Confessions of a Hospital Administrator - Change Your Unit Culture PRN

Don't wait for permission to change your unit workplace culture. Nurses Announcements Archive Article

Confessions of a Hospital Administrator - Change Your Unit Culture PRN

In February, I covered the Health Infomation & Management Systems Society annual meeting for a trade publication. One of the sessions I attended was presented by Air Force Colonel Joe Pocreva, MD, who told how he transformed the workplace culture in the ER at Keesler Medical Center in Biloxi MS.

I was mesmerized by his presentation for a couple of reasons. First, I know how difficult it is to change any culture anywhere. It takes a servant leader who must be transparent and vulnerable. And even then it's not easy. Second, this is a military operation we're talking about. I'm a Navy veteran and command and control is pretty much all the military knows when it comes to culture. Third, this was a physician who followed some pretty good instincts when it came to management. No knock on docs, but medicine is their primary forte.

When we spoke after his presentation, Joe, an ER doc (as he insisted I call him - that's the first sign of a servant leader - they drop the formal titles) told me:

"I found an ER in terrible shape," he said. "Doctors and nurses were fighting with each other and the administration had no idea how to fix the problem. The techs (lab and imaging) were arguing with everyone and the day and the night staffs were fighting at every shift change."

The hospital had the worst rate of patients left without being seen, the longest waiting times for patients to see a doctor, as well as the longest overall length of stay in the ED of any Department of Defense hospital in the country.

Joe relied on data from the electronic health record to define 30 real-time metrics the ER staff needed to improve upon. He ordered only one change - that one physician would move to the triage area. He said he then allowed staff to "unleash their rage" to take ownership to make workflow changes in classic LEAN style.

The results of his culture reinvention were epic. From 2010 through 2014, patients who left without being seen dropped from nearly 500 a year to less than 10. The patient length of stay in the ER dropped 29 percent. And the door-to-see-the-doctor time dropped 78 percent. This achievement placed the ER at Keesler Medical Center not just the best in the military, but among the best performance metrics in the entire hospital sector.

He also said he appealed to the staff about the reasons they went into medicine in the first place; to take care of people.

Being a big believer in the power of cultural change, I called Joe recently and told him I was writing this post for allnurses and asked him what advice he has for nurses who want to change their workplace culture in an environment where perhaps the hospital administration wasn't interested in the idea. I combine this list with my own experience and feedback I got from nurses at The Baptist Leadership Institute (BLI - nondenominational, associated with Baptist Health in Pensacola,FL) nurses leaders.

How to Change Your Workplace Environment

  1. Get your unit manager on board. The best way to do this is to advocate that improving the unit metrics the hospital cares about will improve, which will make the manager look good. Offer to lead a committee of other nurses on the unit to develop and action plan.
  2. Find a physician champion. It's hard for managers and administrators to say no to a doc.
  3. Ask all the nurses on your unit what they think (use a survey). This has to be a bottom-up initiative, not top-down, or it won't work. It's vital to get agreement.
  4. Tie-in your cultural change to your hospital's own stated mission, vision and values. No one higher up can argue about those goals.
  5. Ask for LEAN or Six Sigma training. If the answer is no, nurses are pretty smart - you can figure it out reading about it and associated case studies.
  6. Define your change in both operational metrics and behaviors. For example "We're going to reduce falls and respond immediately to a colleague request for help to assist with moving a patient."
  7. Communicate with everyone on the staff often and in a manner that they find convenient. Don't guess at this - ask them. I heard of a hospital management that decided the best was to implement their cultural change was to post updates inside rest room stalls - without asking the staff what they thought. Turned out to be a really terrible idea that did more harm than good.
  8. Repeat this often: "A good workplace will make us all happier and feel more pride." You'll get recognized when you start to get better outcomes. Other units will come to you and ask how you did it. Administration will eventually show up and ask how we did it. This could be the start of something big.
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ServantLeader

About ServantLeader

John W. Mitchell is a retired hospital administrator and author of the hospital novel “Medical Necessity”. In 2009, he and his administrative team were named "Top Leadership Team in Healthcare for Mid-Sized Hospitals" by HealthLeaders Media.

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Nicely written piece.

The role of a hospital administrator is to put clinical staff in the best position to succeed. I think this is the key concept for health care leadership.

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Specializes in OB-Gyn/Primary Care/Ambulatory Leadership.

Good article. Just one minor comment from a former editor: It's "Six Sigma" not "Sixth Sigma"

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Nicely written piece.

