I've now helped thirteen different Trauma & Acute Care Surgery programs that were in the midst of a turn-around, or at least a re-alignment. And, let me tell you, my batting average has been mixed.
Of the three turnarounds I've helped directly lead, one was an absolute failure. Another was a base hit. A third was a home run. Let me share with you some of what I've learned to help improve your batting average if you're ever in one of these healthcare culture / system change situations. It may be useful!
1. John Kotter was right.
After I failed in a turnaround scenario, I took some comfort in the classic stat that most turnarounds don't work. Whether it's "Change is hard." or something similar, those often-repeated words really made me feel better. I realized, even if the team and I followed the eight steps of culture change Kotter lays out, culture change just plain doesn't generally work.
People don't believe, often, (even if you show them) that things need to change and that they need to move toward that. You've got long odds. Come to grips with that before you start and make sure that the outcome you want, adjusted for the chance of success, is worth it!
After my failure, I thought back to how one leader to whom I reported would repeat "Culture eats strategy for breakfast." to me as an admonishment. It was as if the leader didn't realize that leadership (of which I was a part) owns culture.
We are responsible for culture. If culture doesn't reinforce where we need to go, and is not aligned, well, that's our issue too.
So John Kotter's classic Leading Change article (link beneath) is one I come back to a lot. It serves as a reminder to me that, although I own parts of both my successes and failures, culture change efforts often don't work out.
Of course, that's a real shame. The inability to change when appropriate lets new organizations rise while others fall.
- "This 'telephone' has too many shortcomings to be seriously considered as a means of communication. The device is inherently of no value to us."--Western Union internal memo, 1876.
Nowadays, there's even some evidence that the classic statistic "70% of change management efforts fail" is a myth. (Link here.) And that may be so. However, whatever the success rate really is, my experience matches what Kotter claims: most don't succeed.
Don't beat yourself up too much if you're trying one.
2. Change is as much about the pre-conditions set up as it is about the people performing it.
Choose the change efforts you take on carefully, and realize change is much bigger than you. The groundswell required involves the significant participation of leadership higher on the organizational hierarchy, tangible resources devoted to the change (that's the old "give us resources not just wants"), and an understanding of where things need to go...and that's even before you ever show up. What does success look like? What is the argument / business case for devoting resources and how many resources of what kind?
It's great when you can participate in developing the specifics of what's needed, but you probably shouldn't have to make the case for the very basic requirements. (If you do, that's a marker for a smaller chance of success I'd say.)
That said, it's normal to have to do some teaching, tweaking, and work to flesh things out once you participate in any change effort.
But re-arguing for very basic, relatively inexpensive or non-intensive things should be off the table. The team should already have an idea of the risk, outlay, and return from the culture change they are embarking on!
3. Problems come to you masked as people...and that's why you need data.
We are masters of the ad hominem attack in healthcare and are frequently victims of the messenger effect. Why do we see those used? Because they work!
We are great at resisting change. After all, we really buy into the system we are currently in (think of all that education that went into it) and it really is uncomfortable to move toward the unknown.
Only meaningful data allow us to cut through all of the persuasion (intentional and unintentional) techniques that get in the way of us understanding and improving system performance. In healthcare, meaningful data can be tough to get...especially in the organizations that need it the most. As healthcare (and the world) get more and more complex, we need data driven decision making even more.
I submit that often healthcare organizations which have, for whatever reason, a significant amount of management by fear or a culture of fear are the ones that seem most resistant to management by data. It's because colleagues and staff feel that they may be labeled as underperforming and will be phased out.
In healthcare, because we often have a "Who screwed up?" mentality that indicates an immature safety / quality improvement culture, I see this fear of data a lot. It takes a great deal of work to show how we can highlight and improve shared data that has no provider or patient's name attached.
In some organizations, anytime staff hear about an improvement initiative, culture change, or see something different they immediately dig in...even moreso than I've seen in other industries.
A histogram of door to doctor time, for example, that includes all the patients for a month, but no providers' names, helps put physicians at ease. However, when physicians and APs are measured and reimbursed based on their door to doctor time, chances for meaningful quality improvement decrease. Why?
Because putting staff on the hook for endpoints they can't fully control makes them fearful of process improvement initiatives. It demotivates them when it comes to participating. When we create the illusion that an entire system rides on one person we set ourselves up to fail.
Those important lessons from my Lean education and Six Sigma Master Black Belt training (or maybe that was the earlier Green Belt part) remind me every day of the importance of choosing endpoints wisely.
Try improving the system first and then, when trying to sustain improvements, align the providers even more by reimbursing them to sustain and further improve the portion of the system they can directly control.
