right or score points.
Even though we preach teamwork as essential to high-quality/low-error healthcare as well as improved patient experiences, it is clear that we often are not focused on that concept in day-to-day operations. In the last essay, I said that it was easy to blame staff for falling back to their behaviors focused on self-preservation because while the organization may also preach teamwork, they set up rules and processes that foster a blame-oriented approach to daily operations. In this essay, I will explore ways that leadership can make changes in process and mindset to help steer people away from blame-and-shame, while still maintaining a system that can evolve towards better health outcomes by identifying and eliminating mistakes.
This last point highlights a common, and erroneous binary fallacy. When I say that we need to move away from blaming to find a more solution-oriented forward-thinking team approach, some mistake this for not wanting to hold people accountable. I am not sure if those folks are being facetious or just dense, but I don’t think it is revolutionary to say that we can both understand and resolve the problem moving forward without resorting to a witch-hunt AND still hold people accountable for their lapses. This essay explores ways to fix problems while not reducing every issue simply to a case of failed individual accountability.
Address Powerlessness
One of the reasons why people will justify not embracing teamwork and instead throwing someone else under the bus is because they feel powerless in the situation.
- “I don’t make the rules, I just follow them.”
- “Clearly whoever made this decision doesn’t know how things work in the real world.”
- “Don’t blame me, blame the idiot who ordered this stupid test.”
All of these excuses have one thing in common. The speaker implies that they have no control over their day and is just following orders. They also assume that someone else does have the power. Of course, if you find that person, they will, likely, also claim powerlessness. Their boss, or the board, or the bond-holders, or CMS have the real power. It is amazing how quickly someone can push the blame onto someone else. It is also amazing how quickly any real responsibility vanishes. When the real villain is “market forces,” or “aging demographic,” or “the core rate of inflation” we can all sit around feeling comfortable in our own ineffectiveness. Powerlessness ironically becomes the real power.
If you want to combat the deflection of responsibility, organizations should focus on collaborative decision-making. Often a hospital’s process for admitting patients centers exclusively on the inpatient nursing staff. But the ease of admitting says as much about how quickly housekeeping can turn over a room for admission, the messaging and planning of the emergency department, the ability of doctors to get patients discharged in a timely fashion.2 So any discussion about the process should include members of all of these areas to hammer out an understanding of the pain-points as well as work on a solution. Since not all admissions come through the emergency department, clinics should also be present at the table. I know that some will read this and complain that every committee tasked with tackling a significant problem must be massive. Not necessarily. Their perspective should be present, but all of their butts don’t need to be. The most successful groups I have worked with have managed to bring in a diverse set of viewpoints while only having 8-12 members. If even this seems large, I would point out that any additional struggles to reach consensus with a larger group are offset by not allowing any individual to plead powerlessness, since their team was at the table working on the policy.
Stop Treating Clinicians Differently
From a system’s perspective, the most attractive measures to track are the overall ones, so we see measures like Overall Rating or Likelihood to Recommend on pillars and other dashboards. These are, though, essentially, administrative measures. Because the clinicians are usually assigned other measures that are seen as more closely aligned with their behavior.
So, for example, a system may hold outpatient clinics accountable for a “Likelihood to Recommend this Clinic” measure. At the same time, though, the physician’s medical group will attach scores on the “Likelihood of Recommend this Provider” question to their compensation. While this seems like a good way to get physician buy-in, in reality, it divides the clinic staff among those focused on the performance of the clinic and those focused on the performance of the doctor. This often leads to separating out these audiences when talking about process improvement strategies. This all but guarantees that there will be no alignment and no teamwork amongst groups. Once, I was working with an Iowa hospital trying to improve their clinic patients’ perception of care. I asked to bring all of them into the same meeting to discuss teamwork, but what shot down because it would be too cumbersome to schedule. Too difficult to schedule, even though the two groups (clinic administration/nurses and doctors) met at the exact same time. The real reason why the administration didn’t want to move both groups to a larger conference room was because both groups were chasing different goals. Since they were chasing different numbers, they wouldn’t collaborate on a unified plan. This lack of teamwork would likely be exacerbated when one group celebrated making their goal, as the other group bemoaned missing theirs.