The role of a hospital administrator is to put clinical staff in the best position to succeed. I think this is the key concept for health care leadership.

Unfortunately, it's been my experience that administration only pays lip service to supporting clinical staff and to make change happen, buy in from administration is necessary. I really, really want to believe that it is possible to bring about meaningful change initiated by the nursing staff. Maybe the ED is different. I work med/surg and right now, our biggest obstacle is staffing. We seem to have weeded out the nurses who will not pitch in and work as a team but to work as a team, you need players. So many of us are under intense pressure to reach certain metrics but not given the staffing to actually meet them, especially support staff. We work our butts off but instead of leaving at the end of the day feeling tired but satisfied with a job well done, we leave feeling exhausted and demoralized.

I really, really want to work on a unit where the bottom up change described is possible. I find the can-do attitude of the article inspiring and then I think about the facility in which I work and feel my heart sink because, as much as I want to be wrong, I can't see this working at any of the facilities where I've worked.

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Good article. Thank you for sharing your insights and experience.

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Unit culture will never change until more administrators actually do hands on, bedside care. Hard to change a culture you dont understand. I have found most changes are pretty much hot air.

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Specializes in ER.
Unfortunately, it's been my experience that administration only pays lip service to supporting clinical staff and to make change happen, buy in from administration is necessary. I really, really want to believe that it is possible to bring about meaningful change initiated by the nursing staff. Maybe the ED is different. I work med/surg and right now, our biggest obstacle is staffing. We seem to have weeded out the nurses who will not pitch in and work as a team but to work as a team, you need players. So many of us are under intense pressure to reach certain metrics but not given the staffing to actually meet them, especially support staff. We work our butts off but instead of leaving at the end of the day feeling tired but satisfied with a job well done, we leave feeling exhausted and demoralized.

I really, really want to work on a unit where the bottom up change described is possible. I find the can-do attitude of the article inspiring and then I think about the facility in which I work and feel my heart sink because, as much as I want to be wrong, I can't see this working at any of the facilities where I've worked.

It is entirely possible with the right management team. I don't know if you'd call us working from the bottom up, but we're getting it done. We've gained a new director, manger and assistant manager since October. We already knew a lot of the issues as we were already in the department.

We basically asked for help identifying any issues that we hadn't already. Pointed out that it had taken years for our department to get to the vile state that is was in & to give us some time to fix it. We've gone for our staff only coming to work because they need the paycheck to having a lot of buy-in, clinical ladder participants, and considerably improved metrics. We had been in the 1st percentile for handwashing for literally years. We're now in the 60's, our LBTS rate went from 12% (yes that says twelve) one month last year to 1.1% last month.

This has come with our leadership team (including our Medical Director & Assistant Medical Director) all busting our hump to help make this a place that we want to work. Heck, our assistant manager came in and worked a 12 hour shift as a secretary because nobody else would & there weren't any staff scheduled that knew how. We have a mostly fantastic team of charge nurses and group of staff nurses that work really hard. We've also been fortunate that our medical director has helped to eliminate some of the sandbaggers.

Basically it boils down to being a team effort. I would like to point out that a lot of this has been without a lot of overt high level administration support. Our ED has been essentially persona non grata for quite awhile, and where they send people for their admin careers to die.

tl;dr: It's possible with everybody busting their butt for it.

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Specializes in Pediatrics, Emergency, Trauma.

Interesting article. :yes:

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Specializes in Administrator inspired by nurses.

Ahh - you are, of course, thank you. will see if I can correct edit. I must have been thinking of the movie "Sixth Sense"....

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Specializes in MICU/CCU, SD, home health, neo, travel.

I was a travel nurse for several years. The only hospital I worked in where the nursing culture was noticeably different from anywhere else had a CNO who had started as a respiratory tech and later become a RN before eventually becoming an administrator. Let me tell you, things really were different there! The whole attitude was different. I loved it there even on a crazy busy tele floor that wasn't my usual haunt. I'd have settled down there if a) I could have afforded to live in that city, and b) it weren't so far from The Man who was courting me ;)

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Specializes in Administrator inspired by nurses.

Hi Ceci - Thanks for your message. It's a shame that great culture is the exception, rather than the rule. At the hospital where I served that was most successful, I recruited several travelers to permanent positions because they liked the culture. Travelers know!

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Specializes in Administrator inspired by nurses.

Ahhh - you are of course correct, thank you for bringing this to my attention.

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