Patients Come Second

Patients Come Second,  Paul Spielgelman/Britt Berrett

I was a administrator/manager at Group Health Cooperative from 2002 to 2009. I had no training to do that work. As a consequence, I went to innumerable courses and read many books. A favorite reference book was, If Disney Ran your Hospital which has a catchy title and which  posed a question with a not-obvious answer: What do you think the “prime directive” or Mission of the Disney Company is? The answer: “Safety. No one gets hurt at Disneyland….” The argument is made and then broadened to the relevant messages for running a hospital.

Recently, seven years into retirement I found Patients Come in Second at a used bookstore in San Luis Obispo (SLO). The title was written specifically with my sense of humor and with the promise of an indirect argument, like, “Safety comes first.”

The premise is one I firmly believe in: You can’t provide good health care to people, no matter how good you are, unless you are fully supported. The better the support, the better your care will be. This applies to everyone in,”The enterprise”—janitors, nurses, receptionists, doctors.

Now, define, “support.”

The corollary for me was found at one of my early management course, addressing service— a story was told that I suspect was a, “management-urban legend”: A customer showed up at a Nordstrom’s with a car tire and demanded their money back……. Nordstrom does not sell tires but in this case, a manager got involved and the customer left satisfied.

I was not satisfied.  That was ridiculous. I came to appreciate many motivators for those working in a medical practice. For a patient to be rewarded for the kind of behavior that got the bringer of tires to Nordstrom would in my estimate be a problem for staff morale—not to mention the cost of healthcare. And yet, the consultants used it as an example to drive consumer satisfaction in your practice.  I find this book to have good advice and some of the principles identified were found by me blindly searching over the years how to perpetuate and extend a really great example of a clinic, hitting on all cylinders: The West Olympia Clinic.

THE BOOK:

1. Foundational is the realization that no matter how good you are one-on-one, you need more. There is a mix of people and positions setting you up for success or failure before you ever see a patient: receptionists, business office staff, nurses, central supply staff, and so on. Furthermore, the argument is made that the competitive environment has changed; when I started practice, male physicians had a corner on the market for access to medical care. That is no longer the case with female providers, alternative care models, the internet, and social media all guiding options that are now viable. To succeed, especially with scale, you need vision, understanding of what your patients need, and a team that understands—and acts on those needs. In a sense you need to find a connection between personal inspiration and aligning it with what the company does..

Large organizations, such as where I worked through most of my career, depend on managers and budgeting to manage the care and orientation of staff to the work. It is easy to take pot- shots at how often they got it wrong. For example, consider the nursing shortage: the local hospital developed contracts with a nursing union. Both are bureaucratic organizations and managing care during a nursing shortage was done through formal reading of  contractual agreements. When nurses need flexibility (how long is a shift? Which shifts? Vacations), the contracts prevent that and a hard nosed approach by hospital leadership led to an interesting development not in line with the hospital’s mission.. Many nurses quit, got hired by travel nursing businesses, and come back to the same hospital (now very short of nurses) getting the hours and shifts and vacations they wanted. The continuity of care and use of functional teams is easily lost when this happens. These problems existed at my West Olympia Clinic to a degree—but we had a measure of autonomy in the day-to-day that did allow for service to each other which in turn, made us a clinic with superior patient and staff satisfaction. That experience taught me what follows:

The patient experience is not about you (the medical provider). It is a team effort. From the greeting by a receptionists, to the environment (waiting area and exam room), to the nurse’s interaction, and finally, you—that combination leads to an emotional reaction that has implications for the business as well as the patient’s ability to heal (do they trust you, have confidence in your reliability, did you all make them feel good when after all, they were in a medical office for a problem)?  . So carrying the analogy further--for the manager--, on a plane, you are instructed that in an emergency, you put the oxygen mask on yourself first, and then assist others around you. So it is providing medical care—and health care almost everywhere is in emergency mode.

2) How do you lead to achieve a vibrant and creative workplace that provides great service? He makes a model of Seal Team Six: tightly knit controlled work group with redundancies—each member could fill in for another, and yet given independence to make decisions in the moment to conform to the goal/mission even if the environment changed.  Switching to hospital administration, the militant top down approach for changing behavior does not always find the best answer. An anecdotal story: wait times: you can buy expensive scheduling software (top down). You can hire more providers (top down).  They found that the patient satisfaction scores on wait times were not reliably relieved by such expensive measures but rather by team-based agreements to simply inform patients in the waiting room about delays linked with an apology. The scores improved with no cost involved.  He reviews the need for honesty: if you talk patient care as your ultimate goal but are driven making decisions based on financials, you have to sort that in real time with meaningful locally managed adjustments to improve on patient care and staff morale. Your (the manager) making this real, and personal can build comaraderie and a culture that ups the cost of what a competing business has to offer to steal your best co-worker away. Make working at your facility more than just a job with an associated salary.  The “currency” everyone talks about is money. But a good working environment with a shared mission is also an important currency. Use it!  Celebrating achievements, actions, and problem solving help people feel like they work in such a place. So does giving them some flexibility and control in their workplace.

