Home All Sick Patients, Sicker System?

Peter J Minich, MD, Ph.D, MAPP '06 is author of Rethinking Power in Healthcare: What to do when Authority Fails and Patients Suffer. He is a practicing surgeon in Toronto Canada. He teaches leadership to leaders from all walks of life, in all parts of the world. Visit Peter's Web site. Full bio.

Peter's articles are here.

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.


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Jeff Dustin 20 March 2007 - 3:36 am


Your accomplishments in organ transplantation and organizational transplants are impressive. Since 100,000 Americans die yearly from hospital error, why isn’t there a bigger stink about this in the media? Look at the numbers. In Iraq we had around 3,000 troops die. 9-11 was a disaster of the same magnitude. I try to avoid watching the media obessession on the war (and on Anna Nicole’s stoned face).

As a veteran, I sympathize with the servicemembers over there, but here is what I don’t get. Our national priorities are set by media hype and politics and not by hard numbers. What if we actually spent our national budget on the key problems that are barriers to national greatness? Arguably, fatal disease is one of the very biggest impediments to excellence. You can’t build the Statue of Liberty if you are dead. Positive Psychology is, in part, about exploring human accomplishment. How much excellence is lost when 100,000 human beings perish from a preventable problem?

I am glad that you and professionals like you are addressing this huge challenge. Here’s another challenge for you: can you come up with a Positive Intervention for turning around a bureaucratic organization if you AREN’T a CEO? How can these nurses make a difference without setting policy?

Margaret 28 March 2007 - 3:56 pm

Peter, I thoroughly enjoyed reading your article. I’m now prompted to pass it along to several friends in the medical field. My hope is that medical schools will integrate leadership into their curriculum — do you know of any schools that currently do this? Warm regards, Margaret

Kenneth H. Cohn, M.D. 8 April 2007 - 11:31 am

Dear Peter,

Thanks very much for writing such an articulate case for physician empowerment.

I too am a surgeon who went on to get an MBA and have found my passion in helping physicians and administrators work more interdependently.

I would appreciate your feedback on a summary of a chapter I wrote in my book “Collaborate for Success! Breakthrough Strategies for Engaging Physicians, Nurses, and Hospital Executives,” which was published by Health Administration Press, September 2006. It deals with using web-based tools to form virtual communities that can come to consensus on clinical priorities.

Thanks for your efforts helping physicians find antidotes (ie leadership skills) to overcome helplessness.

