Category: No More Lethal Waits

If you want to transform your hospital to improve patient service, get ready to fight, uphill, against every disincentive in our current system.

Very few reasons exist for hospital administrators, doctors, nurses, or the Ministry of Health to have patients seen and treated promptly.

This post summarizes Step 10, in No More Lethal Waits: 10 Steps to Transform Canada’s Emergency Departments.

Get Political

High functioning teams play in the same direction, at the same time. Canadian hospitals have staff playing at cross-purposes:

• Hospitals lose money for seeing more patients.
• Doctors earn more for seeing more patients.
• Nurses get paid the same no matter how slow (or fast) they work.
• See blog on Canadian Chaos.

No one talks about incentives and control inside the system.

Deal With Unions

71% of public employees belong to a union versus 17% in the private sector. Unionization rates are over 90% for hospitals in Ontario.

Provider unions have grown imperious. Management fears them. See Are Unions Killing Healthcare?

There are 3 rules in healthcare:

1. Always do what’s best for patients.
2. Always do what’s best for providers.
3. Never confuse #2 with #1.

Everybody has to work a little harder, and care for more patients today, than they did in the past.

Unionists are taught from the cradle that nurse to patient ratios take priority over patient needs.

Unions resists process change, if there is any chance that the change might negatively impact union members. Patient benefit is secondary.

Discuss Funding After Governance

People believe that our bloated healthcare system centres on debate about funding vs. spending, or supply versus demand.  But it is neither of these.

Whether money comes from taxes collected by government, or taxes collected by insurance companies, the issue is not about money.

The debate must shift from how money comes in to who is control of how money gets spent.

Everyone demands accountability from the system, but no one gives the people inside the system the freedom or authority to truly control outcomes.

There too many self-interested stakeholders with narrow agendas.

The status quo survives on compromise consensus.

Problem With Salaried Administrators

Most administrators care more about losing their job than pursuing radical innovation for patients.

Administrators spend years working to get promotions into senior leadership. Hospitals give administrators little incentive to tackle the toughest problems.

In a bureaucracy-driven system, leaders focus on being slightly better than their peers, but never to be outstanding.

The risks of true innovation are too high.

Milton Friedman said that bureaucrats risk two choices with innovation:

1. They can block something beneficial, but no one will ever know.
2. They can approve something harmful. Then everybody knows, and the administrator loses his job.

Most bureaucrats choose #1.

Problem With Clinical Administrators

Just because you spent time as a clinician does not mean you understand how other clinicians think. We cannot lump all clinical training together.

When we look at healthcare with untrained eyes, we might think that nurses, respiratory therapists, and physicians do basically the same things.

They all see patients, travel around the hospital, and record their findings in charts, while discussing treatment plans.

This is like saying everyone in IT is basically the same. To the untrained eye, computer scientists, IT repairmen, and website developers basically do the same thing: they work in high-tech.

No one would ever fill a senior IT leadership team with only website developers. They would never assume that such an unbalanced team could champion IT excellence.

In health care, we assume anyone who spent time working with direct patient care should be able to run the hospital.

It’s simply not true.

CEOs who hang around the nursing station will never really know what it means to think like a nurse. CEOs who have watched physicians work will never understand how physicians think.

We Need Doctors in Leadership

See blog posts:

• How Doctors Can Fix Healthcare 
• Healthcare’s Only Hope is Not Government
• Quality Care Requires Freedom
• Leadership in Medicare
• Myth: Physicians Lead Medicare
• Doctors Should Lead Medicine

And stop talking about engagement. We need true partnership.

What Our challenge Is Not

Conscientious providers get tied in knots worrying about the healthcare system.

We’ve done this for decades and it must stop. Until leaders focus solely on patient service, the system will not improve.

The time for political conscientiousness has passed. Emergency providers are on their own.

If government wants to decrease emergency department use, they need to redesign the system so patients are attracted to seek care elsewhere.

It is not for EM workers to bear the responsibility of rationing care for the whole system.

What Our Challenge Is

Patients need humanity and compassion with every clinical interaction.

The most important outcomes for patients are often qualitative, subjective, and impossible to measure.

We need to learn to articulate what medicine is. It must be hard. It needs to be tough and complicated to capture everything we do for patients.

