Today on the balcony I am joined by Graham Lowe, a leader on healthy and productive workplaces. We start our conversation by reflecting on the fact that we are systems creatures. Our experiences of ourselves and others and the nature of our relationships with them are strongly influenced by the systemic conditions in which we exist. Too often we are systems illiterate. A system’s forces push and pull at us, yet we remain mostly oblivious to them. We see ourselves as independents not inter-dependents. We believe our judgements to be objective. We believe they reflect reality. But reality, as we call it, is a construct of our experience of others and our feelings about them and us.
To realize a new vision for the Canadian health system requires everyone’s participation in building relationships that connect different levels of the system. This not only includes the relationship between patients and providers, but providers and their colleagues. What goes on between people defines what a healthcare organization is and more importantly what it can become. Nothing good happens when relationships fail, but imagine how much we can achieve through healthy relationships.
The renewal and sustainability of the Canadian healthcare system requires action first and foremost at the governance level – the ministers, deputy ministers, key policy makers, and the boards and CEOs that are responsible for running each healthcare organization. These are the leaders who have responsibility for articulating a shared vision for the future, then defining the roles they will each play in realizing that vision. This is where the future direction for a coordinated, integrated and patient-centred health system must begin.
Healthcare organizations are often big and bureaucratic. Let’s begin at the top. How often have we seen the top level, formally responsible for the whole, dissolving the whole into disintegrated domains of responsibility? Often, boundary and turf issues begin to dominate, peers begin to protect their domains and resist joint problem-solving. By rebuilding connections and emphasizing common goals it is possible to stop polarization and isolation from becoming the standard operating style.
When this dividing pattern becomes the organizational norm, it signals to those in the organization to focus narrowly on their individual areas, losing sight of the system as a whole. The mid level of the organization senses and adopts the top level culture. Horizontal connections begin to erode. The managers mirror the isolationist behaviour of their superiors. For the patient and the system, unhealthy competition is harmful.
Surely the goals that everyone in the system can rally around are (1) high-quality, cost-effective, safe patient care, and (2) overall improvements in the health status of Canadians. These are the big imperatives that trump smaller agendas, which are at the root of the silos you describe.
As the top and middle levels become absorbed in their own aspirations, the front lines feel like cogs in the bureaucratic machine chafing under the remoteness and perceived dysfunction of their superiors. They at times are caught between competing organizational imperatives that bring them into conflict with their peers. They feel unified as victims and divided by the absence of common direction and purpose. The healthcare system is already suffering from providers’ lost capacity and this can’t continue. Imagine the benefits everyone can gain if by building bridges between people, this friction and the negative energy are replaced with enthusiasm, hope and confidence. Relationships have the power to prevent organizations from falling into holes and finding new paths forward. Since people are the vectors of those relationships, understanding and nurturing their intrinsic motivation is key. A passage from a previous essay: “… through discourse and the application of honest conversation, we can work like Plato did to keep the Socratic fire burning. If that fire is ignited in enough of us, working together, we can solve any and all problems facing our healthcare system.”
We must understand the malaise that poses costly risks to many individual healthcare organizations. When front line staff are not effectively managed, when they don’t feel supported and valued, and when the leaders of their own organization are not modelling collaborative and respectful working relationships, how can we expect them to excel in patient care or service delivery? The lesson from the world’s most successful companies is you put your customers first by putting your people first. This simple principle of people management is a cornerstone for a high-performing healthcare organization.
But before we can continue we are interrupted by a haunting foe. It is the echoing voice of the critic, who views our ambitions to change and improve with profound cynicism.
“Idealists. My bureau groans under the weight of dusty reports, updates and briefing notes with every genuine insight presented to and then ignored by the people you claim to care about. You should be embarrassed. These managers you speak of are disconnected, competitive, ego-driven and powerless like those in all human systems. You waste time trying to ‘fix’ one another, instead of working jointly to master the conditions which rule you. Humans are selfish and ego-driven. They are incapable of humility, self-assessment and unselfish cooperation.”
Imagine the benefits of building bridges between people – of replacing friction and tensions with enthusiasm, hope and confidence. So what needs to be done to align the organizational spaces and create healthy relationship patterns?
- A shared vision that is honoured each day. This places partners at the same table with a common goal. A shared vision might seem critical for those at senior levels. But by its very nature, senior management is one with too much to do and not enough time to do it. Non-pressing items – the organization’s vision, for example – are often neglected. The organization’s vision must therefore be fostered and followed at all levels, so it becomes entrenched in culture.
- Respect for the experience and relevance of an organization’s middle management. This is critical for success. Middle managers handle complaints from the top and from the front lines. Middle managers can act as the bridge builders.
- Diversity embraced. By marshalling our diverse resources we can create powerful coalitions. The challenge is to invite people to come forward with their ideas – to encourage them to take a risk and share their knowledge.
