Excitement about Change and Improved Outcomes

I started my day on Friday at the Partnership for Patients leadership team meeting. Cathy Hamel, our Vice President for Post Acute Care and Cate O’Connor Devlin, our Administrative Director for Nursing Patient Safety and Bed Flow lead this team and they have done phenomenal things! Partnership for Patients is a collaborative effort sponsored by the Centers for Medicare and Medicaid Services to get hospitals to learn from each other to improve care. Our P for P team has overseen the creation of more reliable care that has significantly reduced pressure ulcers, patient falls, catheter associated urinary tract infections, and surgical site infections, among other things. I sat at this meeting so proud to be involved with this outstanding group of leaders who are delighted to be in action and moving us toward our vision.

I asked the Team what I could do to make their work go even faster and they really struggled to come up with anything. They did say that they want my support as they are studying adding hand wipes for patients to help us reduce our hospital acquired infection rates even further. These wipes will add an expense to the budget and they are searching for the best, most cost-effective product. Otherwise, they didn’t need my help…and that is the way that it should be!

Sometimes things don’t go as well. I had a couple of interactions last week where local leaders were struggling to get something “fixed” when it involved more than one department. I encountered a couple of very frustrated individuals who were pushing problems up the chain of command and were accepting answers from colleagues that, in my mind, were unacceptable instead of calmly and respectfully working on the solution.

Hierarchy Vs. Bureaucracy

The larger an organization is, the greater the tendency to have multiple levels of authority. Everyone gets it that someone has to be ultimately responsible for the organization. These multiple levels of accountability are called hierarchy. The Merriam Webster dictionary defines this as Hierarchy (noun): A system in which people are placed in a series of levels with different importance or status.

A hierarchy becomes part of the problem when the levels require non-value added communication or when it leaves people lower in the hierarchy with the impression that they have no power to change or fix things. They then wait for someone above them to fix problems for them. Or even worse, hierarchies can leave the option for silos to be obstructive to change, waiting for the leader above multiple silos to step in and get through an impasse.

When the hierarchy becomes an impediment, it is then a bureaucracy.  The Merriam Webster dictionary defines this term as: Bureaucracy (noun): A system of government or business that has many complicated rules and ways of doing things; a system of administration marked by officialism and red tape.
 
The leaders of the P for P Team are working beautifully across boundaries. They are making offers to and requests of each other continually and they are creating meaningful change. They are never going to their bosses unless there is a barrier that they cannot overcome. We need more of this. The larger an organization becomes, the more managers it needs (hierarchy), the harder it is to keep everyone on the same page and have all line managers feeling like they have the power to generate change.

And, in large, complex organizations with many departments often spread over vast areas, there is a temptation to not work manager to manager and push problems up the hierarchy. (Yesterday, a manager thanked me for getting a problem fixed when he had been given a silly answer as to why the problem couldn't be fixed. I felt really bad that I had to intervene.)

Here is a great example of managers working together across departments to identify a problem, create a plan for a solution and obtain great results:

• When U45 went through an expansion in December 2012, it created two sides – Unit 45A and 45B. The staff quickly realized that the new U45B was not a mirror of 45A including the supply set-up. They quickly found that U45B did not have the general supplies readily available to them and staff was continually going back and forth from one side to the other just to find supplies and equipment needed to provide patient care. Nurse manager Eileen Skaarer recognized that the staff was becoming increasingly frustrated and decided to put metrics in place that provided incredible data – U45B had up to 30 missing pieces of supplies and equipment every day, causing staff to constantly have to search for the tools needed to provide care.
  
  Armed with this significant information Eileen and her team, along with Jim Duerr, Director of Materials Management, and his team, developed a solution to the supply problem on her unit. An Omni Cell and bulk cart storage that mirrored the existing supply storage on U45A was put into place on 45B. The result? According to Eileen, her team is now only searching for one or maybe two missing pieces of equipment/supplies per day compared to close to 30 missing items per day before the two department leaders took action to find the right solution. 

"It's Your Right to Fix What's Not Working..."

As managers and leaders in the organization, it is your right to question decisions or answers that don’t make sense; it’s your right and obligation to work together with other department managers in a calm, respectful yet direct way to fix things that aren't working for the benefit of our patients.

Do not accept what doesn't make sense. Get in action, work together, and cut across silos. Find appropriate solutions to work across departmental lines to fix what is not working and improve things.

Communicate openly and directly. Like the process owners on the P for P Team and Eileen and Jim, take ownership and get in action testing change. And only when the plan isn't being worked by both managers should you escalate it up the chain of command.

I am very grateful for everything that our leaders are doing to get the outstanding improvement that we are seeing. Please keep it up!