3) Fun matters: a legacy I appear to have left at my former workplace was expressed on the door of my old office: “It’s supposed to be fun!”  The examples for making things fun at work are tied to leaders having a common touch. Note the use of “co-workers” in the book by managing leaders when referring to the worker bees. His first example is a new CEO at a staff picnic being in a dunk tank. This made an impression: full suit, four hours, random conversations through the process with his new co-workers. Encouraging skits and laugh at yourself moments are suggested. Doctors for the most part are not thought to be much fun. I agree! He demonstrates with example watching a group of 15 doctors problem solve the task of putting together a video to support getting charts done on the same day (Song, “Jump” by Van Halen with white coated doctors doing just that to the music.). My version: I challenged the doctors early one morning to see if they could legitimately have a chart note written that day with the term, “sexual repertoire.”  I managed it by my third patient…. While at Kaiser S. California, I have gotten to know a receptionist through her very talented repertoire of interactions with patients after delays getting to them and she does it smoothly, with grace, and a smile—-she appears to be having fun at work and once more, spreads it around to patients who have been waiting in a queue.

4) Do we really care?  Slogans and signs don’t make it—his examples of demonstrating appreciation: CEO shows up on the night shift, wanders around with cookies, coffee, and an openness to learning their jobs, problems, and attitudes. One of the greatest management revelations in my life was the caring expressed among co workers sharing time during lunch together. The other significant learning was my introduction to Group Health after being hired by the medical CEO in Seattle; he sat me down in a room, one on one, turned off the lights and proceeded with a slide show of all the clinics in the system. I fell asleep to my embarrassment.……our time would have been better spent talking about work experience, expectations, goals, and of course, family—they after all, were along for the ride.  Can you teach someone to care: An ICU nurse takes care of the victim of a bad auto accident; the family from out of state, came on the run. She notices they haven’t changed their clothes in three days. She brings them surgical scrubs, takes their clothes home and returns with them all laundered. I love this story and would like to think I would be that attentive and caring but most of us on the job have blinders on, worried about specific things and moving on to the next patient. How to break that cycle? When you do, the world (not to mention the workplace) changes. My pessimism leaks through though: how many nurses in a modern hospital work three straight days to even observe this?  When a co worker needs help—help can be supplemented by managers and leaders systemically along with staff driven “go fund me” efforts and this builds caring and a community. I am reminded of a military observation: lots of soldiers go to war with patriotism the motivation. What keeps them in the fight, even dying “for their country” is actually done for the love of their brothers in arms, and not for the country. Ditto the work place. The advice to CEO’s and managers becomes one of intel. Have a network that tells you about struggles and accomplishments. Celebrate your co worker’s kid’s achievements and milestones. You can’t be part of their family but you can acknowledge what’s important for your coworkers.  Leaders want coworkers to help with “the plan” for the organization. How can they do that if you don’t reciprocate? What is your co worker’s plan? Do you know? Do you care?

5)  Outside the 4 walls.  Working for Group Health, I was reminded of my father’s experience living in a town but having his work be irrelevant to that town—he worked for the Navy. We doctors had a marginal relationship with the system of doctors outside our organization in Olympia. Once more, the organization had a similar problem as a business. Group Health would show up for charity events and get the logo on merchandise, but this seemed tepid and superficial as efforts went. On the other hand, our doctors provided an overwhelming majority of charity care at the community care clinic. The authors point out that you want people in the community to have a favorable association when the name comes up. They suggest sharing the costs of the co-worker passions—the example given is a coworker wants to buy a sport tent for cooling at sports events and the company pays half the cost if their logo goes on the tent. The principle applies to other efforts that support and build moral across a community’s various events and enterprises. Being from a large organization, they caution against the option to direct money to national efforts, like recovery from Hurricane Katrina. They would blend charity and advertising with building the community through your own business locally and by extension, the community it serves.

