The Healthcare Efficiency Revolution : A Mid-Level Managers’ Manual for Professional Development [1st ed.] 9783030612313, 9783030612320

Table of contents :
Front Matter ....Pages i-xxx
Premises (Ziv Gil)....Pages 1-31
Deconstruction (Ziv Gil)....Pages 33-38
Smells Like Team Spirit (Ziv Gil)....Pages 39-48
Management 360 (Ziv Gil)....Pages 49-70
Prelude to Action (Ziv Gil)....Pages 71-74
Real Problems, Real Solutions (Ziv Gil)....Pages 75-94
Metrics (Ziv Gil)....Pages 95-104
Crises (Ziv Gil)....Pages 105-116
Considerations (Ziv Gil)....Pages 117-125
Back Matter ....Pages 127-127

Citation preview

The Healthcare Efficiency Revolution A Mid-Level Managers’ Manual for Professional Development Ziv Gil

123

The Healthcare Efficiency Revolution

Ziv Gil

The Healthcare Efficiency Revolution A Mid-Level Managers’ Manual for Professional Development

Ziv Gil Department of Otolaryngology-Head & Neck Surgery Technion – Israel Institute of Technology/Rambam Health Care Campus Haifa Israel

ISBN 978-3-030-61231-3    ISBN 978-3-030-61232-0 (eBook) https://doi.org/10.1007/978-3-030-61232-0 © Springer Nature Switzerland AG 2021 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

To my patients who have trusted me with their care.

Preface

Rubber, Meet Road Many modern healthcare facility management issues are addressed in these pages. Numerous innovations are introduced. They’re based on years of experience with and results produced from implementing new systems and approaches, which in turn were created by reverse engineering how things have typically been done and anticipating likely, even extreme scenarios. With this said, COVID-19 was something altogether different. Don’t misunderstand. The idea of a global pandemic wasn’t off the radar screen. In this century, Ebola, SARS, and H1N1 presented serious challenges. In the early days of those outbreaks, it wasn’t at all clear how virulent those diseases would be, how fast they might spread, or how well they could be contained. Ultimately, none confronted humanity on the scale of COVID-19. And yet, for all the demands this novel coronavirus has placed on hospitals and their staffs, there’s a group of us, who work in a single department of one of Israel’s largest medical centers, the Rambam Health Care Campus, who felt about as well-prepared to weather this immense storm as the circumstances would permit. Our management modernizations over the past 8 years allowed us to continue to function and deliver healthcare services at the highest levels possible, despite the crisis. It wasn’t that we had planned for anything like a once-in-a-century event like COVID-19, it’s simply that we took and are continuing to take steps to raise our standards of communication, efficiency, and reliability. We implemented goals and metrics, and now have objective results to demonstrate that what we’ve done can serve many more patients, and produce better health outcomes without the need for increased expenditures. What we’ve done isn’t unique to us as individuals, our institution, or the national context within which we operate. Among the member states of the Organisation for Economic Co-operation and Development (OECD), there is hardly a hospital or healthcare facility that doesn’t have untapped capacity. In some instances, the solution we discovered came by thinking outside the box. In many others, we chose to construct new boxes. The key to our success? Never let existing thinking box you in. As COVID-19 spread across the planet, we all had to adapt to new ways of living. As healthcare professionals, our hospital and our daily work routines were vii

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completely upended. However, those changes also revealed how our new procedures had positioned us to best meet the coronavirus moment. When it hit, by necessity, it separated our entire department. No more than two or three of us could meet face-to-face at any one time. Like most hospitals around the world, all nonessential surgeries and treatments were cancelled. This allowed our institution to scale back to an operational level that was 30% of capacity. Patients receiving consultations and treatments in our departmental clinic were reduced by 80%. Our staff was not only separated physically, but by time, as we were working different shifts. There was never more than 30% of our departmental staff present in the hospital at any given time. In a significant way, the changes imposed on us by COVID-19 ran counter to what we’ve built. Ours is a multidisciplinary, holistic approach to serving patients. This allows us to foster meaningful connections between people—connections between staff members, and connections between staff and patients. We weren’t prepared to have those personal contacts severed. Nevertheless, the coronavirus experience illuminated strengths in our model, which created opportunities to learn lessons that will make our system better years after the COVID-19 epidemic enters the history books. Here’s one example of how our philosophy-in-action was a boon to us when the pandemic hit. In hospitals the world over, senior departmental managers and vice chairs typically conduct their daily rounds with 15-20 people in tow. Many have been doing this for years, if not decades. However, with COVID-19, they suddenly had to adjust to smaller, scaled-down rounds. We didn’t face that “dilemma.” Eight years ago, we came to the conclusion that grand hospital rounds weren’t offering any significant benefit to staff or patients. Our shift to smaller rounds didn’t negatively affect the professionalism of our doctors, nor the quality of medical services we provide to our patients in the slightest. The precious time of personnel and the needs of those in our care are much better served by small rounds. If there are lessons for other physicians and nurses to learn from a given set of rounds or a particular case, there are other ways that people can get at this knowledge, including through the use of recordings that are archived, indexed, and available for on-­ demand playback. Our innovations have also included embracing the idea that, to the degree possible, a healthcare institution should never be solely reliant on a single expert in a given medical arena. For example, in our Otolaryngology—Head and Neck Surgery department, there are a variety of explicit and associated disciplines—head and neck, otology, laryngology, rhinology, skull base surgery, facial reconstruction, microvesicle reconstruction, and pediatrics. We’ve worked hard make sure that we’re never dependent on just one person in any given field. By identifying at least two physicians from each discipline, it doesn’t matter whether one individual is stuck in quarantine or simply taking a sick day, we don’t have to shut any particular service area down. The regular flow of our patients continues normally. Neither we, internally, nor those who are scheduled for our clinics and ORs need ever be inconvenienced.

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We also accommodated the needs of the coronavirus crisis by dividing our departmental staff into three groups, each working on 24/12 shifts. Each group independently maintained the clinical burden of COVID-19 patients and emergency services without seeing each other at the same time in the hospital. Once again, this was possible only because we were ready for this crisis well before it ever happened.

When Tech Talks, People Act Before the COVID crisis, technology had presented our department with the means to do much of what we need to accomplish without seeing each other in person. We weren’t negating the essential leadership role of managers, only acknowledging that through the implementation of smart, automatically functioning systems, managers need not be domineering figures around whom nothing gets done without their explicit say so. This is principally because, in any healthcare facility, every employee knows the job they were hired to do. Numerous daily tasks and functions are regularly performed almost on autopilot. Our mindfulness of this was critical to the steps we took to improve how we’re now delivering healthcare services. Our calculation was that since so much of what we do every day fits into standardized patterns of behavior and performance, then these are things that lend themselves well to being honed by technological tools. So, we adapted and, later, devised software solutions that can tell us, for example, precisely what’s going on in our operating rooms, in our clinic, in our ER. These are real-time systems our staff can monitor and which can alert us. They allow us to rapidly identify and resolve bottlenecks. We don’t need to be physically present or personally observe problem situations to be able to fix them. Our autopilot electronic systems have not only diminished the preeminent role of the manager in situations where managerial direction isn’t required, they’ve enabled us to better cope with these pandemic circumstances. Everyone was already empowered to keep their individual corners of the department running well on their own. No one on our staff needs a dominant coordinator and big meetings to stay informed, and in line. Our technological systems have created order, efficiency, and improvements in service simply by focusing everyone’s attention on immediate issues and obstacles, and reinforcing already-existing and wellunderstood solutions. This is transparency by way of handheld technology. We’ve experienced and can attest to the profound advantage that comes from knowing what’s happening in every unit of our department simultaneously. Time and resources are optimized, while professional personal interactions are focused on necessity and best possible outcomes. And while our systems work exceptionally well in normal times, they’re tailor-made for managing in isolation or quarantine.

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Calm Seas in Turbulent Times We’ve proven that by holistically reconceptualizing how our department operates we can produce efficiencies that make our professional circumstances less complicated and our patients lives happier. The bonus we discovered is that when going through a catastrophic situation in healthcare like COVID-19, it’s been very easy for us to adjust to and meet the challenges of the crisis. In this same moment, we’ve looked at other departments in many other institutions and see people saying that they can’t divide their departments into three. They’re frustrated because they don’t have the ability to provide continuity of service across those separate parts; they don’t have the personnel to adequately participate in each subset. This is a problem that we’ve not had to face, even in the midst of a pandemic pressures. In fact, the stability of our crisis-orientation operations has been quite remarkable. Shifting into that mode presented no difficulties at all because we’ve nurtured a mindset that’s always ready to consider and swiftly implement practical alternatives to the way things have been done. On the technical front, as soon as it was understood that we wouldn’t be seeing or speaking with one another in the workplace, we knew this could easily cause us to disintegrate into small units and lose the cohesiveness of our departmental structure. To overcome this, we immediately scheduled daily, department-wide video conferences. Everyone attends—secretaries, nurses, residents, and attending physicians. These afternoon, virtual encounters have been critical to maintaining a tight departmental bond. And it’s not a rigid, by-the-numbers get-together that’s directed from the top. It’s more like a family gathering, where people have an opportunity to discuss how things are going on a personal level. We also get briefed from those who have just been on shift about what’s happening in the department and the hospital. We ask each other: How did the day’s surgeries and clinics go? Did problems arise? How were things in the ER and COVID ward? Is there any new know-how to be shared? Have there been new coronavirus admissions? How are our patients who have been admitted elsewhere in the hospital? Even via online conferencing, everything is about preserving continuum of treatments and staying close-knit as a team. This is extremely important, as COVID-19 has stressed our department in a multiplicity of ways. Breaking apart our staff into three parts means that each shift is required to work harder, to put in longer hours, and attend to more emergency cases. Some have been assigned elsewhere in the hospital, working in disciplines unrelated to their jobs in our department. Some have had to do COVID ward duty. Further, the remuneration for many staff members is based on elective cases. With all such procedures cancelled during the peak of the crisis, institutional revenues plummeted and, therefore, incomes for these professionals declined, with some decreasing by half, if not two-thirds. Some nonpermanent staffers had to be laid off. And there’s a mental health toll associated with all of these additional pressures. Therefore, you might expect that some would benefit from having access to crisis intervention specialists. Unfortunately, our institution couldn’t provide these psychological counseling services.

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It’s easy to understand, then, how all of this could cause many of the basic structures of our department to disintegrate, which would translate into a decrease in function. The daily briefings were at the core of our operations while in disaster mode. These sessions went beyond keeping each other informed. They also allowed us to buck up one another’s spirits, and plan for the next 24 h, as well as the week ahead, and how we’ll eventually overcome this crisis. We left no doubt in anyone’s mind that we, as a group, are prepared to care for and protect our medical team members at all costs. It was imperative for individuals working with COVID-19 patients to know that we were there to assure that they’d be adequately protected, even when institutional and governmental resources were unavailable to do so. This included devising and implementing departmental regulations and routines designed to safeguard medical teams involved in carrying out invasive procedures on coronavirus patients. Failure to take these actions would have made it ten times more difficult to maintain our capacity, guarantee 100% staff compliance, and quickly return to precrisis operations. These cyber sessions also allow our managerial staff to get reports that have been communicated to divisional managers from our institutional CEO. This, too, is a very important part of our interactions because when people are in isolation it provides them with big-picture projections and perspectives. The additional knowledge is good for our patients, too. Those in our care have many crisis-related questions and concerns. These may not bear directly on their medical conditions, but our answers can often provide them with peace of mind.

Instilling Hope and Confidence Much will be said in the chapters ahead about things which can be accomplished as, or in consultation and collaboration with a team—shaking off old ways of thinking, flattening hierarchical structures, delegating authority, staff empowerment and accountability, creating and adopting new methodologies, and really taking advantage of high-tech solutions. In the end, though, a manager is a leader. And particularly in a crisis moment, leadership is not a shared responsibility. Some matters cannot be handled by anyone else. Two rise above all others. First, leaders must be able to keep things under control and care for those in their charge. Second, they must be seen to be doing these things, doing them effectively, and doing them with a devotion of head, heart, and soul. This is a must. Crisis is a time of confusion and high stress. It’s a time when leadership plays an important role in ensuring continuity of operations by bolstering the confidence of personnel and providing them with direct support when other, normal channels are unavailable to them. Here’s a COVID-19 example: In our department, we didn’t have the masks that could protect our staff from infection. We had surgical masks, but those are insufficient against the coronavirus. So I spoke with our hospital’s chief epidemiologist, who indicated that national Ministry of Health guidelines stated that surgical masks would provide adequate protection.

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This placed me in a difficult predicament. I had staff who were being asked to serve on the front lines. Regardless of the official policy, they didn’t believe they were being protected. As a leader, I couldn’t just tell them, “Well, that’s the way it is. What can I do?” Their perception was a reality I had to deal with. I had to act. So, I immediately got on the phone and did what was necessary to secure donations of protective masks, which I then personally distributed throughout the department. I went further by getting institutional approval for our doctors to perform certain special surgeries, which then assured that we would be supplied with specific personal protective gear from the hospital. I did those things because, psychologically, it was very important. During trying times, it’s vital to keep morale high. But that wasn’t my only consideration. I acted out of a genuine conviction that I needed to protect our team, that the actions I took were the right things to do. In a time of crisis, when the safety of the team is at stake, people deserve to know that their manager is doing whatever he can to protect them.

Many Medical Cooks Perfecting the Broth Another innovation that has proven invaluable in daily practice and an almost-literal lifesaver in the corona-crisis moment is the multidisciplinary team approach. This is infinitely better than what most patients tend to encounter, going to multiple doctors to receive individual consultations (Fig. 1). The doctors are, of course, looking at the notes and comments added by colleagues, but there’s no direct interactivity between the professionals. Long before COVID-19, our department established multidisciplinary teams around specific disciplines, including oncology, skull base, hearing, and endocrinology (Fig.  2). Within each, we gather all of our institutional experts in a meeting room and discuss complicated cases and their solutions. There, patient cases are presented and discussed, and decisions are collectively rendered on treatments or surgeries. Together, we’re a bit like the ancient Chimera (Fig. 3), combining the best attributes and skills of a variety of creatures to become (in our case) the most artful and ferocious disease fighters and patient advocates possible. As a result of coronavirus lockdowns, our tumor board adopted the use of online meeting platforms and collaboration tools. Other than this, the structure of what we had been doing in person remained the same. Now we’re in the process of fully evolving our digital multidisciplinary team approach to directly connect patients and problems with our professionals. The concept is not simply to have an online teleconference, but to develop virtual rooms constructed around subject areas. In each room, there’s a patient manager or an issue coordinator, and several specialists who are focusing their attentions on a given patient’s case or a point in question. There are structured discussions around and written assignments attached to these, with responses to be submitted within 24-48 h. If someone doesn’t complete a task within a prescribed period of time, the system auto-generates reminder messages.

Fig. 1  Linear treatment. (Credit: Nofar Rada)

Surgeon

Medical Oncologist

Radiation Oncologist

Follow-Up

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Medical Oncologist

Fllow-up

Team

Surgeon

Radiation Oncologist

Fig. 2  Multidisciplinary team approach. (Credit: Nofar Rada)

Fig. 3  The Chimera. (Credit: Nofar Rada)

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Participants can cross-communicate with one another, as well as share and archive charts, files, ancillary documentation, videos, etc. Everything is logged, categorized, and indexed. The progression of any particular case or matter for review can be easily tracked: Who was in charge? What was discussed? Which individuals were asked to do what? What were the results? Our objective is to assemble a large number of experts and pool a significant number of inputs, such that this critical mass of collective experience and wisdom will raise the bar for diagnostic medicine, and improve treatment and surgical outcomes. We began working on this project more than a year before the COVID-19 outbreak. The efficacy of the system is clear when so many of us have been forced to work at a distance and in shifts that naturally keep us physically separated. However, in normal times, we had already assumed that optimal results in diagnoses and care options don’t require an overemphasis on seeing and speaking with one another. This is not a replacement for meetings and conferences, which will always have their place within the spectrum of our work. Rather, the 24/7 platform is meant to work in parallel with what we do, to augment our medical practice, and make us all more efficient in the delivery of healthcare services. We’re developing this system not only for ourselves but also for eventual implementation and use at mid-size to large-scale healthcare institutions around the world. We also believe the reach of this initiative should be able to extend further. For example, rural areas and underdeveloped countries must often contend with chronic shortages of diagnostic tools and adequate numbers of trained medical professionals. In a coronavirus-lessons-learned environment, there’s no reason why this type of multidisciplinary approach can’t become multi-institutional, allowing for the creation of collaborative consortiums within regions, states, provinces, or, in some instances, entire nations. Such an extension of the concept could extend beyond case consultations to resource management and burden sharing, which would likely prove to be indispensable in times of disaster and crisis.

The Horizon The managerial concepts and practices to follow will be beneficial for any hospital or healthcare facility to adopt. However, regardless of any innovation or technological solution, there’s no substitute for management that works. Whether on a departmental or institutional level, whether in normal days or crisis periods, smart management dissects how things are done today, looks at the component parts, understands how they’ve been pieced together, and systematically looks to make changes where change makes good sense. This work includes disaster planning that will best prepare staff and systems, in advance, for what-if scenarios, so that the transition to emergency operations can be as swift and smooth as possible. One more thing: This is an ongoing process. This book isn’t a to-do checklist and once these ideas have been incorporated, the job is done. This is about taking on a mindset that will best prepare healthcare leaders, together with their staffs to always

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have a forest-for-the-tree perspective. Although written from a mid-level managerial perspective, the insights and recommendations on offer will work just as well for those at lower and higher levels of the organizational chart, from departmental unit to organization-as-a-whole. As general perspectives and managerial philosophies can be shared between and advantage individuals working anywhere in an institution, it is hoped that this book may be of particular value to those thinking about or just entering the ranks of healthcare management. We should never allow ourselves to be satisfied that what is working today will always continue to be so. To achieve this, managers must lead. This may sound obvious, but knowing what leadership really means is where our rubber meets the road. Good management is not merely about always being open to new ways of thinking and embracing modern systems. It’s about enhancing the ability to listen. The longer a manager works in any field of endeavor, the more likely it is that that individual will get stuck in particular routines, to rely on knowledge which may be less applicable as the years go by, and to become less productive (Fig. 4). This is in the nature of things. That’s why good management accepts that most of the best and freshest ideas will come from below, not above. And it’s also why managers should step down before the descending phase begins. There’s nothing to fear from being fearless, nor is there any shame in trying out unique approaches that ultimately don’t quite work. Be afraid and ashamed of not making the well-reasoned attempt, of not shaking off anxiety, of not hearing and considering the opinions and suggestions of others. These are the qualities that elevate leaders. These are the characteristics that pave the way for breakthroughs. Finally, be there. In good times, but especially bad, be there. For all that’s been said above and in the pages ahead about cyberspaces, virtual meetings, and automated monitoring systems, to maintain and strengthen good management, people

Stability phase

productivity

Linear phase

Take up phase Descending phase

Time

Fig. 4  Manager’s productivity curve. (Credit: Nofar Rada)

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must see managerial leaders taking on direct responsibility. Leading. Failure to work shoulder-to-shoulder with staff, failure to be with them in the trenches and on the front lines of duty means a terrible price will need to be paid later. “Many of history’s most influential and inspiring leaders showed themselves to be present and flexible. Change is a constant. Challenges are always just over the horizon. In this era of the coronavirus, the strains on our healthcare institutions and personnel are greater than usual. The times call for managers to have courage, and to be adventurous, perhaps even a bit audacious. I hope this book will fuel all of this in you.” Haifa, Israel October 2020

Ziv Gil

with Steve Spencer

Acknowledgments

My heartfelt thanks to Dr. Shuli Bramli-Greenberg of The Hebrew University of Jerusalem who shared a dream with me that this book would come to be. Additional thanks to Nofar Rada who designed all but one of the graphics featured in these pages. In the Department of Otolaryngology—Head and Neck Surgery on the Rambam Health Care Campus, my thanks go to Limor Chen, our clinical nurse specialist, and Tzipi Meshjeev, our nurse coordinator, who work magic to make the dreams of our patients come true. My gratitude to Dr. Salem Billan, a master in head and neck oncology and brother-in-arms. Deep appreciation goes to our chief nurses: Hagar Kabia, Dovrat Levi, Ora Ben-Shimon, and Mila Cohen as well as our department’s administrative staff led by Esti Rosen and Hagit Flink. Their unrivaled dedication to challenging themselves in pursuit of ever-improving patient services is both laudable and breathtaking. And I’m indebted to all of our physicians, nurses, social workers, and administrative personal. The things we developed together and learned along the way have taken us down a fascinating road. Our efforts helped to spearhead positive change across the Israeli healthcare system, which we are now hopeful will be an inspiration to others around the world.

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About the Book

This book is primarily intended as a manual for mid-level hospital and healthcare facility managers (and, indeed, those who have aspirations of becoming so). However, this is not to the exclusion of those who work with managers and other personnel. If you’re interested in learning how high-efficiency management can revolutionize medical care—serving more people, providing expanded services, and improving patient satisfaction—with little or no increase in existing budgets and current resources, then this book will be of interest to you. Since 2012, under the leadership of Prof. Ziv Gil, the Department of Otorhinolaryngology—Head and Neck Surgery at the Rambam Health Care Campus in Haifa, Israel, has been developing conceptual approaches and implementing methodologies for efficiency improvements. Collectively, that team of professionals has produced the remarkable performance outcomes which are detailed in these pages—accomplishments that have transformed their department into the largest ENT referral center for patients nationwide. The chapters tackle common issues and everyday dilemmas, and offer valuable ways to dissect these problems and assess the assets already available to you to address them. You’ll discover the benefits of understanding common situations and how to use cyber modalities to solve them. And you’ll gain useful insights into the actions that generate the best results and most gratifying rewards for personnel and patients, alike. The Healthcare Efficiency Revolution is a proof of concept. Its impact will be magnified when you can see yourself, your colleagues, your institution, and those in your care within these pages. Better still when you put these ideas to the test. Here’s hoping that you’ll find this reading intriguing, perhaps a little surprising, but most of all practical, inspiring, and motivational.

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Contents

1 Premises������������������������������������������������������������������������������������������������������   1 1.1 Storytelling������������������������������������������������������������������������������������������   2 1.2 The Gauntlet Thrown Down ��������������������������������������������������������������   3 1.3 Spread the Health��������������������������������������������������������������������������������   4 1.4 Yeah, Yeah…They All Say That���������������������������������������������������������   6 1.5 The Resistance������������������������������������������������������������������������������������   7 1.6 The Times They Are a Changin’ ��������������������������������������������������������   8 1.7 Prioritization ��������������������������������������������������������������������������������������  10 1.8 The Plan����������������������������������������������������������������������������������������������  11 1.9 The BIG Hurdle����������������������������������������������������������������������������������  12 1.10 Premium Care ������������������������������������������������������������������������������������  13 1.11 The Target Function����������������������������������������������������������������������������  13 1.12 Subsidiary Goals ��������������������������������������������������������������������������������  14 1.13 Second Class? ������������������������������������������������������������������������������������  15 1.14 Presumptions��������������������������������������������������������������������������������������  16 1.15 Can You Spare Some Change?������������������������������������������������������������  16 1.16 If It Ain’t Broke, Break It��������������������������������������������������������������������  17 1.17 The “X” Factor������������������������������������������������������������������������������������  18 1.18 History Class��������������������������������������������������������������������������������������  19 1.19 Hiring Is a Concept, Too ��������������������������������������������������������������������  22 1.20 Enjoy the Ride������������������������������������������������������������������������������������  23 1.21 The Paradox����������������������������������������������������������������������������������������  24 1.22 The Proof Is in the Product ����������������������������������������������������������������  26 1.23 Sustainability��������������������������������������������������������������������������������������  27 1.24 Greed��������������������������������������������������������������������������������������������������  30 1.25 Give It Away, Give It Away, Give It Away Now ��������������������������������  31 2 Deconstruction��������������������������������������������������������������������������������������������  33 2.1 To Know How Things Might Be, You Have to Know How Things Got to Be the Way They Are ��������������������������������������������������  34 2.2 With All Due Diligence����������������������������������������������������������������������  35 2.3 Asking the Right Questions����������������������������������������������������������������  36 2.4 A Problem Well Stated Is a Problem Half Solved������������������������������  37

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2.5 Tick, Tick, Tick ����������������������������������������������������������������������������������  38 2.6 Are We There Yet?������������������������������������������������������������������������������  38 3 Smells Like Team Spirit����������������������������������������������������������������������������  39 3.1 Building Teams, Building Trust����������������������������������������������������������  40 3.2 What’s Your Problem?������������������������������������������������������������������������  41 3.3 Traps����������������������������������������������������������������������������������������������������  42 3.4 It Takes an Orchestra to Play a Symphony ����������������������������������������  42 3.5 Do Unto Others ����������������������������������������������������������������������������������  43 3.6 Example #1: You ��������������������������������������������������������������������������������  44 3.7 Open a Window, Would Ya?����������������������������������������������������������������  44 3.8 No One Can Whistle a Symphony������������������������������������������������������  45 3.9 Wind It Up, Let It Go��������������������������������������������������������������������������  46 3.10 Blame and Shame ������������������������������������������������������������������������������  47 3.11 Readying Your Team for Dragon Slaying ������������������������������������������  48 4 Management 360����������������������������������������������������������������������������������������  49 4.1 Architecting a Self-Sustaining Vision������������������������������������������������  50 4.2 Knowing What Needs to Be Known (and Putting It to Good Use)������������������������������������������������������������������������������������  51 4.3 The Deputy Question��������������������������������������������������������������������������  51 4.4 Lieutenants������������������������������������������������������������������������������������������  52 4.5 Jeopardy����������������������������������������������������������������������������������������������  53 4.6 Authority: Having, Accruing, and Maintaining It������������������������������  54 4.7 Groups vs. Teams��������������������������������������������������������������������������������  55 4.8 Clear-Eyed and Courageous���������������������������������������������������������������  56 4.9 Wait for It…but Sometimes Don’t������������������������������������������������������  57 4.10 Snatching Defeat from Victory’s Jaws������������������������������������������������  58 4.11 A Lesson in Leadership����������������������������������������������������������������������  59 4.12 Autopilot ��������������������������������������������������������������������������������������������  60 4.13 Why Dominancy Diminishment Is Important������������������������������������  62 4.14 Less Is More����������������������������������������������������������������������������������������  64 4.15 Realism ����������������������������������������������������������������������������������������������  64 4.16 Fail-Safes��������������������������������������������������������������������������������������������  65 4.17 No Cover ��������������������������������������������������������������������������������������������  66 4.18 When Exceptions Prove the Rules (and Regulations)������������������������  67 4.19 No Alternative ������������������������������������������������������������������������������������  68 4.20 Excelsior ��������������������������������������������������������������������������������������������  69 4.21 You Know It’s True ����������������������������������������������������������������������������  69 5 Prelude to Action����������������������������������������������������������������������������������������  71 5.1 Presuming from a False Premise��������������������������������������������������������  72 5.2 How’m I Doin’?����������������������������������������������������������������������������������  72 5.3 A Bit About Bottlenecks ��������������������������������������������������������������������  73 5.4 Street Cred������������������������������������������������������������������������������������������  73

Contents

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6 Real Problems, Real Solutions������������������������������������������������������������������  75 6.1 Escape Artists��������������������������������������������������������������������������������������  76 6.2 Quick Fixes ����������������������������������������������������������������������������������������  76 6.3 Changing the DNA of the System������������������������������������������������������  78 6.4 Leaders Lead by Leading��������������������������������������������������������������������  79 6.5 You Cannot Be Serious!���������������������������������������������������������������������  80 6.6 Grand Rounds, Small Thinking����������������������������������������������������������  81 6.7 Waiters������������������������������������������������������������������������������������������������  82 6.8 Here to There��������������������������������������������������������������������������������������  84 6.9 New Member Privilege ����������������������������������������������������������������������  85 6.10 A Bit More on Walk-Ins����������������������������������������������������������������������  86 6.11 The 80/20 Rule������������������������������������������������������������������������������������  87 6.12 Transparency ��������������������������������������������������������������������������������������  88 6.13 Not Merely a Numbers Game ������������������������������������������������������������  89 6.14 Planned Emergencies��������������������������������������������������������������������������  90 6.15 Hello, I Must Be Going����������������������������������������������������������������������  91 6.16 Satisfaction Guaranteed����������������������������������������������������������������������  93 7 Metrics��������������������������������������������������������������������������������������������������������  95 7.1 You Are Here��������������������������������������������������������������������������������������  96 7.2 Look Over There!��������������������������������������������������������������������������������  96 7.3 Critical (Data) Points of Entry������������������������������������������������������������  97 7.4 Data in Action ������������������������������������������������������������������������������������  97 7.5 Instrumentation ����������������������������������������������������������������������������������  98 7.6 Get Retro�������������������������������������������������������������������������������������������� 100 7.7 Resource Limitations?������������������������������������������������������������������������ 101 7.8 Making Change Imperatives an Imperative (and Nearly Automatic)���������������������������������������������������������������������� 102 7.9 The Summit���������������������������������������������������������������������������������������� 103 8 Crises���������������������������������������������������������������������������������������������������������� 105 8.1 Lincoln������������������������������������������������������������������������������������������������ 106 8.2 Rule #1������������������������������������������������������������������������������������������������ 107 8.3 The Map Is Not the Territory�������������������������������������������������������������� 107 8.4 Sixty Seconds�������������������������������������������������������������������������������������� 108 8.5 The 70% Rule ������������������������������������������������������������������������������������ 109 8.6 Worst-Case Scenario Planning������������������������������������������������������������ 110 8.7 Big Time Ancillary Benefit ���������������������������������������������������������������� 111 8.8 Error Types and Negative Opportunities�������������������������������������������� 111 8.9 A COVID Case ���������������������������������������������������������������������������������� 112 8.10 The Choice������������������������������������������������������������������������������������������ 112 8.11 What Would You Do?�������������������������������������������������������������������������� 115 9 Considerations�������������������������������������������������������������������������������������������� 117 9.1 Why Management? ���������������������������������������������������������������������������� 118 9.2 It’s Personal���������������������������������������������������������������������������������������� 120

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9.3 Square Pegs, Round Holes������������������������������������������������������������������ 120 9.4 Managing Managers���������������������������������������������������������������������������� 122 9.5 Succession Planning���������������������������������������������������������������������������� 123 9.6 Why Did You Get in This Business in the First Place?���������������������� 124 Recommended Reading ������������������������������������������������������������������������������������ 127

About the Author

Ziv  Gil, M.D., Ph.D.  Since 2012, Prof. Ziv Gil, MD, PhD, has been the chairman of the Department of Otolaryngology—Head and Neck Surgery at the Rambam Health Care Campus/Technion—Israel Institute of Technology in Haifa. During the same period, he has served as director of the Applied Cancer Research Laboratory at Rambam’s Rappaport Family Institute for Research in the Medical Sciences/Technion Integrated Cancer Center. From 2008 to 2012, he worked at Tel Aviv Medical Center, where he served, in turn, as director of its Skull Base Surgery Service, Applied Cancer Research Laboratory, and Head and Neck Surgery Unit. Between 2006 and 2008, he was a Visiting Fellow at the University of Pittsburgh Medical Center’s Center for Minimally Invasive Skull Base Surgery, and a Clinical Fellow at New  York’s Memorial Sloan Kettering Cancer Center. Prior to this, he was a Postdoctoral Research Fellow in the Department of Physiology and Biophysics at the University of Miami’s School of Medicine. A frequent lecturer and advisor on transforming organizational cultures and change management, Prof. Gil earned his M.D. in Medicine and Ph.D. (summa cum laude) in Physiology and Neuroscience from Israel’s Ben-Gurion University of the Negev. He currently serves on the board of directors of the International Federation of Head and Neck Oncologic Societies, World Federation of Skull Base Societies, Asian Society of Head & Neck Oncology, International Academy of Oral Oncology, Israel Society for Extracellular Vesicle Research, and Israeli Biorepository Network for Research.

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About the Author

His research has been funded by numerous Israeli and international agencies, including the Israel Cancer Research Fund for which he was a Barbara S. Goodman Endowed Investigator and a supported professional in the Jacki and Bruce Barron Cancer Research Scholars’ Program. He is the recipient of the 2018 Youdim Family Prize for Excellence in Cancer Research, as well as many other awards, including those from the Israeli Parliament and the New York Head and Neck Society. Dr. Gil has authored four books on medicine, contributed chapters to almost two dozen others, and serves on the editorial boards for multiple scientific journals and research agencies. His principal research interests focus on cancer invasion mechanisms, tumor metabolomics and microenvironments, exosomal transmission, and drug resistance. He is the leader of several international consortia in head and neck cancer, including the International Consortium for Outcome Research and the Adenoid Cystic Carcinoma International Study Group. In 2014, he established the Comprehensive Head and Neck Center on the Rambam Health Care Campus, the first of its kind in Israel. Since then, he has founded several entrepreneurial ventures for the development of new medical devices, artificial intelligence, drug delivery systems, and medical software. To reduce costs, increase revenue, and improve the organizational performance of hospitals and other medical care facilities, Prof. Gil has also been engaged in modeling new approaches to and introducing tools for healthcare management. For 8  years, he has been working with Palestinian colleagues to promote ongoing healthcare initiatives in the West Bank and Gaza. Their joint collaboration is assisting Palestinian organizations and institutions to independently deliver quality, high-­level medical services, and fostering a partnership between nations.

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Premises

“You can’t achieve anything without getting in someone’s way. You can't be detached and effective.” —Abba Eban, Israeli Statesman

© Springer Nature Switzerland AG 2021 Z. Gil, The Healthcare Efficiency Revolution, https://doi.org/10.1007/978-3-030-61232-0_1

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1 Premises

1.1

Storytelling

I once saw a heartbreaking ad on the internet. Under a photo of a bald-headed young girl with a blank expression, the main text read: “Dana has been waiting months for an MRI. For her, it may now be too late.” It was a plea for putting more resources into our national healthcare system. Otherwise, young cancer patients (among others) would die. The airbrushed picture seemed tailor-made to play on public sympathies. Part of me didn’t half wonder if Dana was a fake character created by a marketing firm to produce this calculated response. There are two ways to look this. On the negative end of the scale, this was a crass and obviously cynical intent to manipulate emotions, thereby making the viewer more disposed to accept the message. On the positive side, Dana was intended to represent very real situations experienced by very real people. If fictional, she was meant as a stand-in for nothing more than a larger “truth.” There are dozens and dozens of ads like these. They appear in print, they’re broadcast over TV and radio, and they’re plastered over the internet. They come from large and powerful medical associations, HMOs, insurance companies, and other special interests. They persistently pound home the idea that there is only one way to provide patients with better and more timely care—more money. This tees up the arguments so often heard in government circles that increased expenditures in one area of the budget necessarily mean that something else must suffer. This concept, known as Pareto efficiency (Fig. 1.1), is a type of dead end. If the central idea remains the same and we all presume that this is only a question of resources, then there’s nothing further to discuss. But what about Pareto improvement, which assumes that gains can be achieved in one arena without there being any negative impacts elsewhere. The relentless messaging about finite resources has a cumulative effect. Patients accept that their expectations must be limited. If more money isn’t going into the system, then their only route to better, quicker care is through their purchase of premium-level services. The vast majority of journalists, politicians, policy makers, Pareto Efficiency Z

Healthcare

A

B X

Pareto efficiency occurs when it is impossible to improve in one arena without making another worse. When an economy is operating at full efficiency, (points A & B) it is not possible to increase Healthcare outputs without reducing Defense outputs. Pareto improvement occurs when one output increases due to improvements in efficiency without any decline in the other output (going from point X to A or B). Advances in technology, knowledge, and managerial skill will caused Pareto efficiency to shift to the right over time (from point A or B to Z).

