Language and Hierarchy

The language we use and the hierarchy that this supports is at the core of creating, leading, and sustaining a safe culture.

The words we use

Listening to the faculty and the future (students) at the Academy for Emerging Leaders in Patient Safety (#AELPS11) over the past three days, I have heard several comments and engaged in more than one conversation regarding hierarchy, ego, and language as barriers to safe care.

During some of these discussions I heard myself and others say things like, “Communicate down to the housekeeper” and “escalate this up to the board”. While I think these comments are made with no malicious intent, and often find myself thinking and saying these things, I firmly believe that we need to be more mindful of what this “directional” language promotes.

When I listen to this language, I hear us unintentionally reinforce professional elitism. The language implies that the housekeeper is at “the bottom” of our organization and that the board member is at “the top”. Perhaps I’m reading too much into this but having served in both roles, and having been on the receiving end of these conversations for many years, I believe that this language promotes the belief that the housekeeper is at the bottom of the hierarchy and not an equal voice or participant on the care team. The more we think and speak like this, I believe, we are at risk of discounting the input of those at the lower end of the equation, as well as elevating opinions and ideas of those “at the top”, often at the expense of safe care to patients.

Listening to the team

One story we heard here was the tragic story of Lewis Blackman – a poignant reminder of the aforementioned point was the nutritionist recognizing that Lewis had not touched his food, and yet nutrition orders never changed. Did the nutritionist notice, and wonder why? Was he or she empowered to voice concern, and what might have happened had that been the case?

The care team in healthcare is made up of everyone that interacts, communicates and cares for the patient and their family. The professionals serving in the housekeeping department may spend more time in a patient’s room than many of the clinically trained team on any given day. Ensuring that these team members are engaged, respected, and listened to as valuable team members is a critical component of safe care.

Perhaps it is time that we re-think the structure and hierarchy of traditional healthcare environments

The need for a structure and redesign

I acknowledge that we need some organizing structure to run our teams and organize [lead] our organizations. That said, what we presently have in many healthcare organizations seems to be getting in the way of supporting an innovative, just, safe, learning culture.

In the words of Malcolm Gladwell from his book, What the Dog Saw, “If everyone had to think outside the box, maybe it was the box that needed fixing”. I am also reminded about the words of Don Berwick regarding system design, “Every system is perfectly designed to get the outcomes it is achieving”

It is fair to say that our current healthcare system, if designed to get the outcomes we’re getting (estimated 400,000 lives lost a year from preventable error) needs to be redesigned.

A different approach

I recently read about an alternate approach to organizing an organization, the idea is called Holacracy and was coined by Brian Robertson. This is an alternate way of running an organization, modeled on some concepts that are being adopted more and more by innovative, forward thinking leaders. For example, peer-to-peer business models have changed how we get from A to B (Uber) and have revolutionized finding a place to stay while on vacation (Airbnb). These “disruptive” companies have started re-thinking their internal structures and have abandoned traditional top-down hierarchies, controls and processes. This approach to running an organization removes power from a management hierarchy and distributes it across clear roles, which can then be executed autonomously, without a micromanaging supervisor.

What’s interesting is that instead of the anarchy and chaos that one might expect, the work is actually more structured than in a conventional company, it just looks much different. With Holacracy, there is still a clear set of rules and processes for how a team breaks up its work and defines its roles with clear responsibilities and expectations.

David Allen, the author of Getting Things Done, summarizes adoption of this approach like this: “Holacracy is not a panacea: it won’t resolve all an organizations tensions and dilemmas. But, in my experience, it does provide the most stable ground from which to recognize, frame and address them.”

Perhaps we’re ready for a different way to organize and deliver healthcare. Perhaps we’re ready to rethink our hierarchies, controls and processes.

Perhaps healthcare is ready for a little Holacracy.

 

 

 

 

 

 

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