ServantLeader

Hi Sally - I understand your frustration. I worked as a senior manager for a large for-profit hospital for nine years and the CEO (my mentor) was very sensitive to treating the staff with respect and appreciation. I worked in a large not-for-profit where the opposite was the case. In my experience - and not to discount your own experience - it always comes down to the authenticity of whoever is in charge.

Here' what I learned working most of my career in hospitals: There is never money to correct a safety issue until something bad happens. Then money can't be spent fast enough.

Ha - very smart counter strategy - well done.

I have occasionally come across clinicians who provided lousy or even negligent care and this is truly shocking. The main character in my novel "Medical Necessity" is such a person. However, most medical errors I investigated as an administrator were, in my experience, based on a bad process. I agree this is still often considered to be negligent, which is why hospitals settle so many lawsuits out of court (it becomes a business decision for the company covering with malpractice insurance). But a medical error, in good organizations, is an opportunity to improve patient care.

And administrators wonder why when charts get pulled during a regulatory inspection (JC, state) or a there is noncompliance. Or they wonder why medical errors (meds, testing, etc). Inadequate floor staffing is stepping over dollars to save dimes.

Well said - it's the staffing, stupid. From my own experience, I have found that balance between what administrators want to control labor costs (the biggest expense in hospitals) and what nurses feel they need to work safely and sanely, is possible. It's difficult for administrators to achieve the other metrics they care about (quality, patient satisfaction, outcome) when the nursing staff is angry every day. I read a lot of anger in the responses to my posts. There's no way of getting around the truth: such workplace emotion is a failure of leadership.

Or unionization. I worked with unions in two hospitals, including a nurses union, and we got along fine. Staff turn to union and lawsuits when they feel they have no other options. It's a shame for both sides, because when leadership creates a great workplace culture, performance metrics become top tier and everyone is happier at work.

Oh yes, it is illegal. But I have seen cases were doing something illegal was not enough to motivate executives to make changes - they had to get caught, first (this is not widespread, but I have seen it first hand). I had such circumstances brought to my attention once and it brought to light a serious understaffing issue, which I corrected.

When I started as a hospital administrator in 2000, an older guy explained to me about how hospitals were becoming more complex to management: "You know, it used to be in the old days you counted the money in the morning, played golf with the doctors in the afternoon and underpaid all the nurses all the time." He was serious. While I know some good administrators who really care about their staffs, not allowing nurses time to take lunch or bathroom breaks or staffing so charting can be done properly makes me think we're not so far removed from those days in some hospitals.

All of your feedback: lack of nursing input; poor work processes (including info overload); inadequate pay, etc all come down to poor workplace culture. As many of you know, I've talked about this topic in other posts. If hospital administrators want to have a market advantage for which there is little competition, they must address nursing concerns. Nurses will set high metrics they can support given the opportunity. Achieving this end requires servant leadership; this is easy to say and difficult to do. Most hospital administrators are taught to be command and control leaders. Herein lies the root cause of nursing unhappiness and dissatisfaction. Thank you for reading my post.

I have been in the room when superiors cut staffing to reduce costs. They never went up on the floors, as did I, to see how such reductions impacted nurses.