0 Defense

Fig. 1.1  Pareto efficiency curve. (Credit: Nofar Rada)

1.2  The Gauntlet Thrown Down

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and academic analysts approach the matter similarly. So pervasive is this concept that it’s become a deeply embedded axiom among healthcare professionals. Nevertheless, a careful reading of the Hippocratic Oath would dictate that it properly extends beyond the actual treatment of those who ail or are in distress. The charge of any medical professional is to ethically, comprehensively, and humbly tend to the pain, illness, and disease that individuals experience. But what about the systems within which healthcare is dispensed? If a hospital department was a person, how should its problems (and the complaints directed at it) be approached? If the Oath is to be fully upheld, shouldn’t the obligation to apply “warmth, sympathy, and understanding” extend beyond the individual patient to the way patients experience the systems that exist to care for them? The Oath commands everyone who swears to it that they should never be ashamed to say “I know not,” nor fail to ask for advice, counsel, and assistance from colleagues when personal knowledge and skill aren’t sufficient to provide appropriate treatment. Isn’t this another way of saying that healthcare professionals have a duty to question the accuracy of things like the “Dana” ad and the “certitudes” they seek to reinforce? The Oath admonishes all its adherents to remember that the illness of a sick human being “may affect the person’s family and economic stability.” Therefore, if the sick are to receive adequate care, it is a “responsibility” to take these “related problems” into account. The Hippocratic Oath fundamentally upholds prevention in preference to cure. Accordingly, logic dictates that healthcare professionals are honor-bound to be champions of efficiency, nonstop advocates for the optimal use of resources, and bulwarks against waste before seeking external remedies.

1.2

The Gauntlet Thrown Down

The Dead Sea Conference. For two decades, this annual gathering has been the most important forum for the discussion of health policy issues in Israel. A few years back, I gave a presentation to the assembled in which I demonstrated, empirically, that immediate and significant improvements to patient care and operational efficiency can be implemented at any hospital or healthcare facility; that these reforms can be achieved without investing much money beyond one’s current budget. If that wasn’t bound to cause consternation and controversy, one aspect, integral to the recommendations I offered, certainly was: Let patients choose their own doctors. What I had to say was received well by some. For the rest, to put it mildly, they said it was horse hockey. In an effort to minimize the data I offered, the chief of the nation’s social security service even went so far as to say that while it all looked very nice, what I proposed wasn’t transferrable knowledge. The results reflected what I could do as an individual leader of a single hospital department. In his mind, no one else in any other institution could replicate what our team had accomplished. Taking that as a challenge, we wrote and secured a large grant from Israel’s National Institute for Health Policy and Health Services Research for the specific purpose of proving that what we did, others can easily do, too. The proposal put forward several noncontroversial statements:

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1 Premises “The majority of adults have either been patients or guests of those who have been treated at a hospital or an outpatient hospital clinic. Many have experienced excessive wait times, lack of coordination among different departments, unfriendly interactions with medical staff, and a general lack of customer service. While outcome data show that the quality of care has been improving for most types of illness, economic data suggest that operational efficiencies have not advanced.”

In other words, hospitals and healthcare facilities in OECD nations are generally not lacking for the knowledge and equipment necessary to tend to patient ailments and diseases. Their problems lie in inefficiencies. Our proposal asserted that new programs and policies at healthcare facilities should focus on performance measures, quality and accreditation, hospital compensation mechanisms, and the sharing of outcome data with the public, with the aim of enhancing care quality in the healthcare system. The problem is the top-down nature of this approach. Initiatives focus on the institution as an abstraction; they concentrate on the organization-as-a-whole as opposed to the service-level units (departments, branches, etc.). Moreover, most program indicators are clinical and fixated on arbitrary measures rather than the execution of activities and quality of service.

1.3

Spread the Health

As regards overall national health outcomes in the United States, there is no direct correlation between spending and quality of care (Fig. 1.2). This graph above shows average life expectancy for all 50 US states in comparison to annual per capita spending on healthcare in those states. The state names are unimportant. What’s relevant is annual per capita spending in the state with the 82 81 80

Age

79 78 77 76 75 74 $ 5,500

$ 6,500

$ 7,500

$ 8,500

$ 9,500

$ 10,500

$ 11,500

$ 12,500

Per capita spending (per state)

Fig. 1.2  Association between life expectancy and annual, per capita healthcare spending in the US, by state. (Credit: Nofar Rada)

1.3  Spread the Health

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highest life expectancy figure is just under $7500, while the state with the lowest life expectancy figure is spending just over that same amount. The state with the lowest spending (around $6000) has a life expectancy figure that’s admirably among the top 10. Meanwhile, life expectancy for the state with the highest spending (around $12,000) is among the bottom 10. Here’s another example: As you can see in Fig.  1.3, the only-through-more-spending-can-we-deliver-­ higher quality-healthcare (let alone increase patient satisfaction, and do all of this while serving more people) argument is inaccurate. A simple internet search on the relationship between healthcare costs and quality will return numerous articles and studies on this question. To be sure, many highlight a multiplicity of factors which can and do impact this dynamic, but none endorse the idea that increased spending is the obvious remedy to achieving better healthcare. Assuming this as a starting point, there’s no reason to automatically presume that an existing hospital department and its personnel cannot become a dream team for all of its patients. What’s important is to ignore those who will insist that this is an impossibility. Our department adopted patient primacy as its target function. It’s the foundation upon which all of our analyses, deliberations, choices, and execution of services are built. Although we have made many changes, our most radical reform has been to overhaul the thinking that had been a barrier to even imagining that we could do what all others (including patients) said we could not. What we’ve done is what we’re doing, and what we intend to continue doing. It’s now a professional way of life.

Overall quality ranking

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N1 VT ND ME W WT CO CT OR MN NE MT DE MA WA RI VA SD WY ID NY NC MI MD IN MO AZ KS PA Sc AV WV NV NM CH TN KY AL NJ FL CA CK L AR TX MS

UT

11 HI 21

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41 51 3,000

4,000

5,000

6,000

7,000

LA 8,000

Annual Medicare spending per beneflclary (dollars)

Fig. 1.3  Myth: Healthcare quality outcomes are dependent on levels of spending. (Credit: Nofar Rada)

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1 Premises

Please don’t read any of this as pie in the sky and happy talk. I promise you it’s not. The problem in most departments isn’t a lack of resources, it’s lack of confidence. We began this new approach by assuming we could deliver for our patients everything that would best serve their healthcare and lifestyle needs. We assumed that we could dramatically increase the numbers of patients who need our care. We assumed we could do this in a way that would be professionally fulfilling to everyone on our staff. We assumed we already had everything at our disposal to bring our plans to fruition. Did every initiative work perfectly right out of the gate? No. That’s why careful preparation, data collection, regular reporting, and team communications are (and will remain) critical. This enables the establishment of realistic goals, minimizes the likelihood that we’ll encounter major obstacles, reduces (or eliminates) the need to make course corrections, and assures the high probability of goal attainment. Our results prove that the patient primacy model is doable. Its efficiencies produce enormous satisfaction and confidence, and generate revenues, which help to fund further improvements and growth. Even with our documented triumphs, those who claim our model can’t work haven’t given up (not quite yet, anyway). They can’t say we haven’t delivered the goods because we have hard numbers that validate our approach. So, the latest claim is that our experience is an anomaly; it’s something that is unique to our department, the nature of its management, the chemistry of our team, and so forth. But we’re in the process of nipping that one in the bud, too. We’ve already had an influence on Israeli institutions, which have embraced patient primacy and are beginning to show results of their own. For readers in other parts of the world, keep this in mind. Before you ever begin, you’ll also encounter skeptics and entrenched interests who will tell you not to bother trying, that it can’t be done. In some instances, there may even be forces willing to take active measures (or covert actions) to prevent your team from being patient primacy pioneers or, at least, thwart your opportunities for success. Have courage. Innovating takes time, patience, and deliberate effort. The outcomes you’ll produce will make you and your collaborating colleagues trailblazers in a movement that is about to revolutionize healthcare.

1.4

Yeah, Yeah…They All Say That

There’s a scene from an old comedic routine in which several couples are slow dancing. Short passages of the music play and, every few moments, the audience hears snippets of the dialogue that’s exchanged between the partners. One goes like this: Woman: “I believe life is for living, don’t you?” Man: “It’s difficult to know what else you DO with it.”

It’s sort of the same thing when some people hear the phase, “patient-centered care.” After all, for what other reason does a healthcare facility exist? It seems so obvious that one might think it should almost go without saying. And yet, paradoxically, it’s

1.5  The Resistance

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said so often in recent years that it’s practically a cliché, which means it’s also nearly meaningless. This shouldn’t be the case. Patient-centeredness can’t be treated as a well-­ intentioned vaguery or, worse, an empty marketing concept with nothing tangible to back it up. It’s not enough for Patient-Centered Care to be written into the preamble of a Patients’ Bill of Rights that uses flowery prose to claim how respectful and responsive we are to individual patient preferences, needs, and values, and how those will guide all of our clinical decisions. It’s not enough to know, academically, that patient-centered care improves patient satisfaction, self-welfare, and mental health, as well as overall quality indices. And however institutionally pertinent it may be, it’s not even enough that patient-centered care also raises morale and boosts the motivation of medical staff, reduces costs, enhances the efficiency of health service usage, and increases the success rate of diagnoses. Yes, our healthcare management systems must be built upon the rock-solid foundation of patient-centered care, but everything we do, daily, needs to reinforce the significance of this concept—to our patients and ourselves. And don’t get me wrong, I’m not saying this is easy. In many traditional, department-based institutions, patients can often be neglected as a result of fragmented systems of care. The internal interests of specialty-driven, provider-oriented, economically influenced organizations that are dominated by profit might promote too little concern for the patient. The same can frequently occur in institutions dedicated to research and education missions. On both ends of the scale, they can lose sight of the fact that quality of treatment is not the same thing as quality of care. Adopting a patient primacy management approach is more than hanging a “Here Our Patients Come First” sign on the wall.

1.5

The Resistance

In a modification of something once written by Cardinal John Henry Newman, Winston Churchill said, “…to live is to change, and to be perfect is to have changed often.” Unfortunately, resistance (at least reluctance) to change is much more the norm than not. Most of us are creatures of habit, so it’s rarely easy for anyone to shake off that inclination toward inertia. Adapting Newton’s first law of motion to a hospital environment: A department at rest in its ways will tend to remain so, while a department on the go in the midst of a change agenda will tend to keep right on going. The only thing that will alter either of those scenarios is a net external force that motivates the former to action or halts the latter in its tracks. In healthcare systems, resistance is rooted in several major factors: 1. Slow pace of management turnover. In many healthcare institutions and national systems, it’s not unusual to find departmental managers holding their positions for extraordinarily long stretches of time. There are no substantive performance assessments or audits, and generally no measurements (other than, on occasion, a look at revenues). Some managers can be in charge for decades,

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straight through to retirement, regardless of whether they’re successful or unsuccessful. So, quite apart from the fact that we can all tend to be less inspired and energetic with age, this type of tenure provides no incentive to be better. 2. Almost zero learning from success or failure. It happens all the time. You can walk into a hospital and observe one department that’s functioning like gangbusters, while another right next door is a torpid mess. There are no efforts made, nor institutional mandates to force unsuccessful departments to discover what makes the top performing departments so successful. 3 . Conflicts of interests. Usually these are conflicts between the interests of individuals in the departments and the interests of the patients or the institution. Another example is conflicts between institutional interests and staff interests. In all, when there are revenue conflicts between two players, this can work against the interests of implementing sensible change. 4 . Lack of transparency. When meaningful, patient primacy target function measurements aren’t taken, assessed, digested, and publicly shared on an ongoing and predictable basis, it’s hard for anyone to see what’s going on behind the curtain. Neither superiors, patients, nor departments themselves have any useful way to gauge whether medical professionals are fulfilling their tasks and obligations at peak, nominal, or substandard levels of performance. Any change has to be based upon an “As opposed to what?” supposition. Change is simple to avoid when very little is being quantified. A little bit more needs to be said about transparency. Many healthcare systems and medical associations oppose transparent reporting. They argue that this will result in people going only to the best institutions, departments, and doctors. They say this will create untenable skews—overburdening high performers, while draining underperformers. They are especially resistant to publishing statistics on individual physicians and surgeons as they claim similar reporting may put some people out of work. And in truth, these assertions aren’t entirely false. If statistics are produced on individual doctors, it can lead to gaming the system. Therefore, incentives must exist to help balance the scales for the benefit of both patients and physicians. For example, if a surgeon knows that certain patients or procedures are more likely to increase their rate of complications, they might shy away from those. But there are ways to correct for this. For example, a point system can be established in which taking on those particular patients or procedures will garner a 20-point bonus.

1.6

The Times They Are a Changin’

When it comes to change in a hospital, start here: Every single component part of its operations—every policy, every procedure, every rule, regulation, program, and practice—will, eventually, change with time. Sounds controversial? It’s not. It’s a statement of fact. On the most basic level, medical science, education, and technology move on. Modifications, if not radical advances in medicine are always entering

1.6  The Times They Are a Changin’

9

the picture as a result of the discovery or invention of new treatments, therapies, surgical techniques, equipment, medications, and so forth. They occur because so long as human beings continue to ail, ache, get sick, and die, there will forever be a quest to improve people’s lives by finding or creating better ways to test, screen, scan, alleviate, nurse, mitigate, and cure. Change. Givens, you say? Surely there’s no necessity to change every intake form, administrative system, personnel guideline, and janitorial protocol. You believe there are certainly some things (many, perhaps) that are so straightforward or have already achieved perfection, that there’s no need to waste time giving them consideration for potential change. Okay, fine. Then let me ask you this: Have all of those “givens” been reviewed since being put into practice? Once? Ever? Have they been codified such that, other than their actual existence, there’s a categorized list that includes for each a brief description, year of implementation, and date of last review? Are there continual measurements of performance metrics for those practices? The answer will probably be: No! It’s generally true of human nature that if things are going along—although they may not be perfect, they might not be optimal, they may be just functional—people will tend to let them be as they are. But the truth is that things never remain as they are. Over time, unless there’s constant renewal and improvement, systems break down because the environments in which they exist are in constant change. When there are fixes to bottlenecks, obstacles, inefficiencies, and other challenges, they can run the gamut from workarounds to targeted solutions to radical innovations. What is a given is that there should be no givens. Conceptually, you can understand how and why a combustion engine functions. However, if you want to improve a particular engine’s design, make it more efficient, or invent a new type of engine that will supersede what’s in common use now, you’re going to have to go deeper than concept. You have to get into the engineering of the engine, literally understand its nuts-and-bolts, before you can think about how it might be overhauled or replaced with something better. In a hospital setting, you don’t have to grasp the whole of the institutional system. For example, if you are a clinical department manager, you don’t have to understand HVAC operations and building maintenance. If you’re the director of an IT department, you don’t have to understand surgical techniques. The chief of surgery doesn’t need to know the complexities of lab services. What those individuals (and all other department heads) need to know is how their divisions operate, top to bottom, inside and out. The process of framing and filtering this knowledge must begin with a definition of target function. In other words, as a manager, what is your vision and what will be the main narrative of your department for the next decade. Whatever it is, it should be original and feasible. This should not be an exhaustive exercise in reverse engineering at this stage. Only the next step should be technical (i.e., looking under the hood of your department so you can create parts, procedures, and maintenance manuals). Finally, once you know how things should fit together you can begin to quantify performance, microanalyze issues, target that which you’d like to improve, and set goals for achievement. But you can’t establish goals if you don’t know

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precisely what’s available for you to work with. It’s like a painter picking out the colors before knowing what portrait or landscape is to be painted. It’s impossible and will invariably lead to making poor decisions. As you examine departmental operations, doubtless, you will identify many things that require little or no change. That’s okay. Just don’t take anything for granted. If nothing else, the effort will confirm for you and all personnel what definitely is working, and place in sharper contrast that which needs attention. Now you’ll have a raw to-do list and you’ll be ready to move forward.

1.7

Prioritization

There are many ways to prioritize and different philosophies can be applied to goal-­ setting. You don’t need to create a descending-order list, but start by thinking about which acts of change can lead toward accomplishing your target function and aims. You might tackle a big problem right off the bat because it represents a limitation to your overall system of operations. Perhaps there’s an emerging issue that must be handled without delay because it’s creating staff divisions or represents a roadblock to your ability to resolve other matters. Regardless, you must prioritize something and give it your full concentration. When analyzing the organizational structures of your environment and breaking them down into component parts, be fully aware of all the resources available to you, and what you’ll need to accomplish your aims. There may be a window of opportunity for you as a new manager to request and receive commitments and reassurances from those you’ll need in your corner as you launch change initiatives. That window may be closed a year later, so try to make reasonable assessments of departmental needs 5 years down the road (and overestimate a bit, as there’s a lot you won’t know early on). Here’s one example from our department. From the start, we determined that a fundamental measurement of success would be patient satisfaction. As satisfaction questionnaires had been distributed by the institution to patients only once in every 5 years, we had to develop a way to perform these assessments annually and on our own. We achieved this by contacting the institution’s general administrative offices and securing their support to provide quantitative and qualitative data analysis services. This assured that we could receive meaningful and timely results from our surveys. In turn, this allowed us to benchmark progress, which only spurred us on to greater achievements. And, of course, we shared our progress with institutional superiors, interdepartmental colleagues, and the general public. Whatever and however you set your priorities, know that your first project will define you as a manager and how others see you and your “Under New Management” department. So, make it count and be absolutely certain that the plan you set in motion cannot fail. Establish objective and achievable goals, set timelines, and start developing ways to collecting data. Initially, this process of change will demand more of everyone’s energies because it’s never been done before (certainly not like I’m going to show you). Once

1.8  The Plan

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everything has been dissected, discussed, and diagramed, it will make periodic reviews easier and faster to accomplish. The comprehensive impact of this work is to permanently reorient departmental thinking. Thereafter, nothing will be off limits for reconsideration, revision, or replacement. This doesn’t mean things will be in a constant state of flux. Certainly not. It does mean that personnel should always be comfortable with the idea of bringing issues to the table and putting forward proposals, with the full knowledge that the entire department, from the manager on down, expects this as a standard operating procedure.

1.8

The Plan

Despite any departmental assessments made and potential solutions proposed for particular problems, an improvement plan must target specific matters to tackle, while setting others aside. There must be area coordinators, implementation steps, manners for the collection and processing of metrics, as well as timelines for the delivery of progress reports and the achievement of goals. Prioritization, however, must rest solely with the departmental manager. Otherwise, section managers will each create their own sets of priorities. Some choices in one area may cause friction, conflicts, or even serious problems in other areas. The pace of progress will be inconsistent and some initiatives may falter or halt altogether. This is too chaotic. All departmental employees can and should help to inform their manager’s judgements about prioritization, but decisions about what to do, when, and how to proceed have to take in the full, panoramic view, which only a manager can have. And bear in mind that these decisions are about more than the achievement of abstract goals. They’re about motivation, momentum, and team building. As such, some of the most obvious problems that are demanding change and improvement might not be an immediate priority for a new manager. It might be more strategically wise to prioritize a series of smaller, easy-to-accomplish initiatives. People will derive pride and confidence from those successes. They’ll then be more focused and prepared to undertake projects of increased complexity and duration. Don’t be confused about the role of leadership here. Prioritization does not mean you’ll be determining which initiatives to pursue and then micromanaging them every step of the way to assure success. Quite the opposite. To advance and sustain long-term progress, your job is macromanagement: Establish priorities, work with staff to set growth targets and general rules for process and reporting. Everything else is about staff empowerment, dynamism, and fostering accountability among staff. You should positively reinforce, encourage, educate, tease, wheedle, and cajole. The goal is to fortify individual employees, groups working in their separate areas, and the departmental team as a whole to be increasingly responsible for achieving goals, maintaining and expanding upon victories won, and conceptualizing these efforts as part of the fabric of their professional lives. To be certain, greater efficiencies and growth are about handling an increasing volume of patients. It’s not a euphemism for making people’s jobs increasingly

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burdensome. If any initiative embarked upon starts producing this result, you’re doing it wrong. When employees feel overloaded, it results in a cascade of negative outcomes—rising levels of stress, physical strain, distraction, mistakes, resentments, and more. This gets magnified because none of us leaves our work lives in the office. Problems on the job bleed into home and family life. Rising numbers of consultations, treatments, procedures, and surgeries automatically imply more work to be done. But substantial development is hardly feasible, much less viable for any prolonged period of time without ingenuity and reward for accomplishment. The idea is to achieve pleasurable, gratifying, pride-inducing, motivational progress. We’re healthcare providers. We cure disease, tend to those who are ailing. We ease pain and suffering. What’s the point of trying to do more if we wind up making ourselves and our colleagues feel sick, tired, and ill-used along the way? Therefore, monitoring and measuring overall success must be sensitive to and solicitous of how people are feeling and thinking about individual initiatives, their workloads, their standing in the department, the degree to which they are being heard and respected, and so forth. This is also a fundamental priority and managers need to be attentive to it.

1.9

The BIG Hurdle

Many target function issues are rapidly resolved when patient primacy is paramount. These include convenient and rapid scheduling options, reduced waiting room times, establishing set-asides for same-day/walk-in clinic appointments, and the big one that patients are always eager to have is the right to choose their own physicians/surgeons. Looking at it from their perspective, what patient wouldn’t want these things? Furthermore, people in need of medical care want ready-access to answers and information. Therefore, what patient, when they feel the need to do so, wouldn’t want to be in direct contact with their doctor, with little delay and hassle-free? No one wants to waste time trying to hack through a phone queuing system just to discuss a personal medical issue. No one wants to wait for hours, many times days, sometimes weeks to obtain answers to straightforward questions and concerns. So how do we make all these things happen? Well, first recognize that most institutions and physicians come at these matters differently. They begin by defining what they believe they can’t do, almost all of which are kneejerk assumptions. They say, “It’s not possible to give patients 100% satisfaction. They can’t get everything they want. Only the essentials can be guaranteed.” They’re immediately convinced that to do anything more will always require mores—more money, more staff, more resources. Beyond that, even though the target function of a hospital is the care and treatment of patients, departments and institutions tend to be so focused on their own trees that they lose sight of the forest. They’re preoccupied with nurses, residents, attending and senior physicians, inter-­departmental relations, and so on. In this context, it’s no wonder there’s a prevailing mentality that, without the acquisition of additional resources, more cannot be done for patients.

1.11  The Target Function

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None of that thinking gets you on a pathway to new opportunities, they’re just bricks in a wall. Once again, you might be surprised by how much can be accomplished when you look at the world through the lens of “What if?”

1.10 Premium Care In most public healthcare systems and basic healthcare plans, the services and service options described above are only available (if at all) at an added cost. Access is secured either by paying for elite levels of care or supplementary insurance. These are revenue streams, which are defended as necessary to preserve the overall integrity of healthcare that’s provided to everyone. Defenders of upper-tiered services say the extra cash goes to fund the ability to offer upper-tiered care and offset the general operational expenses associated with staff, managerial talent, investments in technology and other system innovations. The argument goes that if everyone has access to so-called premium care, then, of course, few would pay extra for “special” services or seek out private providers because pubic systems and basic plans would be giving people the vast majority of the things they need and say they want. The assertion is that public health systems and provider plans would collapse without these additional revenues. Is this a given? It might be if we presume that existing systems are already operating at reasonable levels of efficiency and must acquire additional funding if extra services are to be provided. The built-in assumption is that existing systems aren’t capable of generating their own revenues to support these services unless they can charge fees for premium care. And this will always prove to be true if systems and providers never engage in the type of comprehensive review I’m suggesting needs to be done and must be a part of ongoing operational thinking. The fundamental problem lies in the presumption that healthcare systems are already reasonably efficient. They’re not. And for any in the healthcare field who’d take umbrage at that, not only do I encourage you to read on, but I’d be willing to bet good money right now that I can show you precisely where your institution or department isn’t operating anywhere near 100% efficiency (as a matter of fact, for many, it’s more likely to be half that; 70% at most). The truth is that most healthcare systems have vast opportunities to produce profound improvements in efficiency without overburdening staff, which will generate significant savings and revenues. These can be applied to improving and expanding patient services, and offering better plans. And the totality of all this cannot fail to see patient satisfaction statistics go through the roof.

1.11 The Target Function Assuming you accept the broad-based ideas described above and now want to put them into practice, how do you begin? The easiest way is the inverted pyramid approach; going from generalized concepts down to highly specific details. The

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most general of all is: What is your target function? It’s a question that’s applicable to the department as a whole, every individualized area within it, and each member of the staff. It also needs to take into consideration the consumer, the customer, the client. In a hospital, that’s the patient. Many in the medical profession don’t like this notion because it carries a connotation that places patients above doctors. And most doctors are loath to relinquish their sense of supremacy. With patient primacy as our target function, overall goals are always patientcentered. We examine everything related to departmental and individual professional performance through the eyes of the patient. What do our activities look like to them? How do they experience departmental processes and standards of care? If any of us were the patient, would we be satisfied with everything we now see? As soon we did this, we immediately began identifying lots of things to fix. This is because we all know what we’d want if we became ill and needed treatment in a hospital.

1.12 Subsidiary Goals We believe that patient primacy should be the target function of all hospitals everywhere. Beyond a stated goal, it must be attached to an action agenda, measurable targets, and so forth. If it’s just going to be little more than a platitude on a placard— “We put patient’s first.”—it’s pointless. Our work on patient primacy touches every aspect of our operations, including revenues, employee benefits, and even the sovereignty of the national healthcare systems and health insurance company mandates. Where these create any interference with our ability to deliver high performance execution of our target function, we work diligently to address any challenges. We’re quite serious that everything we do and everything we are must combine seamlessly into the patient primacy narrative. And even though patient primacy is all about medical services and quality of care, there are obviously some areas of our department which have very limited contact with patients, while others have none at all, such as residency programs, research divisions, peer outreach and development initiatives, etc. Nevertheless, we still assess those facets in terms of how they enhance or detract from our target function. This is because you can only ever have one target function. Some of this may sound like it’s stretching the patient primacy concept too thin. Perhaps some may think that we consider those other areas of our operations as less important since they aren’t directly within the patients’ line of sight (consultations, diagnostics, testing, treatments, therapies, surgeries, and the like). But this is not so and, quite frankly, we’re obligated to look carefully and critically at the roles we perform in those areas because they can contribute to the improvement of medical knowledge, pharmacology, training, etc. Patients rely both on the direct services they receive and the overall integrity and improvement of the medical system that exists to serve them. Rarely are there any conflicts of interest between target function and subsidiary goals.

1.13  Second Class?

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A word of caution, though: Subsidiary goals can sometimes be a distraction. If some of these are easier to tend to than say, improving the efficiency of your OR, then there can be a natural tendency to focus your attention on the path of least resistance. I’ve seen this in action. I knew a chairperson who was presiding over a truly awful department. Staff and administrative affairs were lax and patient services were dreadful. By every measure there was disaster almost every place you could look, save one. The department had a gangbusters residency program. How was this possible? On one end, there was an evident display of enormous competence and managerial prowess. On the other end, chaos. So, what was going on? Clearly, resources and effort were being focused where that manager felt best equipped and most likely to succeed. Great for the residents, horrible for everyone else who was left to languish. The problem for that department was that its residency program represented a Pyrrhic victory, at best. The department’s target function was sacrificed to a subsidiary objective. So just bear in mind that all departmental matters, tiny and gargantuan alike, are within the realm of your target function, but they must be taken in their proper measure. Nothing can be neglected. In the case I’ve just outlined, to serve the target function well, the other areas of that department needed to be operating at a nominal level or better alongside that well-run residency program. Otherwise, that program, however good it may have been, was ultimately being built on sand.

1.13 Second Class? It’s also critical to mention that patient primacy doesn’t mean everyone else comes second. It certainly isn’t implying that medical professionals and other members of the departmental team don’t come out winners, too, as a result of patient primacy. Quite the contrary. We’re 8 years on from adopting this as our target function and continuing to shatter records for productivity, efficiency, and revenues. Our self-­ motivated staff is more focused and unified than it’s ever been. We’re happier in our work, thrilled by the service we’re able to deliver to our patients and on behalf of our institution, and darn proud of what we’ve accomplished together. Generating results from a laser-like focus on target function isn’t unique to the healthcare industry. In 1999, Continental Airlines became the first of two carriers (the other being America West) to implement a “Customer First” program. They fine-tuned all of their polices in service of that target function, establishing new operations and shifting the paradigms of thousands of employees toward that singular goal. One year later, Continental ranked first in airline customer satisfaction for both short- and long-distance flights. They also came out top-listed for their frequent flier and business class programs. Saying “Customer First” out loud wasn’t empty sloganeering. They meant it and made it manifest. What’s more, it didn’t impede them from making Fortune magazine’s list of the 100 Best Companies to Work For. To this day, the carrier continues to be a standout in many other best-in-­ class lists, including Most Admired Global Airline, Best Value for Money, and more. So don’t be intimidated to declare your target function to all the world. Be bold, clear, and resolute when you do…and then get to work!

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1.14 Presumptions In any department, organization, or institution, a manager’s worst enemy is believing that a given situation is what it is; the way things have been done is the way they must continue to be done, and that without a significant increase in resources, there are no other options! This is the greatest foe to progress anywhere—be it government or business, politics or NGOs, the public or private sector, even a marriage. And yet, we do evolve and improve. Rather than increased resources being the only road to growth and development of services and revenue, profound advancements in performance can be secured with existing resources or a modest budgetary increase. A number of years back, our hospital convened an institution-wide conference to discuss what we would look like in 2020. Naturally, there were lots of plans offered by many people suggesting ways our facility could become a leader in healthcare. However, there was a core concept around which a vast consensus instantly coalesced: Nothing could be achieved without expanding investments in infrastructure, recruiting additional staff, purchasing new computers and technology, and so forth. It was a rock-solid conviction that if all of that was done, then and only then could consideration be given to achieving leadership status. I take a different view. In my opinion, you need to do two things to become a leader. First, you have to create something new. Second, you have to mobilize people to follow you. And maybe I’d add a third thing, which is a critical nuance related to the first two. Never view your new thing as that which demands fanatical adherents. Yes, you want people to adopt your novel ideas and approaches, but you should always want people to have the opportunity to replicate your successes in their own way. That’s leadership. You don’t even need people to acknowledge or even be aware that they’re following you. As healthcare professionals, as treaters of illness, alleviators of pain, discoverers of cures, and healers of disease, we’re all driven to the goal of trying to make people’s lives better. If the recommendations in this book help to advance that cause, it will be gratifying whether or not anyone knows the origins of the insights and advice I’m sharing with you. As Harry Truman once said, “It’s amazing what you can accomplish if you don’t care who gets the credit.”

1.15 Can You Spare Some Change? More often than not it’s simply time and reflection that inspire change. We live and when we’re at our best, we learn. It’s the same for individuals and collectives. And just as we all have our preferred behaviors, organizations have their own processes, procedures, and unique internal cultures. Change typically comes about as a reaction to a very specific force, such as the need or desire to compete more effectively in the marketplace, to achieve certain growth objectives, to satisfy mandates to keep budgets balanced, or to cut costs.

1.16  If It Ain’t Broke, Break It

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The big challenge is how to create a culture of continual change. Not change for its own sake, of course, but change that is constantly checking itself against objectives and benchmarks. Then, when reached, they inspire analysis and critical thinking sufficient to wonder if things can be better still. To this end, maybe the one major factor that can determine whether change is or isn’t a constant within an organization is the leader. And even when a visionary, change-oriented leader is in place, it should always be remembered that leaders (like everyone else) do get tired eventually. Therefore, it’s crucial for them to be replaced periodically before organizational habits calcify. In the abstract, everyone wants better, more effective and efficient systems. In a healthcare facility, there’s no great mystery about fundamental goals—give better service to patients with ever-improving outcomes, and create an enhanced, motivating environment for employees. The problem is that many managers—especially those entering departments and institutions already perceived to be well functioning—generally believe that the prevailing rule is to maintain the existing system, to preserve the organization. Ironically, through maintenance and preservation of the status quo, such managers are likely to conclude their tenures with departments that are worse off than they found them. This happens not only because systems have an innate tendency to decline when left unadjusted or unattended. It also occurs because competitors are likely to take advantage of this stagnation, establishing their own claims to leadership. For these reasons, managers should always seek to inspire change and improvements. Call it Darwinian evolution if you like, but since it’s the way humanity has behaved since time immemorial. As departmental leaders are wise to embrace this reality if they’re truly about the business of making lasting contributions to their institutions, if not, indeed, the cause of medicine, let’s explore this in further depth.

1.16 If It Ain’t Broke, Break It A system is working, a medical department is going about its daily routines with little or no friction or disruption, things seem to be humming along. Why should a manager do anything other than fine-tune those operations here and there, and just keep the machine running? It seems a mistake to do otherwise. Here’s why it’s not. All of us have a tendency to become accustomed to and even comfortable with the templates in our professional and personal lives. This can extend to the point where we’re so focused on the structure of how things are now that we become fixated on those patterns. When we make change, we’re generally addressing problems. Sometimes organizations go so far as to engage in a strategic planning exercise. Unfortunately, when such an initiative is launched it’s typically because someone decided it ought to be done. Then, when all the retreats have been had and the discussions are complete, the plan gets written up, placed in a file drawer, and nothing significant really changes. What we want to get to isn’t just reactivity or engaging in a one-off process. The idea is to change the way we think about change. Adopting a mindset that considers

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it sensible and routine to regularly re-evaluate what is currently sensible and routine. Could our functional today be better functioning tomorrow? Where should we look for new ideas? What practices can we adopt to assure a continual flow of innovative suggestions? How can we, as managers, foster an environment that encourages and welcomes constant creativity and challenge? And how can we accept that all of this makes us stronger leaders in the best position possible to energize our teams, optimize our patient care, and contribute to the growth and success of our institutions?

1.17 The “X” Factor Not too long ago our Otolaryngology-Head and Neck Surgery department became interested in discovering what factor is the best predictor of functional measures in a hospital division like ours. So, we analyzed similar departments throughout Israel. To gauge improvements in production, we examined multiple parameters, including number of surgeries performed against number of beds available, as well as demographic, geographic, and organizational data. Surprisingly, we found that the only significant predictor of enhanced productivity was replacement of the departmental chairperson. Specifically, outcomes only improved when the manager changed. This may not sound surprising, but here’s where we wanted to go with this. Sure, a new manager coming into a department typically wants to make their mark. They want things to be different. The question is how do they want to make things different? From a patient primacy target function-focused, continuous improvement vantage point, different is not about cosmetics. It’s not getting someone who’s a good physician, a great surgeon about whom the hospital can boast, an individual capable of hiring a terrific team, or better skilled at educating the residents. Making a difference, a real, substantive, tangible difference needs to be a conceptional thing. In our conception, everything can be open to review, change, and improvement. Nothing should ever be sacrosanct. The only question is: When is the right time for change? I’ll have much more to say about this fundamental issue later in the book. For now, though, I’m urging you to understand that change is must. It’s an imperative. And I’m not talking about penny-ante pocket change either. This book isn’t about tinkering around the edges. It’s not about tightening a few metaphorical bolts and screws, and papering over the cracks. This is complete makeover stuff; changing all departmental components and leaving no single brick in its old place. Think about it. If you’re hired to manage a department in a hospital or medical center, you could find yourself in that leadership role for 10 or 20 years. To have an impact, the change you make in collaboration with your departmental colleagues needs to be significant. To do this, you need to operate within this mental framework. And that means thinking big! Does it matter whether you’ve been internally promoted or you’re an external hire? No. There’s no correlation to success here. Still, the task of change can sometimes be a little easier when you’re coming from outside of an institution. Outsiders bring the experience of things they’ve done or seen elsewhere, so new approaches

1.18  History Class

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are practically expected. Conversely, talking about, let alone implementing big change can be difficult if you’re promoted from within. This is because your most significant point of reference is likely only to have been your own organization, which has its own ideas and ways of doing things. It has its own conception of itself and how people should be managed and its medical services delivered. And that concept can be a very dangerous thing.