If not, you'll get what we often see in healthcare now: plenty of system problems expressed as frustration from the physician standing in front of us in the hall. Remember, while you're being barked at, that the doctor telling you about the issues is likely highly intelligent and very hard working. They may be someone tired but they often are not barking just to complain. They survived residency, after all, so it's not like they lack resilience and just want to complain.
Remember: if you have an overtriage rate of 70% and your attending colleagues are q3 on call alone (with no advanced practitioner or resident on the team at night), a full clinic / elective schedule the next day, and a median of six consults at night with two transfers in...don't be surprised if they act out, don't accept every transfer, and / or don't stay to work at your center very long.
These guys and girls are tough, but a bad system beats a good doctor every time.
Consider focusing staffing on nights and weekends, the tough times when trauma patients and other acute patients come in, first. (Most programs don't.)
Many people, APs, physicians, and other staff want to just work days...but that's not when trauma and the difficult cases often come in. Working nights is part of the deal because that's often when people get hurt or something very acute presents.
Bottom line here: create a system that over-works attending staff at night and problems with your system will come to you wearing the faces of your friends / colleagues. Don't be surprised when they don't accept all low risk transfers at 3AM no matter how much you want them to. No one will ever say that they don't accept or set the bar very high because they're tired or busy. Yet if you improve your system the trouble will disappear.
That's how many things work.
4. If you are part of a team leading change in your institution, remember: quality problems often wear the masks of interpersonal problems.
For example, if someone (or a group) in the organization doesn't like the change agenda, or what may become of it, they will often execute that ad hominem attack against someone on your team...or maybe even you. Don't blame them: even if you've done all the steps Kotter lists in his classic article (link beneath this write up) you and the team may not succeed...that's because it's easy to want to remain comfortable rather than go to something unfamiliar.
It's so important to highlight why it's riskier to stay where you are than move to where you need to be...and even if you do, people's comfort, reimbursement, and a litany of things may glue them where they are.
- "First they ignore you, then they laugh at you, then they fight you, then you win."--Mahatma Gandhi
Although some argue whether Gandhi actually said that, it's the idea that counts. My advice: remain patient and calm. (So easy to write, so hard to do).
If your organization understands what's valuable, and really means what it says when it wants something to change, the ad hominem will be recognized and dealt with as much as possible by all the leaders around you. They set the preconditions for change.
For example, if we mean it when we say and teach "stop the line", we don't say that a colleague who felt something was wrong with a patient and told us "I really need you to see this patient. Thank you." was mean. We don't even get angry if they're wrong and the patient is a-okay.
After all, it was tough, but they were worried and stopped the line before the patient got too far along.
So if we hear those criticisms ("She just wasn't nice." is a classic one) remember, if there's a patient safety issue involved, sometimes firm and direct (not yelling or throwing things) may be necessary. The ad hominem of "she's mean" should get tossed out. If my physician was direct to stop the line and help fix me, I'd be just fine with that.
5. Your current low quality system sets up people for friction and disagreement.
Yes, it's related to the previous point...but consider this: in my experience, once you and the team improve a system, there's less interpersonal friction. You may have seen the studies about how people in closer proximity disagree and have more contentious interactions.
Even if you haven't guess what. My experience is that once you improve a system, people get along better. Maybe it's because the new system has clarified for everyone what's supposed to happen...I don't know. But what I do know is that one you've done a project to improve signout, trauma bay layout, or any one of a number of other options, many of the interpersonal issues that used to arrive from that area disappear.
The insight is that the system sets up the chance that people disagree and that the disagreement makes it to your desk.
6. Trauma & Acute care surgery sections that have the ability to collect, collate, analyze, and make sustainable changes in response to meaningful data vastly outperform ones that can't.
That one is self-explanatory, and, in my opinion, the most important of all. Data is the new oil. And even if it wasn't: when politics or any other impediment prevent collection of data, or putting it to work, the team is quickly passed by other programs both within and outside the organization.
That's what makes this one my litmus test for a system on the right track. When a group can do that, success in culture change, and the ability to re-align in the future when a situation changes, is inevitable.
Use those lessons the next time you work to improve your section of Trauma and Acute Care Surgery, and, if you're part of a culture change effort: do the best you can to execute the steps...
...and don't be too hard on yourself if it doesn't work out!
A few of these corporate change efforts have been very successful. A few have been utter failures. Most fall somewhere in between, with a distinct tilt toward the lower end of the scale. The lessons that can be drawn are interesting and will probably be relevant to even more organizations in the increasingly competitive business environment of the coming decade.