You've probably heard of the now controversial Johns Hopkins study that medical mistakes are the third leading cause of death in the U.S. When, as part of an assignment, I asked a Chief Medical Officer at a large healthcare system about medical mistakes, he gave me what I thought a very insightful answer: "In medicine, we rely on the heroic efforts of doctors and nurses not to make mistakes," he told me. "But people can make mistakes. It's not a matter of fault, but a bad process." His answer got me to thinking that if most mistakes are a bad process, what kind of mistakes fall into the rare category of intentional? I once worked at a large hospital system as the media spokesperson. We had an inexplicable incident in which hundreds of patients were exposed to contagious diseases because two sterilization techs improperly steamed surgical instrument packs. The techs, for reasons they never explained, did not follow a process with which they were very familiar. So I started looking around on - as a retired Navy buddy likes to say - "the worldwide Interweb" to see what I could find. Nurses still come off looking pretty good. In case you didn't read my first column last year, nurses have been ranked as the most honest, ethical profession by the public 14 years in a row in a Gallup poll. But this doesn't make the job any easier. Another recent poll found that of the five factors that make up the Gallup-Healthways Well-Being Index - purpose, social, financial, community and physical well-being -more than half of all healthcare workers are thriving in none or only one element of well-being. Additionally, fewer than one in ten workers is thriving in all five elements. As a former hospital administrator, this makes me ashamed. I don't know if this falls under a bad process or not. But a recent study just found that if a healthcare worker knows they are being observed, they are twice as likely to comply with handwashing protocols. I'd be very interested in hearing your thoughts for this finding, which has been dubbed the Hawthorne Effect. Lax handwashing practices pale compared to the $1 billion Medicare fraud bust the feds just made in Florida. Three owners of a home health and assisted living company, as well as a hospital administrator and a physician's assistant were just indicted on money laundering and conspiracy committed over 14 years. Given that close to $2.5 trillion is spent on more than four billion health claims a year, $1 billion may not seem like much (HA - just kidding...). But the laundry list of charges turned up the usual stock in trade for fraud. This included: billing for services never provided; up-coding, including unbundling; performing medically unnecessary procedures; falsifying diagnosis and test results; accepting kickbacks for patient referrals (inurnment); and waiving patient co-pays and deductibles. Physicians have their challenges as well. A recently published JAMA article found significant evidence that doctors who received as little as one free meal from a drug sales rep prescribed the discussed drug at a rate that was significantly higher than their peers. A ProPublica story and a Harvard Medical Business School study earlier this year both concluded that doctors who accepted payments from pharmaceutical and medical device industries prescribed those specific brands at a higher rate than their peers. In an article in the New York Times, an M.D. clinical assistant professor of psychiatry at the N.Y.U School of Medicine wrote an article titled "The Illicit Perks of the M.D. Club." He cited a former Cigna executive whistle-blower who stated that "insurance companies profit by introducing hurdles in the coverage and claims process." The author also noted that since 2010 when the ACA was adopted, "the major insurance companies have seen their stock prices soar. Though the act expanded coverage to millions, a report last year by the Robert Wood Johnson Foundation revealed that 41 percent of health plans sold on the government exchanges had physician networks described as "small" or "extra-small," covering less than 25 percent and 10 percent of local doctors, respectively." So what does all this mean? To me, it suggests that our healthcare system is only as good as its weakest link. Asking unit secretaries to convey orders, appointing nurses as security guards and expecting physicians to deal with insurance companies are, as the Chief Medical Officer said to me, "a bad process". The people in a hospital whose primary job is to identify bad processes are administrators. There are administrators in every organization who develop best practices for safety, quality, compliance and ethics. But a hospital administrator's primary job is to make sure everyone - from nurses to physicians to housekeepers - feel inspired to get up and come to work. It takes a servant leader to be really successful. This is easy to say, but hard to do. One of the biggest misperceptions about servant leaders is they don't hold people accountable to the values and metrics of the organization. My experience is that it is easy to hold people accountable when they have a say in what the values and metrics should be. This, I finally learned, is the easiest way I know to be in charge. Because there is no competition for an engaged workforce.

Thank you Cyndylou. The best moment in my career was when a unit secretary who did not speak to me for the first two years told me that, for the first time in 25 years, she looked forward to coming to work. That's when I knew I was on to something. Creating an inspired work force is the easiest way to be in charge. A servant leader still holds people accountable, but to standards the frontline agrees upon.