1.18 History Class Usually, concept and culture are things that develop within an institution over a long period of time. They become embedded and entrenched. Colleagues, managers, and other personnel up and down the chain are, professionally speaking, born into it. It’s common to see the system-as-a-whole as something valid, which cannot be fundamentally changed. This is rigid thinking, which right out of the box turns a new manager on the job into the captain of a ship already at sea. On smooth, calm waters, it’s easy to keep sailing along quite capably. However, when stormy weather comes and angry waves arise, one’s only play is to make a beeline to the nearest safe harbor. In 1915, when Sir Ernest Shackleton’s vessel, Endurance, was crushed in the ice of the South Pole and sank in the Weddell Sea, its 28-man crew was left stranded on Elephant Island. Shackleton didn’t wait for the remote possibility of rescue, nor did he accept the moment as the last card that fate would hand him. He and five of his fellows embarked in a small boat on an 800-mile South Atlantic journey to reach the Island of South Georgia. From there, he organized a rescue party. Shackleton’s core conviction was an unshakeable faith that he could and would achieve success. He did. Eventually, his entire crew was brought home. This astonishing, true story teaches us that perseverance, commitment, and action, driven by the honorable pursuit of saving human lives, can deliver results. In some instances, though, there can be genuine peril associated with strict, even stubborn adherence to concept. For example, based upon its experience in World War I, France constructed an enormous, complex, and expensive series of fortifications all along its borders with Germany, Switzerland, Italy, and Luxembourg. Built in the 1930s, the Maginot Line was the brainchild of those who had fought that past war against Germany. Their concept of a potential future attack from that country was based upon what they knew. Younger minds opposed the scheme. They weren’t thinking about how the last war had begun, but how the next one might start. The “of course” concept of Maginot’s advocates focused exclusively on a “war of long duration” strategy. After all, for the better part of 4 years, the fiercest fighting during the First World War took place all along that Western Front where the defensive Maginot Line would subsequently be built. It was dug-in, trench warfare; a war of attrition, no less. Until the USA entered the conflict, it was little more than a prolonged, bloody stalemate. Post-war French leaders believed something similar could happen again. Accordingly, they planned for yesterday.

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When Nazi German forces did attack, it took Gen. Heinz Guderian five days to move his troops well into France. The Maginot Line was an irrelevancy, as they came through the Ardennes Forest, which the Line’s planners had presumed was impenetrable by tanks. A month after the assault began the Line’s defenses were encircled, French and British forces were routed, and Paris fell. Almost three decades later, Israel built the Bar Lev Line on the east bank of the Suez Canal to prevent Egyptian assaults following the Six Day War in 1967. Similar to Maginot Line thinking, the strategy was built upon the concept that a line of hard construction fortifications could prevent attacks on the Sinai Desert. In the Yom Kippur War of October 1973, all but one of Bar Lev’s 32 strongholds fell within days. It set Israel back on its heels, and although its army eventually defeated the Egyptian forces, this story stands as an abject lesson in how easy (and often) it is for human beings to fail to learn from failure. This is a highly pointed way of emphasizing that our concepts of what has been always need to be reconsidered, re-tested, and challenged. It doesn’t mean we must always toss aside old ways, only that we must never get stuck in them. As a manager, when you come into an organization and throughout your tenure, you will find yourself in many situations where you’ll have to confront conceptions—some will be institutional, some only on the part of others, some will be your own. It’s important to develop mechanisms that will prevent you and those you manage from getting into entrenched thinking. Organizational cultures and the systems they build are all too often formulated and realized in the service of building “impenetrable, foolproof” walls of procedures. Rarely will you find an institution or even a department whose very nature is to encourage the practice of ongoing innovation and well-reasoned challenge of managerial approaches. However, doing so will assure you and your staff of producing more and a longer-lasting record of achievements. It will also help you to prevent (or at least significantly mitigate) future crises. So, what does this actually mean in practice? It means that to slay the dragons of old ideas, you need to be liberal. And this is something which is problematic for lots of managers and particularly so for managers in healthcare systems, which tend to be very tradition oriented. In fact, they are often cited as being among those institutions which are slowest to adopt change. It’s a stance that is often purposeful, as many professionals believe that in the pursuit of saving people’s lives, change can be disruptive and is, therefore, to be avoided. Another reason for this aversion to change is the fact that the rate of managerial turnover in healthcare systems is generally quite low. It is not at all uncommon to find managers who have held the same position for a decade or more. And this can lead to an atrophying of creativity and innovation. Tradition makes far too many managers fearful of being flexible. Others just don’t know how to do it. Still others are unwilling to entertain suggestions, accept the possibility of transformation, or learn about (much be responsible for the implementation of) new technologies. Regardless, this all adds up to not being open to truly listen or be willing to adopt a change agenda. This creates an implicit situation which suppresses ideas that could challenge how things are done today. Are you comfortable with having your way of thinking tested from below? Does this strike you as a strength or a weakness?

1.18  History Class

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In medical institutions and departments, it’s understandable why receptivity to new concepts is more the exception than the rule. In terms of age, managers are often the most senior persons among their staffs. They generally have long professional histories behind them but, of course, that doesn’t always correlate with knowledge and capabilities. Years in the trenches earned them hard-fought rank and privilege, which makes it all too easy to dismiss anyone not of an equivalent station or above. When they say, “In my experience…” citing their background, resumes, and status, what can be said in response? It’s true. Their experience is the longest. But experience is subjective. And it’s helpful to bear in mind that most of the time impactful experience is garnered from exceptions, not from evidence-based medicine. In other words, experience that was once new, fresh, and pertinent may no longer be so when invoked from on high by management. Today’s hard data, raw facts, and producible evidence should always be part of the managerial equation. This means continuous learning from new examples, studies, and reports. If experience is the only thing that counts, then such managers will be always right based on their subjective memory, but wrong based on the contemporary knowledge of recent years. Fighting in the last war and relying on the experience of yesterday’s battles may inform some judgements, but it’s not enough to prepare for tomorrow’s challenges. In the business world, this tends to be different. Say you’re the CEO of a big software firm and your engineers come to you after identifying problems in the code of your flagship product. Naturally, you’re going to listen. It’s unlikely that you were hired to lead the company because you’re the best, most experienced software engineer. You hire others to excel in that area and it’s a fundamental part of your responsibilities to pay attention to what they have to say. You can’t say that you know better than your engineers because, of course, that’s not the case. If you don’t act on their recommendations, it could result in decreased customer confidence, lost market share, a decline in corporate revenue and prestige. Your board of directors is counting on you to make sure that none of these things happen. Ever. You don’t have the luxury of pre-emptively shutting down conversations warning you of impending trouble. Your failure to listen could mean that you’ll soon be looking for another job. If you’re the departmental manager at a major healthcare facility, you’re the senior person, you’re the smartest, you have the best experience, you have the rank, and in short, you know everything. Everyone else’s job is to get the job done, not to be clever. You can quickly shut down ingenious thinkers and any dissent. You can easily and swiftly dismiss the concepts of others that are different from yours. If you were the chief of engineering of a software firm, it would be different. You’d have many engineers working for you, writing and adjusting code. In that universe, it’s very often younger, less experienced individuals who will see things that more senior, team leaders can’t. Like the CEO, team leaders understand that everyone benefits when concepts and status quo ways of doing things are constantly open to question, revision and, as necessary, replacement. And to achieve real teamwork, you have to build an environment that perpetually encourages this type of interplay and creativity.

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1.19 Hiring Is a Concept, Too There’s an old bit of wisdom that suggests that if we’re all thinking the same, we are all not thinking. That’s just another way of saying that when we’re always playing it safe, we probably shouldn’t expect to achieve any significant breakthroughs. In this vein, as a manager you should be self-assured in your actions and decisions. Don’t be afraid to hire people who are very different from or more talented than you. If you’re a good manager you’ve gained authority over and respect from your staff. The presence of a more gifted doctor won’t upset your applecart. Rather, it will strengthen your team and the departmental culture you’re building together. A great entrepreneur in the automotive industry once told me, “I don’t seek out good managers. I can teach anyone how to be a good manager. I seek loyal people.” I don’t agree with this. It reminds me of Napoleon Bonaparte, who said, “I’d rather have lucky generals than good ones.” And just as loyalty has its limits, luck inevitably runs out (as it did for Napoleon in his disastrous, attempted invasion of Russia in the winter of 1812). A lucky general might overcome a defeat against overwhelming odds, but will likely pay a huge price for it in the bargain. A good general will know how to avoid a futile battle in the first place. By hiring the best personnel you can find, the sum of your departmental parts will add up to a greater whole. What steps can you take to achieve this as a never-ceasing goal? Once again, be flexible in your approach. If you come across a good, external candidate, someone you believe will add new qualities and capabilities to your organization, see what you can do to find a spot for that person to join your team. You may not need this individual at that precise moment, but if their skill sets and background are pertinent enough to excite your interest, you’ll work out the means to integrate them into your operations. The objective is for them to be excellent in the areas in which they excel. There are two strategies to hiring staff and both can live quite well, one next to the other. One way is through an opening for a specific position, for example, a surgical oncologist. As there are plenty of excellent candidates available, you’ll probably have little or no trouble finding a suitable professional. But let’s say that during this search you come across a truly first-rate skull base surgeon. You don’t need a skull base surgeon and you weren’t seeking one. Now you have a choice: Connect the dots as you had planned to do. Don’t deviate. Hire for the position you intended to fill. Alternatively, you could hire that once-in-a-generation skull base surgery find. It might be strategically better to be flexible and not lose the one-time opportunity. Meanwhile, the surgical oncologist post can remain unfilled for a time longer until your department has the resources to reopen the search. This is having a liberal mindset. By taking on a more expansive view of hiring, you can turn a tactical achievement into a strategic triumph. In the example above, that crack skull base surgeon would likely enhance any institutional profile for years to come. It may not be easiest thing to do and might be more difficult still to explain to superiors. But from a smart management perspective, it definitely would be the right thing to do.

1.20  Enjoy the Ride

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1.20 Enjoy the Ride Another “rule” of the healthcare management road is that department chairs pick their residents and attending physicians. Candidates arrive, they get interviewed by the boss, selections are made. Done. It’s just one more “we’ve always done it this way” example. But I want you to challenge this “way of life” concept. This one’s easy to solve as long as you’re confident in your leadership and willing to let go. First, create a system where you’re no longer the one individual in charge of these decisions. Form a departmental committee that includes you as one of its members. You don’t even have to chair the proceedings (in fact, I advise you not to). Second, like everyone else on the committee, you get one vote. The big BUT about your vote is that because you’re the head of the department, you always vote last. However, even the practice of chair-votes-last isn’t good enough. Here’s why: Let’s say you have your departmental committee in place and a particular decision has come down to two possibilities. As the discussions progress, it’s evident that Candidate X has the support of the majority of the committee and that individual gets two-thirds of the vote. Now it’s your turn. But it’s already a moot point. Your vote doesn’t matter. This is when it’s wise to remember that your vote can actually do harm. If you thought Candidate Y was the better choice and you went on record with your opinion, what is your vote communicating? That your team picked somebody you didn’t want. The new person will know this, too, and may feel like an unwanted child. Such a vote will just cause unnecessary tension and potential conflicts. So, the department chair-votes-last rule really means that whether or not the final vote is in agreement with the majority or in opposition to it, the department chair should almost always abstain. By dint of the position itself, does the department chair have the authority to veto the committee and impose a choice? Of course. However, in 8  years working within this committee system, I have never found myself in that pickle. Moreover, on the sole occasion where I really felt one candidate was far superior to the committee’s preference, when I look at how history played out over the following 5 years, I see now that I was wrong. How about the opposite? Were there ever instances when the committee’s pick wasn’t quite as good? Perhaps. But when it’s a group selection, you’ll rarely, if ever, make big mistakes. You may not always get the absolute best candidate, but you’ll never be trapped into single-minded, one-size-fits-all, Maginot Line/Bar Lev-type thinking. It won’t happen because you’re open to listening to other voices. As I will keep reminding you, this liberality of temperament makes you the stronger manager. You’re not ceding power; you’re empowering others and strengthening your team. You’ll thereby gain stature, which is ultimately empowerment for you. It’s boats and swelling tides—everyone rises together. Can this approach work on a larger, institutional scale? I believe so. A healthcare facility CEO who needs to hire a new department chairperson will likely not know the applicants personally. So, the sole, objective criteria that will be used to make an assessment will be the CVs from each of the several candidates. Everything else will be subjective inputs, such as professional references, personal chemistry in one-onone meetings, how thorough are any of the candidates’ plans for departmental growth and development, their views about competitor institutions, and so forth.

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The CEO can widen out this process by including a committee. It just depends on who will be a part of that group. If it’s only going to be the other departmental chairs, it won’t work. There needs to be a spectrum of perspectives and opinion, as any good committee, on any subject that requires serious decision-making, should be formed around the common sense that there are great and long-term benefits to be derived from diversity.

1.21 The Paradox You might think that what’s being recommended here is simply the displacement of an old, closed system and the adoption of a new system of openness where debate and innovation are welcome. You might then wonder: If systems tend to have a way of taking root, implementing their own set of norms, becoming self-perpetuating, and eventually stale, isn’t this going to become another example of, as The Who once sang, “Meet the new boss, same as the old boss”? The answer is no because this isn’t about a system. It’s about an ethos, which must be built in two phases. Phase 1 is deconstructing what is. It’s taking apart what exists, component part by component part and, in Phase 2 building again, reassembling what had been, only in a new form. Phase 1 is not to be confused with destruction, where you blow something to smithereens and have to create an entirely new thing from scratch to replace what’s been destroyed. Phase 2 requires you to use the same essential building blocks from what you had, but to establish a new system, procedure, or entity from them that will advance your service in a new era. New managers should be focused on making the change(s) that will result from this process considerable and dramatic. To be truly evolutionary, you have to engage in big-step thinking. Invest the time and energy necessary to do it right and make it count. This first period of change will be predictive of any improvements to follow. Modifying or uprooting current concepts won’t come through piecemeal analysis. You have to look at the entirety of your domain—services provided, research carried out, training programs in place, and quality of execution in each of these areas. The idea isn’t that everything being examined is going to change consequentially. You only have to be willing to look at all of it, so you can identify your best and most likely opportunity to implement that first, successful, attention-grabbing, concept-­altering innovation. The Catch-22 here is the longer you engage in making change, the more likely it is that you’ll adopt the very habits that created the need for change in the first place. Going down that path will inevitably lead to your undoing and a deterioration of whatever good you were able to bring about. Your greatest accomplishment will be changing the concept that adopting innovation inescapably leads to a new normal, which must eventually decline and languish until a new manager arrives and the change cycle is revived. To prevent this from occurring, be mindful that once you and your team have satisfied the goals of Phase 1, the work of Phase 2 is trickier. From the beginning of your management journey, remember that your real lasting legacy will be to create and nurture a climate that is comfortable in continuously challenging current concepts and your way of managing the system (Fig. 1.4).

Increase variation of surgeries

Conversion to day care surgery

Fig. 1.4  Reform is a continuum of exposure to change. (Credit: Nofar Rada)

Patient fredom to chose physician

Change office arrangement

Disclosure of complications rate

Patient freedom to chose surgeon

Decrease complications

Same-day visit

1.21  The Paradox 25

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To achieve this, you need to build a system that not only can be sustained, but can be sustained without you. Know that this can come only from below, by systematically deconstructing the pillars of your organization and thinking about the mechanisms necessary to achieve this, rather than what might constitute the shortest path to immediate (but potentially ephemeral) success. This is a marathon, not a sprint. Take pleasure in the creativity you are unleashing in your staff. They’ll be proud of you for doing so and will repay your trust in them ten times over through their dedication to their work and desire to always improve.

1.22 The Proof Is in the Product Of the many healthcare institutions, companies, and national systems that exist, some create and perpetuate unsatisfying and unhealthy environments for professionals and patients, alike. Worse, their demotivating, spreadsheet-driven administrative approaches often work against the very productivity and efficiency gains they claim they want to achieve. My suggestion? Focus on the product, which is the sum of quality times satisfaction times volume. Let’s look at this in detail. If doctors are pushed to decrease their consultation time spent per patient their volume may increase somewhat, while quality is likely to decrease, along with the satisfaction levels of both doctors and patients. Eventually, the overall product won’t be so good. All three factors are critical to sustainable success. Mindful of this, achievements can come through increased efficiency and by decreasing complications and complaints. Launching specialized clinics is a good way to increase volume. Trying to cram more patients into the same clinic by simply whittling down the length of time doctors can interact with patients will always have its limits and ultimately bear negative consequences. Here’s an example: In the operating room, say a given surgeon is allocated 30 h/ month for surgeries, but only uses twenty of those. That’s about 67% efficiency. The other 10 h are “lost” for a variety of reasons, such as patient no-shows, operations that start late, lengthy time gaps between operations which force rescheduling of some surgeries, etc. Immediate efficiency increases can be obtained through the improved management and oversight of the OR. Patient no-shows can be decreased by increasing presurgery contacts with patients (e.g., implementing automated text message reminders; telephoning both a week and the day before surgeries to confirm patient arrivals). Late starts and unnecessary time lags between surgeries may require more effort. Getting at the underlying cause(s) and the solutions will often be quite straightforward. In our department, we discovered that delays and lapses were frequently the result of the OR not being ready to receive each new patient. So, we created an OR prep checklist, which must be followed. We almost completely eliminated rescheduling situations by planning our daily surgical calendar better. Relatively simple surgeries get the earlier slots, while those which are more complex or might present the possibility of complications are scheduled for later in the day. If any in the latter group run longer than anticipated, there’s far less likelihood of inconveniencing

1.23 Sustainability

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Fig. 1.5  Total surgeries performed increased only through the efficient use of existing resources. (Credit: Nofar Rada)

other patients and disrupting the preferred flow of OR operations. Our results speak for themselves. As you can see in Fig. 1.5, in 2011, annual surgeries stood at 870. Six years later, the figure was 3510. The rate-limiting factor to achieving this profound increase wasn’t the number of cases, the hours necessary to devote to them, nor even the size of our surgical staff. Rather, it tracks directly with a concomitant rise in efficiency (Fig. 1.6). Therefore, if your first instinct is that higher numbers can only be accomplished with more personnel and/or additional surgical suites, think again. If you’re not taking steps to assure that existing resources are being managed as efficiently as possible, then I assure you that you’ve got buried treasure hiding in plain sight.

1.23 Sustainability Even with the best ideas and the greatest innovations, when it comes to managing a team, there’s a difference between implementing positive change and sustaining it. It can be terribly dispiriting to invest time and energy in the careful planning and execution of an improvement campaign, to then actually achieve advancements, only to have it all slide back to the way things were before. Those reversals make it doubly hard to try again. Some people wonder, “Why bother?” if all their efforts are ultimately going to be for naught. That’s why I draw a distinction between two types of change—those that are self-motivating and those which are not. The former offers employees direct and

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Operating room efficiency

132.0% 125.0%

118.0%

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119.5%

2015

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108.0% 96.0%

100.0% 79.0% 75.0%

72.0%

50.0% 2011

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Year

Fig. 1.6  OR efficiency is a function of resource management and personal responsibility. (Credit: Nofar Rada)

immediate gratification. The change is clearly to their advantage and so they have a vested interest in maintaining it. For example, lab tests for patients. Formerly, our staff followed a template, which indicated if a given person has a certain problem, a particular set of symptoms, or a specified disease, they should automatically undergo a prescribed set of tests. There was no room for variation, no opportunity for a doctor’s assessment to be a potentially mitigating factor. So, we changed this. Now the template is viewed as a standard set of recommendations, but not the law of the land. Doctors make their individual determinations, which are then reviewed (and modified, as deemed appropriate) by the team. The results can be seen in Fig. 1.7. It’s a motivational change because our doctors are given wider latitude to exercise their professional judgements. In so doing, we’ve reduced by nearly half the total volume of these tests. By eliminating perfunctory testing, doctors and other staff have more time to devote to truly necessary and productive activities. And there’s also the ancillary benefit of the cost savings to the institution. As this approach produces advantage to all involved, backsliding into past practice in this area is avoided. Alternatively, let’s revisit something discussed earlier—in patients needing an ENT doctor and our work to make sure that no one ever has to wait longer than 24 h to get a consultation. To address the problem of those who had longer wait times and to lower that percentage to as close to zero as possible required acknowledging that this is purely a patient service goal. It’s altruistic. For staff, although many (if not all) can agree on the objective, it’s abstract. Self-perpetuating success is highly unlikely because there’s no innate incentive to do so. To be a bit crass, for those carrying out the mission, it’s missing the “What’s in it for me?” factor.

1.23 Sustainability

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Number of laboratory tests, per patient

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Monitoring via departmental app begins 0 2011

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Fig. 1.7  Number of in-hospital laboratory tests performed, per patient. (Credit: Nofar Rada)

19.6

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Fig. 1.8  Percentage of in patients waiting over 24 h for a consultation. (Credit: Nofar Rada)

This type of change requires more energy. The only way to reach and sustain a goal which has no built-in personal reward is to create a reporting mechanism. And it needn’t be anything bureaucratic or time-consuming, either. In our case, we gave our on-call surgeon one additional task—at day’s end, report how many patients did not receive a consultation in 24 h or less? Nothing more. Within a day, the percentage in that category dropped from approximately 20% to around 2% (Fig. 1.8). At this writing, it’s eight years later and we’ve never gone back up.

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It’s critical to segregate problems by solutions which, by their very nature, produce some personally desirable outcome for personnel and those that don’t. It doesn’t mean that the former are completely of the set-it-and-forget-it variety, but they are far more plug-‘n’-play than the latter, which demand due diligence and ongoing managerial supervision.

1.24 Greed The target function of some private healthcare systems is to maximize profit, frequently in excess of quality care. Their protocols demand or, at least, create incentives for medical professionals to order up tests and procedures more for the sake of revenue generation than the pursuit of sensible diagnostic or treatment outcomes. We say that patient-centered care should always be the target function that drives our medical decisions. Others will respond by saying how lovely that sounds, but it can only be indulged in a country like Norway, which has significant resources to dedicate to its national healthcare system. They’ll ask how can this be done elsewhere where resource availability is a chronic concern? After all, no system can long be sustained if it’s constantly bleeding money, right? The tragic mistake is believing that the only road to revenue is that which leads to creating more reasons to bill and/or charge a premium for services. It’s a false premise as significant resources are already available and there to be taken advantage of, but for the fact that they’re hidden from view, buried under layers of inefficiency. Tackle this fundamental issue and I promise you that there’s more than enough money to go around. Quality patient care creates revenue. When healthcare systems are more efficient, they generate savings of cost and time. The former frees up resources to maintain infrastructure, while the latter allows for a dramatic expansion in the numbers of patients served. What I argue is this: Look at premium care plans, the co-pays, the numbers of unnecessary tests and procedures carried out, and so forth. Add up all that revenue. Then, stack that up against what can be accomplished through the implementation and industrious management of efficient operations. In this book, you’ll see that if you’re delivering efficient medical care, if you’re maintaining diagnostic and treatment parameters which are solely in service to your patients, and if you’re achieving high rates of patient satisfaction, that’s going to be good for everyone, including institutional and corporate interests. As you venture along on this healthcare journey, like Robert Frost’s famous traveler of poetry fame, you now face two divergent roads. You have to make a choice. One you ought to know well by now. Its bureaucratic and wasteful pathways can lead to further pathways, which take you so far from patient-centered care that you may doubt you’ll ever find your way back. I’m recommending you take the pathway less traveled by. After you do, some time hence, I guarantee it will have made all the difference.

1.25  Give It Away, Give It Away, Give It Away Now

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1.25 Give It Away, Give It Away, Give It Away Now To recap, excluding the USA, one can hardly name an OECD member country that doesn’t have a universal healthcare system. Funding and operational structures may differ but, for the most part, citizens in those nations are entitled to certain, essential medical services. In some places these are more expansive, in others less so. Typically, anything not defined as essential is available for an additional fee or through supplementary insurance coverage. Even in the USA, where most medical coverage is provided through private companies, plans will only provide a set package of services for a particular price. Extra services come at a premium. In any of these nations, if one were to ask why more services can’t be included as part of an essential, basic package of services, the answer will always be the same: “It’s cost prohibitive. If the system had more money coming in, it might be possible.” The perpetual presumption is that the maximum is already being accomplished with dedicated resources. But is it? Are there definitive studies that validate this presumption or is this just one of those cases in life where something is said so often that it’s simply accepted as reality? If your target function is patient primacy, then providing the essentials at highly elevated levels of efficiency can generate both cost savings and more revenue. Those accomplishments may be sufficient to offer services otherwise considered premium price add-ons. Among these, for example, patients should have the right to choose their doctors and surgeons. They should be provided with rapid lines of communication to physicians, nurses, and therapists, which may include direct cell phone numbers. Additionally, similar to the corporate world, departments should publish and distribute annual reports, publicly disclosing departmental statistics on complications, patient volumes, waiting times, hospital stays, tests and surgeries performed, OR efficiency, readmissions, and more. If all departments, everywhere, were currently doing so, then you and everyone else could see where your institution stands in comparison with others. This is an example of transparency which can be used to leverage change, growth, and development. Departmental teams can use annual reports as a mechanism for benchmarking achievement and establishing success goals and improvement targets.

2

Deconstruction

“Sit down before fact as a little child, be prepared to give up every preconceived notion, follow humbly wherever and to whatever abysses nature leads, or you shall learn nothing.” —Thomas Huxley, English Biologist & Anthropologist

© Springer Nature Switzerland AG 2021 Z. Gil, The Healthcare Efficiency Revolution, https://doi.org/10.1007/978-3-030-61232-0_2

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2 Deconstruction

 o Know How Things Might Be, You Have to Know How T Things Got to Be the Way They Are

The same idea surrounding concept construction and entrenchment leads us to the notion of deconstruction (Fig. 2.1). Although often associated with philosophy, linguistics, and the arts, I’m recommending that deconstruction must be a core principal of management. Generally, new managers will take one of two approaches. Many will accept the existing constructs of a department or institution they’re entering, and be incrementalists, tinkering a little here, adjusting a bit there. Some will burn down the house and construct a new one in its place. Managerial deconstruction means going about the business of mentally taking apart one’s domain so it can be rebuilt it in an improved form. What are the component elements and structures? How were they brought together? When and why were systems and procedures implemented? What works? Where are the points of friction? What’s usable? What needs to be replaced or discarded? Who fits and who doesn’t? There are no rules to the deconstruction process. It can be accomplished in a concentrated moment or over an extended period. It may take a month, a year, or longer. It will depend on multiple factors. What’s important to bear in mind is that following deconstruction, nothing will look the same as it was. Along the way, your own process will separate out the elements that comprise technocratic management, which are distinct from the ingredients that will go into your visionary stew. For the most part, you’ll find that the technocratic side of institutional healthcare facility management consists of nuts and bolts—providing and maintaining buildings, offices, clinics, surgical wards, and so forth; utilities; human resource and patient processing systems; etc. That’s all external to the individual departments. Everything else is what happens within any given department. And in modern medicine, departmental management is very much an internal concern. That’s why the one chance any department will have to make profound change can only come through the introduction of a new manager. As you scrutinize your department or institution, you’ll necessarily have to take a hard look at your several units. Each of these has a director or coordinator. Just the Fig. 2.1 Deconstruction. (The Louvre’s Pyramide inversée, Paris, France)

2.2 With All Due Diligence

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same as you might spend the next 20  years in the big chair, unit managers can remain in their positions for equally long stretches. Deconstruction has to extend into these subunits and engage their leaders in the analytical process, with the objective being that the units, too, will eventually take on the new, big picture personality of the department or institution being transformed. There’s no alternative to your direct, hands-on involvement with your units. You must instruct, strategize with, and sometimes even micromanage them. On an institutional level this can be a little more difficult. If it’s possible to work on a regular basis with department chairs (and even, as appropriate, their staffs), it’s advisable because it will instill more institutional cohesion, which will increase the likelihood of all departments making greater and faster improvements. However, depending on laws, regulations, and union relationships, CEOs and managers may be limited in some of the actions they can take. For example, in some situations, outright dismissal of department chairs is restricted to serious infringements of ethics or malfeasance. Leaders who find themselves hamstrung in this way should use the best options available to them, such as sending their department chairs to take university classes in management. To build something with a fresh vision, you need to know, on a granular level, what you really have at your disposal. Deconstruction is essential. With it you’re assembling a sort of toolkit. Then, as you and your team develop big ideas, you’ll know what you can use and how best you can take on the task of construction. You won’t be trying to jerry-rig something or shoehorn it awkwardly into place. Deconstruction also allows you to clear away (or at least properly identify) unforeseen obstacles that could cause problems later on. Whether you’re seeking to lead a department to take its next evolutionary leap ahead, mature your institution to attain new growth targets, or create a true center of excellence, deconstruction is vital to your chances of success.

2.2

With All Due Diligence

You’ve deconstructed the operations of your department, you understand how its component parts are currently constituted, you’ve begun the process of mentally reassembling it, going inverted pyramid-wise from the broadest concepts to the tiniest procedural details, all in service of your target function: patient primacy. Now you need to establish benchmarks for success, timelines for implementation, and metrics. The last of these is particularly important because real change needs to be objectively measured. There has to be data, regularly produced and available for review to determine if goals are being achieved and, thereafter, sustained or improved upon. You’ll necessarily have short, mid-range, and long-term objectives. When a house is being built, there’s a logical sequence of deliverables expected from all those involved in its construction. Obviously, the roofers won’t be scheduled before the excavators. Everything has its moment. Typically, though, after the foundation has been laid, there are a number of overlapping, concurrent activities. Departmental activities should be planned similarly. There’s more than enough to do and sufficient personnel capable of handling their share of the responsibility for change.

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2 Deconstruction

You’re rebuilding your departmental house and, thereby, building your team. Every success and each milestone achieved accrues bonus points. It feels great to be a part of something you can point to and know you and your colleagues made it happen. It’s better when others notice and more satisfying still when they want to learn from your example and ask, “How did you do that?” Triumphs are gratifying. With every notch the team adds to its belt, it’s invigorating, and the added pride and motivation will spur everyone on to conquer the next goal.

2.3

Asking the Right Questions

Dozens of books are written, workshops and seminars held, and consulting firms hired to impart the great hidden secrets of management. Here’s one that costs nothing, which you’re already using every day: A calendar. And although it may be true that you’re not using your departmental calendar to optimal effect, it is the most important tool at your disposal. Departments have routines. There are daily, weekly, monthly, even annual tasks that must be accomplished. Very little is vague or comes as a surprise. Everyone knows their roles. And everything the department does is built on the foundation of this basic, fundamental tool. The trick is to use it to better effect. In terms of “normal” operations, there are so many things we do only because we did them yesterday. We often determine the validity of a hospital department practice based upon whether most or all other departments in the hospital do the same, or because all other hospitals do it, or because it’s a way of doing things that’s been around for decades. But this is the wrong approach. It’s better to analyze each activity on the calendar to determine: • Is its existence and continuation validly serving our patient primacy target function? • If so, is it being right scheduled, right structured, and rightsized? • If not, should it be dispensed with, reoriented, or replaced? Are clinics in operation serving current patient flows? Are the days and hours of operation best serving patient needs and lifestyles? Should there be more clinics? Should a generalized clinic be subdivided into specialization clinics? What about a mobile clinic? Telemedicine? So much of life is obvious until it isn’t. Things are the way they are and go the way they go, well…because they do and have been doing so since no one can remember when. Taking the time to stop and ask very basic questions can result in answers that reveal many self-evident truths and quite a number of innovations. And like the old saw that there are no stupid questions, what’s the harm in closely examining every aspect of the workday and one’s work environment, and inquiring whether or not a given activity and/or resource associated with it complies with or is optimizing the target function? Ask these questions. Those things that remain valid will remain valid. How much time and energy were expended in simply being curious? Guaranteed, though, curiosity will reveal areas where change is desirable and, frequently, necessary.

2.4 A Problem Well Stated Is a Problem Half Solved

2.4

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A Problem Well Stated Is a Problem Half Solved

With deconstruction complete, it becomes easier to assemble a comprehensive list of primary, routine tasks, as well as those which are secondary, periodic, and emergency related. Much team discussion is required for this process. When it comes to categorization, there will be broad agreement about many activities, opinion and debate about others. This objective mapping will allow everyone to see the departmental forest for any subset of its trees; to examine individual component-by-­component parts, how they fit together, and where is their place in the orderly execution of ongoing responsibilities. From there, reassembly of the department can begin. As your team commences an extensive exploration into all of its activities, it will make honest, practical assessments about the average amounts of time that are generally devoted (per day, per week, per month) to each assignment and functional area. Without question, analysis and discussion will evidence where and why bottlenecks and inefficiencies occur. Many of these will be related to very simple things, such as not factoring in, in advance, the fact that 25–30% of daily operations will present patients and issues that are not anticipated. For such eventualities, how about triaging patients and cases when scheduling their appointments? Then, to the degree possible, those consultations that are likely to run longer than the time typically allotted for an average patient might be more evenly staggered throughout the schedule. Perhaps a certain amount of time can be reserved toward the end of any given daily span of clinic hours. Then, if an appointment runs long, it will cause minimal disruption to other patients. What about patients who turn up unannounced? How many of these need to be squeezed in for a sudden, same-day appointment to see a doctor or a nurse? How many need administrative services (e.g., scheduling a future appointment, printing a document, acquiring an authorization form for a laboratory test)? How often does it occur that a doctor or nurse who is scheduled to be on duty calls in sick or needs to take a personal day? Do consultations for certain types of patients generally take longer than others? Build your own list. A lot of what’s “unanticipated” is entirely anticipatable. They’re part and parcel of the fabric of daily operations. They’ll always be problematic so long as they’re treated as abnormalities. For example, if a department knows that, on average, 25% of its daily patient traffic consists of unscheduled walkins, it could allocate special, daily clinic hours, which are totally devoted to walk-in patients. Similarly, if 25% of all scheduled appointments are no-­shows, to maintain operations at capacity, appointments should be overbooked to a similar percentage. The same holds true for new and returning patients. Instead of having all arrivals stand in a single-file line, why not consider ways to segregate those who have come for a first consultation or treatment from those returning for a follow-up visit? Schedule planning and patient-flow analysis should take place on a daily basis, preferably by a dedicated director of outpatient clinics whose primary role is handling administrative issues, including personnel supervision, quality control, and patient experience optimization. When there are no administrative matters to be handled, this dedicated staffer can turn their attention to patient care. A director of outpatient clinics can be helpful in many ways, including capacity staffing assurance. When doctors and nurses get sick and need time off, for any given workday or workweek the director can be organized in advanced for such

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2 Deconstruction

cases, maintaining a list of backup staff who can be immediately mobilized when others are unexpectedly unable to come to work. This avoids unnecessary slowdowns, cancelled appointments, irritated patients, and overworked employees.

2.5

Tick, Tick, Tick

Any plan for change, any individual initiative requires time for phase in, ramp up, measurement, and assessment. But how much time should be allocated to a given project? Your best bet is to adhere to the old saw: Never over promise and under deliver. If you reasonably estimate you can achieve a target in 4 years, define your time period as 5  years. That’s a 25% unanticipated eventualities cushion. Unless you’re Nostradamus, you can’t know with 100% certainty what tomorrow will bring, so give yourself that wiggle room. If you don’t need it and you reach your goal “early,” then you get bragging rights for that, too.

2.6

Are We There Yet?