Narrow-minded medicine makes patients secondary.

We need tough-minded leaders with diverse backgrounds and training who are committed to putting patients before budgets, politics, and ideology in order to sort out the Canadian chaos in healthcare.

 

This gives you a sense of the last chapter of No More Lethal Waits: 10 Steps to Transform Canada’s Emergency Departments. Thanks for checking it out!

Jazz musicians have chops, hockey players have moves, and leaders have favourite ideas they use over and over.

This post summarizes principles that became themes in our ED transformation (No More Lethal Waits: 10 Steps to Transform Canada’s Emergency Departments). Leadership books bulge with other great ideas, too.

[I worry that this post feels a bit breathless, like drinking from a large hose. I promised it for those who do not have time to read the book. Cheers!]

Leadership Principles

Find out what motivates people.

People are moved by different things. For example:

1. Promise of reward.
2. Fear of punishment.
3. Resonance with concepts.
4. Appeal to morality.
5. Social pressure.

If you only speak to one aspect of motivation, you leave out 80% of your audience.

Learn the language of influence.

Doctors, new to leadership, often act like doctors. They investigate, diagnose, and treat.

This does not work well in administration. Influence starts with relationships, shared project objectives, respect, and commitment to work together. Read more here: influence.

Don’t hide the pain of bad news.

Let people work through it with you in the room.

Over-Communicate

It takes 5 communications to get one message across.

Think Complexity

By now, you have probably heard about complexity theory. Check out How to Lead Using Complexity Theory.

• Baking a cake is simple.
• Sending a rocket to the moon is complicated.
• Raising a child is complex. Success with one child is no guarantee of success with the next.

Too often, military and machine metaphors dominate healthcare thinking. Metaphors shape our solutions. Mis-applied metaphors feel awkward and hold teams back.

Learn to Love Conflict

Do not blame conflicts on personality. Look for the ideological debate that underlies the conflict. Very few conflicts are only about Jungian clashes: Personality Conflict – An Excuse Great Leaders Never Use.

Read Governance

Focus on outcome, describe success. People engage when things matter to them, make a difference to them, and are enjoyable for them.

Form follows function, and function follows purpose. We need to understand our purpose in medicine.

Stakeholder needs, wants, and preferences shape what we decide to accomplish but should not block positive change.

Spend time learning about governance. Here’s two earlier posts:

Governance Expert Pearls

Great Decisions Great Governance

Manage Attitudes

These days, no one gets fired for saying, We’re going to lose!

Clinical competence is necessary but not sufficient for outstanding performance.

Attitude must be a key measure of Performance Management.

Process vs Leadership

People change the names but never tire of chicken versus egg debates:

• Which comes first?
• Can leaders lead transformation without a process destination?
• Can departments change, without leadership, if the destination is clear?

I think leadership comes first. Process based on rigid designs that offer grand solutions never work as promised, outside of car factories.

Even assembly line technicians use skill and judgement.

Complex, messy systems, like healthcare, require leadership before process.  Terrible processes can perform reasonably well with outstanding leadership. But we need both for excellence.

 

 

That gives you a taste of Step 9 in No More Lethal Waits: 10 Steps to Transform Canada’s Emergency Departments. One more to go!

Photo credit of my dream guitar Gibson ES 175

Big changes invite even bigger resistance.

If you attempt a major transformation in your department, or even a small change, watch for resistance from where you least expect it.

Everyone talks about progress, but few tolerate change without any anxiety.

This post summarizes Step 8 in No More Lethal Waits: 10 Steps to Transform Canada’s Emergency Departments. It captures some of the issues we wrestled with. You will face different giants. Please add your thoughts in the comments!

Rally Around a Vision

Doctors and nurses make a two-horse chariot. They need to pull at the same speed, in the same direction.

Rally your team around a central vision.

“What’s best for patients?” worked well for our department. You need a target for your team to steer towards.

Some horses never learn to pull as a team. They kick, bite and chafe at the whole idea.

Get rid of them.

You need the right people on the bus, or you will not get anywhere.

Jim Collins, in the bestseller Good To Great: Why Some Companies Make the Leap…And Others Don’t, tells us to hire well.

Do not look for blind followers. Find people who intrinsically enjoy helping others.

