Essays

Essays May 2014
Ghostbusting Series 2 – Synthesis II

Advancing the Art of Healthcare through Shared Leadership and Cultural Transformation

Jessie E. Saul, Kevin Noel and Allan Best

Our synthesis of Ghostbusting – Series #2 has identified three prominent “system level” priorities requiring attention before progress can be made on improving the patient experience. These are: 1) Refocusing on the “art” of healthcare; 2) Promoting shared leadership; and 3) Achieving fundamental change within the culture of healthcare.

 In 2012 Hugh MacLeod, CEO of the Canadian Patient Safety Institute, published a series of 24 essays offering ideas for implementing and sustaining transformative leadership within Canada’s healthcare system. Our synthesis of this first series of Ghostbusting essays outlined a set of guiding principles and mindset shifts required for the large scale system transformation necessary to significantly improve health outcomes and health system effectiveness (Saul, Best, and Noel 2013).

The focus of MacLeod’s first essay series, (Ghostbusting – Series #1), was on the role and responsibilities of senior leaders within the system. But the challenge of health system improvement and reform clearly requires a broader engagement of all stakeholders, including patients, front-line care providers and middle managers. In 2013, MacLeod embarked on a second essay series (Ghostbusting – Series #2) to bring the voices and relevant experience of these key groups into the conversation. If the focus of the first Ghostbusting series was the need for improved leadership, the focus for this second series is the patient and the need for improving healthcare quality, safety and the patient experience.

While the Institute for Healthcare Improvement’s Triple Aim includes improving the patient experience of care as one of its three dimensions, this area has generally taken a back seat to the need for reducing the per capita cost of healthcare. In Ghostbusting – Series #2, MacLeod and his guest contributors argue that the patient experience must be treated as a primary concern if any lasting improvements to patient safety and quality of care are to be realized.

Our synthesis of Ghostbusting – Series #2 has identified three prominent “system level” priorities requiring attention before progress can be made on improving the patient experience. These are: 1) Refocusing on the “art” of healthcare; 2) Promoting shared leadership; and 3) Achieving fundamental change within the culture of healthcare.


I. ADVANCING THE ART OF HEALTHCARE

“The science and technologies involved in healthcare – the knowledge, skills, care interventions, devices, drugs – have advanced more rapidly than our ability to deliver them safely, effectively and efficiently.” (National Research Council 2001).

The practice of medicine and healthcare more broadly involves harnessing the science of what we know with the art of applying that knowledge effectively within specific contexts. However, as our knowledge of healthcare science continues to expand, our understanding of how to most effectively use that knowledge – the “art” of healthcare – has lagged. According to MacLeod and guest contributors to his second Ghostbusting essay series, the art of healthcare is founded on a holistic view of the patient as a unique individual who needs to be recognized as such. This is quite different from a reductive scientific view of the patient as a constellation of symptoms requiring treatment.

Among other things, a holistic perspective entails acknowledging the values and knowledge that each person involved in a healthcare encounter brings to that situation, including the patient, their family members and their care providers, all of whom should be allowed to speak and be heard.

This view requires a re-visioning of the relationships among all people involved in a healthcare encounter as integral to that encounter, with the patient and their experience at the centre, as the focus of concern. Keeping the focus of all healthcare on the patient and their experience is fundamental to achieving a more effective balance between the hard science of 21st century healthcare and the softer art of healthcare practice.

Viewing patients as more than the sum of their symptoms.
In 1904, pioneering Canadian physician Dr William Osler wrote… “It is much more important to know what type of patient has a disease than what sort of disease the patient has.”

If it was important at the turn of the 20th century to advise physicians to see, listen to and treat patients as individuals, it is even more important today. Given our increased understanding of disease complexity, the pace of new drug development, the proliferation of new medical technologies and the demands of ever-changing clinical protocols, it is not difficult to understand why our health system is focused on the treatment of disease rather than the treatment of patients as unique individuals. And as a result, it should be no surprise that patients often feel dissatisfied with their experience of treatment within our healthcare system.

Patients have preferences, values, and histories that need to be acknowledged and respected. They also have families, live in communities, and contribute to society. Today’s healthcare system tends to strip this wholeness and distinction away from the patient when they walk through the door. The system of tomorrow needs to see the whole patient, recognize their place within their family and community, and link them to the resources they need for maintaining their health – regardless of whether those are within or outside of the formal health system. As Margaret Wheatley has said, “When a system is failing or performing poorly, the components must come together to learn more about itself, from itself" (Wheatley, 2005). Expanding our view of health services to encompass a more multi-disciplinary, community-based model is one way to help support the treatment of whole patients.