Solutions such as those offered above (and many others) necessitate critical reasoning and creativity. They require very few, if any, additional resources to implement. They can result in extraordinarily rapid improvements in departmental service outcomes. As new approaches are monitored, honed, and refined, continued improvements will ensue over the course of the months and years that follow. By pursuing a policy of patient primacy, our department performed 2800 more surgeries in 2018 than it had in 2011 (an increase of over 300%). In the same period, we: • Boosted operating room efficiency by more than 65% • Reduced hospital readmissions (within 30  days of initial discharge) by well over 40% • Produced a 90% decline in the percentage of severe complications from surgery requiring hospitalizations over 21 days • Slashed average emergency room wait times (in hours) by 55% • Brought down by over 85% the percentage of patients needing to wait more than 24 hours for a consultation • Increased the annual number of patients seen/treated in our clinic by over 260% • Reduced in-hospital laboratory tests performed by nearly 50% • Saw patient satisfaction and patient willingness to recommend our departmental services skyrocket from around 65% to 98% All of this (and more) offers unambiguous evidence of service improvements for patients. It’s equally clear that smart, patient primacy solutions almost always produce additional benefits for medical professionals, their institutions, and, not infrequently, medical science itself. You don’t have to look at year-end balance sheets to understand that the figures above represent both massive gains in the channeling and use of existing resources, and profound growth in revenues.

3

Smells Like Team Spirit

“None of us is as smart as all of us.” —Ken Blanchard, American Author

© Springer Nature Switzerland AG 2021 Z. Gil, The Healthcare Efficiency Revolution, https://doi.org/10.1007/978-3-030-61232-0_3

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3.1

3  Smells Like Team Spirit

Building Teams, Building Trust

We’ve all seen institutional, personnel flowcharts. They’re hierarchical. Start at the top and work your way down. There’s a literal value in this. You look at it and you know who is in charge of what, who is accountable to whom, which individuals are assigned to which areas, etc. But that doesn’t visually capture what daily life at the office is really like, now does it? Medical workplace environments are more like overlapping circles. Some people spend a great deal of time working alongside and interacting with one another; others far less so. In a related sense, while a hospital department should function as a team, it’s also true that within that team are subset teams of nurses, surgeons, secretaries, attending physicians, and so on. Each has specific competencies, knowledge, experience, expertise, and needs. From a managerial standpoint, the leaders of those subset teams may constitute a type of inner circle or kitchen cabinet. Such a group can be an extremely helpful set of advisors. They should be relied upon to generate new ideas and to be a sounding board for the ideas of others. They should also be seen as an expedient way to disseminate information, and keep departmental efficiency and progress running apace. What’s most important is for this group to be loyal, above all, to the ideals of the profession of healthcare, and then to the institution for which they work, the department within which they work, and the colleagues with whom they work. At all times, people should be encouraged to speak freely, even if their opinions are at odds with the status quo or whatever is seen as today’s prevailing “wisdom.” Good managers never achieve this by emphasizing superiority and subordination. Instead, they build their kitchen cabinets by identifying current employees or recruiting people who are (or seem likely to be) comfortable in leadership roles (i.e., coordinating the work of those below them). But that’s not enough. These individuals should also be talented and creative in their own right and have some intestinal fortitude in the bargain. I don’t want to get too highfalutin here, but assuming that all of these individuals are true to an ethical code and have a constant desire to achieve advancements in medicine and patient services, each will offer the utmost of what they have to give and bring out the best in their peers. And outliers are never to be feared or repressed. Quite the opposite. More often than not, it’s those who are marching to the beats of different drummers who will be seeing things from the freshest perspectives and coming up with the greatest innovations. A manager’s inner circle so constituted won’t turn into a game of thrones. Rather, it will showcase what benevolent, generous, mission-centered management looks like. In this environment, a well-nurtured kitchen cabinet radiates these attitudes and behaviors to subset teams within the department and the outer circles of personnel. The inner circle can be a fixed set of individuals, but it’s not required. It may be advantageous to have different cabinets focusing on specific sectors of the department or particular initiatives. As the individual strengths and weaknesses of cabinet members come into sharper focus, they can be assigned tasks or shifted into new roles where their greatest skills can be put to best effect.

3.2  What’s Your Problem?

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Plus, the diminution of managerial dominancy over time cascades from the top and ripples outward to the department’s several divisions. This frees staff to take on appropriate and maximum levels of responsibility, and seek new levels of achievement. It also unleashes unrealized capacities that already exist. People aren’t competing against one another or the institution. They’re competing against externalities that say they can’t achieve a higher goal without more resources.

3.2

What’s Your Problem?

Understanding and ingratiating oneself with personnel is fundamental, but there are also the mechanics and internal engineering of operations. It’s offices, equipment, examination rooms, surgical wards, diagnostic tools, laboratories, computers, hardware, software, interconnected systems, apps, the Internet of Things, and more. It’s patient interactions from scheduling and initial consultations, to testing and follow-­ ups, to surgeries and therapy. It’s statistics and more statistics—totals of patients seen and surgeries performed annually, average wait times and hospital stays, percentages of complications and readmissions, on and on. The narrative that emerges from the bundling of and interplay between these component parts tells a story about functionality and dysfunctionality, the satisfactions and dissatisfactions of patients and staff, nominal efficiency and total inefficiency. To obtain the most accurate and complete picture, along with a set of recommendations and objectives for change, here’s what not to do: Don’t hire a fancy-schmancy consulting firm to do the job. The idea that a bunch of expensive, high-powered analysts are going to descend on your department for a week and produce a report detailing all of its problems and how they can be resolved is, for the most part, fantasy. Even with all their knowledge and experience, what they will accomplish cannot avoid displaying a significant element of superficiality and sterility. It’ll wind up being a tremendous waste of time, money, and energy. And the advice offered will either be wrong, pegged to an unrealistic timeline, or nothing which internal management couldn’t have figured out on its own. Which leads me to the bigger reason not to do it: It’s shirking responsibility. If you’re in charge, then it’s on you. You can’t walk in with a consultant’s report and tell the staff, “Well, this what they say we have to do, so now we’re going to do this,” and honestly think folks are going to salute smartly and do it, do you? There’s nothing organic about the process. There’s no buy-in. Besides, what does this communicate to the team. At best, the message is muddy, confusing, and abstract. At worst, it says that management isn’t up to the task, which is hardly a great way to inspire people to action. A manager’s effort needs to be all in, speaking to everyone from the institutional president and CEO to the janitorial staff. The picture that needs to be seen and, more importantly, the problems that need to be solved are in their stories. As described, these problems will begin to order themselves. Some will be minor, others of greater significance. Ultimately, what needs to arise is one main

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problem. This doesn’t mean a problem that is above all others; that nothing moves forward without addressing it first (although this might be the case). What I’m talking about is a significant problem, which most staff members can see and agree is a problem, they want it fixed, and have given every reasonable expectation that they’d be pleased to help in the implementation of a solution. Build a strategy around achieving this goal. The satisfaction and pride people will take from that initial accomplishment will give them confidence to tackle the next big problem.

3.3

Traps

A manager’s superiors are, of course, major players, but it’s often wise to keep in mind that the nature of their positions places them at a distance from many issues. Their perspectives are a highly pertinent part of the mix, and maintaining positive relationships and healthy dialogues will always be beneficial (but, of course, this should be true with any class or rank of personnel). This said, what managers must never do is fall into the trap of assuming that the best (or worse, only) source for input and counsel on team-fortifying, progressive, and dramatic results-producing change comes from above. As the best advice always comes from within and below, it’s also a trap to assume that subordinates won’t have creative ideas on how to fix problems. So it’s of paramount importance, especially early on in a new manager’s tenure, to talk less and listen lots (especially if prior management was top-down and not amenable to working creatively and collaboratively with staff). Finally, it’s important to take into consideration factors that are institutionally external. For example, the nature, structure, and regulatory framework of a given national health system or insurance coverage regime may present impenetrable barriers to internal change. Accordingly, managers should understand where desired change will be resisted by forces entirely beyond their control. Tilting at windmills is one thing, but pounding one’s head against the wall is quite another.

3.4

It Takes an Orchestra to Play a Symphony

It’s axiomatic that most of the work that’s done in your department or institution is being carried out by your team. Your role is similar to the conductor at a philharmonic concert. The musicians don’t need the one wielding the baton to play their instruments, but they do look that individual for critical guidance, direction, and ideas on how they should interpret the compositions they’re performing. If you’re leading a group of people, more than almost anything else, positive stimulation is essential. What’s the difference between an infantry soldier and green beret private? While the former can carry 50 pounds for 20  miles, the latter can carry double the weight and go twice the distance. Why? It’s not about physical strength, it’s inspiration and mental fortitude. Put simply: Motivation is a force multiplier.

3.5  Do Unto Others

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When it comes to team motivation, I have found that the best strategy is management that’s based on the narrative of the nuclear family. It’s the whole ball of wax. So, assuming your home life is reasonably stable and loving, there are no books you’ll need to read, workshops you’ll have to attend, or certifications you’ll be obligated to acquire. You already know what to do. And the basics are, well…quite basic. I once asked one of our department’s attending physicians, who had served as a medic in the 2006 Lebanon War, what made him go from one soldier to another while under heavy fire, taking care of the wounded while his own life was at risk. He answered plainly, “They’d have done the same for me.” Managers should have this same level of care and concern for their own team members. Along these lines, during the 2020 COVID-19 pandemic, our institution had a shortage of N95 masks. It became impossible to provide them to all staff and our team began to have serious concerns about the risks they were being asked to face without being appropriately protected from the virus. I spent the start of this crisis period not at the hospital, but going to organizations that could donate personal protective equipment to us. In the end, ours was the only department in the institution (outside of the dedicated coronavirus ward) that had this type of mask available for all of its personnel. And it wasn’t just that our people felt protected, they understood that I truly cared for their well-being, which I do and always will. This has been a motivator and has served as a team force multiplier.

3.5

Do Unto Others

In coining the Golden Rule, Hillel the Elder, the ancient, Jewish religious leader and scholar said, “That which is hateful to you, do not do to your fellow. That is the whole Torah; the rest is the explanation.” So, right out of the gate: Don’t ever humiliate anyone. If you believe that you can single out a staffer for some perceived or actual failure, humiliate them, and everyone else is going to be okay with that, you’re deluding yourself. It’s demoralizing for everybody. It puts the whole team on edge, worrying if next time it’s going to be one of them that gets the tongue lashing or the nasty memo. Next, show your team members that it’s not all about what they do for you. You all work for an organization and, beyond that, as healthcare providers, for the greater societal good. Yes, you’re the leader and your staff answers to you, but you should never lord that over them. Rather, demonstrate that their concerns are as important to you as is their professional output. How do you do that? It’s a cinch. Don’t limit your conversations to shop talk. Ask your colleagues about things outside of the organization. If someone’s mother is feeling poorly, ask how she’s getting along? If an employee’s child is competing in a sports tournament or for an academic honor, inquire about the outcome. Chat about holidays, hobbies, and horsefeathers. Take people out to lunch or after-hours drinks once in every so often. I’m not encouraging going so far that you start treating the office like it’s a kaffeeklatsch. I’m merely reminding you that none of us leads completely

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compartmentalized lives. We have professional obligations, home fires to tend to, dreams, aspirations, sadnesses and joys, moments of despair and celebratory elation. Showing that you care (better still, actually caring) is a way of extending your friendship and humanity to them. You spend more waking hours of the day in your office than you do at home, so you’ll all be more productive and do better work if you genuinely get to know and like one another.

3.6

Example #1: You

Second only to nuclear family-style management is leading by example. Know when it’s your job and yours alone to take on a particularly tough assignment or shoulder a burden which might carry great risk. When it comes to frontline fighting, your team needs to know that you’re not there only to send them into battle when the going gets tough. Staff will accept being led if they know you accept that with leadership comes added responsibility. You must be ready to answer the call of duty when those trying moments arrive. You can choose to do less, but be prepared to sacrifice a proportional share of the authority they’ll grant you to lead and the respect they’re willing to offer. Equally, when things go well, share the credit. I’ll give you an example. I assigned a research project to one of our department’s residents. I defined the parameters of the task, gave instruction on how to carry out the data analysis and, in truth, wrote most of the paper that wound up getting published in a very respectable journal. Then, I sent a note to the whole team, which congratulated this resident on a job well done. From this one credit, I gained two things: Number 1, I acknowledged the work of a fellow staffer who was delighted to have been publicly recognized, and Number 2, everybody knows that I shared the spotlight with a dedicated member of the team. So, since you get extra credit for giving credit, why not do it?

3.7

Open a Window, Would Ya?

You’re in a room. Maybe it’s warm outside. Perhaps your building’s central heating system has been turned up a little too high. It’s stuffy. You open a window and feel a cool breeze. It’s a literal breath of fresh air. Analogously, interactions with colleagues are often similar to being stuck in stale environments. The lack of adequate communication and communications systems can make professional life a bit stifling. We need to crack a few metaphorical windows. A department can’t make, maintain, or build upon change if it doesn’t allocate an appropriate amount of time for regular team interactions, particularly for planning. Running on autopilot and only handling individual problems on an ad hoc basis will barely suffice for the status quo. Over time and left to their own devices, entropy will have its way with everything. If you never tune-up your car, you shouldn’t be shocked when a major system eventually fails.

3.8  No One Can Whistle a Symphony

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In a hospital department, planning meetings are essential. Looking ahead and being prepared, at the very least for the week and month ahead will vastly minimize “surprises.” It will also greatly ensure that necessary resources will be available, and little or nothing will be able to jeopardize either your patient primacy target function or your efficiency in its execution. Your departmental calendar and every need associated with it comes through planning. And sensible planning is achieved with the comforting air flow of good communication. In our department, we meet every Thursday to discuss the week that was and to ready ourselves and our game for the week to come (and the days thereafter). Originally, these meetings were only for the managers of attending physicians, nurses, residents, and secretaries. This was mainly due to space limitations. As a result of COVID-19 restrictions, we shifted to video conferencing and invited all team members to attend. Since then we’ve had meetings with over 30 people online. At first, I was a little surprised at how enthusiastic our staff was to participate. But they genuinely like being involved and in the loop. We have had a similar experience with our tumor review board meetings at which clinical cases are assessed and discussed. Initially, only doctors attended. However, when these became videoconferences, we’ve had many nurses and paramedic staffers join in. It’s gratifying to have personnel from all sectors of the department participating in these sessions. It imbues all of us with a greater sense of professional, mission-focused camaraderie; that’s it’s not just surgeons who are treating our patients. It’s all of us, together, as a medical team.

3.8

No One Can Whistle a Symphony

An orchestra. It has several sections. Its target function is to entertain an audience. It has a single individual who establishes priorities and directs the players in their separate and collective roles. When the players are in sync and things are operating at peak efficiency, their component parts add up to a harmonious whole, whose results are validated by those on the receiving end of their labors. There are overt and subtle channels of communication, in rehearsal and on the concert stage. If things are well communicated, well timed, and well executed, they might be rewarded with a standing ovation. On the other end of the scale, rotten vegetables may be hurled. In a hospital department, communications tools and platforms allow everyone to be prepared, practiced, and pleasing to patients and colleagues, alike. Departmental team members need to communicate with one another, individuals need to communicate with the manager, and the manager needs to communicate with area coordinators and the rest of the team. Equally important, patients need to be able to communicate with staff (all staff). And patients cannot be a peripheral part of the conversation, nor can their communications be treated as a postscript. Most communications will be electronic. Text messaging and email are a given. Your hospital may have its own intranet. The institution might have dedicated apps

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or it might allow your department to be a pioneer in the development of its own app. Regardless, in the adoption or creation of any particular communications system, it will be necessary to ascertain what is and isn’t in compliance with institutional rules and regulations. Beyond this, we’re once again back to the issue of patient primacy. Better communications need to result in improving the execution of all those things that serve this target function. If systems are a closed loop in which professionals are only communicating with professionals, then these communications will be operating on a flawed premise. Your department must have direct communication links to your patients. This includes those you have treated and those you’ve yet to treat. And let me tell you, an automated appointment booking telephone line and a voicemail box ain’t enough. Understand that here, too, prioritization is a factor. All sorts of patients may be communicating with you. They may be new patients, long-standing patients, inpatients, or outpatients. All communications must be screened and triaged as they arrive. In our department, for example, although patients are informed that it may take up to 7  days to respond to non-urgent communications, we understand that some may demand rapid replies, while others may be red flag alerts requiring drop-­ everything-­now, emergency responses.

3.9

Wind It Up, Let It Go

Too much time is frittered away by not sharing responsibility. It’s not that micromanagement is never warranted. It can have its place, but it should be applied surgically. Otherwise, train, prepare, and orient your staff well, give them projects to oversee, and let them report back to you, as appropriate. That creates stronger, more self-reliant professionals. It also establishes lines of accountability, which sharpens the managerial capabilities of your subordinates. Find increasing ways for them to take command of discrete aspects of your operations. If there’s no compelling reason for something to be centralized, delegate! This isn’t just good management practice and it’s not only about how you manage others. It’s about how you manage you! Every time you’re doing something that can be handled as easily and as well as (if not better than) you can, you’re wasting your own time, which can be better spent doing something that your staff members can’t. Take a moment to really think about all the attention and energy that gets invested in things that you probably don’t need to involve yourself in. Is your say so essential on the hiring of every secretary, every assistant, and every nurse in the department? Would it make a fundamental difference if you weren’t the last word on approving clinic supplies or each new surgical tool? You’ll have to sign off on the paperwork, so it’s not like any of this will fly under your radar unnoticed. Centralization is a time suck. It springs from the dominant manager concept and it runs counter to everything this book is about. Furthermore, centralization does not stem from confidence. Rather, it’s a result of low self-esteem and insecurity.

3.10  Blame and Shame

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3.10 Blame and Shame This can work on the negative side, too. I encountered a situation where a staff member executed a surgical procedure that wasn’t successful. I could easily have disassociated myself from what happened. I could have said, “Hey, it wasn’t me.” But as the department head, as the team leader, I accepted responsibility because it happened on my watch. This will happen because life ain’t perfect and neither are any of us. No one can produce at 100% all the time. We all know this intuitively, but it bears saying every once in a while. It’s also beneficial to the long-term health of a team when its leader bears the brunt of any negative fallout from such incidents. Better that than the personal devastation that professional embarrassment will cause to the individual who erred. When a manager stands up for and is united with the team, its members will recognize that even in the worst situations and the darkest hours, every individual on staff will be supported in their efforts. In the U.S. Civil War, Pickett’s Charge (the final assault of the Battle of Gettysburg) resulted in Union soldiers repulsing Confederate forces under the command of Gen. Robert E. Lee. The South’s losses were heavy. At one point, when field Gen. Cadmus Wilcox came to Lee to tearfully report the devastated state of his brigade, Lee shook his hand and replied, “Never mind, General; all this has been my fault. It is I that have lost this fight, and you must help me out of it the best way you can.” The point being: As a leader, whether you did it or not, you did it. If you actually did it, then there’s no question about it. If you didn’t do it, it’s your responsibility to be accountable for your department and the actions of your team. Just as I have throughout my career, you too are likely to make multiple mistakes. Sometimes these can be very serious matters. But regardless of whether they’re large or small, remember that we all tend to learn more from failure than success. Accordingly, staff failures should be seen as teaching opportunities, not moments to stigmatize or disgrace anyone. Work with your team members, helping them to discover how to avoid repetitions of error and potential duplications of disaster. Everyone will be more focused and motivated to get the job done right the next time around. Punishment for failure is pointless. It doesn’t instruct and it’s demotivating. It’s just telling someone to sit in the corner with a dunce cap on. You can, however, sanction people; that’s different. Sanction means that because an individual has a problem in properly executing a particular task—in the case above, a surgical procedure—they’ll be prohibited from doing that operation unsupervised for however long it takes until it’s certain they’ve received adequate training sufficient to demonstrate that they can correctly carry out the procedure on their own. Typically, you won’t face situations which result in such extreme consequences. And delegation doesn’t mean you are ever unaware of anomalous goings on in your arena. As a leader, you’re there to raise the standards of performance of everyone in your charge. There will be situations when your professional judgement and obligation will require you to step in and call a halt to some project, or change how a

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patient is being cared for. Those situations will demand extra time and attention on your part. Be prepared for such moments. Act responsibly, swiftly, and skillfully. Be as patient as possible and always positively directed and solution oriented.

3.11 Readying Your Team for Dragon Slaying Like your nuclear family, everyone responds best to positive reinforcement. Anything that damages confidence, trust, and motivation is to be avoided, as it’s infinitely harder to rekindle those things once you’ve done something (like punishment) to break those bonds. In healthcare facility management, concept-shattering change will never happen without folks who are fired up and ready to go. So now that you know how to dissect, deconstruct, dream big, delegate, dole out credit freely, delight in the company of others, direct and discipline with a deftness of touch, you’re now prepared to take on your cause for good.

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Management 360

“Leadership is the art of getting someone else to do something you want done because he wants to do it.” —Dwight D. Eisenhower, American Army General & 34th President of the United States

© Springer Nature Switzerland AG 2021 Z. Gil, The Healthcare Efficiency Revolution, https://doi.org/10.1007/978-3-030-61232-0_4

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4  Management 360

Architecting a Self-Sustaining Vision

For any of what I’m advising to really work you have to keep it as top-of-mind-­ awareness that you are building a self-perpetuating, self-rejuvenating system. If you are ever tempted to believe that your ultimate goal is just over the horizon, remember that the horizon is simply an imaginary line in the distance that recedes the closer you get to it. The system is way of life, it’s an everyday thing. If your drive, ambition, and conviction is grounded in a belief that our profession, as caregivers and healers, calls upon each of us to do better for our patients and the good of medicine itself, then you’ve got to become a productive change manager. You’re the only one in an effective position to lead conceptual change, to initiate and hone the process of deconstruction and reconstruction, to nourish and give flight to big ideas. This can all seem quite intimidating. These are mountains to climb. So, if it makes you feel more comfortable, start with a hill. In terms of Team Management 101, one of the first changes I implemented in my department was something incredibly easy to do. I analyzed the data and saw that a lot of staff energy was being scattered and not put to best effect due to a lack of anticipating the previously unanticipated. So, as already referenced in Chap. 2, we now have weekly meetings. All the unit managers and secretaries, chief residents, and managing nurses get together for a 30-minute session, and we solve a lot of problems by making sure everyone is aware of simple things, such as which staff members will be on vacation in a week’s time, who’s having a problem with a sick child or parent, and might need a day off at a moment’s notice, and so on. We have backup personnel ready to replace anyone who is suddenly unavailable. Our levels of service don’t suffer, no one on our team is inconvenienced, and our patients don’t get pissed off because of delayed or cancelled appointments. Patient scheduling takes up most of our meeting time. The objective is to be crystal clear about who will be where and when, who’ll be working and who’s on deck. It’s all plotted out, hour-by-hour, week-by-week. It sounds straightforward and, in many ways, it is. At first, though, this required some deconstructive thinking, which led us to embrace “the law of the unexpected,” which we define as the percentage of work that you might otherwise not anticipate, but you’ll have to do nonetheless. We had to think through the technical mechanics of what has to happen when we need to shuffle people from one place to another. To reduce confusion and irritation, we had to prep staff to be flexible in their own expectations. Initially, I was a very dominant player in these sessions, frequently proving solutions. Two years later, I said that I’d still attend, but wouldn’t run the meetings. The chief resident, nurse practitioner, and chief attending physician took the helm, while I chimed in as necessary. The year following, I was essentially a bystander. Another year on, I stopped attending; they didn’t need me anymore. They’re all perfectly capable of handling things on their own. If there’s something that demands my involvement (which happens maybe once a month), the door’s always open. Team management in action means that if someone can do your job as good as you, step aside and let them have at it.

4.3  The Deputy Question

4.2

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 nowing What Needs to Be Known (and Putting It K to Good Use)

A department head doesn’t need to be involved in day-to-day clinic management at all. What must be known is whether the clinic is optimally serving the department’s patient primacy target function and satisfying the goals necessary to maintaining that standard. This demands more than easy and open channels of communication between clinic manager and department chief, such as informal discussions, e-mail updates, or periodic text messages about this or that, or even verbal summaries presented at staff meetings. All of these are good, but they’ll almost always be sporadic and anecdotal. What’s required is formal reporting. Don’t confuse this with mindless bureaucracy and paper pushing. Too many organizations pointlessly put their personnel through box ticking exercises. Employees fill out forms and file reports that are rarely read and summarily filed. They’re never used for any type of institutional self-reflection, or as an opportunity for serious problem solving and planning. If reports are being filed simply for the sake of doing so, it would be just as well to not do it at all. It’s time wasting that’s ineffectual at best, destructive at worst. If your workplace superiors asked you to regularly spend a portion of your professional hours engaged in carrying out empty, rote gestures, you’d probably begin to harbor mild resentments and lose motivation. This is the exact opposite of the way things should be. When a department establishes benchmark objectives, they should inspire ambition and high performance. Therefore, there should be as much care and attention focused on creating and implementing reporting mechanisms, as there is on goal setting. Specific, discrete aspects of given operational areas should be broken down into measurable, component parts. It’s difficult to gauge progress and growth, let alone sensibly adjust for bottlenecks and backsliding without the routine production of systematized reports, which contain both quantitative and qualitative elements. Regardless of whether particular reports are generated on a daily, weekly, or monthly basis, the trick is to find the least time-consuming, least burdensome methodologies possible for the collection, logging, and processing of objective data and subjective observations. Efficiencies in reporting should be as prized as efficiencies anywhere else in the department. Seek and embrace opportunities to make this work as automated, seamless, and transparent as possible. If a data collection process is found to be a time killer or generating information that is of minimal value, it should be reconsidered, adjusted, or dispensed with. Reporting that’s viewed as a chore or an afterthought is a sure sign that it’s not being done right. Team members should always consider reporting to be a practical and highly useful tool toward goal fulfillment.

4.3

The Deputy Question

There may or may not be a sound and valid reason for a department head to have a deputy chief of department. In many large corporations, it’s not uncommon to have a Chief Executive Officer and a Chief Operating Officer. CEOs generally provide

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vision. They set forth business objectives and define corporate strategies. COOs are responsible for the execution of day-to-day activities toward the achievement of those ends. Something somewhat analogous can occur in a large hospital. Removed from the oversight of daily operations, a department head would be able to dedicate more time and attention to matters pertaining to institutional and departmental visibility and growth, research initiatives, grants acquisitions, fostering partnerships, etc. A deputy department chief would serve similarly to a COO. What would be considered odd is a department with several deputy chiefs. Where it exists, it makes one wonder: Why are multiple deputy department heads considered necessary? What are they all doing? And how did such an arrangement come about in the first place? On its face, it seems like too many cooks. More to the point, a situation like this creates diffuse, confusing, and even contradictory lines of authority, any or all of which are bound to cause varying degrees of disorder and chaos. Of course, the “deputy chief” title may have no meaning at all; secured as part of a contract renegotiation, handed out as a reward for service, or offered as an incentive. In those cases, it’s an empty gesture. My advice? In all matters: Make it meaningful and make it count. Titles should clearly tell others what a given staff member does and where they exist in the organizational hierarchy. Nothing more, nothing less.

4.4

Lieutenants

In any high-functioning hospital, a department head and/or a deputy chief will work to identify and groom the right people to manage professional classes (e.g., surgeons, attending physicians, residents, nurses, secretarial/administrative personnel) and specific departmental subsets (e.g., clinic, surgical ward, ER, laboratory). Beyond capability and commitment, each individual has to demonstrate a real desire to take on greater responsibility. This may be innate but, if not, there are certainly incentives that can lead many staffers to assume leadership roles. Sometimes a vote of confidence and an appeal to ego is all that’s necessary. As a departmental chief, letting a staffer know that you believe in them and that they have the right stuff to succeed can be a powerful motivator. Occasionally, a bit more is required, such as the offer of an extra benefit or a salary increase. Once on board, you’ll need to invest some time teaching lieutenant managers what they might need to know. Those who have served in similar capacities elsewhere may have less to learn in some regards, but every work institution has its own uniqueness. Organizational cultures and methodologies differ. The process of assembling a well-functioning team requires esprit de corps, which needs to be built and continually nurtured. Teaching and counseling a new lieutenant requires more time and effort. As a comfortable working rapport is established, and that individual evidences increasing readiness to efficiently handle the managerial tasks for their area, you can gradually withdraw from constant to as-needed oversight. The key, once again, is a communicative environment, objective reporting, flexibility, and trust.

4.5 Jeopardy

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A high-efficiency department assumes competent, self-assured leadership, strategically selected and well-groomed lieutenants, and clearly defined, universally understood lines of reporting and accountability. Staff allegiance is to the execution of the department’s patient primacy target function. Individuals support one another in the achievement of daily tasks and goals, and have confidence that their department head and respective section managers can be relied upon for guidance, spot training, and practical decision-making. When these elements gel, you’re looking at a dream team. Assembling one isn’t an impossibility, but it’s also not the easiest thing to do either and, even when accomplished, harder to maintain. Getting and keeping a team’s performance average as consistently high as possible takes focus and constant dedication. Personality types, attitudes toward workplace hierarchies and protocols, and the vicissitudes of life will always present challenges. While none of these individually, nor the interplay between them will necessarily hamstring or shatter team cohesion, a department should be alert to developments which can.

4.5

Jeopardy

Lieutenants are team leaders in their own right. They were tapped because they were seen to possess what it takes to succeed in the management of their corners of the department. If they’re not empowered and supported, devastating consequences can ensue. Case in point: A lieutenant makes a decision that a subordinate dislikes. In protest, the subordinate storms off to the department chief to complain. The complaint might be procedural (“I don’t think he has the responsibility to do that.”), personal (“She never liked me and just wants to make me miserable.”), or rebellious (“I don’t accept their authority!”). If the chief takes the side of the complainant or simply says, “Don’t worry about it, you can answer directly to me now,” it undermines the authority and morale of that team leader. There’s a ripple effect, too. Other team leaders will think that the same thing could happen to any one of them. This may cause them to be circumspect in how they manage and in the decisions they make. Other employees may decide that they, too, can go straight to the top anytime they have a grievance. It’s very damaging all around. Some situations demand the bypass of a team leader, particularly if the team leader is suspected or being accused of serious misconduct, or criminal activity. But those are extreme circumstances. If a department head receives a complaint, it has to be respected because perception is reality. Whether the chief considers the matter trivial or significant, it must be handled. That starts with a little patience. Hearing out an unhappy staffer can go a long way to diffusing tension. Sometimes, 90% of what people want is simply the opportunity to blow off some steam. No promises (other than to look into the complaint) should be made. Next, the team leader involved must be approached. If it’s deemed that this lieutenant exercised poor judgement or could have handled the situation better, they

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should be coached to improve their capabilities. If the chief believes the original decision or action was rational, some advice and counsel is still in order. A broken relationship with a disgruntled employee needs to be repaired and every reasonable effort should be made to do so. If a pattern of complaints is associated with a particular team leader, perhaps something is occurring in their personal life that’s interfering with their ability to lead. Perhaps they just can’t deal with the stresses of leadership. If they can’t be helped to improve their performance, they might have to be reassigned, so someone else can take on that leadership role. In some instances, disciplinary action might be necessary. Possibly the staffer needs to be fired. Above all else, nothing is purely about individual actors. Everything ultimately has to be filtered through the prism of what’s best for the long-term cohesion, camaraderie, and capacity of the department writ large.

4.6

Authority: Having, Accruing, and Maintaining It

Remember when you’d have a substitute teacher in high school? Well, that’s a (pun intended) textbook example of where a title or position of authority doesn’t automatically translate into respect. After getting the gig as a manager, your leadership will be something that’s earned as much as it is asserted. You can run the most congenial and collegial department in your institution but, from early in your tenure and consistently throughout, you must establish clear lines of and protocols for the exercise of authority. In so doing, it’s not that anyone’s contribution, opinion, or talent is being stifled, only that everyone understands where authority resides and what being authoritative really means. Authoritative authority is providing clear, unambiguous direction, counsel, and overall leadership. This is not to be confused with micromanagement, which is when a manager (through words, actions, or both) contends that no one else in the department is capable of handling what really amounts to simple managerial tasks. You can avoid getting caught in the micromanagerial mire by progressively building your departmental systems in a way that properly conveys responsibilities and accountability for the achievement of goals upon appropriate personnel. This can be accomplished by allowing people, over time, to rise to the level of their capabilities, aspirations, and the innate possibilities you see within them. In the case of something as straightforward as the management of my department’s outpatient clinic—which serves approximately 30,000 people per year and is staffed by dozens—our clinic manager is fully entrusted to completely and appropriately handle (and rise or fall completely on the merits of performance outcomes) many major tasks. These include efficiently overseeing the processing of patient inflows and outflows; assuring minimal delays in appointment scheduling; keeping waiting room times to 20 minutes or less; and monitoring that doctors, nurses, and other employees arrive and leave on time. Success doesn’t require enormous amounts of imagination. It certainly does demand detail orientation, patience, and dedication.

4.7  Groups vs. Teams

4.7

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Groups vs. Teams

Let’s play Word Association. I say, “team,” you say (more likely than not) “sports.” And we know what sports teams do—they play to win. When a team is playing at the top of its game, individual players (along with managers and coaches) add up to a greater whole. Even when there’s a superstar or two on the squad, it’s the teamwork that shines. Everyone pulls in the same direction. Philosophy and objective transcend individual egos, internal rivalries, and other negative qualities. It’s the authority of the team that wins championships and gold medals. A team is always on a journey, always following a roadmap. It strives to reach each new destination on time and according to plan, which includes the reasonable anticipation of slow-going passages, hazards, detours, and so forth. When adversaries are encountered, like an ancient Greek phalanx, its members huddle in close formation to protect one another against the slings and arrows of battle. Differentiate this with what I’ll call the “authority of a group.” A team is, of course, a group, but not all groups are teams. A group is just a bunch of people that get together. Sometimes, like a group of people that forms on the subway platform waiting for the next train to arrive, it’s completely random. Other times, groups form because members share a particular characteristic and/or they have personal concerns they’d like to defend, causes for which they wish to fight, changes they want to push back against, and so forth. So, even if yours is the most wonderfully collaborative team imaginable, never indulge the impression that this implies some form of group authority. Group authority is a group managing the manager rather than the other way around. Group authority is a consequence of bad management. And group authority must be actively prevented from taking root. Indeed, a well-organized group of just a small handful of people can often be stronger than any manager overseeing them. If they rise up in opposition to their manager, they can get that individual fired. For this reason, the work of building, nurturing, and maintaining a team is not to be taken lightly, given lip service, or approached as an after-thought. And never underestimate the good sense and utility of fostering a team atmosphere at all levels of your department, from the janitorial crew to the senior surgeons. This is a big issue in our modern era because so much of what constitutes managerial performance is based on how an organization looks from the outside. This isn’t only about patient perceptions or even the possibility of press coverage, as social media feeds and crowd-sourced review sites can play an enormous role in what institutions will and won’t tolerate as it relates to their public image. In a department, there can be productive groups. Nurses, for example, can come together as a group to positively advocate for nursing policies and procedures which they believe will better serve the target function, advancing the interests of patient primacy. They might have grievances related to their area of departmental operations, their treatment as professionals, or some other matter directly associated with their collective role as nurses. If what they seek for their group gives due consideration to the greater good of the team and overall target function objectives, then there’s nothing wrong with the existence of this type of group.