What we are advocating is captured in one word: culture. Strong people-focused values, a compelling vision of the organization as a great place for both patients and staff, and a spirit of sharing ideas for doing things better – these are the hallmarks of the leading healthcare organizations today.
Every other business has had to retool its services and programs to meet new and changing customer expectations. Why is our environment slow and resistant to system change? Is it because the silo comes first and the system comes a distant second? Is it because stakeholders try so hard to distinguish themselves from all others that they become blind to the fact they are much more alike than different? After all, we all have a calling of service.
Do you see people pulling away from one another because they reject a common bond and a capacity to relate to and understand those they believe are beneath them? Our potential is limited because we are unable to work collectively; creating the necessary harmony needed to change. We must develop the capacity to think and act systemically. This will help both individuals and the organization overcome the defeating patterns of organizing and behaving that sustain ineffectiveness. At a fundamental level, we forget that every individual across our complex healthcare system has the potential to undermine or create successful system dynamics at any point in time.
Healthcare organizations are structured as pyramids, with a broad base. That base is where we find the hundreds of thousands of front line workers – from nurses and doctors to kitchen and cleaning staff, administrators and IT staff – who possess the hands-on expertise to significantly improve the performance of their organization and, at the same time, make their area a more personally rewarding place to come to work every day.
Dissatisfaction with the current state of organizational conditions is the first step towards progress. Imagine the healthcare system to be a multi-storey building. We have stairs, halls, ladders and balconies. We call them networks, institutes, agencies, foundations, etc. In addition, we have independent stairs and ladders called the delivery system. Too often, leaders were more concerned with the drama in the upper floors than the relationship flaws on the stairs and ladders. Instead of thinking and acting as isolated silos under siege, governance and managerial leaders can choose to see themselves through another lens; a lens in which they see their organization in relationship to a local health service delivery system – your community partners in the delivery of care.
Rather than laying out a map of the future and giving staff a big push from the top of the organization, it means working alongside them to define new roles, power relationships and behaviours.
Next Week’s Guest on the Balcony of Personal Reflection: John Abbott in a conversation titled “Strategy and its Interplays.”
Click here to see the First Series of Ghost Busting essays.
Click here to see essays from the Second Series: The Ghost of Healthcare Consciousness.
About the Author(s)Hugh MacLeod is CEO of Canadian Patient Safety Institute. Graham Lowe, Ph.D., is President of The Graham Lowe Group Inc. and author of Creating Healthy Organizations: How Vibrant Workplaces Inspire Employees to Achieve Sustainable Success.
Marcy Saxe-Braithwaite wrote:
Posted 2013/05/14 at 12:24 PM EDT
very interesting commentary, thank you for your leadership and sharing your perspectives/thoughts. How will we shift the culture within health care to ensure accountability, transparency and promote healthy workplace behaviours.
Robert Pental wrote:
Posted 2013/05/19 at 08:29 AM EDT
I have had the honor of reading these essays , wandering as it were along the hallways and between the balconies. In these travels I could not help but notice a trend in their content and perspective. Now, before I publish my observations, let me say all have been well written and completed by those thoroughly versed in healthcare decorum. Moreover, they are all obviously planned events and so suggest in their substance a personification of the writers. That being said, might I suggest a calmer approach to the future. Seriously, I know all of you are leaders, or regard yourself as such, but from where I sit you all need to calm down, or, as the younger generation says, "Chill".
The unstated tone of having avoided or barely survived disaster combined with predictions inundated with the evidence based fear of the avoiding of yet another disaster, that if we are honest and transparent, has not occurred, is a bit unsettling. What is more, such an approach does not portray or project confidence in yourself or those with whom you surround yourself - namely the patients.
Yes, challenges will present themselves. However, this approach of questions layered in questions about the questions questioned, surrounded in another layer of the best results from the best answers based on the best evidence from the best researched research, entails among other things a degree of tail chasing that would leave the most dexterous not knowing what way is forward, let alone where to stand.
Granted, the literature out there implies that the most effective way to induce change, or keep resources active and engaged, as opposed to letting them grow complacent, is to generate a perpetual thread of crisis, that strangles if we move from it and entangles us if we stay in it. Which if the case were true would mean a degree of immediacy and urgent action is required. Or put it simply, I don't know where all the time is to complete extensive studies, research, and compose in-depth referenced essays if we are on the precipice of disaster.
And so finally, this response is not to say there is not work to be done, nor is it to say what has been shown in the essays is without merit and worthy of respect. However, if you want to change the way you work, then perhaps you should first change what you are working on. What is more, if the goal is to create lasting and enduring results at multiple levels, then the work to complete it must also be of such quality and quantity that it takes flexibility to finish. And so, seek out trust that people might be trusted; decency that people might be decent; creativity that people might be innovative; compassion that people might care; diligence that people might be thorough; and understanding that people might be understood. Seek out, in other words, that which even if you follow it still enables you to hold a position that leads. In the meantime then, we'll see you in the halls.
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