“ If there is to be a transformation of our health system to support the delivery of comprehensive care across the continuum, [we need to] …engage not only with health system partners but [also] with new partners in community support, social services, health units and health promotion agencies, who together contribute to an integrated plan for health for each individual. (North Perth Family Health Team and MacLeod, 2013)

We need to balance the science of healthcare with the capacity and willingness to tailor care to the specific needs of individuals and their families. And to achieve that, we must recognize the talents and tacit knowledge of front-line care providers and how they can help advance the art of healthcare.

“Maybe the key to establishing a new dynamic wholeness in healthcare requires that we find more meaningful ways to enable caregivers and patients to apply their wisdom and courage to rebalance our use of highly refined technologies, tools and healthcare practices....” (Holt and MacLeod 2013)

In their essay Where has the voice of nursing leadership gone? Bard and MacLeod (2013) mention the essential role nurses can play in advancing the “art” of healthcare. As they explain, this is a role of nursing that has been suppressed over time and needs to be fostered anew by creating a culture that “encourages the expression of the intellect, passion, commitment and experience of frontline staff to make real changes that satisfy healthcare consumer needs and expectations.” (MacLeod and Davies 2013)

The importance of relationships

“Healthcare is a touch business. It’s all about relationships.” (Macleod et al. 2013)

The art of healthcare involves much more than consideration of bedside manner and clinical judgment. It involves the relationships between people: doctors with nurses, patients with their families and communities, and healthcare providers with patients and families. It is the nature and extent of these relationships that make healthcare as an enterprise unlike any other business. Yet these relationships are currently out of balance. Restoring the art of medical practice requires re-visioning these relationships as true, functional partnerships.

If we are to improve the patient experience, we must take our direction from patients. The patient’s voice must inform all aspects of healthcare, from finance, to policies, to building design. However, we can also learn much about the patient experience from people on the front line of healthcare delivery. Leaders in healthcare must pay attention to the voices and experiences of people throughout the system. It is only by bringing together all of these perspectives that we can obtain a coherent and relatively accurate picture of our system of care.

In the relationship between patients and care providers as it typically exists today, there is a significant imbalance of power. A patient, coming under the authoritative care of a health professional, may feel vulnerable and ill equipped to advocate for herself. This is a time when the patient experience should be of primary concern for the healthcare provider.

“When you enter a doctor’s office or hospital there is a profound shift in power. You give up your body and power to a team of professionals, a team of strangers. This experience is quite different than any other service sector where you have the power to walk away and never return. In a healthcare environment, you don’t get to vote with your wallet... More than just “fixing” the immediate “complaint,” patient empowerment involves taking the initiative to advise patients - how to best manage their condition(s) and the risks and symptoms they may encounter from complications.” (Cox and MacLeod 2014)

Addressing this power imbalance starts with putting ourselves into the position of the other,
establishing a relationship of mutual trust and respect. Communication is key and must be encouraged and allowed to occur freely in both directions, with multiple opportunities for feedback. Patient engagement or communication is not an item to be checked off a list. Rather, it is a vital process that must be built into the everyday operation of our healthcare system. It cannot be an add-on to what we do, but must be embedded in our practice as healthcare providers.

To help make this happen, Cox and MacLeod recommend that healthcare providers receive training in methods of patient engagement, including how to initiate, receive and answer questions from patients and family members. “Far too many healthcare organizations view patient experience as (just) making and keeping patients happy. This misses the point – patient experience is also about a hospital’s philosophy for the delivery of care.” (Cox and MacLeod 2014)

II. SHARED LEADERSHIP
Improving the patient experience requires a shift in our model of organizational leadership, from a top-down, hierarchical, command-and-control structure to a system where every individual is empowered with leadership responsibilities and is allowed some latitude for making decisions or initiating changes where they are needed.

The concept of shared or distributed leadership is a common theme in the literature on large-scale transformation of health systems (c.f. Best, Greenhalgh et al 2012). It is particularly relevant for changes to improve quality and patient safety, given that direct contact with patients and their families happens not in executive boardrooms, but on the front lines – at the bedside, in waiting rooms and emergency departments – where the art and science of healthcare are practiced every day.