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There are no perfect worlds here, of course. People are people and some struggles, even principled ones, are fought on narrow grounds. It happens. Sometimes the big picture can’t be seen or fully appreciated. In those instances, most if not all team members will be grateful for every minute’s worth of investment that went into implementing and maintaining free and open channels of communication, and a genuinely collegial working atmosphere. Many problems can be resolved amicably and relatively rapidly when individuals have faith that they can speak their truths confidently and believe that what they have to say will be fairly considered. Even if certain requests can’t be granted or demands fully met, there is often peace of mind in knowing that respectful attention has been paid to matters raised. When the authority of a group is destructive, it’s a self-absorbed faction. They’re aware of the big picture, but they don’t care, think it’s less important than their perceived needs or, worst of all, are actively seeking to undermine it. When this occurs, team authority is either dramatically weakened or absent. If the former and the faction isn’t well organized, the team may be able to bring some faction members around to working toward productive goals. If the latter and the faction presents a united front, the rest of the team may risk disintegrating into other self-­interested blocs. The existence of a faction or factions can signify weakness in departmental leadership, but not always. A department chief can genuinely be (like the slogan on a dollar store coffee mug) the World’s Best Boss and still have contrarians to contend with. One can be honest, smart, trustworthy, and empathetic; a great mentor, self-­ aware, inventive, and inspirational; an individual ready to stand shoulder-to-­shoulder with departmental colleagues, take flak for them when they’re under fire, and fight for their needs…and, for some, for whatever reason, that still won’t be enough. No need to break out the violins, as this, too, comes with the management territory. Accordingly, like it or not, a manager confronting destructive, authority-of-the-­ group factionalism needs to own this. And for the greater good of the cause, this may mean resignation is the best course of action. It’s very hard for a manager to look at this type of situation objectively. Every right, sensible, and reasonable move has been made and, yet, nothing has improved. Although professionally and personally painful to face, sometimes that’s when the ultimate act of managerial talent is called for—knowing when it’s time to exit the stage gracefully and make way for new blood.

4.8

Clear-Eyed and Courageous

Eventually, managers will confront tough, sometimes unpleasant situations. Most managers don’t create departments out of whole cloth, they inherit those that already exist. Early on, it’s critical to identify those employees who are not going to play on the team. This is different from the outliers and other creative thinkers I described above. Here, I’m talking about contrarians and loners; those who see departmental advancement as a zero-sum game in which they’re competing against colleagues for their own advantage. Whether it’s one staffer or several, managerial self-deception can be toxic to the whole department if swift action isn’t taken. Managers shouldn’t waste time

4.9  Wait for It…but Sometimes Don’t

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believing that a problematic individual is suddenly going to have a Damascus Road moment. When personnel are out of sync with the rest of the team, it’s better for everyone (themselves included) if they get off the departmental bus as close to the very next stop as possible. This may be a transfer to another department where they’ll be a better fit. If that course of action isn’t available, their departmental exposure needs to be limited to activities where their unhelpful or negative qualities will have minimal impact on others. Perhaps they can be positively encouraged (even assisted) in a job search, so they can secure employment elsewhere. As a last resort, if dismissal is an option, that trigger may have to be pulled. The longer such situations are ignored and the longer decisions aren’t made, the worse things can become all around. A manager in this position will appear to be weak, while non-team players will hinder (or worse, attempt to sabotage) change initiatives. In putting together a departmental team, a sensible manager should carefully look at every staffer and confidently attest to the reasons why each individual ought to be a player. Lacking those justifications for anyone means they shouldn’t be on the team. Players advance the department’s patient primacy target function, contribute to established goals, and take pride in their own efforts and the work of their colleagues. They’re appreciated by their departmental peers and by management.

4.9

Wait for It…but Sometimes Don’t

Equally, when someone leaves or retires, and a replacement needs to be hired, or when the department expands and additional personnel are required, it’s vital to avoid becoming heavily reliant on in-house recruitment. That can be tantamount to in-breeding. It carries the risk of there being too many similar perspectives and opinions under the same roof. There should always be a healthy mix of internal and external hires. And when personnel need to be hired, the process must be done right. Bad (or at least less than optimal) recruitment can sometimes be more disruptive than leaving a position vacant. For key medical staff, such as surgeons, managers may be better off to satisfy themselves that they’ll need to take up some of the departmental slack personally and/or reduce some of the volume of cases being handled by the department. This will buy the time necessary to wait until the right person can be recruited. This might be a delay of months; in rare instances, even years. However, in the latter circumstance, a strategic decision will almost always be made. For example, in an ENT department, it might be natural to want to replace an exiting laryngologist with another laryngologist. But what if a good fit can’t be found? Maybe this will present a good opportunity to develop the department’s capacities in otology or some other field. The department adapts, accordingly, restructures its growth and development planning to suit this new reality and moves on. This type of flexible thinking can be highly advantageous. It can bring new vitality to a department and its personnel, taking them in directions they didn’t know they wanted to go. As touched upon in Chap. 1, this can also be achievable when an exceptional person comes along, but there’s no immediate position needing to be

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filled. And here we may define “exceptional” in many ways. An individual might have unique talents or an interesting background. The person could even be exceptional for being unexceptional, save for the fact that they show tremendous promise as a stellar fit for the team. In any of these scenarios, if it appears this will be quite a catch and management can maneuver things, accordingly, a place should be found for this individual and the hire made. This won’t happen often, but managers should be prepared for the possibility.

4.10 Snatching Defeat from Victory’s Jaws It’s literally been trial-tested time and again: No good lawyer ever asks a question in court without knowing the answer in advance. Doing otherwise introduces the possibility of uncertainty, of something being said that could lose an entire case in an instant. Now consider a department manager who’s surrounded by talented, devoted lieutenants and a skilled, industrious staff. It’s a marvelous team. It took years of purposeful and creative effort to get it to be as good as it is. Everyone gets along famously. Then, the chief gets a bright idea for a new initiative for the department to take on. It’s a notion and only in its formative stages. So, what next? Doubtless there will be discussions, meetings, data collection, and analysis. But with whom, in what order, and in what configurations. There’s no playbook for this. Decisions here will be based on experience, relationships, and not a little bit of intuition. Maybe a gathering of the team leaders, perhaps a series of one-on-one chats with each of them. Maybe discrete assignments are handed out so further information can be gathered. Possibly other staff are brought into the conversations. In the end, here’s the stupidest thing a department chief will ever do in the course of these activities: Call a meeting, present a well-formulated plan, and ask people to vote. Why is this a dopey move? Because let’s say the room is almost evenly split and the idea gets defeated (or approved) by one vote, or it’s 50/50 and the chief’s vote is the tiebreaker. In that one moment, in that single action, the team has been set against itself. Likely not irreparably, but if a good amount of time and energy went into putting the plan together, some folks in favor may harbor resentments at those who blocked it. Conversely, those opposed may view their plan-enthusiastic colleagues differently; thinking them less than sensible or just plain foolish for wanting to pursue something they view as so clearly wrong-headed. The department manager is in an impossible situation. It’s obvious to everyone that the chief wanted the team’s endorsement or it wouldn’t have been presented for everyone’s consideration in the first place. There are several ways out of this dilemma, but they run from disastrous to far from ideal: • If a majority of the staff rejects the plan, the chief could pull rank, insist on knowing better than everyone else, and go ahead anyway. That will be read as a big ol’ F.U. to the team. There’s just no good reason for a manager to be in this

4.11  A Lesson in Leadership

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situation or to choose that path. Not only will it make staff angry, they’ll have little incentive to give their best to implementing a plan that’s caused such divisions and which most downright dislike. • The chief could accept a thumbs-down and suggest that the team should go back to the drawing board. Maybe the plan can be revised and improved, maybe the department needs to think about some other initiative(s) to tackle. There’ll be disappointments all around, but many will, at least, see reason in this approach. • In the case of a tie, the department manager could decline to vote, but that would only be a symbolic gesture because, once again, the team already knows what the chief wanted. • The chief could set a high bar and suggest that unless say, 75% are in favor, the plan won’t be approved. If that route is chosen, it’s better to establish the 3/4 rule in advance of the vote. Obtaining more significant buy-in before proceeding can tamp down hard feelings but, once more, many in the minority will be unhappy. All of this is a department manager unnecessarily creating competing factions and potentially damaging a well-running team. The better approach is for the chief to do the homework, with or without assistance and feedback from team leaders and other staff. Department personnel don’t even need to know a plan is being considered. There are many ways to have people gather data and information without them being aware that these are components of a more significant effort. As a plan forms, the chief can work with staff, individually and/or in small groups, to win them over to yes. Ultimately, there may be no vote at all. With the preparatory work well-­ accomplished behind the scenes, staff will anticipate what’s coming and be ready to roll. The process may take time and due diligence, but it’s preferable to the alternatives above.

4.11 A Lesson in Leadership You’re a department chair and a surgeon in your own right. A patient presents with an abscess that needs to be drained. However, the patient’s attending physician has a contrary view and insists that surgery isn’t necessary. You’ve carefully analyzed the case. You can see that a board of reviewing professionals has offered an inconclusive assessment. You’ve heard and weighed the arguments against the operation, but your professional knowledge and experience dictate that the surgery should be performed. As the manager, you have three options: 1. Education. You could try to offer your thinking on the matter. You can attempt to make convincing arguments. But as this is one of many situations in medicine that just aren’t black-and-white, what if the surgeon remains opposed? 2. Cut to the chase and be the boss. Tell the surgeon that you’ve made a decision and the operation must go forward. The problem with this is the surgeon will be irritated. No one wants to be forced into doing something they don’t want to do or believe shouldn’t be done. Like it or not, that resentment (even the potential

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it) is bad for the patient. It’s a mental distraction for the surgeon and could result in a poor surgery. So, maybe it’s just best to…. 3. Let the attending surgeon decide and avoid surgery. But what if you think that this will harm the patient? Would you be willing to sacrifice your target function, patient primacy philosophy for this? 4. Tell the surgeon that it’s not a problem if they don’t want to do it. Relieve them of the obligation and say that you’ll take care of it yourself. After you say this, it may wind up that you will have to perform the surgery, but I believe that 9 out of 10 surgeons will think, “Wait a minute! This is my patient. I’m an excellent surgeon. I can’t have someone else doing the surgery for me.” This will probably lead them to agree to doing the operation so long as they think that it’s not an outright mistake, but just one of life’s agree-to-disagree situations. The final decision was theirs, not yours. This reinforces mutual respect and guarantees the likelihood of a more focused performance in the OR.

4.12 Autopilot There are too many managers who honestly believe that effective leadership is not only exercised by being the top dog, but being seen to be acting like the top dog. In the wild, this is called dominance behavior. In large human endeavors, it’s counter-­ productive. New managers should strive for the opposite (Fig. 4.1): This graph depicts the change in a department chairperson’s dominance over time. The green curve shows a gradual decrease in dominance as the departmental team is being trained over time to better handle their functions. The brown arrows indicate the chair’s degree of involvement in unusual or unpredictable events. Note that the frequency and amplitude of the arrows also decrease over time as the team grows in skills and experience. Their capabilities and confidence therefore increasingly allows them to handle such events independently.

Dominance

100%

0 Year 1

Year 2

Year 3

Year 4

Year 5

Year 6

Years

Fig. 4.1  Ideal managerial dominance curve. (Credit: Nofar Rada)

Year 7

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Accordingly, when working to build a solid team, a savvy manager must take the time and care to assess the strengths and weaknesses of staff members, and assign the right tasks to the right people. This must also include a self-assessment. In this regard, some big picture, big ideas managers may be less adept at handling the details. Such individuals need to tap or hire an employee who is highly proficient in and has the patience to assist in the implementation and oversight of the detailed aspects of change initiatives, systems and procedure maintenance, etc. Technocratically minded folks also tend to have a knack for noticing meaningful minutiae that most others miss. They may see where a plan hasn’t been fully thought through and might benefit from the collection of further background information. They may have insights and recommendations regarding parameters and measurements that are indispensable to defining success or failure. In Fig.  4.2 below, you can see the profound difference between two types of supervisory approaches. The supervised environment on the left requires the constant monitoring of staff by departmental managers and their deputies. It’s a fixed, non-learning system that offers no opportunities for autopiloting. Alternatively, the unsupervised environment on the right encourages staff to self-monitor their activities. It also demands that they take on greater responsibilities, which necessarily implies that they are learning and experiencing more. This, in turn, makes them sharper and more seasoned professionals, and eventually leads to high functioning, self-governing departmental systems. Through coaching, counseling, mentoring, teasing, wheedling, and cajoling, managers empower personnel, as this is the only way to unleash the dynamic potential in any department. As authority and responsibility are apportioned and delegated, the evolution of a manager’s tenure needs to make the transition from hierarchical, segregated, and continually supervised functions to networked and minimally supervised functions. Over time, a good manager should not need to be an omnipresent figure because the team has routine matters well in hand.

Supervised

Unsupervised

Fig. 4.2  Transparent and networked functions. (Credit: Nofar Rada)

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The goal should be to develop a team and a system of operations that function well with increasingly less reliance on the leader. On a day-to-day basis, the more indispensable is the manager, the more that manager will be micromanaging. That’s the precise opposite of optimal efficiency. Team members are hired because they possess the core competencies necessary to do their jobs. A good manager should impart experiential wisdom and knowledge to help staff members grow and improve professionally. To have a real team, personnel must be encouraged to be an integral part of devising and implementing patient primacy solutions. Staff need to be empowered to take on the maximum level of responsibility demanded by their individual positions. Progressively, a department leader thus becomes a macromanager. Through open communications, operational data transparency, and targeted oversight, most of the details of a department’s daily functions can run on a sort of autopilot, whose self-­ correcting features may include an assistant(s) to the manager, technocrats, routines, and computerized operations. Everyone should be freed to do the best of what they can do in their jobs, so the manager can have more and more time to do what other team members cannot—consider future strategies and new directions for the department. Perhaps this is developing a new treatment and care option, starting a specialty research lab, forging creative alliances with universities or other medical institutions, establishing personal relationships with foundations and their officers in advance of competing for major grant funding, working to attract other substantial philanthropic gifts, etc. Of equal importance, astute managers understand that they’re not merely agenda setters, they’re mood, pace, and general environment setters, as well. When there’s a particularly challenging, even a potentially dangerous assignment (e.g., performing surgery on a COVID-19 patient), managers must lead and be seen to be leading. This has nothing to do with seeking or garnering praise. This is about serving as an example and demonstrating an unflinching willingness to make sacrifices for the protection of the team and the good of the department. This also means bearing the brunt of the responsibility for departmental lapses and failures. A manager may not be the direct cause of such incidents, but honorable leaders accept that when something happens on their watch, they have to own it on behalf of their team and take necessary steps to correct missteps, make amends, and so forth. Finally, in much the same way that Thomas Jefferson wrote that governments derive “their just powers from the consent of the governed,” management derives its approval to manage from subordinates. In this light, managers are also wise to keep in mind a lesson from the military: Officers eat last. When personnel know that their leader is ready to place their interests first, the unit will be all the tighter for it and they’ll be all the more willing to be led.

4.13 Why Dominancy Diminishment Is Important In typical managerial environments, when a new manager is hired, the individual either comes in as an already-dominant figure or gains in dominancy the longer they’re in charge. Either way, this is generally an impediment to progress because it

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is in the nature of things that as we age, we lose some (or a lot) of our youthful edge. Naysay it all you want. Insist that you are (or some older colleague is) just as sharp and curious as any 25-year-old just out of medical school. In your heart you know that, at absolute best, any exception you can cite to what I’ve just said only proves the rule. And by the way, there’s no shame in that rule. It doesn’t suggest that older professionals don’t have very valuable knowledge and experience to contribute. Of course they do. That’s not at issue. The problem is that we learn things when we’re young. Perhaps we get inspired and synthesize old lessons with new ideas to devise innovative solutions. This is certainly true of a great many Nobel Prize-winners. After they shake hands with the Swedish king, have a lovely dinner, and return home, the next great ideas are typically coming from their students. And that’s okay. Didn’t Sir Isaac Newton say, “If I have seen further, it is by standing upon the shoulders of giants.” Attaining a leadership position is no small accomplishment. Nevertheless, eventually we all tend to get acclimated to certain ideas; accustomed to workplace environments and to the way things are done there. There’s a tendency for managers to think of themselves as giants, but to forget that if the next generation is to see further, they’ve got to allow at least some of them to stand on their shoulders. Strong or increasing managerial dominancy tends to favor what is and stifle fresh thinking. When a dominant manager retires, because the system they oversaw was so bound up in their supremacy, it crashes and the cycle begins again when their replacement takes over. It can be even more complicated if a particular manager maintains an emeritus position and/or has an ongoing, post-retirement relationship with or influence over a former superior. In such instances, even a successor might get boxed into the old system. The stature of a good manager is elevated further when they allow for the infusion of new people, independent thinking, and original ideas. When others take notice, they’ll know under whose guidance and within what system all of that specialness arose and flourished. You might conceptualize a manager as a big avocado tree which, as it grows and matures, develops a big trunk and long, leafy branches. It’s a fixture and it casts quite a shadow. It’s impressive to look at, but left as-is it will only produce about 20% of its fruit-bearing potential. Nothing much grows below such a tree. Why? Because there’s a lack of sun, while the tree itself is sucking all the minerals and water out of the ground. A more ominous arboricultural analogy can be drawn to cypress trees, which make certain that nothing grows below them as the leaves they shed are toxic. Sadly, in the managerial world this type of thing is all too prevalent—managers who block the sunlight, hoard all the nutrients, and sometimes have a poisonous impact on everyone around them. There may not be much that a cypress grower can do to create opportunities for other plant life to grow, let alone flourish around their trees. On the other hand, a smart avocado farmer who wants a bumper crop of fruit knows that this can be done by just pruning back some of the leafage to allow in more sunshine. Good managers can let the sunshine in when they diminish their dominancy and support lower ranking team members, providing them with the knowledge, resources, and latitude to thrive in their own domains.

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A pruned avocado tree may appear to be less imposing, but it will be wildly more productive. What’s more, it will require less water and grow better, more flavorful avocados.

4.14 Less Is More A powerful motivator is the desire for ego gratification. We all crave it. However, department managers must have a healthy perspective about this impulse. There are, of course, some who require constant attention. They demand their name must be attached to any initiative in which staff is involved and they take direct credit for the labors of others. But such behavior is always an awfully long walk for a short drink of water. These individuals don’t get the praise and recognition they seek precisely because of their own pettiness. By always wanting more, they will forever get less. Hogging the spotlight demeans and belittles the contributions of personnel. It’s demoralizing. Over time, it creates resentments and can act as a corrosive to the entire system. On the other hand, the ancient Chinese philosopher, Lao Tzu, believed the finest leaders are those who are not omnipresent. Their success is best exemplified by shepherding a team toward the accomplishment of goals which, when achieved, prompts them to say, “We did it.” It’s a misreading of this concept to think that such a leader is forgotten or considered inconsequential. To the contrary, the self-­ congratulation and pride that a team rightly takes in its victories are a direct consequence of the critical mass of their collective talent, skill, and sweat equity, along with the training and counsel, foresight and planning, delegated responsibility, and trust invested in them by their leader. Teams whose egos are well cared for know this and will freely express their gratitude as a result. When respect and admiration run in both directions, we once again see the force multiplier effect at play. Internally, manager and team progress together. The more appreciation the former affords to the latter for jobs well done, the more honor and acclaim will be returned to the manager on the round-trip. Further, as external parties take note of departmental advancements and innovations, there’s a natural inclination for those observers to wonder, “Who runs that division?” The manager in charge, thereby, gets a double shot of ego gratification.

4.15 Realism As much as this book has thus far addressed the need for managers to respect and trust their teams, like anything in life, this can’t be idealized. Human beings evidence a spectrum of personality types and that will affect departmental interactions between staff and the individual performance of doctors, nurses, residents, and secretaries. A lot of trust goes into these relationships. For the most part, managers will accept what is reported to them as truthful. When it comes to medical matters regarding treatments, therapies, surgeries, and so on, there are system records which can be consulted should the need exist to verify a given reported fact. Even so, there are no absolute guarantees that every staff

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member will behave honorably at all times. It’s only a matter of that thin line of trust. The question is: To what extent should trust be sensibly extended? Let’s consider a hospital department that employs 100 people. How many of them can the manager trust? 100%? Probably not. Maybe it’s 90%. Perhaps it’s less. I’m not suggesting that a number needs to be determined, only to be aware that even with the best of outward appearances, a perfect score is unlikely. Additionally, there are gradations of trust. For example, unless a formal complaint is filed or hard evidence is produced to the contrary, it may be quite reasonable to trust that staff are not engaging in unlawful activities. Regardless, what’s plain and simple is that when a problem arises, it must be dealt with and the responsibility to do so rests solely with the head of the department. And a manager confronting a situation is always better off to call upon support from their institution, rather than trying to contain things as an internal, departmental affair. An institutional human resources department exists for more than the processing of payrolls and the administration of benefits. Their specialized training and expertise should be tapped to handle serious personnel matters, especially if an alleged offense is considered to be fireable. This cannot be emphasized enough. If an employee is deemed to have been involved in conduct that constitutes a breach of contract, a violation of institutional rules and regulations, or outright illegality, a manager must not hesitate to bring HR into the picture (at bare minimum, to report the situation to an immediate superior). It’s not only the right thing to do, it assures that all involved are protected. HR and, as necessary, upper management, can offer appropriate guidance and recommend by-the-book advice as to what options may be available, what steps can or must be taken next, etc. The immediate engagement of HR will reduce, if not eliminate, the possibility of after-the-fact questions being raised about what the manager of the employee in question knew, when was it known, and what action(s) were taken. Naturally, a significant case of misconduct implies a shattering of trust. However, if the manager facing this situation does not act in a swift and transparent manner, it can shatter the trust the institution has placed in the manager. So, it’s critical not to be alone. And this makes perfect sense when one considers how often the hospital environment offers disincentives for wrongdoing and safety-in-numbers protections. For example, in an operating room, there are always several people present during a surgery. Similarly, a doctor is never the only individual on duty in a clinic. Everybody is supervising each other. To the degree that any aspect of departmental activities might still be presenting opportunities for team members to be functioning without the presence, involvement, or oversight of colleagues (particularly those involving a doctor and a patient in a closed room), managers should work to make those situations more transparent to professional peers.

4.16 Fail-Safes We have gone beyond the ubiquity of handheld devices and apps. Our lives are now increasingly defined by seamless, cross-platform interactivity; profession, institution, and even departmental-specific software; and the Internet of things, where

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everyday objects we use at home or at work are embedded with computing devices that are directly connected to the Internet. All of this makes it easier than ever before to log routine departmental activities transparently or, at least, with very little effort. These digital tools are another way to improve efficiency and prevent misconduct. If staff know that certain data is being recorded and that any attempt to alter or erase such data will also be recorded, it’s far more likely that folks will stay on the straight and narrow. That said, to err is human. Accordingly, for everyone’s protection and to preserve the dignity of the department, a passgate system should always be in place. When a team member seeks to amend some data, it should trigger an immediate, digital request to a supervisor or departmental chief, who must either approve, deny, or inquire further about the request.

4.17 No Cover No matter how observant, no matter how skilled, no matter how hard a manager tries, there will always be someone who, if they are really determined to do so, will find a way around every rule, every protection, every oversight mechanism that’s set in place to deter misconduct. Serious issues of impropriety can involve any member of the staff, at any level, and come in various shapes and sizes. They may entail inappropriate sexual relations, financial scandal, unsanctioned medical treatments, or something out of left field. If the fates are kind, maybe some manager, somewhere, can serve a long tenure and never have to face such an incident. Since the odds suggest otherwise, no manager should be shocked when an incident occurs, nor should they be unprepared, in advance, for how to respond. These moments are very difficult for managers. A team member who has been implicated in alleged misconduct is someone with whom they’ve been working closely. Personal feelings can’t be uncoupled from the situation. Even when the offense is grave, there may be a natural inclination to do whatever may be possible to keep one’s colleague from going to prison or, at least, having their life ruined. Unfortunately, a manager cannot indulge sentimentality over duty. Incidents must be reported. Reporting needn’t be immediate. A manager might first decide that an internal investigation is warranted. When the time does come to report, it doesn’t necessarily have to be the filing of an official complaint. It can start with something as simple as a phone call to a superior. What’s important is that responsibility for action moves beyond the department and is thereby a shared endeavor. And there’s no getting around it, reporting can be the toughest part. If misconduct leads to dismissal or worse, remaining staffers may view their manager in a very different light. To many of them, reporting may feel like an act of betrayal. They may feel that, as a team, the manager should have been loyal to a fellow colleague. They may find it hard to understand or accept that any attempt on the part of a manager to delay the initiation of a formal process (much less to cover up an incident) automatically implicates the manager in an act of misconduct. In a moment like this, a good leader can mitigate the disappointment and disillusion of the team by confronting the staffer in trouble to make a few professional and personal statements:

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1. “As your manager, it’s not my place to make any final determination as to whether a conduct violation did or did not occur.” 2. “If a violation is determined to have occurred, it’s not my place to pardon bad behavior, sanction it, mete out some other form of punishment, or call upon law enforcement authorities to become involved.” 3. “Although I can’t shield you from the consequences of provable wrongdoing, I want you to know that I’ll stand by you regardless of the outcome of this process.” Perhaps more than any other action, it’s that last statement which demonstrates a managerial commitment to treating one’s departmental team like a nuclear family. Even when flesh and blood has been convicted of involvement in a heinous crime, family will typically lend whatever support they can because sticking together is what families do. Many managers won’t do this. In fact, more often than not, they’ll turn their back on a beleaguered staffer. That’s not leadership. Leadership is carrying out professional obligations ethically and properly without abandoning a fellow colleague. Not all team members will be happy about the way things play out, but managers who display this type of courage will find themselves gaining in stature and respect. The result will be a tighter bond among team members. Every person in the department will know that in a crisis they can count on their manager to remain on the front lines of the most difficult battles, that they will always be supported, and never left behind. Institutional personnel manuals will often address how violations of ethical codes of behavior will be handled. However, to the degree that these are seriously considered, they’re read as an abstraction; they’re about someone else in some other department. It’s therefore smart for a departmental team to be well advised by their manager that along the continuum of possibilities there definitely does exist this type of extreme. They should know what will ensue if a colleague is suspected of or charged with wrongdoing, including how their manager must treat the situation. And they should be reminded that just like so many high-profile political scandals, cover-ups invariable fail and only make matters far worse. These points may bear periodic reinforcement and must be repeated anytime an incident occurs.

4.18 When Exceptions Prove the Rules (and Regulations) With everything that’s been said about reporting incidents of employee misconduct, does every transgression need to be reported? Generally speaking? No. For example, if you’re confident that nothing will happen if you report a given incident, it may be reasonable to conclude that reporting on that case isn’t the best way to handle that problem. So, then what? Well, just be aware that sometimes there are no hard and fast rules about hard and fast rules. Let’s say your hospital has a regulation that its surgeons are not permitted to use their vacation days to perform operations in another location and receive compensation for their work. It’s not a law, it’s an employee policy. But what if you discover that someone in your department is occasionally violating this rule? Although it’s clearly misconduct, it isn’t a grievous infraction either. If you’re not looking at a flagrant, serial offender, then this may be a case of low-level misconduct and there are several ways to deal with such situations.

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The most direct and obvious option is to talk to the person. Tell them, “I know you’re disregarding an employee policy. Don’t do it again.” Should the matter end there? Maybe. If the individual is a valued employee, perhaps take a wait-and-see approach. If the situation persists, re-evaluate. The next step might be to adopt a three-strikes attitude. Give the employee a warning: “We’ve had a conversation about this once and yet here we are again. So, I’m just letting you know that if this happens a third time, it will need to be reported.” The employee won’t be happy about being called on the carpet (twice), let alone having the threat of escalated action held over them. You can’t control that. What’s important is maintaining the general perception (by that employee and all other team members) that leadership decisions are based on ethics and sound management principles that serve the department’s patient primacy target function and institutional mission. Particularly when it comes to personnel matters, a good manager should always be (or at least want to be seen as) someone who is empathetic, caring, and flexible; someone whose judgements are rational, well reasoned, and never arbitrary. Let’s complicate things a bit now. Using the same misuse of vacation days example above, what if the offending staffer has been problematic in other ways? There are no allegations or proofs of additional rules violations, only that this individual doesn’t seem to be working out as a good fit for the long-term needs of the team. In this light, immediate reporting might be seen as prudent opportunity. This is not incongruent with being flexible and reasonable, and it’s certainly not being arbitrary. This case is just that, a case. And while cases ought to be judged on their merits, there are typically variables that come into play, which must be considered. In this instance, flexibility may not best serve overall managerial goals. Therefore, it may be quite reasonable to take a stricter course of action. This employee might also be summoned for a one-on-one meeting, but only to be advised that, in keeping with HR policy, the known violation must go on record. The short, sharp, shocked method could result in better performance from the marginal staffer. If it doesn’t (especially if other transgressions occur), this creates a shorter path to termination for cause or it simply motivates that employee to seek a position elsewhere.

4.19 No Alternative Some issues are clear-cut. There are civil and criminal laws, which necessitate the involvement of regulatory agencies, the police, and other investigative bodies. There are no gray areas or managerial wiggle room. Known violations, credible accusations, or even serious suspicions of malfeasance must be reported. It’s not only one’s professional duty to do so, it’s one’s responsibility as a citizen. If the matter involves alleged conduct which caused or could have led to physical and/or mental harm to another, as a human being, immediate reporting is a moral obligation. It could be an allegation of one employee physically assaulting another or verbally abusing a patient. It could be information coming to light (and this is real) that a group of doctors was purposefully altering the lot numbers and expiration dates on outdated and quite expensive cancer drugs in a misguided and reckless attempt to contain institutional costs. It’s of no consequence if you know, work alongside, or

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are friendly with any of those who have been implicated. The moment you hear that lawbreaking may have taken place it must be reported without delay. Even if you know that upper-level institutional management has already been alerted by others, you must still report. This is because legal investigators routinely want to know who knew what and when did they know it. It’s also because you might be in possession of some piece of information that was only shared with you, which might be key to determining the facts of a case. This isn’t just a do-the-right-thing kind of thing. Without question, violations of the law must be punished; seriously unethical and/or dangerous individuals need to be fired. There are also reputations involved—institutional, departmental, and those of your colleagues, not to mention your reputation. Public perception is critical. People will instantly think “cover up” if there’s the slightest hint of a lapse between internal knowledge and those facts being reported to the proper authorities. Problems compound exponentially the longer serious matters go unreported. Lawsuits may be inevitable, but swift and decisive action may help to minimize the severity of their outcomes. A stellar public profile is priceless. Damage it and it can drive away patients and talented staff. It might result in lost opportunities to secure grant funding and major philanthropic investments. It could even impact hospital accreditation or trigger a period of legal monitoring that could extend for years. Never gamble with institutional honor.

4.20 Excelsior The steady and continual rise upward. Excellence. Who would ever say that that’s not a desirable goal? No one. Of course, stating that desire in the abstract and achieving it are two different things. If you want to create a center of excellence, beware of imitating others. First, you’ll eventually be spotted as a copycat, which may greatly diminish any stature you may have attained or hope to attain as a leader. Furthermore, what can be great for one institution, which exists within a particular context and environment, may prove to be completely unworkable or just plain wrong for a different institution with its own unique traits and characteristics. Excellence is achieved by observing, learning, and innovating. Leadership requires followers. Followers pursue success goals. To establish a center of excellence, you have to be a pioneer. You can start by looking around and accumulating ideas, but don’t forget that somewhere along the line you’re going to have be creative. You have to determine what you and your team can do that no one else can and develop a roadmap that best assures your opportunities to excel in that arena.

4.21 You Know It’s True Every researcher and scientist in the academy knows that fresh thinking always arises from the minds of young people. They’re full of energy, motivation and, above all else, they’re generally devoid of mental restraints; the kind that principle

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investigators (PIs) tend to have after 20 years laboring in the trenches. We were all that way when we were fresh out of school and raring to go. As we get older, however, our lightbulb moments don’t come quite so frequently. Often as not, new ideas aren’t hampered because of our physical age, per se, but by how effortlessly we accommodate the concepts that molded us in our youth. If you’re a healthcare facility manager in a teaching institution, be satisfied that big scientific findings and grand conceptual leaps forward generally won’t be coming from you. They’ll be coming from your students. Don’t run from this truth. Embrace it! It’s okay. You have a huge amount to contribute apart from novel ideas. You know how to make dreams come true, which is quite a feat! Draw out the best ideas from the brightest young people around you. Plant your genius garden with these. Give them water and sunlight, and let them flourish. This is your task. No one else can take on this challenge and responsibility. It takes smarts and talent to be really good at it, not least because it means setting aside one’s ego. Don’t fail or great solutions and innovations may die on the vine. Here’s a personal example. At the Rambam Health Care Campus in Haifa, Israel, I serve as PI and director of its translational cancer research lab. For 15 years, we’ve been working on understanding how cancer cells migrate along nerves toward the central nervous system. This is a devastating situation for many cancer patients and a phenomenon known to be incurable. In the course of our work, we discovered a subpopulation of immune cells, known as endoneurial macrophages. They’re responsible for causing these neural invasions and we learned how to prevent them from doing just that. As our lab was fully oriented toward neural invasion cancer studies, a new, young PhD student of mine, Yoav Binenbaum, came to me one day and said he believed that these macrophages secrete small nanovesicles, called exosomes. He wasn’t sure this was so or where any research might lead, but he needed my approval to proceed. My natural inclination was to rely on my existing concept (just as I indicated above). Although I wasn’t interested in nanomedicine, I told him it was okay if he wanted to move ahead with his investigations. This said, although I didn’t mind that he was satisfying his curiosity, I knew, of course, that this type of work was never going to be the focus of our lab. I thought, “Our specialty is neural invasion. That’s what we do.” Well, he went off and conducted his research, which returned the first medical evidence that genetic signals are transferred from immune cells to cancer cells. These same signals are used by cancer cells as the means by which they can reprogram the neural metabolic landscapes they invade. We identified the content of these exosomes and how cancer cells are able to internalize and use them to thrive. After determining their lipidic structure, we were able to imitate the behavior and artificially manufacture synthetic exosomes, which serve as a new anticancer drug delivery platform. By now you may have guessed that our lab’s specialty is exosomes. Since then a patent has been secured, which may lead to a revolutionary advance in the way cancer patients are treated. The takeaways from this story? As I’ve been saying, be attentive to and on the lookout for bright, young talent. Also, never say never.

5

Prelude to Action

“It ought to be remembered that there is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things.” —Niccolò Machiavelli, Italian Writer/Diplomat/Philosopher

© Springer Nature Switzerland AG 2021 Z. Gil, The Healthcare Efficiency Revolution, https://doi.org/10.1007/978-3-030-61232-0_5

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5.1

5  Prelude to Action

Presuming from a False Premise

When conducted at all, patient surveys are almost always experience-specific and retrospective. Patients who have received consultations or treatment are asked about their interactions with the department, the quality of care dispensed, and the thoroughness of follow-ups. Questionnaires inquire about hospital stays, surgeries, postoperative therapies, and so on. All of these tend toward affirming what already exists. There’s a basic presumption that the essential constructs of the system are valid. Criticisms are rarely, if ever, seen as suggesting the need to do much more than tweak what is, rather than do something totally new. And other than those vague, open-ended final questions (e.g., “Is there anything else you’d like to tell us?”), surveys often miss (or intentionally avoid) that which is aspirational. Hospital department managers and administrators already know quite a number of things that patients would like, such as reducing their time sitting in waiting rooms, to schedule appointments, and receive responses to written inquiries. However, if the presumption is that not much can be done to satisfy these known desires, then these questions won’t be posed. Why ask if the responses will only serve a theoretical purpose? If it’s assumed that certain things can’t be changed, why disappoint patients further by setting up the expectation that they might? Here, too, deconstruction is helpful. Set aside any notions that automatically preclude making a start. If you’re not looking for something, you’re probably not going to find it! Begin with “Why not?” and “How could this be achieved?” Engineer new solutions rather than jerry-rig old systems. Thereafter, with implementation plans prepared, solicit patient feedback about service and care efficiencies. Ask specific questions related to issues your department is now ready to substantively address. Discover what are patient priorities. With those results in hand, get to work. Once again, there’s a psychological benefit and a multiplier effect to going this route. The team gets to wrap its arms and creativity around problems that need resolving. Patients get to feel like their opinions matter, particularly when the gap between a given survey and solution deployment is relatively short. Everyone gets a charge out of that kind of responsiveness. Be clear though about the limits of surveys and other channels for patient communication. If you don’t know something, you can’t ask a question or offer a multiple-­choice option about it. When considering patient feedback, learn to read between the lines. Sometimes it requires interpretive skill to pick up on an underlying message. At times, several pieces of seemingly disparate information can point toward a desire that patients can’t quite articulate, but is there to be revealed through sensitive analysis and discussion.