Summary taken from: Chapter 11. Building Community and Collaboration with Blogs,
Kenneth H. Cohn, Glen Mohr, and William Ives, in: Collaborate for Success! Breakthrough Strategies for Engaging Physicians, Nurses, and Hospital Executives. Kenneth H. Cohn. Chicago: Health Administration Press, 2006. http://www.ache.org/pubs/cohn.cfm
Biographic information
Dr. Cohn is a practicing general surgeon who divides his time providing surgical coverage in New England and writing, speaking, teaching, and consulting. Dr. Cohn can be reached at ken.cohn@collaborateforsuccess.com or via his website, http://www.healthcarecollaboration.com.
You may forward this information at will, provided that you reproduce it in its entirety and notify the author. Thank you for helping disseminate information about how we can work more interdependently to improve care for our patients.
The blog proved to be an invaluable tool for our Medical Advisory Panel. The backbone of the blog was a summary of each meeting in outline form that was posted within a day of each meeting. The blog facilitated our work by providing a convenient platform for continuation of the discussion. Members who couldn’t attend a particular meeting could stay informed. And it was particularly useful when it came time to write the summary report. Having this organizational tool allowed me to recognize important themes that were relevant to the majority of the medical staff. (Medical Advisory Panel co-chair)
Physicians are becoming increasingly disaggregated. The failure of reimbursement to keep up with rising expenses has forced many practitioners to increase the volume of patients they see and treat, thereby limiting their time for activities other than direct patient contact and hence limiting time with referring physicians.
New web technologies offer simple and convenient ways for clinicians to share information, to find others who have the information they need, and to keep in contact with one another. The purpose of this summary is to discuss the use of blogs to create virtual medical communities. What is a blog?
A blog (short for web log) is an easily maintained web site that allows a group of geographically disconnected people to form a virtual community. A blog makes communicating simple and convenient by making it easy to add new information, by archiving everything in a permanent, searchable database and by automatically notifying subscribers when new information is added. Blogs simplify communication.
Blogs create a searchable and instantly accessible archive. Everything published on a blog can be readily accessed through a full-text search. For example, once someone answers a question on a blog, the answer becomes part of a permanent searchable knowledge base.
Blogs encourage transparency. By making the interaction of the group more transparent, blogs invite participation and break down silos and hierarchies. For example, new members can get up to speed quickly and begin receiving the information they need by searching the archive and subscribing.
Blogs enable secure centralized management. While blogs encourage transparency, they still offer control.
Case study
The utility of blogs in facilitating a clinical priority-setting process is outlined in the following case study.
A 750-bed West-Coast hospital system began a structured dialogue process to engage physicians in setting clinical priorities for the next three to five years as it planned the construction of a new hospital that would consolidate two campuses. A Medical Advisory Panel (MAP) was formed of sixteen clinically active physicians who committed to attending weekly meetings in return for a commitment from hospital leaders to give serious consideration to implementing the MAP recommendations, as described in Chapter 1. The MAP heard presentations from physicians in all major clinical areas on their recommendations to improve care for the community and foster better physician-physician and physician-administrator communication and collaboration. The MAP collated the recommendations into a consensus report, which highlighted the need for major improvement initiatives involving information technology, radiology, the operating room, and the intensive care unit.
A password-protected blog was created to support the structured dialogue process. To make it user-friendly, the blog design included pre-set content categories for Presenter Reports, Meeting Minutes, and Implementation Status. It also included prominent links to such common tasks as adding content and downloading materials. A blog administrator was trained and charged with regularly updating the blog, maintaining the flow of discussion, and ensuring that the blog discussion was integrated with the weekly face-to-face meetings. The administrator was also provided with an aggregator to facilitate seeking outside sources of information and bringing them into the structured dialogue process. Throughout the process, a physician-facilitator monitored use of the blog, customized the functionality to serve the panelists’ needs, and coached the administrator.
In the first month of the structured dialogue process, panelists learned how to use the blog during a 20-minute presentation that explained:
1) Its purpose in supporting the structured dialogue process and saving physicians’ time;
2) Examples of ways blogs are used elsewhere in healthcare organizations;
3) The login procedure, likely tasks, and how to obtain technical support.
The blog facilitated the structured dialogue process at every step, as explained below.
The blog provided a convenient distribution point for material relevant to physician presenters and their reports. Panelists could download material that explained the structured dialogue process and criteria that reports were expected to address, which they gave to physician presenters in their department. When presenters submitted their reports, they were uploaded to the blog, which generated an automatic e-mail linking to the report on the blog and reminding panelists to read the reports prior to the weekly MAP meeting.
Within two days after each MAP meeting, minutes were posted to the blog, which helped panelists keep track of what they had done. A calendar maintained on the blog kept important details from being overlooked.