The value of shared leadership was previously presented in the first Ghostbusting series, in the essay Accountability for Performance (MacLeod and Closson 2013). “If the healthcare system is to improve its performance over the long term, it must shift from a paradigm where no one – or only a few – are accountable for achieving a particular set of results, to one where a wide range of players is accountable for achieving a broad range of results. … Accountability for achieving results must go beyond boards and management – and beyond a vague concept of shared responsibility – to include physicians, other healthcare providers, professional associations, regulatory bodies, government, regional networks and the public” (cited in Ball and MacLeod 2014).

Two sub-themes concerning shared leadership emerged from the Ghostbusting Series #2 essays:
1. Transformation of our healthcare system to improve the patient experience starts with “me.”
2. Everyone must be accountable and engaged to improve quality and patient safety.

Transformation of our healthcare system starts with “me.”
Transformation of our healthcare system requires a shift in our shared cultural mindset – a shift that must start at the individual level. “Ultimately, wholeness in the system begins with each one of us. We must attempt to change whatever needs to be improved within ourselves. And if system-related factors beyond our individual control need to be changed, then we should bring our concerns forward to those who can affect change and initiate a dialogue to make things better” (Singh and MacLeod 2013).

It is essential that everyone involved in healthcare take this principle to heart. True transformation cannot start at the top and trickle down. It must start everywhere, with everyone agreeing to walk a few steps in someone else’s shoes. Executives must engage with middle managers, and front-line staff members with executives. Everyone must talk with patients and families. LISTEN to understand. ACT to make a difference.

At the same time, healthcare leaders must demonstrate the change they wish to see. If we desire a culture where staff are celebrated for identifying errors rather than being blamed, executive leadership must model that attitude as a priority. Culture change must happen at all levels of an organization, but it cannot happen without the active support of leaders “walking the talk.”

“Leadership is the result of saying at a deep level, ’I think I can, I think I can‘ in an organization that sets its tracks uphill and at an angle worthy of a challenge. It is up to the leaders to take that very first step, thus demonstrating a willingness to forge ahead while instilling in others the courage to act and persevere.” (MacLeod 2013)

In transformative change, every individual exists in a state of potentiality, of walking the line between continuity and change. Each person must ask “What can I do to change how I think about patient safety? How are my thoughts, actions, and words influenced by fear or uncertainty? What can I do within my own sphere to engender trust and communication with my colleagues, with my direct reports, with my patients?”

Everyone must be accountable and engaged
Once begun, system transformation must continue through engagement, empowerment and accountability of each individual within the system. Everyone, including patients and family members, must feel sufficiently empowered to “stop the line” – to identify when something is amiss and initiate corrective action. Individuals must be supported, protected and ultimately rewarded for taking such action. The importance of this mindset shift was emphasized throughout the second Ghostbusting essay series (c.f., Ford and MacLeod 2013; Sears et al. 2014; Bard and MacLeod 2013).

Such system transformation requires education, training, mentoring, and modeling to shift mindsets and behavioural norms so that people feel empowered to speak up when necessary. Those who identify patient safety issues should be recognized and rewarded. Acknowledging lessons learned and making procedural shifts to improve quality of care should be standard operating procedure.

Continuing education opportunities should be available for everyone in the healthcare system to enhance our collective quality and patient safety practices. Patient input must be sought proactively in ways that empower patients and their families at a time when they feel powerless, thrust into an alien environment with unfamiliar rules, language, and social norms.

To facilitate the engagement of all individuals within the health system in transformative change, Mastin and Macleod recommend that patient safety theory and practice be made an integral part of training for healthcare providers (Mastin and MacLeod 2013). In addition, Holt and MacLeod suggest that health organization performance development plans should routinely include continuing education of staff “to enhance our collective quality and patient safety practices” (Holt and MacLeod 2013).


III. A CULTURE IN NEED OF CHANGE
To improve the patient experience in measurable, meaningful ways requires nothing short of a change in healthcare culture, founded on trust as a shared value. Only within an organizational culture of trust, where errors are treated as opportunities for learning and improvement, can we overcome the counterproductive practice of attributing blame and seeking retribution. Finally, we need to understand that changing culture to improve the patient experience is an ongoing process. There is no end point to this journey.

Building trust
Human error does not exist merely because humans are found in proximity to error. Error exists in context. It is only by talking about our failures that we can figure out the changes required to avoid the same failures in the future. However, this is difficult within a prevailing culture of blame, retribution and scapegoating.