5.2

How’m I Doin’?

A few decades back, there was a New York mayor famous for always asking the city’s citizens that question. In our department and in a variety of ways, we do the same thing on a regular basis, which includes the annual distribution of a questionnaire to everyone who we’ve served during the prior 12 months. There are many

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things those who’ve been in our care tell us that reinforce what we already know about changes we’ve implemented to better serve the interests of patient primacy. That tells us we’re on the right track. Sometimes we learn things that hadn’t quite been on our radar, while other comments help us refine our change agenda.

5.3

A Bit About Bottlenecks

Bottlenecks are not an anomaly. They exist in every system. But the thing about bottlenecks is that they’re dynamic, they change and shift. You solve one bottleneck here and it might reveal (or generate) another bottleneck there. Even after you address a particular bottleneck, there’s no guarantee that it won’t resurface or morph into a different problem. This is simply another way of stating one of life’s most obvious facts: Perfection is not a thing that can be obtained, only that for which we can perpetually strive. This is more reinforcement for the central tenets of this book: Look at the whole of your department, deconstruct every aspect of it, and understand its component parts. See how they’ve been fitted and joined together. Inevitably, the process will evidence processes which are less than optimal, are no longer well suited for the times, or hardly work at all. These are barriers to increased efficiency. They’re bottlenecks. The identification of these must be synthesized with patient feedback. That’s why our department conducts the annual survey referenced above. It’s understood that when a patient points to a departmental issue that is the source of frustration or irritation—similar to a pain from which they might be suffering— they may not know the precise source of the problem, nor its treatment or cure. It’s the job of medical professionals to come to these determinations regarding procedural (as well as bodily) ills forensically. Then, a course of action must be chosen, embarked upon, measured, and assessed for success, failure, or indifferent effect. Worthy alternatives must be considered, as well, and held in reserve should their need arise. Between diligent and ongoing efforts to locate, describe, and examine potential solutions for given bottlenecks, and the perspective of patients overlaid on top of these, management is in the best position possible to prioritize which problems should be tackled and in what order. In so doing, never underestimate the power of catalytic change. Prioritize initiatives by both ease of implementation and most immediate impact. The ability to produce relatively rapid, measurable results has a multiplier effect on staff morale, team cohesion, and motivation. This will be further spurred on by patients who notice and express their gratitude for efforts that are clearly focused on improving the healthcare and administrative services they are receiving. It’s a truly virtuous cycle.

5.4

Street Cred

The reputation of any organization should always be evaluated by its weakest link. A department may boast the world’s finest and most accomplished surgeons, but if the nursing crew is bad, patients will have greater rates of complications and the overall performance of the department will suffer.

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Taking this a step further, Delos “Toby” Cosgrove, past president and CEO of the Cleveland Clinic, once depicted the following scenario: Imagine a hospital that’s invested lots of time, energy, and money on providing the best patient services imaginable. The doctors, nurses, therapists, lab technicians, social workers, and administrative staff are all perfect. However, during a hospital stay, on the closet door a patient notices a spot of blood from the person who last occupied that room. From the patient perspective, that single incident spoiled the entire experience. The hospital believed it had thought of everything. But they overlooked janitorial services. Thus, the weakest link.

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Real Problems, Real Solutions

“You are what you believe in. You become that which you believe you can become.” —Bhagavad Gita, Hindu Scripture

© Springer Nature Switzerland AG 2021 Z. Gil, The Healthcare Efficiency Revolution, https://doi.org/10.1007/978-3-030-61232-0_6

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6  Real Problems, Real Solutions

Escape Artists

We’re all pleased to hear happy news. Like anyone else, healthcare facility managers would prefer to look at the sunny side of life, which can lead to a tendency toward managerial escapism. From an external standpoint, observers will form their opinions about a department or an institution based upon its poorest performers. They won’t necessarily dismiss the good points, but they’ll certainly want to identify those aspects where service is least reliable. The problem is that management will go to great lengths to hide negative statistics. They shy away from harsh realities, preferring to shine the spotlight on all those things that are Best in Show. This isn’t trivial. A lot of time and energy goes into pumping up and promoting what’s already working. There’s a logic to this, but it’s misplaced. It’s avoiding real problems that really can be solved through focused management. And just think of the P.R. bounce one gets from announcing the identification of problems, a commitment to implementing solutions, and actually achieving results. One gets points for honesty, courageousness, determination, and (if all goes even modestly well) success. Everyone cheers on that kind of ambition and leadership. What follows are several examples of problems our department identified and how we resolved them.

6.2

Quick Fixes

You might be amazed at the number of solutions that require practically no discussion, are simple and fast to implement, and produce nearly immediate results. We had one that our department couldn’t resolve for years. It was the cause of frustration among a number of our team members and great consternation to a significant number of those seeking our care. The issue: Making sure that patients hospitalized in other departments and who needed consultations were seen or, at least, received responses to their concerns within 24 h. It was viewed as a complex and unwieldy problem involving attending physicians and residents, nurses, and other staff. All these moving parts and personalities. Some consultations started or ran late, and not infrequently there were postponements until the next day or the day after. In a few instances, patients were completely neglected. Over a quarter of the calls requesting consultations required more than 24 h to be resolved. It was seen as a very difficult problem to fix. We nipped that one in the bud in a day through the magic of reporting. We requested to be informed, every day at 5:00 pm, how many unattended consultations remained at the close of business. Nothing more. There was no suggestion that any sanction would be forthcoming if patients hadn’t been seen or responded to; no overt or implied threats whatsoever. We just asked for the report. It’s human nature that no one wants to be responsible for turning in a bad report. Everyone wants to hand in good news, or at least minimize anything negative. Facing this situation, the staff had two options: • Produce a false report, which is a disciplinary offence on the institutional level. A person can lose their job for that. • Make sure the consultations got done.

6.2 Quick Fixes

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Which choice do you think they made? If I was to give you a golden solution for improving departmental operations and efficiency, and I was forced to boil it down to a single word, here it is: Accountability. Once again, though, prioritization is critical. There are tons of things for which reports can be valuable. Many problems might be similarly solved in the fashion I just described, but such requests need to be judiciously made. It’s unreasonable to want 20 different things to be accomplished in a relatively short time span and think all that’s required is for personnel to be filing endless reports. That’s not achieving progress, it’s just staff abuse and it diminishes the effect of reporting. Another way to generate status information is through the use of automated systems. People are always entering useful information into their workstation computers during the course of any given day. If a program can be seamlessly run at day’s or week’s end, which can instantly extract, format, and process discrete bits of that data, it may be able to instigate the same type of human nature responses as the one cited above for patient consultations. It doesn’t matter if a staffer or a computer algorithm is producing a report. If staff know that management and other colleagues will have access to certain information, that alone can encourage desired outcomes. Additionally, if these reports are sent to everyone, including the person in charge, this reinforces accountability. For example, we wanted to upgrade the efficiency of our OR, which we defined in three ways: 1 . Start surgeries on time. 2. Finish surgeries on time. 3. Decrease unanticipated time lost between surgeries. To facilitate our efforts, we established several goals: • Any delay in starting the first surgery of the day shall be no longer than 5 min. • Closing down daily OR operations more than 60 minutes before its normal closing time of 3:00 pm will constitute poor planning (as that hour or more should have been used to slot in an additional, short-duration procedure). • The maximum time between surgeries should be no longer than 20 min. As ever, accountability was the road to success. In launching the initiative, the importance of improving efficiency was discussed to secure buy-in from the team. But we had to go beyond this. Once again, our enforcement methodology was plain and simple: a weekly report to be sent to our OR manager containing a list of those surgeries which fell outside of our defined efficiency parameters. Reporting. No sword of Damocles hanging over anyone’s head. The unhandled cases were reported back to the given resident and attending physicians in charge of those surgeries with a note urging them to please make sure to reduce the incidence of such inefficient events. The result? We altered the DNA of our OR system of operations. As of this writing, we’ve increased our OR efficiency from 70% to 130% efficiency. This superefficient level of success came about because our people were inspired by their own triumphs and wanted to see if they could go beyond the defined parameters for 100% efficiency. They wanted to set tighter parameters for themselves (e.g.,

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reducing the gap between surgeries from 20 min to 10). Like great Olympic athletes, they were looking to shatter their own personal best records. Bear in mind, though, that optimization is not about squeezing every last drop out of people. To serve the patient primacy target function, staff need to be respected and well treated, happy in their work, and professionally motivated. Reporting is a tool, not a weapon. Use it strategically and use it carefully. Be flexible in its application. Allow it to animate team discussions and problem-solving. And learn to know when data has taken you as far as it can. Even for the most over-achieving over-achievers, there can come a point when reasonable limits have been obtained. Never push beyond that (or allow staff to insist on going further), otherwise some people may reach their breaking points. Chaos and disorder may ensue, which can then produce an increase in unanticipated events and result in burden imbalances, tensions, dissatisfactions, and conflicts among team members. There will be backsliding and efficiency numbers will decline. In such an environment, all the gains so meticulously won can be lost quicker than you might imagine.

6.3

Changing the DNA of the System

It’s not uncommon that patients will occasionally have problems with secretaries and other administrative staff members. Maybe they’re inefficient, perhaps they’re less than welcoming, or they’re just ill-mannered. What’s the result? Someone with a poor attitude might intentionally work slowly or be downright rude just to be irritating. This ruffles patients’ feathers and creates staff tensions. Arguments flare up in waiting rooms and reception areas, and sooner or later formal complaints get filed. Patient satisfaction is reduced and staff morale is negatively impacted. More importantly, there’s a lot of wasted hours and energy that goes this. And there’s an actual financial cost to that waste. How do you address such problems? Staff meetings? Training? Disciplinary actions? Possibly. Or you could try this: Directly in front of all secretarial stations and patient intake desks, place a sign that reads: “Your satisfaction is our ultimate goal. If you have any questions or complaints, call me directly.” Signed below is the name and title of the departmental manager, along with a personal cell phone number and an e-mail address. For added impact, put it on your departmental webpage and as part of the signature field of all outgoing departmental e-mails and text messages. Will this solve every issue? Definitely not. Will it take care of 99% of these matters? Almost certainly. Will it create a constant flow of complaints and calls to the manager? Absolutely not (I can attest to this personally). Know why? Because if your system is good, people are happy. When people are happy, they don’t usually complain. On the other hand, if your system is bad, I trust you’d want to know about that. Through this strategy, there’s no need for a manager to go to a troublesome staffer and say, “Look, if I get one more complaint, I’m going to fire you.” That’s

6.4 Leaders Lead by Leading

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managing through fear and negative reinforcement, which only compounds the problem. Go the route that I’m suggesting and staff members and patients, alike, will know those signs are there. Everyone will know the boss means business and is leading by way of self-example. Should the need arise, patients can go straight to the place where the buck stops. It breeds confidence. Patients will actually feel that their satisfaction is truly an ultimate goal. More significantly, for problematic personnel, the signs are a form of self-enforcement. Polite and efficient service provision isn’t an abstract notion on a job description, it’s mandatory for maintaining employment. Don’t comply and the chief is gonna hear about it in a flash. It’s an extremely powerful tool whose implementation and ongoing management costs extend to printing up a bunch of signs.

6.4

Leaders Lead by Leading

If you’re a departmental manager reading this now, I’ll bet you’re chafing at the idea of putting up similar signs in your shop. You’re thinking that you didn’t get to be where you are to have to deal with such matters. You’ve got more important things to do. I can assure you that I only receive a handful of calls in any given week. I tell you that none of this has distracted me in the slightest from my other responsibilities. And still you might say, “Well, that’s you.” Or you’ll insist that “In my community, it’s different…” You’ll explain all the many reasons why this couldn’t possibly work for you. My experience simply won’t translate to your world. Well, you may be right, but the signs are more than sharing your cell phone number with your patients. The signs are also one, small way to demonstrate seriousness about patient primacy to your customers, to your staff, to your colleagues, to your superiors, and to the world. Their results in improving personnel productivity and patient satisfaction can be objectively measured. In fact, our metrics quantifiably demonstrate that improvements in patient satisfaction (Fig.  6.1) can be achieved without raising an existing budget by a single penny. Furthermore, no additional investments, nor premium-priced services are required to upgrade all other departmental performance metrics. There are many such latent efficiencies waiting to be discovered and actualized. And in numerous instances, new initiatives can have a multiplier effect. Once again, let’s look at those signs. Their positive impact goes beyond secretaries and administrators to the medical staff. At first, doctors and nurses will be skeptical. They’ll say this is just a gimmick. They’ll think the whole thing is a lie or the number is simply going to a permanent voicemail box. Once it becomes clear that this isn’t a stunt, some will even think the manager is just plain nuts. A little further on, when it sinks in that this is an effective strategy toward the delivery of better care for more people, it adds to the honor, dignity, and self-confidence of the entire team. Of their own accord, everyone will be motivated to drive themselves further if they see and acknowledge that their manager is able and willing to be that accountable for the operational success of the department. Modeling leadership in such an overt manner produces tangible dividends.

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6  Real Problems, Real Solutions 100% 93%

95%

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Fig. 6.1  Patient satisfaction/willingness to recommend Rambam Health Care Campus ENT department services. (Credit: Nofar Rada)

6.5

You Cannot Be Serious!

On our departmental webpage and throughout our clinic and ward corridors, there are a number of unexpected communications options that are readily available to patients. For example, similar to the strategy described above, you’ll find the e-mail addresses and personal cellular phone numbers of the managers in the department. They’re not listed in tiny print or buried in some digital corner where only more adventurous folks will go. The information is right out in the open and we sincerely invite patients to contact us should they feel the desire or need to do so. These are our direct communication lines with the patients. The phone numbers don’t redirect to a general switchboard or that of a secretary. We receive them, we answer them (and, if need be, forward them to those best capable of providing an appropriate response). Every week, my colleagues and I get phone calls from prospective and existing patients who have questions, or who want to come to the department for a consultation about some health concern or another. If patients choose not to ring us up, they’re free to send a text message or an e-mail. Yes, I know. You’re thinking this cannot be real. There’s gotta be a catch because this can’t possibly work. But I’m telling you that it can if you’re always attending to your patient primacy target function. And let me give you a tip. Patients are smart. They don’t harass you or bother you with nonsense. They’ll communicate with you if they feel desperate. This is why, in any given week, very few patients reach out to me directly. Just the same, with each and every person who chooses to exercise this option, I feel it only reinforces the validity of the strategy. The ongoing fact that

6.6 Grand Rounds, Small Thinking

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only a tiny handful of patients ever feels the need to contact me demonstrates that our system is well functioning. Look at it this way: If they’re being honest, product manufacturers will confirm that most of the communication they receive from customers is negative. That’s true for even the most successful companies with gangbusters sales that have been around for generations. Why? Human nature. If you buy a refrigerator and you’re satisfied with it, you’re generally not going to write to the firm and say, “My, what a fine fridge this is. Doesn’t it just keep my fruits and vegetables fresh and crisp! Thank you so much.” You just use the product. If you’re thrilled with it, maybe when you need a new one, you’ll seek out that manufacturer again. You communicate through your wallet; through the marketplace choices you make. It’s important to note, too, that having managers’ cell numbers on the wall is not only for our patients. It’s also for the staff. Think for a moment about the impression it makes, for example, on secretaries and nurses who see just how far managerial personnel are willing to go to be of service to those in our care. It’s a message that says high-level staff are about the business of high-level dedication to the target function of patient primacy. It’s walk-it-like-ya-talk-it. And it’s a game changer. It boosts the morale of every member of the team and inspires them to be more focused and achievement oriented in their own spheres. So, the only question remaining is: Why don’t all departments do this, everywhere? I can’t give you an answer, but I’ll bet real money there are those who’ll be ready to offer a million excuses why not. For the past eight years, we have been freely offering direct e-mail addresses and cell phone numbers for management because we’re confident that we’re committed to serving our target function. Once again, patients do contact us, but we’re not worried about being inundated with complaints about inefficiencies, bad attitudes, poor service, and other negative qualities. Does it happen? Sure, from time to time, but it’s rare. Speaking personally, maybe get one call per week. Almost none are complaints. The rest are about issues which, for one reason or another, haven’t been resolved. In such instances, I have rarely had to spend more than 2-3 min on their concerns. I’m attentive to what the patient wants and, if I can’t offer an answer right there and then, I pass the inquiry over to a colleague whose obligation is to respond in a timely fashion. Overwhelmingly, though, as the head of the department, patients don’t call me unless they feel it’s a necessity to do so. If their needs are being met elsewhere, what do they need me for? To tell me how fresh and crisp their fruits and vegetables are?

6.6

Grand Rounds, Small Thinking

Among the significant changes implemented by our department was how we structured hospital rounds. Several years ago, we did what almost all the surgery departments in Israeli hospitals have been doing for decades and continue to do—the chair or a vice chief leads a large gaggle of attending physicians, residents, and students to make bedside visits to all the patients. These occur 3-5 times a week. Charts get

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reviewed, progress is assessed, and those being led around get a bit of an education. Oh, and then there’s the patient. But there’s hardly any time left to actually have a discussion with the person in the bed because the gaggle must press on. I once asked one of the department chairs in our hospital why he still conducts grand rounds and what he believed he was achieving by doing it. He looked at me like I had three heads. Then he said that this is how things have always been done. A halfmoment later, he added that he was doing it for the patients. I responded, saying patients don’t really get anything out of this. So he offered that there’s also the training aspect. I countered that teaching is better accomplished by way of a much smaller teaching round. I explained how our department now conducts two such rounds daily with only a couple of attending physicians along with four residents. I elaborated on this new practice with my colleague, explaining how this is of increased value to the doctors, as they can get more directly involved with individual cases and have greater opportunities to ask questions about and explore issues. Better still, for the patient, this approach is far more personable. As opposed to the intimidating circumstances of a grand round, the intimate nature of the teaching round allows patients to solicit more opinions about their conditions, which adds to patient satisfaction. Finally, my colleague said, “You know what, this is the way I let staff and patients know that I’m the boss.” Well, okay then. I couldn’t argue against that. But his answer didn’t surprise me in the least. As a young physician being led on grand rounds 20 years ago, the chair of the department I was in said pretty much the same, but more crudely: “You know why I do these rounds? So everyone will know who’s the biggest monkey in the clan.” Back in our department, we asked ourselves: To the patient, what’s the benefit of having a large group of doctors crowd into their room and talk about them for several minutes, mostly in the third person? Being hospitalized is stressful enough without a bunch of strangers barging in unannounced, nattering away about their case with all the warmth they’d summon up to review a lab rat study. Why is teaching in this manner taking precedence over what’s in the patient’s best interests? Concluding that grand rounds are not a fit with our patient primacy target function, we scrapped this antiquated practice.

6.7

Waiters

The ingredients: A medical clinic, a moderate to large-sized city or suburb, and a patient needing to see a doctor. Mix those together and the result is inevitable—the wait. It can’t be helped. It’s a simple question of supply and demand. More doctors and the patient can get an appointment sooner. Fewer doctors, well…get in line. This is an immutable reality, right? Now, let’s see how a manager can influence this (and many other) core measures of performance. In our clinic scenario, we’re assuming a fixed and steady number of doctors. The standard operating presumption, therefore, is that the only factor which can impact how quickly an appointment can be scheduled is the number of patients who need to see a doctor. Now take a look at Fig. 6.2:

6.7 Waiters

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It took 3 years for our department to slash average wait times by well over 60%. Figure 6.3 shows what else we achieved. In the same 2011-2014 period, we increased by well over 50% the number of patients we care for annually in our clinic. By 2017, the six-year rise was considerable.

30.0

27.8

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Fig. 6.2  Reduced wait times to see a doctor (days). (Credit: Nofar Rada) 25,000

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Fig. 6.3  Total number of patients seen/treated in the clinic. (Credit: Nofar Rada)

2018

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Teamwork, dedication, thoughtfulness, creativity, planning, and execution were required to achieve these (and many other) core measure successes. What we didn’t need (nor did we ask for) was a significant increase in our staff or our budget. With this said, there are a few big takeaways from these graphs: 1. It’s always worth wondering if the common wisdom is really so wise. You might discover it isn’t and, as a result, generate new intelligence. This may become the new common wisdom. If it does, mazel tov! Just be sure to keep your pride in check because one day someone else might come along to ask how wise is your wisdom. If that happens, remember that you were once where they are now. It’s okay. That’s how things should be. 2. By challenging existing dogmas, we unlocked huge, latent efficiencies within the existing infrastructure of our department. 3. Through the implementation of our new intelligence, we identified inevitable limits to some of these efficiencies. For example, note in the second graph above that while we continued to see a dramatic rise in our clinic numbers for the 2014-2017 period, wait times seen in the first graph for the same period rose by over 35%. The steadiness of that increase, matched against the profound surge in clinic attendance, clearly communicates that if we want to get those wait times down again, additional personnel and resources will be required.

6.8

Here to There

As our experience and empirical evidence shows, the rate-limiting factor to decreasing wait times to see a clinic doctor and increasing the number of patients seen annually in the clinic wasn’t the number of doctors on staff. So, what made the difference? The first thing to say is there’s nothing unique about our circumstances—not the country we’re in, the nature of our healthcare system, or how our professionals are educated and trained. Before we implemented our changes, we handled our patients the way almost all medical departments the world over handle theirs. With the exception of urgent care cases, a first come, first served philosophy prevailed. Until 2011, it worked like this for our patients: 1 . An individual would contact us wanting an appointment to see a doctor. 2. Within a week, the patient would be contacted by a doctor for a preliminary evaluation. 3. Within another week, an appointment would be scheduled, typically for a date approximately 2 weeks after that. It doesn’t really matter if your personal experience is somewhat different. Maybe it’s a little better and a bit less bureaucratic, perhaps it’s worse. I can’t address the specifics of your experience. However, I hope you’ll be inspired by our solutions in a way that will help you to dissect your own operations and devise homegrown improvements.

6.9 New Member Privilege

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As our data suggests, our first year (2012) was spent making some minor adjustments, but otherwise analyzing issues and deconstructing the component parts of our patient scheduling system. During this period our numbers improved only modestly. In our discussions, we determined that preliminary evaluations were a major bottleneck to flowing more patients into our clinic. Of course, while triaging patients can seem quite sensible, our doctors were needing to devote a considerable amount of their professional hours screening individuals to determine if they should be seen in our clinic, referred elsewhere, or offered some other advice. If a given person was cleared for an appointment, the evaluating doctor would then need to communicate with the secretarial staff to request that the patient be scheduled for an appointment. We decided that this process was a gigantic and unnecessary time suck. So, we scrapped it. No screening, no pass gates. Anyone who wants an appointment in our clinic gets one. That immediately cut wait times down by about 2 weeks. We discovered it’s far more efficient to see whoever thinks they need our care because (1) the vast majority of them do, and (2) for those we can’t help, it takes far less time to advise them in person. In comparison to 2011, our numbers since 2012 represent powerful before-and-­ after contrasts. Our initial increases in patient numbers were simply due to the fact that we were scheduling whoever asked to be scheduled and doctors were spending substantially more time actually treating patients in the clinic. Increases thereafter can be attributed to adding refinements to the system, plus the benefits of positive word-of-mouth promotion. Our satisfied patients told family, friends, and colleagues about their experience, and this drove additional patients through our doors.

6.9

New Member Privilege

The other change we implemented had to do with thinking through precisely who are our patients. We created general categories and affixed percentages to those. For example, there are patients who need to see us urgently, there are those who see us on a regular basis, and there are new patients. Of the latter two, there are very important differences between them, which can profoundly impact efficiencies. A new patient necessarily requires more time. There are more forms to fill out, more essential data to collect, and more conversation to be had with the doctor. Established patients are already in the system. They’ve been processed. Their conditions, care, and treatment needs are known. They’re fully informed on the several communication routes they can use to rapidly reach us. Plus, they know that they can drop in, unscheduled, whenever they feel it’s necessary. So, we decided to prioritize first-timers. It’s not a profound advantage over established patients, but this preferential edge allows us to capture and retain more new patients in our system. This is because new patients are typically grappling with a new problem (or at least one that has reached the stage where they’ve decided professional care is warranted). In these moments, people can be quite anxious. They want to see someone as quickly as possible, if for no other reason than to know

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precisely what they are dealing with and how they can best be treated or cured. If they can’t see us fast enough, they’ll go somewhere else. Established patients are already ours and so long as we’re taking good care of them, they’re not likely seek care at another facility. Equally, we have set-aside hours that are dedicated only to new patients. We’ve designed it in such a way that we can accommodate those new patients we’ve scheduled and those who are simply unexpected walk-ins. So, if we know we can reasonably use this time to see ten patients, but we only have five who are scheduled on that day, we know we’ll have no problem welcoming a few walk-ins. If we have eight scheduled patients, we still have room at the inn. Additionally, we take into consideration the no-show factor. Accordingly, if 20 patients are scheduled for a given clinic on Wednesday and the no-show rate for that clinic on this specific day is 30%, it means six more patients can be accommodated. We monitor our set-aside and no-show numbers on a weekly basis to be certain we’re never fully booked, as we never want to turn anyone away. Whenever it looks like we’re reaching scheduled-patient capacity, we make adjustments so we’re always ready to welcome newcomers.

6.10 A Bit More on Walk-Ins Unscheduled patients arrive in hospital clinics every day. Some days a few more, some days less. The reasons why they come is less important than the simple fact that they’re a fact of life to be dealt with as the given moment demands. Right? Wrong. Not analyzing, quantifying, and reorganizing patient scheduling protocols with unexpected arrivals as a built-in factor is a tremendous error in planning whose negative impacts can ripple throughout the entirety of clinic operations. Notice that I use the word “unexpected,” not “unanticipated.” If there are daily arrivals of unscheduled patients, how in the world can they be unanticipated!? The trick is to turn the unexpected into the expected, and respond, accordingly. When our department looked at the number of unexpected patients, we saw that 30% of our patient flow consists of these walk-ins. If our clinic is caring for 150 patients per day, 30% is 45 people. That’s a big number. If there’s never any planning for this now-expected contingency, then it’s like the entire department collectively stepping on the garden rake over and over again, constantly thwacking itself in the head. Without a plan, the flow of clinic operations will be endlessly disrupted, day-in and day-out. It’s dispiriting for everyone involved. Administrative staff have to deal with scheduled and unscheduled patients alike. Walk-ins tend to require more time to process in. Lines get longer. Personnel are under pressure to keep things moving along. A doctor who has 20 patients on the schedule winds up seeing 26. And what about the patients? Scheduled patients deal with a bit of all of this lack-of-planning fallout. There are lines, added waiting room times, frustrated and harried staff. No one’s happy. It’s a mess.

6.11 The 80/20 Rule

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The quick-and-dirty solution is to put up a big sign stating unequivocally that unscheduled patients will not be seen. That tactic will fail on two fronts. First, if an unscheduled patient has bothered to arrive in your clinic, very few will heed the sign. They’ll believe the message is for someone else, not them. Either their condition is such that they genuinely need to be seen (in which case, they’re a legitimate exception to the rule) or they’ll convince themselves they can butter up the intake staff sufficient to be squeezed into the schedule. Second, turning people away runs counter to the target function of patient primacy, whose goal embraces caring for as many people as your system can efficiently accommodate. So, whatever mess you had before putting up that sign, now it’s worse. Here’s a couple of ways to deal with walk-ins (but, as your mileage may vary, feel free to devise your own fixes). Let’s consider the example of the 20-patient doctor above. Twenty patients is a full schedule. So, if in this clinic there’s the expectation that 25% of patients will be walk-ins and anticipated no-shows have been factored in, then instead of scheduling 20 people, it’s more sensible to schedule fifteen. Now the interests of all can be satisfied comfortably. When flexibility and breathing space are incorporated into the schedule, the elasticity makes it easier on everyone. Another option is to dedicate and promote a portion of a clinic’s daily or weekly schedule solely for walk-ins, with assigned doctors tending to patients on a first-­ come, first-served basis. Sometimes they’ll be very busy, other times not so much. Measured and assessed over time, the idea is that just enough hours will be designated for walk-ins such that all of these patients can be reasonably accommodated with a balanced flow that’s comfortable all around. This is also great for institutional development. It’s advertising copy and bragging rights to say, “Need a doctor’s opinion right away? We’ll be happy to see you in 24 h or less because we’re always ready to serve YOU!” Properly managing walk-­ ins is a major boon to operational efficiency, it contributes to an exponential rise in patient flows, it makes everyone on the departmental team more relaxed and happier, and it certainly doesn’t hurt to be able to show your institutional directors big-­ time bottom line success.

6.11 The 80/20 Rule A hospital department rarely gets into the weeds on internal productivity measurements, which is a mistake because that’s where the efficiencies are hiding. For example, the mean number of patients per doctor per day might be looked at. That abstract figure is supposed to be saying something about overall, institutional productivity. The problem is that there can be significant variability between doctors. For example, there might be some doctors who are seeing an average of 30 patients per day, while many others might only be seeing 5. It’s the Pareto (80/20) principle in action (i.e., where 20% of the doctors will be doing 80% of the work, while 80% of the doctors will be handling the other 20% of the work). The only way to change a situation like that is for management to be more proactively involved in monitoring

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the productivity of individual physicians on a regular and ongoing basis. The fix can be as simple as requiring a spreadsheet to be submitted at week’s or month’s end. Nothing complex. Two columns: Doctor’s Name and Patients Seen. That’s it. That one obligation can make most of the 80/20 dilemma self-correcting. And this isn’t about shaming anyone. It’s about team building. If everyone can see the numbers, it’s clear to all which staff members are doing as much as they can and which ones aren’t. Since no one really wants to be in the latter category, no one’s going to want to report low numbers. The monitoring becomes motivational. At first, some on the less productive end may improve their performance only for the sake of not standing out in those reports. However, as those improvements contribute to department-wide success in treating more patients and generating more institutional revenue, this is likely to become a source of personal and collective pride, which then fuels everyone on the team to tackle and conquer new challenges. Of course, getting to the point where 80% of the doctors are working at capacity is neither as smooth, nor as uncomplicated as that. There are personalities involved, in some instances longstanding careers and work histories. Some folks will be slower to adapt. Time, patience, nurturing, and even a little gentle noodging may be required. And no reasonable manager should expect every doctor to be working at peak performance continually. The idea is to identify and close up wide differentials between one doctor and another, and to fill up as much of that “empty space” with patients who can now be seen as a result of found efficiency.

6.12 Transparency Transparency lets in the sunshine, which is not only the best disinfectant, it’s also a marvelous motivator. The Doctor’s Name/Patients Seen fix above is transparency in action. Further to the implementation of that reporting protocol, we have been sending a monthly e-mail to all of our doctors, which shows the number of clinic patients each of them has seen during the prior month. They can see where they stand in the ranking and how they are faring in comparison to their colleagues. Those lower down on the list are encouraged to try harder. The presumption is always that there may be legitimate reasons or issues impeding someone from doing better. We engage with them positively to see how we can work together to increase their patient volumes. Whoever tops the list in any given month receives a personal note of thanks and appreciation from me or the chief of our outpatient clinic. This stuff is basic. Simple. Can’t be more elemental. And it works. It’s a reminder that sometimes we can overthink problems. We spend years and years toiling to get advanced degrees and training. We’re incredibly highly educated individuals working in complex, sophisticated organizations. And yet it’s incredible how motivating a gold star at the top of a test paper and a word of praise from on high can be. If someone sees they weren’t #1 this go-round, they might decide to put in a little extra effort so next time they can be Employee of the Month. Naturally, this approach advances a workforce only so far. Collegial encouragement is all well and good, but rewards are even better. These can come in sizes large

6.13 Not Merely a Numbers Game

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and small, and can be institutionally formalized or extemporaneous. The type and scope of rewards offered can be a function inventiveness, although these are almost always limited by local and institutional circumstances. Maybe an annual financial bonus pegged to performance can be structured into contractual terms of employment. Perhaps certain privileges can be extended, such as more flex time or the opportunity to attend expense-paid conferences. It can even be just the boss taking a stellar team member out to dinner at a snazzy restaurant. I can’t suggest what will be do-able in your context, but you do need to create psychological incentives. And something else about psychology that’s highly pertinent here. You might think that doctors who are working very hard would be pissed at those who are hardly working. Equally, you might think that the latter crowd might be relatively happy as their workloads are smaller. Neither case is entirely true. First, as medical professionals, we like to see patients. Second, we’re colleagues, team members working for a department and a greater institution. Given the right environment, reporting/monitoring, and incentive structures, most people will take both personal and collective pride in achievements. Doubtless this is the case everywhere. Most healthcare professionals will describe what they do as a “calling.” They see their work as making a positive contribution to, quite literally, the health of society. When the narrative of a department is built upon enhancing this philosophy, everyone is more satisfied.

6.13 Not Merely a Numbers Game From what’s been said, it would be easy to think that there are certain factors which make it difficult or impossible to increase the number of clinic patients a given doctor regularly sees. For example, a department chief is presumed to have a higher level of training and expertise, and therefore may be handling more complicated cases. Less experienced doctors may not be dealing with those. So, a younger physician might be seeing more patients, while a more seasoned person will be seeing less. But do the factors of case complication and years of service really affect personal patient counts? We analyzed this question and concluded there’s no correlation here. What determines the volume per clinic or the time per patient per clinic is individual performance. It’s one’s personal preferences when dealing with patients, not the complication of their cases that makes the difference. Some professionals take more time in their patient interactions—asking questions, conducting tests, analyzing and considering problems. Within relative boundaries, there’s not a thing in the world wrong with that. Others are more direct, able to process situations a little faster, and prescribe next steps a bit more efficiently. If one is less experienced with the particulars of given case, almost all doctors will call on a more knowledgeable colleague for assistance in arriving at diagnosis and treatment options. What we don’t do is to impose an arbitrary average-time-spent-per-patient rule. That would be a wrongheaded for our professionals and our patients. We do set reasonable per day/per doctor objectives to be accomplished within a given shift.

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The result is that there are always some doctors who reach the daily mark a little earlier in the day, others later, with none needing to get into overtime hours. There are also pragmatic ways to handle variables in personality, practice, and pace. For example, in our ENT department, we’ve created sub-specialty clinics. As such, sinus specialists only see patients with sinus diseases. We have similar, segregated clinics for patients with sleep apnea, cancer, larynx and voice disorders, speech difficulties, swallowing troubles, ear problems, and pediatrics. Patients with nonspecific, undiagnosed complaints are sent to our general ENT clinic. With this infrastructure in place, we’re better positioned to more accurately track the satisfaction and complication rates associated with any given doctor.