Collaborative Goal Setting
Even if an organization can get everyone chasing one goal, they often fail to capitalize on true teamwork by still focusing on individual performance. It is interesting that a health system with a dozen hospitals and seventy-five clinics will aggressively standardize nomenclature, logo, appearance, color scheme, scheduling, electronic health records, etc., but still measure hospitals and clinics in isolation. So, the effort to make us all walk and talk alike does not extend to their service scores. The corporate leadership will still talk about how Hospital A is doing well, but Hospital B and Hospital C are not doing well. This compartmentalization may make sense when it comes to blaming3 it still is an interesting departure from all the standardization work; we only care about how each function in a vacuum and not as part of a clinically-integrated network.
The administration wants patients to trust the logo in all situations, but don’t treat all of those situations as equally relevant or important to the whole system. By not reframing success and failure as part of a systemic advantage or flaw, you foster an environment where people can protect themselves rather than the system. If a patient comes into a critical access hospital emergency department and gets admitted and then transferred to a tertiary care hospital in the system with the appropriate specialists available, the system wants that patient to feel like they are safe under the shelter of the logo at each step of the way. But by parsing those areas apart, you are tacitly allowing:
- The ED to say that the inpatient floors are crowded and staff are overworked.
- The critical access hospital nurses to say that the tertiary hospital will be bigger and less personal.
- The tertiary hospital nurses to say the CAH was bare-bones and not adequate.
The same standard for care or commitment to best-practice medicine bumps up against, “Well, I did my best, good luck at your next stop for care.” Batting compartmentalization, especially in the eyes of their patients, is a constant struggle for health systems.
The most creative way of combating this silo mentality that I have seen was how Parkview Health in Fort Wayne, Indiana approached this.4 For example, with their outpatient scores, they reported clinic scores individually, but they set their system goals globally. This meant redefining success. Instead of stating that any clinic who performed above the 75th percentile would get a reward, they decided that if, say, 50% of all clinics performed above the 75th percentile, EVERYONE would get a reward, even the ones who failed to reach the mark. If they did not meet that goal, NO ONE would get a reward, even those who met the mark. Every year, they could ratchet up the metric by changing the percentage of clinics needed to reach the target score.
For those quick to bemoan that failure is rewarded or success is punished, realize that this does two important things. First, it forces managers to look beyond the four walls of their clinic and consider how their performance is impacting the system brand. Patients may be shifted between primary and specialty care, or between different specialists. This approach means clinics care about the other clinics they refer their patients to. Second, it forces managers to look beyond their four walls and realize that they only succeed when everyone succeeds. This creates an environment of social pressure and social assistance. It encourages training and shadowing across clinics. My performance impacts others, so if I am currently succeeding, it is in my best interest to help clinics on the bubble. If I am at a clinic on the bubble, it encourages me to welcome input and assistance from high-performing clinics.
Create a True North
Health systems will often pride themselves on having a unified message where all employees are focused on a single goal. They will often describe this as the whole system following a True North. So, instead of everyone operating as they think best exemplifies the mission, vision and values of an organization, everyone knows their purpose in the grand plan. The problem with this is the same as the problem with operationalizing teamwork. Organizations assume everyone understands the importance of this. Organizations don’t often do the hard work to translate the broad vision back down to individual workflows. I remember working with an expanding organization and rounding on staff at a skilled nursing facility, discussing the growth initiative. While they understood the motivation behind the growth, they were primarily concerned about what would happen to their services and their patients, as system resources might be diverted elsewhere. Without clear messaging to them, they had already started to form a bunker mentality, where protection of their staff and their patients was their primary focus and system growth was seen as a threat to this.
It can be easy to blame staff for focusing on self-preservation at the expense of a team mentality. But for us to combat this in staff, we must first ask the question of what we have done to permit, even foster, this mindset. Often decisions made for reasonable strategic reasons can encourage staff to redefine their work. Other times, decisions can have unintended consequences. These past two essays are not designed to direct blame at any level. Indeed, that would be the opposite of any intended take-away. It is simply to point out that reasonable people acting reasonably can still make decisions that hurt the collective. Assuming that everyone is smart enough to row in the same direction is often not a safe assumption, especially when they cannot see or hear the coxswain.
1I am pretty sure I have told this story before, but in my defense, it is a illustrative story.
2By the way, a standard measure most hospitals track is the number of inpatient discharges performed before 11am. This is a measure that most hospitals fail so miserably at, that it ceases to be a useful gauge of performance.
3I could have said “hold people accountable” but let us be honest, that is just corporate-speak for “blaming” since I have NEVER heard a CEO say, “I would like to hold Hospital A accountable for being awesome!”
4I should point out that it has been some time since I have worked directly with Parkview, so if they have abandoned this model, it makes me sad. If you work for Parkview, you can let me know, either way. If you work for another system that uses a similar model, you can let me know that as well.
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