Can Healthcare Get Better?: Culture Change and the Power of Frontline Staff

By Paul Shank

A new vision of healthcare managment, recognizing the power of the front lines, turning change from a top-down program into a collaboration of teams at all levels. Healthcare can get better, but only if we start the process of change and recognize the value and importance of everyone. The question that must be asked to make all decisions is what's best for the patients.

• Language: English
• Publisher: BookBaby
• Release date: Apr 2, 2021
• ISBN: 9781098361778

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Copyright © 2021 by Paul Shank

Can Healthcare Get Better?

All rights reserved.

No part of this publication may be reproduced or transmitted

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or invented, without permission in writing from the publisher, except by a reviewer who wishes to quote brief passages in connection with a review written

for inclusion in a magazine, newspaper, or broadcast.

Paperback ISBN: 978-1-09836-176-1

eBook ISBN: 978-1-09836-177-8

Printed in the United States of America

Acknowledgments

Writing a book is sometimes described as a lonely, or at least an individual task, but nothing could be further from the truth. A word of encouragement from an acquaintance can mean the world at times, input from editors – both formal and informal -- have helped mold this manuscript. Foremost among them is my friend and colleague, Dinah Massie, who has been part of this project since it started as a dissertation.

Some of the most important help came from my beta readers, Paige Schulz, Tom Gavagan, Cornelia Gamlem, Natalie Messer, and Ann and Tom Stafford. Finally, special thanks to Susan Devereaux, for a great job that she made look easy!

Dedication

For Susan,

Sine qua non

Foreword

I first met Paul Shank at a health center down towards the Gulf of Mexico from Houston where refineries regularly explode and hurricanes blow in the ship channel. He was running from the front desk to patients to care providers. I had never seen a health center manager so actively engaged in operations with the staff on the front-lines. Most managers ruled imperiously from the center managers office without emerging often. We later worked together in the convention center at the Astrodome, setting up a field hospital to address the needs of 30,000 Katrina evacuees from New Orleans after the hurricane.

Most books on the US health care system review its many disparate confusing and dysfunctional parts in its patchwork of insurance programs and services which are inscrutable to most patients. I was happy to read Paul’s practical guide to working and surviving in health care. Especially since many healthcare workers are underappreciated and overworked; subject to considerable stress and risks of injury and infectious disease like Covid. Adding to the situation is the shifting ground of health care organizations from nonprofits to for-profit enterprises.

Fortunately, the author has reviewed the literature on organization culture in health care and management literature for our benefit. I hope the reader will find his folksy wisdom to be as valuable as I have.

—Thomas Gavagan, MD, MPH

Preface

In researching my dissertation about organizational culture, I realized that a lot of important knowledge about it was available, but totally inaccessible to most managers. It was written in academese and published in journals few managers could locate. There are lots of business books out there, but most are extended essays with more personal opinion and experience than anything backed up by actual research. Yes, my dissertation was written in academese. It’s required. And it’s available online with all the other dissertations ever written. It will cost you $35 and it’s not worth it. If you’re really interested, send me a request by email and I’ll send you a copy for free.

Understanding organizational culture is crucial for managers at all levels. As I wrote the dissertation, I knew they needed that information, but a dissertation is not the appropriate vehicle, so I promised myself I’d turn it into a book when I had time. It’s been a long time, too long, but I’ve finally written the book.

This book is about organizational culture, written for managers and students who will benefit from a broader understanding of organizational culture — its origins, definitions, how it can be used, and its limitations. Organizational culture ties in with organizations’ behaviors, leadership, change, and the assumptions managers and employees use to make sense of their environment. This is a book for managers who want to better understand organizational culture — what it is, how it works, and how it can be used to change the organization for the better.

I started in healthcare in the late Sixties, and although I took an extended detour into other professions, that detour served me well because I was able to see other management systems and styles. In fact, not much has changed in healthcare management since the Sixties. That’s another reason for the book. We need to move into the third decade of a new century. Yes, we have computers and electronic health records (EHRs), but our management style is still primarily top-down, command and control. We call groups of people teams when they are really just groups of people. We call managers leaders when they are really just managers. We’ll talk more about this later.

Finally, I wrote this book because Toni Morrison said, If there’s a book you really want to read but it hasn’t been written yet, then you must write it. I wanted to read a book specifically about healthcare management, and how to make healthcare better. At the micro level, which is frankly the only level patients really care about, healthcare needs to get better. Healthcare won’t get better with a new CEO, even if you pay them a lot of money. It won’t get better if you reorganize the organization. We’ve done that. It will only get better if we listen to the people on the front-lines and recognize the wealth of knowledge they possess. They know what the problems are and they mostly know how to fix them. But we, as managers, aren’t listening.

Introduction

Coming together is a beginning; keeping together is progress; working together is success. —Henry Ford

Who Is It For?

