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.
Last speaker of the day
Several years ago I found myself in the audience of a quality and safety conference at Harvard University. The last speaker of the day took the podium with little fanfare and no slides. What a welcome change…
With his very generous permission I’d like to share my memories and notes from that day, the lessons and leadership “keys” he shared then, ring true now, and continue to resonate with me.
And now for something completely different…
Mike Dowling is the President and CEO of the North Shore-Long Island Jewish Health System (NSLIJHS). Prior to becoming president and CEO on January 1, 2002, Dowling was the health system’s executive vice president and chief operating officer.
Mike served in New York State government for 12 years, including seven years as state director of Health, Education and Human Services and deputy secretary to former governor Mario Cuomo. He was also commissioner of the New York State Department of Social Services. Before his public service career, Dowling was a professor of social policy and assistant dean at the Fordham University Graduate School of Social Services and director of the Fordham campus in Westchester County.
Mike presented at the Eleventh Quality and Safety Colloquium (Cambridge MA – August 14-16, 2012) – my notes summarize his comments. Without any slides, Mike shared “7 Keys” to creating a “Premiere Healthcare Organization” by stating, “NSLIJ is not there yet, but we are on a journey toward this, and I’d like to share it with you…
Have a coherent idea of where you want to end up – a clear VISION
- Not just the “what” but the “why”
- You must be able to engage EVERYONE’S head and heart in the VISION – in the “why…”
Have a positive attitude
- Be optimistic and believe that it is possible – a “can do” attitude
- Be responsible for outcomes and model personal accountability – “if it is to be it is up to me”
Have a complete commitment to transformation
- Be ready to think differently – we CANNOT be risk averse
- Be open minded – healthcare is NOT unique – exceptional, high-quality organizations are NOT industry specific
Engage and develop EVERYONE
- Lead a continuous culture of learning
- Be mindful of who you hire, who you promote, who you let go
- Remember: People + Values + Behaviors = SUCCESS
- Use simulation
- Make a core part of your curriculum mandatory
- Break down silos and train people across disciplines
- Manage your board and medical staff
- Change how we do medical school training
Become deeply consumer focused
- Everyone you serve is more educated and informed than ever
- Expectations are constantly changing
- Constant communication of the “why” from #1
- Top down, bottom up, side to side
- Face to face, electronic, multi-media, print, etc. etc.
- You CANNOT over-communicate
Most of all – remember that:
- we do great work every day in healthcare!
- we have much to be proud of!
- we do make a difference!
Mike closed his remarks with the words of Sir Winston Churchill, “Success is going from failure to failure without losing enthusiasm…”
Thank you Mike, you continue to inspire and encourage!
A conversation with Chuck Lauer
Last year I had the wonderful opportunity to be introduced to Chuck Lauer, the former publisher of Modern Healthcare, by my good friend and colleague Kristi Peterson. Chuck and I spent considerable time talking and emailing about a subject of mutual interest and something we are both passionate about, accountability, specifically about the idea and concept of ‘personal accountability’.
This concept of personal accountability, and the choice to change the words I use when I think about accountability, are in part lessons from the leadership, writings, and friendship of Linda Galindo.
Chuck went on to pen a piece that appeared in Beckers Hospital Review on August 17th 2013. I just re-read it, and thought I’d share it here again. Enjoy…
We hear a lot about “accountability” in healthcare — from the boardroom, to the workplace, to new payment methodologies like “accountable care organizations” — but most people don’t have a clue about what the word really means.
Everyone knows the basic definition: Accountability is a kind of answerability. The word derives from having to give an account — to clearly explain what you are doing. But the actual definition goes much deeper than that.
Richard Corder, assistant vice president of CRICO, a Harvard-affiliated malpractice and patient safety organization, has thought a lot about what accountability is — including what it is not. It is not, he told me recently in an email, about saying “yes” whenever your approval is sought. “In healthcare, we have fallen for the belief that good service means saying yes to everything,” he said to me. “Saying no — and being clear about why, and when you may be able to meet, chat, review, discuss — is a liberating, time-saving, accountable action.”
One of the things often missing in today’s workplace, he said, is a lack of clarity about what accountability really means. “Treating everyone the same is disrespectful to our high performers and excuses (rewards) our middle and low performers,” he said. Fairness is not about treating everyone the same. As leaders, we understand that we have to treat, manage, coach and lead people differently — based upon performance and needs.
“In healthcare, we are currently spending a lot of time (and money) talking about and pondering the ‘accountable entity,'” he told me. “We wax and wane poetically about the who, what, why, when and where, when all the time it’s staring back from the mirror. We are the accountable entities.”
That gets us to the heart of the matter: Accountability has to start with you! If you are ever going to be successful and fulfilled in your life, you have to be accountable to yourself. Sure, you can kid yourself about how good you are, and you can even fool other people by what you say and how you behave. But do not forget that the hardest person to satisfy is you! You have to judge yourself and live with it every day!
Each of us is an accountable entity. That’s why, when leaders lead with clarity and conviction, honesty and transparency, they bring with them inspiration and determination. They have become accountable to themselves! It’s a contagious enthusiasm that permeates their organizations. Talented people are attracted to institutions where leaders are dedicated to innovation, creativity and risk-taking. They fully accept that answering to oneself is the key to success.
I have had the honor of meeting a lot of great people — people who have made a difference and achieved unparalleled success in sports, business and other pursuits. None of them really caught fire until they took stock of themselves and became accountable. Some did this when they were young. Others didn’t face up to themselves until they were older. But in all cases they look back and say that being accountable to themselves is what changed their lives.
Richard Corder said personal accountability means always trying to be clear. When confronted with a problem, you can say, “I tried, but they wouldn’t let me,” he said, or you can say, “Can you help me figure this out? I need to get some clarity.”
It’s important to put some effort into establishing clarity, he said, offering me a quote from the inspirational speaker, Mark Victor Hansen: “By recording your dreams and goals on paper, you set in motion the process of becoming the person you most want to be.”
Listening to yourself can help you put your plan into action. I don’t know about you, but I have conversations with myself all the time, and from what I can gather from colleagues and friends, they do the same thing. This enables us to begin to develop a sense of our own accountability.
With accountability comes additional responsibility. For instance, in your job, do you speak up when you feel something could be improved? Or are you so concerned about the risk of falling out of favor that you don’t say anything?
In healthcare, we too often delude ourselves into accepting the status quo and are unwilling to try new things that just may be more efficient and guarantee a better experience for the patient. Accountability has to start with people who are willing to hold themselves to a higher standard and be answerable to themselves at all times. The goal is to never deviate from your dedication to excellence.
The road ahead is paved with uncertainty, and you will probably have to drive over many potholes along the way. The whole industry needs leaders who have the courage to look into the future with clear eyes and to inspire their people to do the same. We need to be willing to bring about the changes that healthcare so critically needs. It isn’t going to be easy. Those who hold themselves personally accountable to mission and vision and to themselves will be the stars that inspire all of us with their courage.
Richard Corder gave me a kind of motto for personal accountability. It’s all simple, two-letter words that go like this: “If it is to be, it is up to me.”
I have already put them up on my office wall.
Thanks again Chuck for the friendship, mentorship, interest, and support.