6.14 Planned Emergencies We tend to think of an emergency as a sudden and unexpected situation. However, you’ll see that’s not quite accurate if you consult a dictionary. There, the word is defined as a moment or circumstance which demands immediate and decisive action. And therein lies the problem. In hospital emergency rooms across the globe, we receive and care for an outsized number of patients who satisfy the idea we typically have about emergencies, rather than what they really are. All too often, ERs are treating people who really should be going to the Distress Room or the Discomforted Room (if either of those existed). This has very real negative consequences on people, budgets, and overall operations. Emergencies can require staff to work late or irregular hours, and on-call personnel to be placed on duty. This can impact payroll expenses, as overtime, weekend, and holiday pay scales may be triggered. Extra hours take a physical toll and can result in some team members being tired and less focused the following day. Consequently, some patient appointments may have to be cancelled and rescheduled. And some patients, with conditions that genuinely require emergency care, may be forced to wait longer than is necessary to see a doctor. Treating emergency cases that aren’t genuine emergencies causes inefficiencies to ripple through the system. This is generally because most managers presume that it’s impossible to plan for emergencies. The notion seems oxymoronic, but it isn’t. Just the same as in any other hospital department, in an ER, patient data is collected and ER cases logged. A long-term analysis of this information will evidence the types of incidents that prompt ER visits, the types and quantities of resources necessary to treat those cases, and the types and numbers of personnel who have had to work excess hours to accommodate ER needs. More intrepid investigators will examine short-term data to see if specific dates when staff worked overtime can be mapped to incidents in the subsequent day(s) where regular patient appointments were cancelled and rescheduled by the hospital (and then to determine causation). It doesn’t require an extraordinary effort to turn much of the “unexpected” in an ER into that which is expected because it’s more than reasonably predictable. Checklists, incident scenarios, symptom databases, and guidelines can be created to

6.15 Hello, I Must Be Going

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2.4

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Fig. 6.4  Average ER wait times (hours). (Credit: Nofar Rada)

better triage ER arrivals. The vast majority of absolutely, positively, immediate-totreat (ITT) emergencies are usually straightforward. They’re I-know-­it-when-Isee-it emergencies that need to be rushed into an OR or admitted for medical treatment or supervision. Cases not flagged as ITT can be classified according to time to treatment (TTT) protocols (i.e., TTT within 1-6 h, within 6-12 h, 12-24 h, or 48 h). These patients can be admitted to the hospital or monitored in the ER. All other patients should be advised how to manage their situations until they can see a nonemergency physician the next day or as soon as possible thereafter. We’re proud of the work we’ve done on this front and have the numbers to prove it (Fig. 6.4). Reorienting an ER may take some doing. But the proper management of ER resources isn’t only about the ER, the patients who seek its services and the personnel who work there. ER management is inextricably linked to the rest of departmental operations. Patients whose circumstances do not warrant emergency treatment should understand the true nature and purpose of the ER.  They must accept that screening and efficiency measures exist to assure that should the day come when they or a loved one is facing a bona fide life or death situation, the fullest and most rapid resources will be available for them in the ER.

6.15 Hello, I Must Be Going A patient is scheduled for an operation. Check-in occurs at the hospital on the scheduled day and the surgery takes place as anticipated. Assuming no complications, the procedure performed will be associated with an average number of hospitalization hours or days. There’s no universality in this arena. Recommended hospital stays for given surgeries can differ from one system, institution, department, or doctor to another. In the USA, these decisions are generally in the hands of insurance companies whose discharge guidelines rarely leave much, if any, room for attending physicians to make local determinations for their patients. How and why it comes to be that the precise same procedures will result in different recommendations or mandates for hospital stays is a different discussion for

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another book. For our purposes, it can generally be stated that a best practice in medicine dictates that a hospitalization should provide necessary time for professionally monitored recovery. The patient should be discharged as soon as it is deemed that such a release will do no harm. Our department grappled with this core performance measure and found efficiencies that have helped us to slash our average hospital stays nearly in half (Fig. 6.5). This resulted in our department’s average stays ranking lower than any other hospital ENT department in Israel (Fig. 6.6). 4.0 3.2

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Fig. 6.5  Average hospital stay (days). (Credit: Nofar Rada) 5 4

Days

Rambam Health Care Campus 3 2 1 0 Hospitals

Fig. 6.6  Distribution of ENT department stays in Israeli hospitals. (Credit: Nofar Rada)

2018

6.16 Satisfaction Guaranteed

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We did this by going beyond defining (and being transparent about) anticipated hospital stays per procedure. We now have built-in systems that double-check and validate hospitalization stay extensions, and facilitate the exiting process or, in some instances, transfers to convalescent facilities. Accordingly, if a patient requires an extended stay, a written justification needs to be provided and approved. Additionally, most of the steps necessary to complete discharge paperwork are prepared shortly after our patients check-in. Why? It’s the simple wisdom of Abe Lincoln: “Leave nothing for tomorrow which can be done today.” As there are many things that won’t change during a hospitalization, why leave the writing up of those details until the moment of departure? For example, with certain cases it’s understood well in advance of surgery that rehabilitation or special equipment will be required as part of the recovery process. Not preparing for these known details just keeps everyone waiting—the staff who have to fill out discharge data forms, departing patients, families, etc. A convalescent transfer can take additional amounts of time to locate an available facility and prepare the patient for medical travel. Checklists and procedures assure that necessary steps (including the consideration of options) can begin as soon as feasible and be concluded at the earliest possible moment. We’ve developed this for every surgical procedure and the information is inescapable—it’s in the O.R, it’s in the offices, it’s in the patient charts. They detail precisely how patients are to be prepped for surgery, what antibiotics and other medications are (or may be) administered to them, what (if any) special monitoring may be required or advisable, and so on. Everything that must happen, as well as what can and should reasonably be anticipated is in these guideline documents. One would have to be trying awfully hard to miss a step in our department!

6.16 Satisfaction Guaranteed At the time of this writing, our department and another in our hospital are partnering on a new initiative that’s focused on gauging the impact of using nurse coordinators (NCs) for the efficient delivery of high-quality services and improving patient satisfaction. We are explicitly not studying clinical measures, such as complication, survival, and readmission rates. Instead, we’re examining the hospitalization experience completely from the patient perspective, examining issues including length of stay, pain management, the responsiveness and bedside manner of doctors and other personnel, ease of navigating administrative and bureaucratic matters, etc. NCs are entirely patient centered. Their function might be thought of as facilitator, advocate, ombudsman, and task master all rolled into one. Objectives are to maximize comfort, minimize stress and anxiety, and reduce time lags between patient requests/needs and their satisfactory execution. An NC is the only member of the entire departmental staff who interacts with each subset of the team—doctors, attending physicians, residents, nurses, nutritional personnel, social workers, physical therapists, administrators, and janitorial workers. Thus, NCs also help to harmonize the actions and attitudes of the team around their patients. Through specific activities and cumulative effect, NCs can help to more acutely sensitize all involved professionals to the patient experience.

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Much of the work is quite straightforward. For example, a patient says they didn’t get an answer they were seeking from their doctor. The NC contacts that doctor immediately and makes certain that, without delay, the doctor comes to see the patient or the patient is brought to the doctor. This positive patient advocacy extends beyond discharge, as it is not uncommon that patients will have questions regarding healing, home care, physical therapy, and other topics. Assuring that these patients also receive rapid responses can improve postoperative outcomes and reduce unnecessary return visits to the hospital. Preliminary results of our NC implementation program have been mixed, although efforts are ongoing. In our department, the NC had the type of across-the-­ board impact we were hoping to achieve. However, in the other test deployment department, the NC’s impacts were more narrowly focused on doctors, nurses, and other medical staffers. Even on that score, the NC wasn’t able to affect the attention that patients received from the doctors, only nurses. This NC also didn’t have any impact on readmissions or, indeed, overall patient satisfaction. At this moment, our analysis is that having an NC working directly with patients isn’t enough to achieve the comprehensive results we’re after. Since we accomplished our goals in one department, but far less so in another, it’s our belief that NCs may be decidedly more effective if they are among the individuals responsible for recruiting and retaining the entire departmental team. This might necessitate a fusion of nurse practitioner and human resource development skills. This project is worth mentioning in these pages partly because we think this initiative-in-progress still holds great promise. It also demonstrates what I have been emphasizing in this book. The lessons, advice, and experiences imparted herein aren’t a set of how-tos. To be sure, some ideas are transferrable, ready to be copied or adapted to local settings and needs. But as we began, change your conception of hospital department management and you’ll see that the process of innovation and reinvention is (and should be) never-ending. Taken too literally, this can sound exhausting. It shouldn’t. Changing your conception doesn’t mean everything you’re doing today must be changed a week, a month, or a year from now. It doesn’t mean you should constantly seek to overhaul your processes and procedures. It does mean you should always be open to questioning whether things are working as well and as efficiently as possible. It does mean you should never allow yourself to get set in your ways. Encourage your colleagues not to do so either. Establish and nurture an environment of exploration, examination, enterprise, resourcefulness, and ingenuity. Accept new ideas and proposals (and recognize that youth is often the wellspring for these). Vet them, debate them, put them to the test if they inspire the team and seem worthwhile. Always have a new horizon to reach, a mountain to climb, a dragon to tame. Tilt at a windmill once in a while. Noble experiments are just that, noble. Some succeed, some don’t. Not quite getting there is no excuse for never trying again. Sustain your enthusiasm for medicine, and honorably, diligently, and humanely care for your patients. And remember that trailblazing on their behalf is the noblest pursuit of all.

7

Metrics

“Measurement is the first step that leads to control and eventually to improvement. If you can’t measure something, you can’t understand it. If you can’t understand it, you can’t control it. If you can’t control it, you can’t improve it.” —H. James Harrington, American Quality Expert

© Springer Nature Switzerland AG 2021 Z. Gil, The Healthcare Efficiency Revolution, https://doi.org/10.1007/978-3-030-61232-0_7

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7.1

7 Metrics

You Are Here

It’s pointless to plan for change, set out an agenda, and establish a timeline for the completion of tasks and the attainment of goals if this work doesn’t include metrics. You must have objective means and systems to measure what’s happening and what you’re accomplishing. You’ll want to look at your data in comparison to a given level of performance as from a date certain. The data should be plotted, graphed, and summarized periodically. You’ll want to analyze and discuss this data at regular, agreed-upon intervals. Based on this, procedural adjustments and course corrections may be necessary. At times, a project may need to be halted and retooled entirely because a particular plan simply isn’t working. Multiple change projects will be taking place simultaneously. There will be separate teams, each responsible for their own set of deliverables. You should appoint team captains whose obligations will include the production of periodic reports. Regular or ad hoc staff meetings might also take place, so everyone can be informed of advances and/or setbacks occurring within the separate teams. And if the COVID-19 pandemic has taught us anything, we’ve all discovered that video conferences are frequently just as good as in-person gatherings and, in some instances, better. Is it possible to make change without all this data collection, coordination, and consultation? Sure. But you won’t really know if any given change is actually happening (or, to the degree that you’ll know change is occurring, how well or poorly it’s being executed). Whatever ensues will be haphazard, inconsistent, and likely unsustainable. Also, you won’t be able to objectively demonstrate your success to anyone else. It will be only words. No real numbers involved. If you want to know how far you’ve travelled on the road to change (let alone reach any particular destination along the way), you’ve got to be able to work with comparative measurements of where you’ve been and where you are.

7.2

Look Over There!

Too often and for far too long, hospitals and healthcare systems have been measuring the wrong things and touting those numbers as if they were meaningful. Among these, none is more irrelevant than the number of beds. As health professionals, we don’t care, treat, or have therapies available for beds! We provide services to people. The size of a department isn’t its bed count or its square footage. If you want to know the size of a department, the size of any healthcare institution, measure what’s consequential, measure what relates to the target function of patient primacy—the number of patients served, the quantity and variety of procedures being carried out. So why are bed counts and floor measurements still a thing? Maybe because they’re fixed and easily countable assets. Measuring the several aspects of target function requires putting systems into place to collect this data. Is this difficult to do? In the twenty-first century? Hardly. So, what’s holding back progress on this front? In some instances, the answer is uncomplicated: No one’s thought to do it yet. At other times, it’s managerial resistance to

7.4 Data in Action

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adopt new technologies, which is a widespread problem in the healthcare field. Of course, these days, many measurement systems are practically plug-and-­play; requiring very little in the way of special skills or training to operate, much less understand. This aversion to technology will likely sort itself out over time, however. One other reason why there may be resistance to collecting target function data is that there are those who don’t want to know. Once again, one rarely sees a change in a bed count. Patient and procedure counts change all the time. Moreover, they’re benchmark statistics, which beg a fundamental question: Are we doing as much as we reasonably can with existing resources? If not, the next questions will quickly and logically follow: Why not? and What can we do to change this? Status quo a-okay types and those who don’t want the added responsibility of making improvements will likely not be interested in target function statistics.

7.3

Critical (Data) Points of Entry

So how does a department (or an institution) begin the process of moving toward (and ultimately maintaining) patient primacy policies and procedures? The first thing to accept is that a significant component of this work involves data acquisition and analysis. Time and attention must be paid to implementing the means to collect usefully relevant information; then to examining and discussing it on a weekly, monthly, and annual basis. Again, this is not about strategic planning. This is an ongoing managerial methodology. This is a paradigm shift. Initially, this will require a good bit of effort. Naturally. It’s something new. It’s a sea change from how things have been done before. However, once the right systems are in place for data collection and scrutiny, and both management and staff are truly comfortable with this approach as a standard operating procedure, it quickly becomes second-nature. It’s not something that occasionally occurs apart from your work as healthcare professionals. Rather, this must become an integral part of everyone’s obligations. Real, substantive change of the sort I’m talking about cannot be achieved without looking at and evaluating data, without identifying specific operational practices that can be objectively measured, and measuring these regularly. If you treat this process as an educational moment for a select group of employees or a team-­ building exercise for the department, you might attain some nominal improvements, but they’re unlikely to be lasting. Unless this is systematically woven into your how-­ things-­are-done-here mindset, the successes achieved from a short-term initiative will decay over time.

7.4

Data in Action

Here’s an example of data power. In our department, we saw an increase in readmissions, but wondered whether all of them were really necessary. We didn’t need to examine every patient’s chart or engage in a lengthy conversation about the cases.

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Percentage of hospital readmissions

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Fig. 7.1  Percentage of hospital readmissions within 30  days of initial discharge. (Credit: Nofar Rada)

In fact, it didn’t take long for us to devise a quick method to acquire an answer to the question. We implemented a policy that required an approval from an attending physician for each readmission. As soon as we agreed that readmissions would no longer be automatic and that a senior doctor had to sign off on them, readmissions dropped by 50% (Fig. 7.1). It was such a simple thing. By putting that one self-screening pass gate in place, our residents had to stop and think if they could really justify a given readmission decision to the chief. We also believe that our readmissions have gone down due to overall improvements we’ve made, which have seen complications and extended hospitalizations decrease (Fig. 7.2). Of course, there are lots of situations when readmissions are urgent, advisable, and sensibly erring on the side of caution. All the same, in many other circumstances, an extra moment’s worth of consideration can just as easily lead to a professionally sound decision that’s enough say, to send a patient home with antibiotics and a referral for a follow-up visit to the outpatient clinic.

7.5

Instrumentation

Another important tool whose use I encourage is what I call The Dashboard. This is taking advantage of readily available and/or relatively easy to develop technology to create the means to look, in real time, at what’s going on throughout a department. What’s happening in the OR? Do any problems need resolving in the emergency room? Are there lengthy waits in the clinic? How are in-ward inpatients doing?

7.5 Instrumentation

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Percentage of hospitalizations over 21 days

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Fig. 7.2  Percentage of severe complications/hospitalizations over 21 days. (Credit: Nofar Rada)

What’s the status of patients being cared for in other departments? This needs to be a robust and comprehensive tracking system that’s capable of providing updates as soon as any given situation changes—minute-by-minute, hour-by-hour, day-in, day-out. One could be on a beach in the Maldives and still know precisely how things are back home (unless, of course, you live in the Maldives). The Dashboard is total transparency. It’s a powerful tool and it’s for everyone— from the manager to the attending physicians to the residents and nurses to the administrative staff. Its most obvious benefit is that it immediately projects the user into a department’s here and now. If something requires adjusting, if a colleague needs a leg up, if a crisis looks like it might be pending, seeing it on The Dashboard means a lot of tiny fires can be put out before they even have the chance to flare up. The Dashboard is a greater asset still because it acts as preventative care for departmental operations. The lack of efficiency in many hospital departments is frequently due to the fact that there’s no transparency. Everyone is tending to their own corners of the department without there being any way to gauge whether or not things are proceeding as they should. This tool prevents a lot of problems from ever occurring simply because it reinforces self-motivation. Take but one example: Clinic waiting times. Let’s say your department decides to examine this metric. You select a methodology to collect data over a defined period of time. From the numbers, you discover that, on average, from check-in to greeting a caregiver, patients are sitting in the waiting room for 45 min. This is not an irrelevant abstraction. As is, your clinic can only schedule and serve a certain number of patients on any given day. But what would happen if you could cut that average wait time by one-third? How many additional patients could be scheduled? How would that impact service figure totals over the course of a year? What would an increase in annual consultations represent to your institution in terms of revenue?

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This, then, becomes your departmental goal. Your team discusses the problem, carefully examines the obstacles, and devises a plan, which is put into action. You’re measuring what you’re doing. The Dashboard would come in mighty handy here, wouldn’t it? The data transparency it provides keeps everyone honest and on target by evidencing whether things are proceeding apace or if there’s something lacking in the implementation of the plan. If it needs adjusting or someone’s encountering difficulties, these bottlenecks can be discussed and wrinkles ironed out. And you know, if you’ve really bitten off more than you can chew, the data will let you know if you’ve been too ambitious. Data helps to identify problems, quantify their severity, establish achievable goals, and set forth plans, which may be modified (or abandoned), as necessary. No data, no progress. Which brings me to data analysis.

7.6

Get Retro

Real-time information is great, but it’s only context of the moment. Substantive, long-term growth in service and efficiencies must rely on retrospective analysis of results. Once again, in many departments this rarely happens. To the degree that it does occur, it’s staccato and stagnant. It’s a monthly meeting or an annual review. As there’s not enough time to drill down deep into the data, the exercise is more review-and-summary than an effort to dynamically interpret and apply analyses and conclusions toward solutions whose results, themselves, will be measured and revisited frequently. A retrospective analysis should examine everything that can meaningfully be measured in your system. You want to look carefully at every possible data point and decide first whether it is important or not (i.e., does it offer substantive information regarding the target function and, if so, is the data an accurate and useful reflection of what it’s measuring). You’ll then prioritize what data is most necessary to gather, and determine what data in combination will paint more illustrative and informative pictures. You’ll crunch your departmental numbers and extrapolate from them the stories they tell. From there, you’ll apply course corrections, overhaul approaches, abandon old ways, and develop new initiatives. This is an ongoing process. Over time, you’ll develop more items to measure for which additional data will be collected and synthesized with other data. Through retrospective data analyses, you’ll find many a beast to kill. For example, one year you might choose to look at your complication rates. The raw, complications figure isn’t very meaningful. So, you’d establish a structured data collection and analysis protocol to measure, for example, your weight of negative margins, results following complete tumor resections, etc. You might want to reduce hospitalization times so patients can safely and sensibly be discharged. Or you might want to see your readmissions numbers decline. In each instance, you’d necessarily scrutinize different measures simultaneously to see which within a given question are dependent upon, associated with, or impact another. This will trigger diagnostic problem solving: How and why are particular things happening? What can we do to improve? Having put certain changes into effect, did we get better or worse? How and why? What next?

7.7 Resource Limitations?

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The demands upon and resources available to different departments and different institutions may make it less possible to carry out retrospective analysis sessions on a weekly basis. So, how often should they be held? The short answer: As frequently as they can be conveniently scheduled and result in meaningful advancements. If weekly doesn’t work, make it every 2 weeks, or monthly. If even that’s too much, do it quarterly. The point is to make a serious and dedicated effort. As you accrue victories, you may discover that you’ve created efficiencies sufficient for you to schedule more sessions. You might even realize that these are your indispensable pathways to progress. Data should ultimately serve as an objective measure of success. And success is pride. It’s motivation to take on subsequent, measurable challenges. It’s individual, departmental, and institutional reputations which, in turn, are about demand for service and bottom-line revenues. As such, consider doing what every publicly held corporation in the world is obligated to do: Publish an annual report. Present an executive summary from the departmental chief; offer a departmental profile and management analysis highlighting significant challenges and achievements of the year gone by; and transparently disclose your numbers be they good, bad, or indifferent, along with year-on-year comparisons. When you first do this, you’ll gratify some and astonish the rest. Everyone in the medical profession acknowledges that this sober, sometimes life or death business of healthcare is about people’s lives and welfare. Anyone can say they put their patient’s first. A report like this demonstrates to all the world that you’re bound and determined to stand by objective data that proves your commitment to this ideal and to doing better.

7.7

Resource Limitations?

Having said all this about objective measures, data collection, retrospective analyses, and the strategic improvements that can result from this work, it begs the question: Why, in the third decade of the twenty-first century, aren’t these a part of the standard operations of all hospitals. The answer is that most departments and institutions don’t think it’s possible. To the degree that they believe it can be done, they’re concerned that once this data is available, they’ll lose control over it. Besides this, many don’t yet accept that the type of data I’ve been discussing is what bears on their ability to create efficiencies, to serve more patients, and improve the delivery of healthcare services. The attitude that remains fairly entrenched among hospital administrators and medical professionals is that the only limiting factors are the numbers of doctors, nurses, therapists, and so forth, and the amount of other resources available (financial, physical plant, equipment, etc.). They’ll say, “Why do I care about quantifiable results? The only important results are what we’re doing every day; the people we’re treating.” There’s a built-in assumption that everyone is working at nominal or better capacity, and no one can control, much less optimize, the internal environment any better than it’s currently being done. If you begin with the presumption of 100% efficiency, and the idea that growth can only occur with more money, more people, more space, then it’s no wonder most professionals think it’s a waste of time to look at the data. No new resources, no improvement. Simple.

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The reason to take a deep dive into the data is, of course, that it tells a breathtaking, myth-bustingly different story. As I’ve emphasized throughout this book, most healthcare systems aren’t being held back due to a lack of resources; they’re being inhibited by inefficiencies (which in some cases are quite massive indeed). It’s not about resources, but resource management. I’ve shown where our department has produced substantial, far-reaching, and sustainable improvements without the need to acquire much in the way of additional resources. We’re not superheroes, we just created order, accountability, and efficiency. What we’ve done, you can do, too.

7.8

 aking Change Imperatives an Imperative M (and Nearly Automatic)

When our department first began to seriously examine performance metrics, we were analyzing data on a quarterly basis and making decisions regarding how we could improve on a quarterly basis. It rapidly became apparent that 3 months was too long a lapse between setting into motion one set of initiatives and another. We would implement certain changes which weren’t working as well as anticipated, but we weren’t adjusting to circumstances and evidence fast enough. The lack of more immediate responsiveness meant we were losing focus and momentum. As there was nothing we were learning about the effectiveness or ineffectiveness of a given change from 90-days’ worth of data that we couldn’t already see in a 30-day data set, we quickly shifted to monthly reviews. Additionally, to make even faster changes, with assistance from our institution’s IT department, we established the means to acquire as much meaningful data as possible through online methodologies. One of the tools they developed for us was a real-time map, which shows what’s happening across our department. With it, we can see, for example: • The distribution of our patients throughout the hospital • The time, ward, and operating room in which any particular surgery began and was concluded Whether through the use of a custom-designed app or adapting one that’s commercially available, there really are no good excuses not to include modern, networked technologies in hospital department management today. This type of transparency allows for the instantaneous observation of efficiency in motion or the lack thereof. In our case, the daily surgical schedule begins at 8:00 am, with 30 min between operations. Even factoring in the possibility of a complication arising in theater, for practically all surgeries, there’s an anticipated time window in which they’ll take place. If our system shows a late start or a given operation running beyond a particular window, we can make an immediate inquiry or, at least, take note of anomalous activity and address causes and circumstances within a day or two. Equally, we can monitor our patient flows in the emergency room. We can see the total number of patients and how long each has been waiting to see a doctor. Other than critical cases, an hour’s wait is reasonable, 2 h acceptable, but more than that raises concerns that need to be investigated and potentially addressed. Waits beyond

7.9 The Summit

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a certain limit are red-flagged, as are issues regarding tests (i.e., which patients are waiting longer than 24 h to be tested or have their test results examined and a follow-­up consultation scheduled). A rapid response-enabled system like this is ideally suited to data that doesn’t require time for number crunching and analytical reports to be written. The problems it spotlights are unambiguous, even if the reasons why they occurred are not. This said, most of the time the reasons are clear-cut, often having to do with inadequate preparation, detail oversight, staff lateness, etc. These are not difficult problems to solve. What’s more, the system assists with sensible burden sharing. For example, a chief surgeon or a head nurse may be reliably punctual. Staff lateness may not be their fault, but they do hold positions of influence and managerial power (and are already modeling good behavior). Knowledge of their consistent, on-time performance can allow a department head to direct them to oversee their areas of operation more meticulously. They can, thereafter, be held to account for actions they did or didn’t take to improve the performance of those in their charge. Often, a word to the efficient is sufficient to get folks to be more attentive and punctual. System-produced data may also be repurposed to create tag clouds (also known as weighted lists), which can be used to visually depict individuals and/or operational areas that are experiencing more and fewer problems. As the crux of most cases are about personal responsibility and accountability, no one wants to be the name appearing in the biggest text. Accordingly, it really doesn’t take much effort at all to effect significant improvements in efficiency. After the first few conversations are had regarding system-spotlighted issues, performance statistics improve dramatically because team members know that unnecessary lapses won’t go unnoticed. As a result, the existence of the system helps reinforce standards and benchmarks. Beyond this, it takes very little to build in add-ons, such as an auto-generated text or alarm notifications when a surgery starts late or a patient is waiting over 2 h to be seen; or one that automatically sorts data, creates charts and graphs, and produces weekly, monthly, and annual reports. The latter is especially valuable when examining mid-range and long-term trend lines related to the core measurements of essential operations. In fact, this type of functionality now makes it possible and very easy for our department to issue our corporate-like, year-in-review reports. This helps us to place in stark focus how efficiencies are vastly expanding the numbers of patients we can serve, the savings we’re generating, and the revenues we’re producing.

7.9

The Summit

You can see that it doesn’t matter where your department is on the efficiency scale. Noteworthy gains are relatively easy to come by. However, if you really want to reach peak efficiency with all current resources at your disposal, you’re going to have to examine those final few percentage points carefully to determine what’s keeping you from the top. One such item that was holding us back from peak performance had to do with hospital discharge documentation. Our numbers were showing that 5% of our inpatients were being released before a medical certification report had been filed. When

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we investigated why this was occurring, we discovered that some team members were issuing discharge paperwork without this accompanying medical report. We solved this problem by implementing a computerized, two-step pass gate system. Now, a discharge can only be executed if a discharge order has been completed and a final physician’s report is filed. If one of these is missing, red light; the patient cannot be released. This may seem trivial, but it’s not. Just because a doctor intends to discharge a patient doesn’t mean complications or circumstances won’t arise between that intent and the reality of the discharge moment. Overlooking that final reporting step can result in premature release and eventual readmission (the latter being a core measure that we’re always keen to keep as low as possible). We’ve also built out other systems. For example, while late starts in the OR or excessive delays between surgeries still trigger auto-generated app alerts, we now include a “Reason” field in surgery reports, which must be completed for non-on-­ time cases. In this way, we don’t need to get into the vagaries of memory. This is particularly helpful in detecting patterns of causation, which may require more dedicated attention to resolve. What all of this points to is the progressive power of persistence. Personnel need to know, believe, and experience change as way of life, not a novelty. The collective impact of consistently doing things right is instilling a sense of momentum within all involved. It’s creating an army of change agents who understand and embrace change as inevitable and positive. Planning a change agenda amounts to very little if it doesn’t result in the production of executable plans. Seemingly executable plans can fall flat if management and/or staff are too lax or too rigid. The ability to nimbly make well-considered course corrections (or, as necessary, rapidly move on to Plan Bs) is an asset. Lasting change will never be firmly rooted if change initiatives are sporadically introduced with little or no coherence between one project and another. Erratic implementation and enforcement are also to be avoided. Shrewd strategies are constructed as much around desired objectives and outcomes as they are upon the fundamentals of human psychology. Establish early goals which are the least disruptive and taxing, yet are eminently achievable. With each new victory, people will be willing to devote more energy and effort toward the attainment of more complex goals, just so long as the realization of those ambitions deliver both departmental/institutional efficiencies and professional/personal rewards. There are, of course, limits to efficiency gains. However, for most hospitals and other major healthcare facilities, reaching those frontiers is a long way off. This is because they’re not even aware of the remarkable productivity to be had from everything right in front of them at this very moment. Smart institutional leaders who take up the efficiency banner and produce the type of results that have been demonstrated in these pages will be heroes to their boards. But department managers don’t have to wait for institutional mandates or even, in most instances, approvals to undertake efficiency initiatives, as managerial job descriptions already tend to call upon professionals to manage the resources at their command as efficiently as possible. Accordingly, if you’re a department head, you’ll just be doing your job if you embark on a change agenda in pursuit of efficiencies.

8

Crises

“A crisis is an opportunity riding a dangerous wind.” —Chinese Proverb

© Springer Nature Switzerland AG 2021 Z. Gil, The Healthcare Efficiency Revolution, https://doi.org/10.1007/978-3-030-61232-0_8

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8.1

8 Crises

Lincoln

If you’re in management, particularly upper-level management, you may be an excellent organizer, you may be a tremendous visionary, you may be beloved by one and all on your staff. But if you lack fortitude in times of crisis, you may find yourself being dragged down and defeated by adverse circumstances. Dramatic incidents involving accusations of scandalous, even criminal activity can occur through no fault of your own. Nevertheless, leadership demands that you have the intelligence and composure to cope with the stress and turmoil that accompany such moments. What you do and how you behave when crisis comes can define your career or send you packing, looking for another job. The impacts of a serious incident are almost never isolated to those accused or proven to have been involved in wrongdoing. Team cohesion and morale can suffer profoundly. Superiors may question why and how it could be that you were unaware that rules, regulations, or laws were being violated. There may be scrutiny from the press. And then there’s public perception. You could fill a library with all the books, articles, documentaries, stage plays, movies, and TV programs about Abraham Lincoln and, in particular, his presidency, which precisely spans, end-to-end, the Civil War years in the USA. Much has been said of his “team of rivals” cabinet members, as well as his battlefield generals. But for all the discussions and debates between themselves, only one person had the awesome and sober responsibility to make those life and death decisions. Only one person was ultimately accountable. A five-alarm fire disaster won’t announce itself. No one’s going to ask if you’re ready. You may be able to consult with your team, but they can’t do the job for you. You have to have the stomach to navigate an emergency and the finesse to address the unique concerns of the several constituencies you’ll face. If you don’t possess those personality attributes, content yourself that you, too, might be consumed by the conflagration, or maybe you’re really not best-suited for a leadership role. Even if you can handle a given crisis with all the requisite skills, a deftness of touch, and never striking a false note, you might still find yourself being asked to resign. You might even resign of your own accord. Whether you’re pushed or you jump, the decision is often reached simply because the aftermath of crisis demands a house cleaning. If only due to professional proximity, a completely innocent manager sometimes needs to be sacrificed in favor of new leadership. If the resignation option is purely in your hands, you might opt against it, genuinely believing that you’re the best person to lead in a crisis moment, that anyone else will not handle things as well as you can. Although this may well be so, it’s wise to recognize that this is just another form of the “I’m irreplaceable” fallacy. You might also object to resignation because doing so could make it appear as if you are in some way involved in or responsible for the crisis, even though you had absolutely nothing to do with it. You’ll worry that this could prevent you from getting another managerial job or keep you unemployed for a lengthy period of time. Your professional prestige may be on the line. Your family life may be disrupted. You may be torn between what’s best for the greater good and what’s best for your good.

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What’s the right decision? There is none. Only you can sift through the multiplicity of facts and factors, and reach a conclusion. Whichever way you go, it won’t be perfect. Although resignation may be the bitterest pill you’ll ever have to swallow, just remember that it’s not an uncommon prescription for the ailment of institutional shame and embarrassment.

8.2

Rule #1

At some point you will need to deal with adversity. That’s life. So, forewarned, forearmed. You don’t live in dread of the arrival of a potentially calamitous moment. That’s paranoia. On the other hand, never be overly self-assured. Don’t get cocky. You’ve got smarts and experience. You know what constitutes straightforward action and proper procedure. You’re also aware that associated with these there exists a spectrum of variation and anomaly. In theory, you’re prepared with the necessary knowledge to handle almost anything that might come your way. So, you’re suddenly facing adversity, maybe a crisis. Now what? Rule #1: Face the hard truths. More than any other mistake in management, that one tops the list. Don’t dodge, deflect, or deny that what you’re seeing is what you’re seeing. Trust your instincts and remember that you can’t develop a valid, potentially life-saving plan if you ignore reality. I’ll give you an example…

8.3

The Map Is Not the Territory

In pre-GPS days when I was in the army, we navigated with maps. On one occasion, our unit was supposed to be between two mountains and next to a valley, with a river nearby. At least that’s what was printed on our foldable piece of paper. The problem was that we couldn’t see two mountains, only a medium-sized hill. There wasn’t a valley. And the small stream ahead hardly qualified as a river. So, we had two choices: • Rationalize the situation: That small hill? “Must be one of those big mountains on the map.” The stream? “Must be the river.” The other big mountain the map said was supposed to be 300 meters away. “Must be that mountain about three kilometers off in the distance.” We could have contented ourselves that we knew exactly where we were, everything was fine. • Accept the hard truth that we were someplace other than where we thought we were, admit it to ourselves, double-back to the last position where we were certain we were in sync with the map, and begin again. Had we gone with the first option, we’d have plodded on for several more kilometers before coming to the conclusion that we should have trusted our eyes and instincts, which were telling us that something was off base. By then, we’d likely have wasted so much time and gotten so lost that the possibility of backtracking to a known location would have been impossible.

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In that instance, the stakes were pretty low. Those were just training maneuvers. Sometimes, though, hard truths are literally about life and death.

8.4

Sixty Seconds

I was once part of a team of skull base surgeons working in the operating room. During the course of removing a tumor, one of the surgeons accidentally injured the patient’s internal carotid artery, which is the main artery into the brain. It’s a very rare, crisis event. Start the clock. In general, from the second this occurs, there’s approximately five golden minutes to correct the injury. Survival (including the avoidance of brain damage) requires the laser-focused reactions of several people. The cornerstone of such an event is for the lead surgeon (and, indeed, the whole team) to acknowledge the hard truth as quickly as possible. The sooner that every professional in the surgical suite recognizes what’s occurred, the sooner they can activate emergency measures that must be orchestrated simultaneously. Everyone is highly trained and experienced. Everyone knows what to do. But if there’s a failure to perceive reality clearly, there’s no way to respond appropriately. And that could result in permanent damage to the patient or even a loss of life. Once the team (anesthesiologist and nurses, included) accepts what’s happening, lightning-fast planning and subsequent actions will follow. Had this been an open-skull procedure, the injury would have been readily apparent and the solution—applying a clamp to stem the bleeding—practically instantaneous. In this case, however, with surgery taking place through the nose into the brain, the artery couldn’t be clamped. This meant that we had an extraordinarily short amount of time available to us before the situation turned dire. On this day, the problem was that the operating team wasn’t facing the hard truth. He reacted as many would do, denying the fact that the carotid artery had been nicked. At that moment, my task was to convince my colleague otherwise. Thankfully, with a surgical navigation system at our disposal, this took very little doing. I placed the stylet in the location of the injury and there was the CT evidence that the artery was bleeding out. Thirty seconds have passed. Hard Truth #1 was firmly established, adjunct personnel were immediately called in—two anesthesiologists, four nurses, and several technicians. With the emergency response team assembled, a plan could be developed. However, most plans aren’t abstractions. They’re not just dry steps to follow out of a textbook. They involve people and time. At that moment, we had very little of the latter to spare and quite a number of the former (in that operating theater and on other floors) who needed to be corralled. Stat! If a given surgery is proceeding without incident, not everyone in the OR is in the same mental or physiological state. Therefore, a crisis demands a galvanizing, snap-­ to-­attention announcement: “We have a situation, an internal carotid artery injury.” Nine words and everyone hearing them knows exactly what is his or her immediate

8.5 The 70% Rule

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responsibility. A whole series of emergency actions are triggered regardless of what choice is ultimately to be made to stabilize the patient and resolve the crisis. Forty-five seconds. There’s about 15 s left to act. The next, most logical thing to do; the first, best option is to buy more time. If a surgeon sees blood during the normal course of an operation, there’s an intuitive solution: apply the suction tool. But a crisis can often require tossing aside standard practice intuition for what the hard truths compel you to do. The patient was bleeding out from a major artery. Applying suction would have only exacerbated the problem. Hard Truth #2: Stop the bleeding. To have panicked and acted intuitively would have made a bad situation worse and wasted more time, entirely the opposite of what our hard truths required. The best, most immediate option then was to get a sponge, put it in the hole and physically hold it there until the patient’s blood pressure rose to just above 120-­millimeters of mercury. Which we did. And we stemmed the bleeding. Stop the clock.

