December 21, 2011 at 8:04pm
When you go to a hospital, who cares for you? As a patient, you will see physicians, nurses, and maybe a few medical assistants or lab techs. There is a lot more going on beind the scenes, though. The stakes are high: everyone and everything must work as intended to give you the best care, to make the best use of every dollar on your medical bill. To ensure quality care with the highest safety standards, a complex regulatory and compliance network exists, forcing hospitals to create complex layers of bureaucracy to ensure adherence to standards. But is this really necessary? Can we create a management structure in large healthcare organizations that is flatter, more efficient, less politicized, and flexible enough to put the patient front and center in everything we do?
Two years after I joined my current employer, a meeting was called including every person who would be involved in the patient treatment for a relatively small unit in our hospital servicing about 500 patient a year. Working in the unit full-time for three years, I was sure I knew most people. Imagine my astonishment when I walked into a room filled with 50 people, more than half of which I had never met in my daily duties caring for patients!
This event visualized for me the large percentage of money and effort going into administration and management of a large medical center. I still refuse to believe there cannot be a better way to spend our patients' medical bill. It cannot be true that we need to hire so many people verifying healthcare providers are staying in compliance with rules and regulations. How can it be that the people billing the patient for our services have never even observed a single patient procedure after many years of working in the department, leading to many questions and decisions on documentation requirements which may or may not fulfill regulatory compliance requirements?
Another aspect of the issue is the challenge of healthcare managers to stay connected to the Gemba, to the clinic. On too many occasions, I participated in meetings observing managers asking questions which made clear they had not observed the daily clinical challenges in many years. There is no time budgeted for going to the Gemba, never allowing a clinic visit to rise high enough on the priority list of daily tasks. This, in turn, leads to very frustrated and disengaged staff, who are caught under the impression that their leaders do not understand the daily struggles and challenges they are facing.
The solution is as radical as it is simple: term-limits for managers in healthcare.
How would it work?
First, we need to identify the leadership positions which are good candidates for this change. The first criteria is based on qualifications of managers in e.g. an academic medical center. Most mid-level managers have risen through the ranks. Nurse managers have been nurses; department administrators have been nurses, nurse practicioners, radiology technicians. Even the Chairs of Departments are selected for their merit as physicians and researchers; there is no requirement for an MBA or any other formal leadership training other than practical leadership potential as observed in their work before their appointment to a leadership position. The second criteria is for positions where there is a need to stay creative to maintain momentum for change. Those include leadership positions such as Chair of a department, Clinical Directors, and other academic leaders.
Therefore, these positions could be filled on a term-limit basis, e.g. for 2 to 5 years. After a term is over, the manager would return as equal among the team members, with another team member now taking on the leadership role.
Being leader for a well-defined term will bring a strong incentive for staying connected to the Gemba. Each manager will now lead with the knowledge that in the near future, they will return to work in the very environment they have created for their team. As leader amongst equals, the managers will not be apart from the community, but integral part of the patient care team. This will help the healthcare managers to stay close to the patient care. Connecting to patients, putting the patient as the central motivator for every action and decision, will be much easier for a manager who remains closely connected to clinical care, and who views the leadership role as a temporary, not permanent, step away from daily clinical care tasks.
By being part of the community, hierarchical structures are broken down as well. All to often, we see communication between leadership and healhcare providers break down because managers do not explain the background of certain decisions, and healthcare workers disengage because they feel as if they have no control over the work environment. By limiting the time any member of a team is in a management position, a manager is compelled to provide leadership training to build a strong pool of possible successors. This will enhance the change of managers being seen as enforces to managers serving the team by building the conditions for the healthcare team to succeed.
A manager who will remain part of, and not above, a team will also be compelled to be very conscientious about decision-making. Adhering to the Golden Rule will become a much stronger goal, because as managers they will want to be the best role model possible for good management. A well-managed team of healthcare workers which has to be less concerned about politically driven decisions will feel empowered to address difficult issues without fear of repercussions. This is essential in healthcare, where issues of error prevention, staff performance, and professional conduct are difficult to address bacuse of the inherent power imbalance between physicians, staff, and patients.
Small steps are key to implementing a change away from bureaucracy and hierarchy to healthcare teams managing themselves. I can identify two areas in which implementation can be started.
Teams that are good candidates for a rotating, term-limited management model are teams consisting of a homogeneous group of professionals. Examples are: nurse managers for a unit; medical dosimetrists in Radiation Oncology; x-ray technicians in Radiology. In these homogeneous teams, the managers typically come from within the profession and have eventually been promoted to management.
The second group of candidates for rotating leadership would be academic leaders or directors. Examples are themedical chairs of a hospital department, clinical medical directors, or medical physics directors. Leadership on this level requires setting goals, driving change, bringing fresh perspectives to drive change. Managers in these roles run the risk of loosing momentum after 5-10 years in a certain role, as well as risking their decision making process being influenced by political considerations.