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.
Change and personal accountability in health and care!
Standing on the shoulders of the rebels, the crazy ones, the trouble makers and the boat rockers – these are the folks that I am blessed to call my friends and my colleagues; these are the people that push the envelope for change, that embrace the hard work and the ones I love!
Here’s to Colin Hung, Linda Galindo, Helen Bevan, Tracy Granzyk, Dave Mayer, Michael Bennick, Paul Westbrook, Paul Levy, Katy Schuler, Steve Farber, Jake Poore, Diana Christiansen, Jason Wolf, Coleen Sweeney, Carol Santalcuia, Jason Gottlieb, Chris McCarthy, Kip Durney, Jim Rawson, Debra Barrath, and many, many more.
Changing the culture of healthcare takes a village of the committed, personally accountable, energetic, loving and audacious. I love these change agents!
Please join us on March 24th 20:30 EST (8:30 pm) on Twitter for a tweetchat #hcldr
Culture and Love – a story from 2014
As 2014 drew to a close last week many a news outlet spent time reflecting back on the highs and the lows of the past year. Whether framed as a “top 10 list” or presented more as the best and the worst, here in northeastern Massachusetts one particular story caught my ear.
This was the Market Basket Story, a tale of unparalleled employee unity and pride, and living proof that a small group of committed people can in fact make a difference.
If you’re unfamiliar with this particular tale, there was a real cast of characters; long-time feuding, wealthy family members, unfairly (some would argue) fired senior executives, passionate, committed employees, and deeply loyal customers.
Bottom line: local grocery-store chain CEO fired by cousin (hate each other) board member, employees (loyal is an understatement) outraged and walk off the job, stand-off ensues, employees rally for the fired CEO to be reinstated, customers stay away at the request of employees (and there are no supplies on the shelves) and eventually the fired CEO buys enough shares to take control of the company and is reinstated – celebrations all around and bonus checks for employees!
The news story that I heard a few days ago was celebrating the fact that the entire body of employees has been recognized as the Boston Globe’s “2014 Business Person of the Year”, and reflecting on the leadership of Arthur T. Demoulas, the reinstated CEO, making the statement “… he was reinstated along with his culture of generosity, kindness and caring.”
I love this statement! His Culture!
Think about the words, his culture. This is not an abstract, difficult to grasp concept – this is his, the way he leads, the way he works.
In our work to improve safety in healthcare the word ‘culture’ gets tossed around all too easily. It’s easy to blame the culture, almost as if doing so excuses the behavior. It rolls off the tongue as part of our standard vernacular, and is often the response to much of what ails us:
Q: “Why are some of your operating rooms using surgical checklists and others not?”
A: “That’s just the way we do things here, it’s our culture…”
Q: “What stopped you from speaking up when you saw your senior colleague acting in that rude, disrespectful manner?”
A: “That’s the culture on this team, keep your mouth shut and your head down…”
It strikes me that we cite or state culture as the root-cause of the problem because it creates the impression that fixing or changing it is nigh on impossible. That to tackle, change or create a new culture is a myth so complicated that we best not even try…
The Market Basket story annihilates this myth.
Health and care leaders listen up
Culture is the way we act as leaders. It is the tone we set, the expectations we communicate, and the behavior, language and performance that we tolerate.
Culture is the way we (you and I) do things. Do you want a communicative, fair, safe culture? Then communicate openly about the good, the bad and the ugly. Be fair with the people that choose to work in your organization, and with the way you make decisions (don’t interpret as treating everyone the same…), and model an environment where speaking up about your mistakes and owning them is celebrated not frowned upon.
Remember, if it is to be it is up to me.
“His culture of generosity, caring and kindness.” The reporter goes on to interview Arthur T. (reinstated CEO) and he describes some additional tenets by which he runs his company, with fairness, justice, and connection to the human soul.
They’re running supermarkets people, and he’s talking about connecting to the human soul…
He nails it when he shares that the secret to this incredible story is to remember that they are, “… in the people business first, and the food business second.”
Health and care safety in 2015
People business first, medicine business second.
People is where our focus needs to be. Caring and healing our patients and their families, absolutely, it’s the calling that many of us responded to that finds us doing the work we do. But it needs to be more than this…
I propose that in 2015 we need our focus to be more on the people that provide this care – as leaders we need to make these people ‘the business that we are in.’ They will take care of their patients.
Commit to being in the people business first. The care givers; the nurses, the technicians, the physicians, the patient care attendants, the unit secretaries, the managers, the supervisors, the housekeepers, the pharmacists, the social workers and each other.
Provide the generosity, kindness, love, fairness and justice that connects them to their purpose, reminds them of their calling, and creates a safe environment for them to deliver the best care possible.
The reporter for the piece on Market Basket closed out the segment by suggesting that the Market Basket employee’s actions have presented other companies throughout the Commonwealth and around the world with a challenge of sorts – loyalty is one thing, these folks though clearly love where they work, and who they work for…
From loyalty to love!
Perhaps for 2016…
Looking for a change in mind set or a new perspective? Take a moment to watch or re-watch the 1946 classic movie: It’s a Wonderful Life.
Jimmy Stewart and cast transport us back to a simpler time with a powerful message…
Sometimes it takes a close call to remind us how lucky and fortunate we are, and how a positive attitude can change your perspective and therefore your reality.
How family extends beyond who we are partnered with and the children we have, and includes our friends, neighbors and the people whose lives we touch and who touch us each and every day. And as Clarence (the angel) reminds us in the closing scene, “No man is a failure who has friends.”
So if you think, even for a minute, that you and your efforts don’t make a difference, nothing could be further from the truth. Everything you do, however seemingly small, makes a difference.
What a wonderful life.