I was reading through the ongoing Winter 2016 Nursing Article Contest at allnurses. I came across one entry, an unpublished letter titled, Dear Hospital Administrators. A sentences that particularly stood out: This letter broke my heart - not just for the nurses, but for the administrators too. Because I'm here to tell you they are unhappier than you nurses are, but they just don't know any better. At least at the end of the day you have the ethical pride that comes from helping patients. You make a hands-on difference. But the average hospital administrator leaves at the end of the day feeling like a dog that has been trapped on the freeway. Here's why: most hospital administrators are taught to be command and control leaders. A command and control leader is taught they are the problem solver, the idea person. If they can't figure it out, they are a failure. So most administrators scramble every day to hide the fact they can't meet such impossible leadership standards. This is why they piss-off nurses and everyone in a hospital because no one can manage that much detail. It's why they stay off the floors because they don't want to hear how they are failing you. The best day in my career was when I figured out that if empowered the frontline to tell me how their job should be done, my day got a lot easier. Not only do nurses, therapists, housekeepers and the kitchen staff know the solution to the problems they face every day, when it is their ideas to make changes, it works. I learned that nurses are smart people who will quickly find a work-around to my lousy idea to fix a problem or improve efficiency. Here's what happened when I created a bottom, up culture: I worked a few hours less every day; I was called at night a lot less often; profits went through the roof because nurses and patients were happier; quality and outcomes put our hospital in the top 15 percent in the country; and I got a standing ovation from 300 employees who lined the hallway from my office to the front door on my last day. Changing culture is easy to say and hard to do. Because it means command and control leaders have to make the transition to servant leaders. Servant Leaders share decision-making. They create such an environment through a shared set of values and behaviors. It takes about 18-24 months to make this transition if its done right. But here's the kicker - it means that nurses have to hold each other accountable to these new standards. And not every nurse makes it because there are some people who thrive being employed in a dysfunctional work culture. In my next post I'm going to talk about some strategies that you can take to start building an inspired workplace culture in your hospital. It can start with you and your department. Then when your performance metrics begin to get noticed by your Administrators and they come around to ask what's going on, you can smile and say - "It's because we're happier." Don't be surprised if your command and control leader wants to be happier too.

And the word should be succinctly, not succulently...

Agreed. I finally learned that if I wanted to manage any problem in a hospital, to ask the nurses and as much as possible, do that. Nurses always came up with better solutions than I or my leadership team could figure out. I looked smart and the nurses, patients and medical staff were happier - win-win.

As I used to tell my late, lovely father-in-law it's OK to use pain meds if you have pain. He had an unusual late stage cancer of the bile ducts and he was afraid of getting "hooked" on pain meds. He was a retired Navy pilot and of the generation that toughed-out their pain. It seems to me the answer lies somewhere in the middle, but I do not have experiences such as yours to really have an insightful opinion. You sound tough, too. :)

These patients are often operating from a place of self-delusion, convinced the world is against them. It's their defense mechanism so they don't have to admit they are addicted.

It's usually out-of-the-box thinking that come up with better responses and patient care. My experience is when an opiate patient realizes there is not other course available, they will either seek help or move to street drugs. So the answer needs to be multi-faceted and extend outside the walls of the hospital.

HA - that's poignant and funny.

I agree that the there is a tendency to be unsympathetic to narcotic pain addicts. It would be cheaper in the long run and better patient care to develop the addiction resources to treat them.

You are too kind Emergent, this is a fine compliment, thank you.