If we think of the patient as a “customer” of the healthcare system, we might ask ourselves, “What does great customer service look like?” The answer, according to Cox and MacLeod involves three concepts: “Attention to care, communication and trust. When one of these elements is missing, patient safety and quality breaks down” (Cox and MacLeod 2014).

The second Ghostbusting essay series offers several recommendations for elevating the level of trust within the healthcare system. Investigations into patient errors, for example, must focus not on individuals in close proximity to incidents, but on the systemic issues that lead to errors. This perspective offers a path to improvement that addresses the root of a problem and engages people close to the issue in developing the solution.

Systems thinking is a valuable tool for enabling this type of transformation. From a systems approach, people must have access to appropriate opportunities or mechanisms for expressing concerns and/or ideas for improvement. More than problem identification, system thinking can help identify the source of trouble and address the issue from multiple perspectives. The result is a more robust approach to improvement. “The Canadian Incident Analysis Framework provides a wealth of resources to support such systemic analyses, including the importance of bringing the patient voice and perspective into the investigation” (Sheps, Cardiff, and MacLeod 2014).

Culture change: A journey, not a destination
Achieving a patient-centric culture within the healthcare system is not a destination, but a way of being or a mindset. We will never achieve a perfect system of care or completely eradicate the occurrence of patient error. However, we can take to heart the knowledge, from much study of organizational culture, that change is constant and responding attentively and carefully to change is better than ignoring it. As expressed in one of the Ghostbusting Series #2 essays, “Safety is enabled every day by people managing the trade-offs inherent in the work itself, and recognizing the surprises that seemingly crop up out of nowhere. … It is continually created and re-created by those doing the work” (Sheps, Cardiff, and MacLeod 2014).

From a systems perspective, organizational practices and protocols are always in a state of flux; what works in one time and place will need adjustment to fit different contexts and times. Realizing this truth about systems and organizational culture is an important step toward actualizing the culture required for improving patient safety for the long term.


CONCLUSION
Improvements in patient safety must be built on a three-legged foundation consisting of the patient voice, practitioner ears, and organizational support. First, the patient must be at the centre of every interaction within the healthcare system, and recognized as a unique and whole individual, extending beyond the boundaries of the shift or room within which care is provided. Relationships among everyone involved in a healthcare event – including the patient, her family members and all care providers - form the backbone of the healthcare experience. Prioritizing these relationships and listening carefully to the patient voice allows us to tip the scales to achieve a better balance between the art and science of healthcare.

Second, everyone in the healthcare system must share the responsibility for listening and watching for threats to patient safety, and the authority for taking action to make changes. The eyes, ears and hearts of front-line care providers and middle managers must be fully trained on the target of improving the patient experience if progress in this area is to ever be made.

Finally, and perhaps most importantly, improving the patient experience requires a change in culture. This change must be embraced by and reflected in the actions of everyone within the system. Furthermore, everyone must understand the fundamental truth that change is an ongoing and healthy process. All organizations undergo constant change, but healthcare organizations that embrace the patient voice, encourage shared leadership, and seek to build trust rather than apportioning blame, are bound to evolve in a patient-centric direction.

These themes complement the simple rules and mindset shifts that emerged out of the first Ghostbusting series (Saul, Best, and Noel 2013). By ASKING questions of patients and staff, leaders can test assumptions and create clarity of purpose. By LISTENING to hear the perspectives of patients, front-line providers, and middle managers, leaders can create alignment of effort. Leaders can then use the wisdom and insight they have gained to TALK, to fuel new conversations with people to create credibility of leadership.

Both Ghostbusting series have emphasized that leadership in the healthcare system requires acknowledging that power and knowledge must be shared. This shift in mindset requires nothing less than a transformation of culture. As the Chinese philosopher Lao Tsu put it, “When I let go of what I am, I become what I might be.” Letting go creates the space for relationships and a collective identity to develop, for information to be shared, and for the talents of everyone within the system to be valued and used. On the strength of these behavioral and mindset shifts, we can achieve the collective accountability required for making significant improvements in healthcare quality and patient safety.

About the Author

Saul, Jessie E., Ph.D. Associate, InSource Research Group. President & CEO, North American Research & Analysis, Inc. Best, Allan, Ph.D. Director, InSource Research Group. Associate Scientist, Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute. Clinical Professor, School of Population & Public Health, University of British Columbia. Noel, Kevin G., M.A. Director, InSource Research Group.

References

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