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
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.
Find a physician champion. It's hard for managers and administrators to say no to a doc.
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.
Tie-in your cultural change to your hospital's own stated mission, vision and values. No one higher up can argue about those goals.
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.
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."
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.
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.
I was an administrator and I found my "corporate" overlords in both for-profit and nonprofits to be exactly as you describe. I rounded almost every day and came to understand what was going on the floor and when something was out of whack. Top,down change is hot air; change needs to come from the bottom, up to be effective.
Specializes in MICU/CCU, SD, home health, neo, travel.
I was an administrator and I found my "corporate" overlords in both for-profit and nonprofits to be exactly as you describe. I rounded almost every day and came to understand what was going on the floor and when something was out of whack. Top,down change is hot air; change needs to come from the bottom, up to be effective.
To me, the basic problem is that administrators, especially the younger ones, go through the "BS/HCA" program and never, EVER touch a patient! Most have absolutely no clue what our jobs are really like. In my *ideal* BS in Health Care Administration program, every single one of them would work a minimum of 6 months as a tech. I mean doing the down and dirty, which means they would all have to get their CNA licenses. Following that, they would have clinicals during the rest of their educational time which would involve shadowing the rest of the hospital employees for a specified amount of time each, from the maintenance/housekeeping and dietary staff through transport, radiology, respiratory, and most especially they would rotate through the various nursing departments....all of them. If they have previously been employed in any of those capacities, they could be excused from that particular rotation but not the others. There are too many administrators who have NO CLUE about what *really* makes things run. They only see numbers and count beans.
There are too many administrators who have NO CLUE about what *really* makes things run. They only see numbers and count beans.
This sounds like our old director. He had a Bachelor's in Business Admin & had from the auto industry or something. Literally no idea, whatsoever. He came to staff meeting once and told us that they were going to increase nurse-patient ratios. The 20-25 nurses in that meeting told him that he could find a new staff then, because we weren't going to endanger patients and our livelihood.
Please note that this is a non-union facility in an at-will state.
I would like to just say thank you for the information given by servant leader. I happen to know him as I personally worked in a facility where he was employed. I still have a letter he wrote to a physician-when a nurse filed a grievance about the doctor's inappropriate behaviors . Servant leader was very professional in addressing the issues, listening to both sides, and ultimately standing up for the nurse. The Dr left the facility, but before leaving he had several sanctions placed on him. Thank you servant leader- JM.
He was also known for never believing that any job was beneath him. He was very visible on any shift, could prepare and deliver meal trays, mop a floor or help out wherever needed-while still maintaining the respect of all.
ServantLeader
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I was an administrator and I found my "corporate" overlords in both for-profit and nonprofits to be exactly as you describe. I rounded almost every day and came to understand what was going on the floor and when something was out of whack. Top,down change is hot air; change needs to come from the bottom, up to be effective.