8.5

The 70% Rule

As soon as we addressed the most intense part of the crisis, everyone could calm down. Phase 1 of our plan was successfully completed. We were all in sync and ready to consider Phase 2, which involved an assessment of the immediate environment, including obstacles to avoid, bypass, or overcome. Our patient lost blood, which meant other problems, including low blood pressure, decreased urine output, and coagulation issues. Those all needed monitoring and attention. We had to order more blood to be transfused, medications to raise the BP, and get platelets ready in case of clotting difficulties. However, those were all fairly straightforward matters. So far, so good. We had faced the hard truths, understood exactly where we were, and selected the equipment necessary to meet the moment. Nevertheless, even with the time we had bought to think, we still had a situation on our hands. Our patient’s internal carotid artery wasn’t bleeding out, but neither was it repaired. We had two options at our disposal: 1. Take the patient one floor down, to an endovascular suite where specialists could execute a procedure that would cauterize the wound. 2. Fix the artery ourselves. On the golf course, when you’re faced with a difficult situation, you’re frequently advised that your optimal choice is to select a club that you know you can play with successfully seven out of ten times. If I’m confronted with an obstacle that requires me to hit the ball 200 yards over a tree, then, theoretically, the best club for me to tackle the task might be a 4-iron. Now, if I was Tiger Woods, I’d surely go with that

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(since he’d likely make the shot ten out of 10 times). Me? I’m a 14-handicap player. With a 4-iron in that situation, if I’m lucky, I’d have four out of ten odds. Since I’m not a big gambler and my objective is to hit successfully seven out of ten times, I’d stick with the 70% Rule and choose a 7-iron. That’ll likely buy me 160 yards. More importantly, the likelihood of my ball hitting the tree (and taking me even further from my goal) will be low. These odds of success include more than the calculus of matching personal skill and the right equipment to a given moment. When you minimize unnecessary risk, you reduce tension and anxiety, and increase your confidence. This allows you to focus better on your objective. You’ll thereby be more likely to succeed, which will make you feel more capable of tackling the next problem that comes your way.

8.6

Worst-Case Scenario Planning

As with so many other crisis situations in medicine, with our internal carotid artery patient, there was a solution scenario most likely to satisfy (or do better than) the 70% Rule and a worst-case scenario in which 10-20% of patients in a similar circumstance would die. Selecting a scenario that’s safest and more likely to produce the most positive outcome for a patient is always going to be the crisis solution that’s best for any medical institution. The reputations of successful, well-respected physicians and surgeons aren’t built upon them being daredevils and dice rollers. So, we considered the relative merits of the endovascular method versus the DIY approach. Purely from a procedural standpoint, the former was, hands-down, the best option. The big question was wonderfully summed up by these few words on a billboard that a major carrier put up just outside Chicago’s O’Hare Airport many years ago: “Until we get the beaming thing figured out.” Sure, if we could have called on Mr. Scott, said “Energize,” and had our patient instantaneously materialize in the Endovascular ward, that’s the route we would have taken. But a transfer to another floor would have required us to place the patient on a different bed, apply another type of anesthesia, physically maneuver down corridors, and get into and out of an elevator, all the while with my finger firmly holding down a sponge to stanch the bleeding. There was a lot of process and risk involved in simply getting to Endovascular. I estimated that our chance of pulling it off efficiently and effectively was 50% at most. It wasn’t a 70% Rule solution, so we nixed that option very quickly and decided we’d repair the artery ourselves. Once we made that decision, everything else fell into place. We knew what we needed to do because it’s all been done before. We had knowledge of and experience with existing, textbook procedures of how to accomplish the task. Objectively, comparing our surgical approach to that of our endovascular colleagues, there was no contest. Endovascular would have been the preferred way to go. The obstacle was getting there. Worst-case scenario planning and the sensible application of the 70% Rule reduced the chance of catastrophe to zero. What weighed most in the balance was choosing the approach most likely to result in patient survival and optimal recovery under the circumstances.

8.8 Error Types and Negative Opportunities

8.7

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Big Time Ancillary Benefit

The option we chose not only left us with plenty of room within which to maneuver, stop the bleeding, and resolve the crisis. We even managed to achieve our initial, primary objective, which was the removal of a tumor. This was exceptional on a number of levels. It’s better that we were able to tell the patient that a significant problem occurred during surgery, but the primary procedure was successfully completed nevertheless. If we had not been able to complete the surgery (and certainly if we had gone the endovascular route), we would have had to saddle the patient with the mental burden of the surgical error and a still-unremoved tumor. Worse, as a result of the carotid injury, no one would have re-attempted this surgery. This would have left the patient with a botched operation and a serious cancer yet to be dealt with.

8.8

Error Types and Negative Opportunities

In management, there are three types of errors—mental, execution, and strategic. In some situations, one sees these occurring in pairs, if not all together. Mental errors include being too rigidly adherent to certain concepts or procedural approaches, or simply ignoring hard truths. Execution errors include not understanding obstacles, how to overcome them, and how to develop and deploy valid models. Strategic errors include taking risks, not allowing for time and space within which to maneuver, and not complying with the 70% Rule. Here’s a few childishly simple words to live by: Never indulge negative thinking. This isn’t only about considering a goal and avoiding telling yourself, “Oh, I’ll never be able to do that.” It’s more than boosting your confidence. In hospital situations, negative forces can be a literal killer. Patients can die, institutions can collapse, you can get sued or fired, or both. In life, you’re always being presented with negative opportunities. Learn to trust (or at least train) your gut to shun any impulse that will lead you toward these. This has to be balanced against overconfidence and cockiness. Sometimes you can feel it in yourself. You want to take bold action, but there’s something inside that’s telling you you’re not ready. Something just feels wrong and you know, instinctively, whatever you’re considering isn’t going to work. What do you do with that urge? Walk away. Clear your head for a few moments. Then, come back and reconsider. Try again without the clutter of all those negative thoughts. Remember, if you think that you’re going to fail, it’s more than likely you will. Thinking positively about how your actions can achieve what you want to accomplish allows you to orient your thoughts toward solutions. Negative thoughts are the basis of reasons for failure.

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A COVID Case

Early April 2020. Sunday morning. It’s the height of the first wave of the coronavirus crisis. Phone rings. Senior attending physician on the other end says, “You need to operate on this guy.” Fine. “What’s the reason?” I ask. “Patient needs a tracheostomy tube,” is the response. I reply, “No, that’s the procedure. The reason is something else.” After a bit of sputtering, I’m offered, “The guy’s been intubated for 3 weeks. Now we gotta do the operation.” I start getting suspicious. I try again: “Wait a minute. You’re still not giving me a reason for this surgery.” I paint a picture, “Look, if this fella has an airway problem, I’ll do the operation to save his life. If I can’t save his life, maybe I can buy him more time. If he’s in agony, I’ll do it to alleviate his pain. Those are reasons.” Once more I press to know what’s behind this operation; what’s the objective. The response: “Okay, lemme think about it. I’ll get back to you.” Under normal circumstances, placing a tracheostomy tube is a straightforward affair. We have a checklist. If certain criteria are met, we perform the operation. If not, we pursue other treatment options. Establishing that there’s a good reason for doing this surgery typically doesn’t require an enormous amount of thought. But the COVID-19 era is hardly what one would call a typical time. Next day. Another phone call. Different doctor. More of the same: “The patient has been intubated for 3 weeks and he needs the surgery.” Again, I ask the reason. Finally, the shoe drops: “He’s a coronavirus patient.” I said, “Fine, but you need to understand that this won’t be a routine operation. To get him from the COVID ward to the OR, we have to shut down the corridors he’ll be traveling through. That’ll require blocking off a significant amount of the operating theatre. It’ll potentially place everyone involved in the patient’s transportation at risk, let alone the risks to be faced by the surgical team. So, let’s consider again if it’s expected that this procedure is going to help this gentleman.” COVID-19 had already compromised the patient’s health in a variety of ways. Beyond the prolonged need for ventilation, his liver was barely functioning, and he was on the verge of multiple organ failure. The patient’s condition was bad. It wasn’t likely to improve with surgery. Even the odds of short-term survival were pretty slim. Nevertheless, a life’s a life. So, I agreed to the procedure, but asked my colleague to re-evaluate the patient’s current condition carefully. If it would be his professional assessment that the man had a chance of recovery, we’d get him into the OR as quickly as possible. It was a judgement call and this attending physician had to make it. Still, I offered to go to the COVID ward myself, to observe the patient, and discuss how we might best proceed.

8.10 The Choice While waiting for a go/no-go decision on performing this surgery, I was turning over in my mind several issues. The preliminary facts suggested a very high probability that this patient was going to die with or without the operation. It was,

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therefore, not unreasonable to wonder if doing the tracheostomy would be pushing our institutional systems to the edge. Several colleagues at an Ivy League institution in the USA had already told me that they weren’t performing surgeries on COVID-19 patients. Their conclusion was that unless and until a coronavirus patient survived the disease, such operations were of extremely limited value, clinically speaking. Plus, setting aside the added expense of time necessary simply to prepare for any of these surgeries, such operations place surgeons, medical, and other hospital staff at risk. Weighing together the risk-benefit ratio and the capacity to adequately care for the totality of their patients led them to decide against COVID-patient surgeries. In our situation, if the tracheostomy was going to happen, a qualified surgeon from our team would need to do it. I had six options: 1 . Ask for a volunteer. 2. Tap the individual whose prolonged absence from duty would be least disruptive to the hospital. 3. Select the youngest individual with no (or the fewest) associated risk factors. 4. Choose the most experienced surgeon. 5. Draw straws. 6. Lead by example; as departmental chief, do it myself. Let’s examine these individually: • Asking for a volunteer. • Pros: The idea is to convey a message of fairness. Everyone on staff gets together, a volunteer is requested, someone offers to do the job. Risky missions throughout history have relied on brave souls ready to put themselves forward for some greater good or higher calling. As it’s preferable to have someone who wants to do something rather than somebody who doesn’t, requesting a volunteer will tend to raise the fewest objections from the team. • Cons: Volunteering introduces a high degree of randomness into the equation, not least because it sets aside all other considerations or potential screening criteria in favor of a single factor. But what if the volunteer isn’t the right person for the job? What if the volunteer is over age 50 and/or has underlying health problems? Further, when a departmental manager asks for a volunteer, it establishes a paradoxical situation because the person asking the question is implicitly not volunteering. If a chief decides to lead by example, the matter is summarily closed. Staff are informed that they’re being kept out of harm’s way and that’s that. • Upshot: Seeking a volunteer isn’t an invalid approach, but it may be seen as less strategic than some of the other options. And as it clearly exempts the chief, that individual is well advised to have a better excuse for not being among those who might potentially be chosen than, “It’s good to be the boss.” • Tapping the individual whose prolonged absence from duty would be least disruptive.

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• Pros: Staff are in the middle of a crisis situation and under considerable strain. They’re working longer hours and unusual shifts. The nature of their work already places them at increased risk of contracting the disease. If any one of them is exposed or gets ill, and must be removed from the workplace for several weeks, colleagues will need to step in to take up the slack. Therefore, it can make good sense to select the individual whose absence will be low-impact on the overall flow of departmental operations. • Cons: Even if this actual reason is never stated openly, it may be reasonably surmised by others, including the person selected. The messages being sent are “least valuable” and “most expendable,” which are neither team fortifying, nor votes of confidence in the person being given the assignment. • Upshot: This is a cold calculation. It may be strategically wise in the short term, but could have some negative consequences on staff cohesion and morale down the line. • Selecting the youngest individual with no (or the fewest) associated risk factors. • Pros: Similar to the option above, except in this case the gamble is that youth and relative good health will offer greater odds of protection against contracting the disease and, if infected, an increased chance of a full and speedy recovery. • Cons: On a larger scale, youth suggests less experience, which can present an increased risk of running into problems during surgery that may cause infection not only to the surgeon but also to the rest of the OR team. A more seasoned professional may be aware of surgical options to minimize this risk. If the young surgeon encounters a difficult-to-handle complication, there may be the need to bring in assistance from a more experienced doctor. This extends the risk and renders moot the strategy of selecting the youngest surgeon. • Upshot: Still a cold calculation. The difference is it will be a clinical determination based upon a medical evaluation of the staff. The only serious repercussion that could come from choosing this route is if it backfires in the ways described above. No one would be at fault, but people are people. If something goes wrong, someone will always say, “You should have done something else.” • Choosing the most experienced doctor. • Pros: A “just the Facts, ma’am” decision. A usual sort of surgery being performed on an unusual patient demands the experience and instincts this professional can bring to the OR. If anything out of the ordinary should occur, it’s best to have the best with scalpel in hand. • Cons: Experience implies age. With age can come particular health problems. Both can increase the risk of contracting the disease. • Upshot: Yet another cold calculation. It’s perfectly sensible if the needs of the patient are the only consideration. But they’re not. If this surgeon should become ill, the hospital loses a high-level professional for a period of weeks or months. If the doctor dies, hundreds, if not thousands of patients will be denied the very knowledge and skills which motivated invoking this option in the first place. • Drawing straws. • Pros: From the department chief to the newest attending physician on staff, it’s an all-in strategy.

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• Cons: Although all participants would be deemed qualified to perform the surgery, it may still be a less than satisfactory outcome if the least experienced person winds up performing the procedure. What if some participants oppose the process (either because they think it shouldn’t be based on luck or they just don’t want the assignment)? What if someone pulling the short straw is at increased risk of infection, has young children or other, mitigating family considerations? • Upshot: This approach is totally random, completely egalitarian. Taken at face value, it should result in the fewest and least vocal objections from the team. Nevertheless, the cons here suggest the possibility of negative impacts on the staff if the selected individual falls ill. • Leading by example. • Pros: COVID-19 is a genuinely scary disease. Like anyone else, medical professionals have spouses, children, parents, and others in their personal lives to worry about. Common sense and a reasonably self-protective nature will dictate steering clear of danger. But physicians and nurses understand that there may be times when duty will demand them to put their own health at risk to care for the sick. In these moments, a department chief who shoulders the burden and shields other staff from being placed in harm’s way can be quite a tonic for the troops. Even for the most jaded, this will be acknowledged not merely as a gesture of kindness, but an act of courage whose effect may be to bind team members closer together. As they’ve been looked out for, personnel may be more willing to have one another’s backs in the future. • Cons: An argument can be made that a department chief may be too valuable to place in such a risky situation. On the other hand, most of this book is about the adoption of a managerial approach that embraces the delegation of authority; self-monitoring systems; data collection, analysis, regular reporting, and accountability. A department head’s dominance should decrease over time. Therefore, a manager in this situation who’s deemed to be “too valuable” is probably doing it wrong. • Upshot: There are good, team-oriented justifications for choosing this option, which might pay big dividends on the other end. Nevertheless, if a department chief is in any or several higher risk categories, choosing against this option may be equally pragmatic.

8.11 What Would You Do? In our circumstance, we never had to make a decision. As already indicated, COVID-19 had severely debilitated the patient in question. By the time my colleague agreed to re-evaluate the gentleman’s condition to determine if there really was a sound reason for performing the tracheostomy, the patient had passed away. Regardless, the options and arguments presented here will almost certainly be applicable down the line, perhaps for another coronavirus patient, perhaps for a

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patient suffering from a different disease. What’s important to remember is that none of these scenarios exists in complete isolation from the other, and there is no right or wrong answer. It’s a cost-benefit analysis—with factors that need to be weighed moment by moment, institution by institution, resource availability by resource availability. The answer you arrive at today won’t necessarily be the same one tomorrow.

9

Considerations

“They may forget your name, but they will never forget how you made them feel.” —Maya Angelou, American Poet & Civil Rights Activist

© Springer Nature Switzerland AG 2021 Z. Gil, The Healthcare Efficiency Revolution, https://doi.org/10.1007/978-3-030-61232-0_9

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9.1

9 Considerations

Why Management?

In institutions, organizations, and businesses of all kinds, many people find themselves occupying a managerial role. I don’t mean they went to bed one evening, had a visitation in the middle of the night from the Promotion Fairy who sprinkled the Magic Management Dust over them, and they woke up in charge. What I mean is that it’s not uncommon for an individual to be on a career track or encouraged to advance in rank, and they do so, well…because they do. Rising to greater heights of responsibility happens almost by rote. The problem is that the climb up each rung on the ladder often happens because it’s what’s expected, rather than the result of a systematic consideration of motivating factors and options. These expectations can come from any one or a multiplicity of constituencies—yourself, your family, your friends, your colleagues, your employer. Those can be powerful forces. Like being on a conveyor belt, you may feel yourself being propelled forward because you don’t want to disappoint others or yourself. At a certain point, you might discover that you’re living dreams that aren’t yours. There’s frequently not enough time devoted to really thinking through, objectively and systematically, what you might imagine are fundamental questions, such as: 1. Do I really want to be a manager? 2. What does the job entail? 3. Am I prepared to take on those responsibilities? 4. What difference can I make in the job? I can’t emphasize strongly enough the absolute necessity of conducting this kind of self-investigation. Don’t simply mull over these matters in your mind. When analyzing the first question, fold a piece of paper in half, write “Pros” on one side, “Cons” on the other. If you have more positive reasons than negative, perhaps you do want to take on greater professional challenges. Answer the second question by making an exhaustive list of what would be required of you if you got the gig. Go beyond the dry abstractions that typically appear in institutional job descriptions. Examine everything you know about a given managerial position and reflect upon the sorts of things you’ve seen play out in day-­ to-­day reality. Much of that will fit into the printed job description, while others (e.g., crisis management) will not. Question # 3 is about more than a skills assessment, but let’s start with those basics. You know the old saw that goes, “Those who can, do; those who can’t, teach.” Of course, that’s not only insulting, it’s false. Some can do and teach. Others can do, but have no clue how to teach. And sure, there are some who can teach, but can’t actually do. I mention this because there’s a prevailing narrative in medicine that insists you can’t be a good manager if you’re not an excellent doctor. But that’s as specious as the argument about teaching. The skill set required to be a terrific doctor isn’t precisely the same as that for a great manager. Therefore, this question can seem deceptively simple. If you see yourself as a highly competent and accomplished doctor, congratulations! It appears you’re prepared to take on those medical

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responsibilities. Now decide if you can (or, at least, are up to the challenge of learning how to) handle managerial responsibilities and whether you’d actually like to do so. If you get to question #4, but have little or nothing to say in response to it, then you may want to ask yourself a more essential question: “Why do I want to be a manager?” There can be several valid answers. As a manager, you’ll likely be dealing with a wider range of professionals. If you’re reasonably personable, disciplined, and organized, you might be thrilled by the thought of supervising people, as well as overseeing and improving the division in which they work. If this is not an appealing idea, it ought to be a red flag moment. It doesn’t mean you absolutely shouldn’t be a manager, but beware. If you really don’t care to interact much with people, this fact could cause you some serious problems in a management position. Perhaps you believe a particular managerial post will be a more interesting job than the one you have now. If so, you owe it to yourself to, once again, go beyond generalities and abstractions. Ask yourself: “Is it really more interesting?” There may be some aspects of a management job that you’ll find intriguing. You might give those things outsized importance in comparison to what the rest of the position requires. Those other things may be less interesting to you and wind up taking far more time to do than the “more interesting” things you’re seeking. You might want a management job because it’ll mean a bigger salary. And while that’s not an insignificant motivation, make sure you can answer this question: “Is being a manager the best way for me to make more money?” Perhaps there are alternatives that will make you happier. Maybe a particular management position will grant you a bigger paycheck, but prohibit you from engaging in other money-­ making activities. Maybe you’d like to be a manager because there’s an allure to having power and prestige. Fine, but never forget that with added privilege comes extra responsibility. In management, you’ll ultimately be accountable for the professional performance and conduct of others. If something’s not going well, you’ll have to provide an explanation to your superiors. Are you personally prepared to bear up under heavy scrutiny when a serious issue, such as sexual harassment, arises? You may not be involved in a given incident, but what if questions are asked about workplace environment and culture? As a manager, you may be held to task for not having done enough to implement preventative measures. There are endless stories of perfectly honorable managers who have done everything by the book, yet they’re still asked to resign because something untoward happened on their watch. If you’re able to accept that this, too, is part of the spectrum of management, you might have the intestinal fortitude for the extremes of leadership. There can be many good reasons to decline to put your name forward for a managerial position. If skills and experience don’t fit together with a comprehensive awareness of what will be required of you and a real desire to take on those obligations, you might need to reassess whether management is right for you. And remember, sometimes a new horizon isn’t necessarily what may seem logical and

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predictable. Equally, there can also be an optimal level of professional rise. Just because you can advance doesn’t mean you must. You might already have the best, most fulfilling job you’ll ever have. Don’t leave it on a whim or because people tell you it’s time to move on (or up).

9.2

It’s Personal

Managing is more than carrying out your duties precisely as your predecessor did. It’s more than doing what’s expected of you. You have to make the position your own. It’s the difference between paint-by-numbers and creating an original work of art that you can sign your name to. Beyond what you must do, what do you want to achieve and whom do you want to influence? What unique wisdom and vision are you bringing to the table? In my own case, I was (and remain) committed to advancing the concept and practice of patient primacy as the driving force in medical care. Different from those who went before me, different from my colleagues, this has been my aim. I’ve worked to shape everything I do as a manager around the implementation and improvement of this target function. It’s my signature contribution. It’s my personal touch. Remember that there are always new hills to climb and fresh victories to be won. To make a positive, managerial contribution, you don’t always need to create something out of whole cloth. You can take great pride in noticing and educating yourself about an excellent innovation taking place elsewhere, which you firmly believe should be replicated throughout the healthcare system. Disciples of great ideas are often just as important as their originators; sometimes more so because they adapt, improve, and perfect the initial models.

9.3

Square Pegs, Round Holes

You’ve thought through everything about a managerial position and you have good answers for all the questions. Now you need to pick the right place to achieve success. This can be a lot more difficult than you might image. For this, read up on some of the voluminous amounts of material that have been written about the significant corporate culture differences between Apple and Microsoft. Think, too, about some of the biggest corporate merger flops in history (e.g., AOL and Time Warner, Daimler-Benz and Chrysler). On paper, everything about those deals looked perfect. It wasn’t the nuts-and-bolts of business bottom lines that killed those “marriages,” but the mismatch of corporate cultures. You can be an accomplished professional in one organization and easily find you just don’t mesh with another. You’re working in the same profession, you have the requisite talent and background to succeed, and yet you can’t make a difference (or worse, you encounter outright resistance and hostility to your ideas and/or leadership style). Often, the reason for this type of failure is institutional culture. And while many things within organizations can be altered and updated, internal cultures can be the most intractable to change.

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In fact, very often the most elusive piece of information about any organization is the nature and dynamic of its culture. Even the cultures of gigantic, decades-old, and much celebrated institutions can be hard to discern and decipher. So, do your homework: • Try to find articles and news reports about the institution to which you are considering applying. Remember to take those with a grain (if not a boulder) of salt, as some coverage can be agenda-driven or skewed simply because the object of focus is sensational or salacious. • Visit employer review websites, which feature the comments and observations of current and former employees. Be aware, of course, that those offering opinions are self-selecting and their views are quite often highly subjective. • If possible, try to talk with an insider or three to see if you can discretely acquire some candid perspectives on the internal culture. Here, too, there will be subjectivities. A current employee may not want to say anything negative about their employer or their work environment. If you speak with an individual who is a personal friend or close professional acquaintance, they may sugar-coat their comments because they’d like to be working alongside you. Thus, the motivation will be to downplay anything that might dissuade you from applying. The opposite is also possible as there may be people whose personal agendas will be served by discouraging your application. None of what you learn from these sources should be taken as gospel. Rather, they’re imperfect peeks behind the curtain. Singularly or collectively, you’re looking for a gut check. If what you read and hear puts you reasonably at ease and makes you feel like you’d be a fit in the organization you’re investigating, go for the job. If something just doesn’t seem quite right, it could be an indication that this might not be a match made in heaven, and you should seek other opportunities. The biggest mistake to avoid is convincing yourself that you, by yourself, can change an entire institutional culture. Improving performance and creating efficiencies—even implementing a new departmental or organizational philosophy, such as patient primacy—should not be confused with a shift in culture. Cultures are built on interpersonal relationships and managerial dynamics. It’s about people and how they work with one another within the confines of the place in which they work. People are hired over time. Each subsequent hire can often reinforce the last, as a tendency toward certain types of experience and personality types can creep into the process. In astronomy, there’s something known as “dark energy.” As of yet, we can’t see it, nor have we the means to detect it or fully comprehend it. But as it comprises 96% of the entire universe, it has to be taken seriously. It’s not a bad analogy for institutional cultures. They exist in the space between everything else which can be defined. Cultures aren’t codified and they’re hard to describe to others. Nevertheless, they’re an undeniable force of nature.

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9 Considerations

Managing Managers

Healthcare facility managers frequently confront bottlenecks as a result of restraints that prohibit them from taking responsibility for and resolving simple matters. It has nothing to do with their personal capabilities or their personalities. Ostensibly, managers are hired because they’re skilled, accomplished professionals who are considered to be good fits for the areas they’ve been tapped to lead. You’d think that their bosses would want independent decision-makers ready to handle the daily duties of tactical management while they tend to bigger-picture, strategic affairs. The problem is that most managers can only maneuver tactically in one direction; they can only say, “No.”. They can stop something from happening or send it elsewhere, up or down the chain of command, for someone else to pass judgement on. Below the manager, any decision is as likely to be negative than if it came from manager’s desk to begin with. Any issue requiring a “yes” goes upstairs where approval is not a given. Worse, it solidifies a system in which “yes” decisions can only be made by higher ups. This can impose unnecessary, even detrimental limitations on departmental, even institutional efficiency and growth. Strategy-level managers and CEOs don’t need, nor do they want to be burdened by having to consider and then pass judgment on issues that their tactical-level managers can just as easily (and are likely better equipped to) handle. So, what happens? Only those tactical issues that demand attention get sent forward. Everything else languishes, festers, gets forgotten, or dies a death of neglect. This is the way many healthcare facility management systems are built. Lots of upper-level managers and CEOs believe that this is the way to manage. In my department, I’ve worked with my staff to reconceptualize everything we do on the basis of patient primacy, and to develop this target function such that changes which are put in place can be self-sustaining after I’m gone. My objective, therefore, has been to achieve a dominancy curve in which I become a less and less commanding presence over time, in which our personnel and the systems we’ve implemented can function on their own when I’m no longer helming the department. This implies two things: • First, that people below me are trained and confident individuals who can independently address questions and issues presented to them from team members whose work they oversee, as well as other colleagues. This is the opposite of a centralized system in which subordinates are only permitted to provide factual information and guidance pertinent to getting the job done or reject requests made of them, with all of those needing to be passed along to a superior. Such a centralized system is likely to produce negative consequences after the department chief steps down, which is something that should be avoided, as any gains that have been achieved may well decline significantly or vanish thereafter. • Second (and this one is tricky), even though we intend for our successors—to my role as department chief or any others who work in the department—to inherit the system we’ve built, that system isn’t a static set of policies and procedures. Rather, our system is fundamentally about always having the latitude to analyze,

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experiment with, revise, and overhaul practices when necessary or sensible to do so. We want a self-rejuvenating system to prevail in which the dominancy of any new manager declines until the point of departure. This may sound like a totally absurd concept. However, I argue that managers should be less oriented to think in an inward-directed fashion (about their positions of authority) and to think more from an institutional point of view or, more importantly, from the patients’ point of view. I earnestly believe that this is a natural evolutionary process. Besides, when the dinosaurs became extinct, the world didn’t vanish into oblivion. Rather, it developed and became a better place to live (at least from the perspective of the human race). What’s so profound about this is it’s not diminishing managerial impact, it’s increasing it. There are numerous things a manager’s staff can accomplish perfectly well (or better) by themselves. Equally, there are some things that only a manager can do. By freeing managers from micromanagerial tasks, they’re able to deal with a whole variety of nexts—departmental expansion planning, research and grants acquisition projects, new partnerships, securing investments for start-up initiatives, cultivating major donors, developing community and peer outreach programs, forging academic and international alliances, and so on. It even frees up people like me to write books like this to help readers like you to make progressive, positive change in your own corners of the world!

9.5

Succession Planning

You can’t really plan for succession. Commonly, what underlies such planning is a type of replication strategy that’s attempting to solidify in place a personality and temperament type. If you’re a manager, you can’t (and shouldn’t) try to distill whatever you believe to be your positive traits and attributes into a checklist that you hope your superiors will use when they’re scouting for your replacement. You can’t clone yourself (and besides, it would be ill-advised even if you could). When asked by his patients, “Who will operate on me?”, one of my colleagues used to hold up his hand and say, “You see my fingers? My team is like my fingers. Everyone is the same. I trained them all.” When he stepped down as chair, they had to hire people from outside the department in an attempt to keep pace with developments elsewhere. As those who remained weren’t prepared to function cohesively without their former leader, they didn’t have the capacity to adopt to a new era in surgery and so, outpaced by their competitors, the department declined in scope and stature. As one of our fundamental goals is to decrease managerial dominancy over time, a successful succession process should result in the hiring of truly fresh blood, not a carbon copy of the past. An optimal manager will be a self-confident, ego-secure individual who can make the best use of the creative opportunities inherent in a motivating system that encourages constant reinvigoration, innovation, and reform, which empowers its personnel to take on maximum responsibility toward the achievement

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of optimal patient care and peak performance. Assertive sharers should be welcome. Lone riders who look like they’re just out to make a name for themselves are to be avoided, as they can be destructive. And such individuals can ruin everything. As institutional CEOs and upper-level managers are rarely involved in the day-­ to-­day details of departmental management, hiring a new manager for a department is that once-in-a-decade (sometimes two) opportunity to put their stamp on how a given department will be run. And while a departmental manager on the way out can have an influence on the selection process, the question is whether it’s wise for them to do so. Now I’m going to throw a curveball and say no. Surprised? Let me explain. A manager heading for the exit isn’t smarter or more capable of choosing a successor than those further up on the institutional management flow chart. What this manager will have is more in-depth, personal knowledge of their realm—the people within it, their personal and collective personalities, skills, talents, and capabilities, as well as the overall dynamic of day-to-day operations. Those are highly valuable insights and they should be shared with superiors, as it will help to inform their judgements. Beyond that, however, I consider that knowledge to represent inherent bias, which can translate into conflicts of interest. Like it or not, it’s improbable that an outgoing manager can assume an objective distance sufficient to only consider what will be best for the department or the institution. Conflicts of this sort can take on many forms. If inside candidates are being considered for succession, a departing manager might be thinking about a close (or difficult) relationship they’ve maintained with a particular person. As regards any candidate, there might be considerations that place the existing team’s preferences over institutional needs. Perhaps post-retirement thinking will come into play, as an existing manager contemplates how to stay on for a time in a consulting capacity, as a researcher or teacher, or seeing patients and continuing to produce revenues. All of these can be rewarding outcomes for the institution, but only if the arrangements are entered into with good intentions, which minimize or eliminate any conflicts of interest. Regardless of whether or not a departing manager is directly involved in hiring a successor, I’d say it’s almost always even money whether the selection of a particular candidate will be a great pick or less than stellar. In other words, it’s a 50/50 proposition and the exiting employee’s participation won’t likely make a big difference in the process one way or another. Therefore, if we assume professionalism, good faith, and clear hearts and minds, then leaving these hiring decisions in the hands of managerial superiors is probably best.

9.6

Why Did You Get in This Business in the First Place?

Most doctors and other healthcare professionals chose their career paths because of a desire to treat illness, cure disease, ease pain and suffering, and so on. The primary motivation is others. Managers should remember this when their departments achieve successes. Point the spotlight elsewhere.

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Victories are collective achievements. It’s the department’s name that should be in lights. If there are standout staffers, they deserve special attention. The more magnanimous a manager is with publicity, the more they’ll gain from reflected glory. Superiors know who’s leading those departments that are attracting notoriety for their achievements. And managers can add those achievements to their resumes. Anything else is an ego massage, which is nice from time to time, but not necessary. And managers who constantly take credit for the work of others simply because they’re in charge ultimately fracture the esprit de corps required for high-­ performance teams. Equally, as they say that imitation is the sincerest form of flattery, the same share-the-wealth principle holds true when colleagues and departments in other institutions see managerial success elsewhere and choose to adopt similar approaches. More than flattery, this is an acknowledgment and endorsement that something of substance and value has been accomplished. This creates a sense of excellence for manager and team alike, not only in what has been achieved, but what everyone hopes to achieve next. If meaningful change is occurring, success can build upon success. Momentum can spur on more widespread, institutional change which, in turn, may lead to revolutionary changes within entire networks, in national systems, and global orientations toward the establishment of new standards for everyday practice. As a manager, I want every other manager to be successful. Their success means better healthcare. If someone can improve upon anything our department is doing or create their own innovations, I’m more pleased still. When I saw several departments in another major medical center extend to patients the right to choose their own surgeons, it was all over the media. Although I was the one who introduced the idea to that institution’s CEO, my name was mentioned nowhere. So what? If the result is happier and healthier patients, well…I’m a happy guy.

Recommended Reading

Collins J. Good to great: why some companies make the leap...and others don't: HarperBusiness; 2001. Collins J, Porras JI. Built to last successful habits of visionary companies. 10th revised Ed., Good to Great series (Book 2): Harper Business; 2004. Collins J, Hansen MT. Great by choice: uncertainty, chaos, and luck: why some thrive despite them all. Good to Great series (Book 5): HarperCollins; 2011. Cosgrove T.  The Cleveland Clinic Way: lessons in excellence from one of the world's leading healthcare organizations: McGraw Hill; 2014. Freud S. Civilization and its discontents. Translated by James Strachey: CreateSpace Independent Publishing Platform; 2018. Fried BJ. World health systems: challenges and perspectives: Health Administration Press; 2012. Friedman M. Capitalism and freedom. Fortieth Anniversary Ed.: U. of Chicago Press; 2002. Greene R. The 48 laws of power: Penguin Books; 2000. Machiavelli N. The prince: CreateSpace Independent Publishing Platform; 2015. Maslow AH. A theory of human motivation: Martino Fine Books; 2013. Maxwell JC.  The five levels of leadership: proven steps to maximize your potential: Center Street; 2013. McGregor D, Cutcher-Gershenfeld J. The human side of enterprise. Annotated Ed.: McGraw-Hill Education; 2006. Sinek S. Leaders eat last: why some teams pull together and others don't: Portfolio; 2017. The 21 irrefutable laws of leadership: follow them and people will follow you. 10th Anniversary Ed., Good to Great series (Book 5): HarperCollins Leadership; 2007. Seltman KD, Berry LL. Management lessons from Mayo Clinic: inside one of the world's most admired service organizations: McGraw-Hill Education; 2017.

© Springer Nature Switzerland AG 2021 Z. Gil, The Healthcare Efficiency Revolution, https://doi.org/10.1007/978-3-030-61232-0

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