If you need staff, do not hire out of desperation. You will regret it for years.

Expect Resistance

In Step 4, Redefine Nurse to Patient Ratios, we discussed concerns that nurses have with this approach to EM care. Docs have their own hang-ups:

Irregular shift start/stop times.

Eventually, physicians get comfortable estimating when they will get called in on a particular day.

Even so, uncertain start times drive some docs crazy. Physicians need to be totally convinced of how a flexible start time benefits patients and doctors, or they will hate it.

For 90% of the shifts, start times follow a predictable pattern.

Cancelled shifts.

Especially in the early days of a flexible schedule, some days will have more doctors scheduled than patient volumes warrant. If docs are not busy, then a shift might get cancelled towards the end of the day.

Eventually, doctors get used to this. They realize that, overall, it is better to be productive AND have short wait times than to have only one or the other.

Pressure to pay attention to flow

Some departments try to manage patient flow without giving any responsibility to the docs working that day. Asking docs to monitor and manage flow irks some physicians.

Either they get used to it, or they move to work somewhere else. Most end up staying because they appreciate the improved efficiency.

Competition/productivity

If you measure productivity, you invite competition. Groups need to spend time celebrating differences as a fact of life.

Equality does not exist in real life (no matter what the utopians say).

Loss of Superman/Saviour Identity

In a chronically backed-up ED, faster docs gain a reputation as ‘Saviours of the ED’.

They walk in and nurses say,

“Oh thank God you are here! We’ve been drowning in patients with Dr. X and Dr. Y working. Please save us!”

The new approach eliminates this kind of praise. All days have short waits. All docs work to the speed at which they can provide safe, high quality care.

Transparency of productivity

Many docs do not want to know how quickly, or slowly, they see patients. Short wait times and maximal efficiency demand that productivity is explicit.

Loss of control

Docs try to control what happens on their own shift. If they care about what happens to the whole department, they have to cede control for staffing to someone who takes responsibility for scheduling 24/7.

Some docs hate this. They want their Tuesday morning, just like they’ve always had for 20 years.

Teams for Their Own Sake

Build strong teams. Teams must see value in membership beyond any tangible benefit to the organization. Team members need to value being in the team simply for the sake of being in the team.

If leaders try to build teams only to get great metrics, staff will see through it and balk at being involved.

Change Pain

Many people hate change. They would rather cling to what ‘works’ in the past than try something new.

Teams criticize leaders for not being transparent. But leaders often do not know exactly how something will get done. They just have a vision of where the group should go.

Learn to Love Complaints

Celebrate great complaints. Bad complaints focus on safety. Jump to fix them ASAP.

Good complaints move up Maslow’s hierarchy and focus on staff’s inability to express themselves, or fully use their training.

Change attracts attention. Other departments will notice and try to shut you down.

For example, infection prevention and control pretends overcrowded waiting rooms do not exist.

But as soon as you start bringing the waiting room into your department, they show great interest in having a minimum number of square feet per patient, terminal cleans, and other nitpicking issues that they ignored in the old paradigm.

Nonsense Sound Bites

Some stupidity refuses to die. Be prepared to respond, with a smile, to nonsense repeated at the highest levels.

“Match demand with capacity”

People talk about building bigger EDs to match patient demand. No. Improve flow to match patient demand, first.

“Nurse-to-patient ratios promote great care.”

No. Rigid RN-Pt ratios guarantee that unscheduled patients will wait.

“The literature supports modern triage.”

The literature also supports using parachutes. Ideally, you should never need to use a parachute.

“Patients need stretchers.”

If patients can wait for hours in the waiting room on chairs, then they can sit in chairs while receiving treatment inside the ED.

“Low Acuity patients block the ED.”

This myth refuses to die. Sick, admitted patients block the ED. Low acuity patients take a few minutes to see and treat. They NEVER block the ED.

“Quality Care requires patients to wait.”

Over 400 articles, at last count, show how waiting harms patients.

“Quality care” for the one patient lucky enough to get inside, while 100s of patients wait, does not define quality.

For EM, time equals quality (see Step 1 – Revamp Triage).

This gives you a taste of what’s in Step 8. Please check out No More Lethal Waits: 10 Steps to Transform Canada’s Emergency Departments for more.  Thank you!