Few procedures are more complex, more demanding than organ transplantation. Few are more satisfying; seeing a patient leave hospital with a new lease on life is incredibly gratifying to those that cared for the patient. This is the world from which I have come and practiced in for over a decade. It is typical of many areas of healthcare in which dedicated clinicians devote enormous energy benefit the lives of those less fortunate. These efforts are proving to be sporadic and not sustainable. At a time when Americans should be enjoying the fruits of the labor of several generations of dedicated clinicians with access to enormous funding and world class research, we are not. We are stumbling. That 100,000 Americans die in hospitals every year from medical error is a portrayal of a much more serious problem. Physicians, nurses, and other clinicians have lost the ability to influence the environments in which they practice so that they can execute their craft safely, with care, compassion, and innovation.
I started practicing surgery at a time in North America when those that fund the healthcare system had decided that costs were out of control (and they were), and had to be ratcheted down. In relatively short order, “Payers” achieved this by drastically truncating funding to clinicians and hospitals. It became clear to those in charge that doing things well was not rewarded any differently than just doing things. In just a decade, professional traditions that reflected carefully thought out practices vanished, as did quality. It became very easy for administrators to minimalize the complexity of what clinicians did to achieve false but lucrative efficiencies. This has had a devastating effect on clinicians. We are constantly forced to rethink how we do most everything, with fewer and fewer resources. Things are run so lean, that a little less now means harming a patient. Clinicians simply don’t know how to scream any louder. Many have become apathetic, angry, and helpless. That 30% of nurses are depressed two years into practice attests to the toxic environment.
In 1996, while serving as surgical director of a transplant program in Nashville, I started to methodically look at the problem. I did so for the simple reason that the toxic environments in which clinicians were being penalized for trying to improve them were rapidly becoming the bottleneck to good patient outcomes. If I were to quickly build a transplant program, I would have to prove to the referring nephrologists that patients leaving my program had a better chance of walking out the door with a functioning kidney than they did elsewhere. This meant insuring that every aspect of patient care was done perfectly, from admission to discharge. This was a huge organizational challenge for which I was not trained.
I was lucky enough to meet and ultimately work with Terrence Deal, a world authority on leadership and positive work environments. Prof. Deal had worked with hundreds of organizations world wide – hospitals, corporations, school boards, even the Swiss Army. Deal’s observations resonated with me. People in any organization can only be positive, energetic participants when they have the skills to influence the environment with their own ideas and vision, no matter how small. Doing this requires a skill set that clinicians are simply not trained with. We are scientists, technicians, caregivers, detectives, but not organizational leaders. Deal’s work has unequivocally proved that if people are trained to understand the complexities of organizational life, they can become effective leaders. There is an antidote to the learned helplessness that so many clinicians have contracted. In the next 5 years I put these leadership skills into practice as I built a transplant program in which we completed over 100 living related transplants with 100% success. Our hospital enjoyed the lowest complication rate in the entire system.
In 2006, a conversation with Martin Seligman developed these ideas further, “This problem is common to all the scientific disciplines. We lack the social political intelligence so critical to shaping our institutions. Doctors, nurses are no exception. Teach that and you have really got something. It is the antidote to learned helplessness.” So that is exactly what I have done. With that background, and two more graduate degrees, I crafted an approach that has been successful in motivating and teaching clinicians regain control, creating safe, innovative environments.
But how do you do this? First, it is essential to convince clinicians that they have the ability – and responsibility – to create positive clinical environments designed to achieve the best possible outcomes. This is a huge paradigm shift for clinicians. We have been trained to focus on the patient, not the patient’s surroundings. Next, clinicians must learn how to rigorously analyze the organizational limitations that are limiting care. Lastly, ideas need consensus before they become a sustainable reality. These last two steps require leadership competencies that again, are not front and center of medical and nursing education. Not even on the sidelines.
Why should hospitals and the clinicians that populate them be interested such skills? Fifteen years ago, it is unlikely that anybody would have listened to these ideas. However, in the last five years, the highly publicized data on medical error has put the spotlight on hospital dynamics. At least 100,000 Americans die from medical error every year. I suspect the number of Americans that receive care that is less than what is scientifically possible is at least ten-fold that figure. The inability of doctors and nurses to communicate that which is impacting care in a positive, effective way is at the heart of the problem.
The delivery of safe, compassionate, affordable, and innovative care is possible, even in tight fiscal environments. It is the productive of highly trained clinicians who learned the leadership skills to shape positive organizational environments that are dynamic and positive; skills that foster collaboration, creativity, and problem solving.
Minich, P. J. & Deal, T. (2003). Sick Patients Sicker System: How Clinician Leaders Become System Healers. Peter Minich Publishing.