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...