As a hospital CEO, I listed my home phone number in the admission kit for each of the three hospitals where I served. I invited patients to call me at anytime if they had a concern or problem they didn't feel was getting resolved. I did this because I had such confidence in the nursing staffs and House Sups to deal with patients, that I knew that I would not get many calls. And for the most part, this was the way the scenario played out. The exception was the disappointed narcotic pain med patient seeking a refill in the ER. While I know I don't need to explain the drill to ER nurses, it was a learning experience for me. Of the phone calls I received in the middle of the night (always after midnight), 80 percent were from patients who were angry they could not get the pain pills they wanted in the ER. Getting Fooled By Pain Pill AddictsI'll admit, I was naive at first - I was sympathetic to their suffering (and remain so to their addiction). I was like the new family doc right out of residency I hired who wrote a pain script on his first day of practice for one of the area's most notorious doctor shopper. When advised about this patient, he looked rather shocked and said "Well, he sure fooled me." It turns out, a lot medical scrip writers get fooled. There has been much recent data and attention on the increased use of prescription pain meds - I'm not going to restate what we all know. But two recent observations strike me as especially telling. Dartmouth economist Jonathan Skinner was recently quoted in a New York Times article about the rapid rise in overdose deaths among whites (turns out docs are more cautious in writing scrips for black patients, but that's a story for another day...) that: "It is like an infection model, diffusing out and catching more and more people." And according to The Association of Community Affiliated Plans, between 1993 and 2012, inpatient admissions for prescription opioid overdoses increased by 150 percent. ER nurses get to see those patients too on the way up to the floor. A Gun in the FaceMy late night calls from a narcotic pain med seeking patient always went through three stages. First (apology) the caller would say they were so sorry to wake me up in the middle of the night. The second (self-pity) was the longest part, which included a run down of the patient's medical condition and pain issues. I would dutifully explain that I was not a physician and could not tell the ER doc what scrips to write. I also explained that pain meds were highly addictive and the patient should consider the damage the meds could cause, including accidental overdose. Then the third stage (anger) would kick in. I would get yelled at and threatened with lawsuits. I would urge the caller to see their primary care doctor and whatever specialists were needed to resolve the cause of their pain. But it was obvious these callers mostly did not have underlying medical conditions for pain - they just wanted the pills, because they were addicted. As inconvenient as it was for me to get rousted out of bed in the middle of the night, it paled to what nurses and other staff had to endure in the hospital. At one hospital, a staff member ducked out of a back door in the middle of the night for a cigarette. Rather than use the secure smoking area in a well-lit area in front of the ER, this staffer propped a door open with a rock in a dark courtyard. A minute later, a man stuck a gun in her face and marched her up to the main medical floor where the House Sup was summoned. She had to unlock the Pyxis machine and hand over all the narcotic pain meds to get him to leave. From that day on, wherever I served as CEO, nighttime and armed guards were standing operating procedure. Also, any staffer who was found smoking via a secure door got to come talk to me so I could share the same story with them. I know that on any given night ER nurses are the first responders in this growing epidemic. Addicted pain pill patients take up an enormous amount of your time. The Huffington Post succinctly summed up the problem in an article on 1/25/2016: "Most agree on the causes behind the problem, citing uneven prescribing guidelines, marketing of the drugs by the pharmaceutical industry, few limitations on access to the drugs, economic factors and an inadequate number of treatment facilities for drug misuse, abuse and dependence." Taking Care of Patients Outside the HospitalSome hospitals have taken to posting signs in the ER that that no pain med scrips will be written. But a growing number of health systems and insurance companies are taking a more integrated approach, which is the often-unrealized benefit of the switch to value-based medicine under the Affordable Care Act. The days are gone where patients are discharged without support, knowing that if they returned the hospital would be reimbursed again (or not paid again, depending upon the patient). Hospitals are getting better at following-up with caseworkers, discharge nurses and social workers to stay in contact and support ER super utilizers - formerly called frequent flyers, which is now deemed pejorative. But you know the patients of whom I speak. NPR recently highlighted a program by CeltiCare Health Plan in Massachusetts to preventively deal with the growing opioid epidemic among its mostly 50,000 Medicaid members. If you are unaware of what steps your hospital is taking to proactively manage population health to keep patients out of the hospital - ask. I think you will be surprised at how healthcare is changing right before our eyes. It is my hope for all nurses that the promise of reinventing healthcare will eventually make your job easier and more enjoyable.

FancyPants - You make an excellent point that I, as a hospital CEO who has served at two hospitals, have long held. Satisfied patients are a direct result of satisfied associates. The path to high HCAP scores is an engaed workforce who feel empowered to manage their own morale. Easy to say, hard to do. Great workplace culture has to be driven from the bottom up, not the top down - which doesn't work. Nurses are smart and are the kings and queens of work-around when an administrator comes up with poor solution to a problem - like improving HCAP scores. The secret to creating great workplace culture, I have learned, is rather than telling associates what I can do to improve their satisfaction, I ask them - and they I try, as much as possible, to do what they ask. Sounds like you have smart leader at your hospital.