I wrote this book for front-line managers and supervisors to give them some of the insights I wish I’d had when I was in their position. Some of you have mentors who truly value the staff they have, but most of you don’t. Management in healthcare is only one of many areas that need to change if healthcare is going to get better. As you know, healthcare is still a hierarchical command and control system. I don’t know how it all started. Respect for physicians morphed into a belief in their infallibility, but the system hasn’t done physicians any favors either. They are burning out at an unsustainable rate.

The command-and-control system may have come from the military, but the military doesn’t use this system anymore.

Healthcare management doesn’t work like that anymore. Workers today want to be heard. They want to be part of the process. Watch how a team operates during a Code Blue or other crisis. First, we have a team, not a group of people who happened to be in the vicinity. A group is not a team. A group is what you have in a pick-up softball game. Everyone knows a little about the position they are asked to play, but do you think they could pull off a double play?

A team is a group of trained professionals who practice together and work together. They know each other’s skills and weaknesses; they all know they can do the job no matter how tough it gets. But there are some things about teams that most people don’t understand. First, there is a leader in name only. Everyone knows their role in the operation and they are very good at it. There may be a shot-caller, someone who monitors the overall project, letting everyone know what’s going on. But there’s no one barking orders.

There are always things that go wrong. The difference between a group and a team is that a group needs to be told what to do next. A team knows things will go wrong and they plan for it. If you watch a real team, you don’t even realize things didn’t go quite right because they know exactly what to do when things go sideways. That’s when you’ll see it, if you know what to look for. There’s a subtle shift in the members’ roles. They cover for each other. Things didn’t go the way they wanted, no big deal. It’s a team. They expected something like this. No one has to say anything, certainly not cast blame. The world is unpredictable. The situation changes and the team changes to adapt. They carry on.

This doesn’t just happen during a Code Blue in an ICU (Intensive Care Unit). Maybe it’s not so dramatic but watch a real team in a busy primary care practice.

Let’s set the stage, first. Most of the staff members in primary care are clerks and medical assistants, with a smattering of nurses. The staff is highly trained and skilled with computer programs that rocket scientists would find challenging. And they juggle mission critical data on multiple patients as calmly as you’d follow a recipe. They are paid a pittance, but that only shows that the system is broken. These are professionals in every sense of the word, even if they don’t have certificates and diplomas hanging on their walls. Trust me on this, the system would collapse without these people.

Primary Care is not a quiet backwater in the healthcare world. It’s every bit as unpredictable as an ICU and requires the same teamwork. Every patient is a new opportunity to throw the day into chaos. I call it, Oh, by the way…. It’s the comment a patient makes just as the provider touches the door handle to leave.

Does this look infected?

Is this medication supposed to make my heart jump?

My daughter died last week, and I want to kill myself.

Welcome to primary care.

A group would have to call a supervisor to figure out what to do. But a real primary care team communicates, and they make the adjustments to take care of all the patients. Watch closely and you can see that same subtle shift as responsibilities change, room assignments are moved around, clerks shuffle patients to other providers and providers ask how they can help. This shift in patient load happens because the providers and staff know that tomorrow it could be their patient with, Oh, by the way…. It’s a team and they cover for each other. Maybe a life doesn’t hang in the balance, but maybe it does.

This book is for those front-line people, the professionals with and without diplomas, who go the extra mile every day. The lead nurses, supervisors, and managers. The staff who form their own teams, usually without anyone even knowing, and when things go sideways, they make the subtle shifts no one sees. These are my people and I love them. I hope this book will help you understand how valuable they are, and how we can tap their knowledge to help healthcare get better.

What Is It?

This book is about organizational culture and change. Organizational culture is that nebulous thing that people talk about like you could see it if you squint just right. You can’t see it, but you can feel it and you can even quantify it. Change is mandatory, and you can sometimes see it, but it’s not always easy to quantify, unless you know where to look.

If you change processes, you change the culture. The question is, how do you go about this so you get the culture changes you want. Traditional command and control management sends a memo out on what to change and how to do it. It’s straightforward and simple. Do as you’re told. How would you like working in such a place?

A memo says the top of the chain doesn’t trust the front-line to figure it out. How could they? The front-line staff don’t have MBAs. As Frederick Winslow Taylor would say to workmen in his factory, in 1900, You’re paid for your brawn, not your brain. Maybe 100 years ago this was true. But that attitude isn’t going to work today.

Healthcare today, especially if you’re in operations, on the front-lines, is a business and the business of healthcare is making sick people well in a way that makes money for the organization. Whether you work for a publicly traded, nationwide corporation or a small non-profit, the bottom-line is the primary consideration. If the bottom-line is red, that’s bad; and if it doesn’t change fast, changes will be made. Sure, it’s always been that way, there’s no mission when there’s no margin. But mission and margin used to be equally important. Today, with corporate ownership, ROI (return on investment) is critical. Investors expect to make money. Lots of it.

To be successful today, operations have to change, and culture has to change. Changing