6) Part of having a happy staff: no whiners, losers, or jerks.  The author goes on to describe each category and the effect they have on staff, often unrecognized effects, until the offender is gone. This requires managers who are in touch and thinking of the enterprise with a longer view than today’s problems—they have to recognize a jerk and differentiate it from a great worker who is stressed or disappointed, not being able to do their best. It requires backbone and knowledge to be confident about a decision to fire someone who is bad for morale, especially in a world of worker shortages. This chapter points to the value of analyzing the problem, and acting on that analysis. I had a couple doctors who were not only making the work lives of others miserable, but were in fact miserable themselves.  The “healer” in me wanted to “fix them.”  Mistake! I remember the relief (and that of the team nurse for the unit involved) when I gave notice to a doctor who had repeated her patient and staff interaction errors many times, despite remedial training. While difficult, it was a relief, just as outlined in this chapter of the book.  A manager needs to check in with staff, all staff, on what is motivating them, if they are “on board” with the mission of the work, and if they are affecting others negatively , to see if they understand that.  They address HR as being perceived as, “the enemy” by many managers. This should not be the case and if it appears to be so, some clearing of the air and the same check-in as above re motivation and being on board with goals.  Lastly , good hires preclude having to fire….. A related last best practice: spend more time with your best providers and less with your less motivated employees. They are more likely to be the path to a higher functioning team than any manager. Support them. Understand them. Develop them to help with the mission even if they do not want formal leadership themselves.

7) What should a health care business measure? They argue, staff, patients, and finances in that order!  My life as a manager has been spent balancing costs, service, and quality of care. All require a functional team. I experienced the downward cycle described: When you manage a business with an eye on costs, charges, and profits, your process will find you cutting costs—usually decimating your workforce and staff. This leads to worse service and quality of care. Spread sheet exercises are math exercises and not leading an organization. Top priority? Go to staff, get surveys on what their view reflects and engage them to improve it. Costs are on the table but let them demonstrate what variables they can control with service, quality, and costs in mind. He encourages a mix of staff from different departments looking at costs and service with an eye on problem solving. Compare your organization to others, your competition. Ask for groups from different departments to work on solutions to specific problems with a time frame attached. Lunching with Staff is mentioned as a place to, “take the temperature.” The leader in that meeting listens, facilitates, and celebrates good performers with service and quality top of the list—no lecturing.

8) It isn’t the money. Focus on your staff creatively and regularly. This is art. When you are new, you get credibility observing and asking questions and not moving too fast—you don’t know your audience, yet—you don’t know the high performers who are disappointed nor do you know the “losers, whiners, jerks.”  Make a point of publicly celebrating the work no one sees. Reward spontaneous good acts (like picking up garbage when it isn’t your job or helping the ICU family above). Look at what is in their work spaces….what is on their desk or walls—what’s important to those people in that space? DON’T reward people for the company’s or the team’s financial performance; acknowledge it but reward the teaming qualities that make working there better.  Anecdotes with the artistic approach: halls with pictures of staff and an inset picture for each showing their passions away from work. Drawing for money to go to a charity of the winner’s choice but the applicant pool is from staff-driven nominations with the specified reason for the nomination.  Show the organizational chart with CEO at the bottom.

9) Commit to lifetime learning: there is CME (continuing medical education) and there is trying to advance your skills.  Support your staff doing this: the Nursing Aid going to LPN school or the LPN going for an RN degree. You may lose these people when they advance but they will appreciate your support and there is a good chance they will be back with depth for your organization that other hires won’t have. The support to improve should not be programs to define what you want them to learn. They have to find their passion and your job is to show interest and support it. You can teach preparatory skills—A pre-workshift (voluntary) class showing how to put a resume together or manage an interview, or even dress for success.  Train outside of silos—-nurses and docs together for example. My favorite T Shirt that both my nurse and I had: “Be nice to Nurses, they keep your doctor from killing you….”  Large organizations offer mentoring; this can be done on a smaller scale anywhere. I was fascinated to learn when I left management how many peers had asked for and got formal mentoring. I never thought to ask.

10—When I read a book by leader-managers who are passionate about their work, I remember feeling that passion but not knowing how to channel mine other than directly through my work one on one. Were I more thoughtful and directive, I might have harnessed some of that to better inquire of my co workers specifically what motivated them and determined where we lined up and where we did not. My daughter (a nurse practitioner in private practice) has a staff that “takes the temperature” and have been known to, without permission, clear the decks and find her time to attend to her family when the need is there; she would never ask! This happens only when they know what is going on—there is heart to heart communication with people who care. Her staff have gone to hospitals, unasked, to be with people who have no relatives when they are dying.  Behavior like that can be unique and individual but it can grow when you demonstrate it, talk about it, and reflect thanks for it to those who support you. So in the end, this book advises you to do what you can to have the structure of a business, competing with the best and yet finding and developing the mission among team members —this is very very personal work. This recipe has to be started with original ingredients (good employees, good mission, adequate resources) and not out of a box. When the COOP was suffering in the market place, and consultants were sought, their advice was in fact, “out of the box” and rarely was taken up in any long lasting or tangible form.  I have seen and lived the real deal and it is compatible with many of the points in this book.

Good managers and star employees are critical for this work. If only they grew on trees…..If everyone could see the structure as science or engineering and put it together and making it grow as “art” just like the doctor (I AM dating myself) with great bedside manner, the health care crisis could be repaired.