As the presentations drew to a close, the blog’s search engine facilitated report writing. A large amount of data accumulated in the course of the MAP meeting weekly for eight months and hearing an average of two presentations each week. Panelists could search the archive to find recurring themes and specific comments and examples that otherwise might have faded in memory or have been too time-consuming to locate in the minutes and reports.
The blog also served as the location to post drafts of the MAP report to allow panelists to provide important feedback at convenient times for them.
Building solidarity and community The blog permitted panelists to interact outside the confines of weekly meetings, as new ideas surfaced and new issues appeared and the secure, password-protected site allowed panelists to discuss what was on their minds without fear of outsiders reading their comments.
The 24×7 access decreased barriers to participation and allowed even reticent panel members to contribute to the structured dialogue process. Some panelists found it easier to reflect over weekends than during Monday morning meetings. The blog provided a way to capture their insights. For example, after spending a frustrating weekend on call, a physician panelist posted a detailed log of the time he wasted in Radiology trying to access studies of critically ill patients on whom he was consulted. His comments focused the MAP’s attention on Radiology service issues early in the process and gave others an opportunity to reflect on time they had wasted searching for imaging studies on their patients. One participant commented, “I thought it was just me.”
The blog also allowed physicians who missed a meeting because of vacation, illness, or a conference to remain current and as such, facilitated the process moving forward during the summer.
The blog encouraged members to contribute information that they found relevant without worrying about wasting scarce meeting time. Some physicians used the blog to provide outside reading for fellow panelists, for example, an article on differences in cost of care between the US and Canada.
Because successive drafts of the final report were posted to the blog, the writing process became transparent and supported the development of a consensus report, in which all panelists could take an ownership role.
In short, the blog allowed the Medical Advisory Panel to pursue a data-driven approach to clinical priority setting based on the material in physician presenters’ reports and lowered barriers to participation. When polled at the end of the report-writing process, panelists unanimously endorsed continuation of the blog into the implementation phase and have asked senior administrators to become part of the weblog community by extending them passwords to the site.
Lessons learned
The design and approach employed in the case study ensured that panelists clearly understood the purpose of the blog and how it could facilitate the structured dialogue process. In addition, it was important to have responsive support that not only handled technical issues but, more important, monitored use of the blog and adjusted the design and functionality to serve the panelists’ evolving needs. For example, initial use of the blog was limited to distributing presenter reports and meeting minutes. Later, new categories were added for implementation notes and links to the final report drafts.
Blogs allow people who may be geographically disconnected to network and collaborate at times that are mutually convenient. The user-friendly search characteristics facilitate using a blog as a data repository. Blogs facilitate project management by allowing team members to know what is happening without wasting their time playing telephone tag and thus help them implement new ideas in a timely fashion.
The transparent engagement that blogs facilitate encourages healthcare professionals to share their thoughts and feelings and makes it safe for new approaches to emerge by lessening risks of humiliation and failure. For complex organizations that acknowledge that innovation occurs at the edge of chaos, blogs allow people to try out new ideas and benefit from the collective intelligence of their group.
Key Concepts
• A blog is an Internet-based, user-friendly content management system, useful for harried professionals seeking ways to make their time count, improve their practice environment, enhance physician-physician communication, and facilitate physician-hospital collaboration
• Blogs make it easy for healthcare professionals to collaborate with colleagues at times of mutual convenience
• Blogs mirror the way practicing physicians work: decentralized, searchable, available 24 x 7
• A proactive but flexible organizational policy regarding blog use that encourages informal communication and discourages leaks of proprietary information and patient health information is necessary to foster spontaneity and serendipity

Kathryn Britton 8 April 2007 - 12:31 pm


People at all levels make a difference in a negative way all the time. We call it “the slow roll” — that is, the way people can deep six a policy they don’t agree with by just not putting any energy into it.

I think Peter’s work exemplifies a major challenge in a number of fields — that is, first you have to face reality (we are not going back to medicine as it was in the 60’s) and then you have to act collectively for improvement. To act effectively, you have to believe that you can make change — that is, learn optimism to replace learned helplessness.

It would be good to see some specific examples from Peter where people have made changes. Examples of successes, how ever small, are great ways to start people learning optimism.

(Jeff, how did we luck out getting you so involved in all these conversations! What a gift you’ve been.)

Jeff Dustin 8 April 2007 - 1:26 pm

To my new friend Kathryn,

I love me, too 😉

What I’ve struggled with is that there are people who actively impede workplace happiness. I’ve worked for a true sadist who enjoyed the attention he received by humiliating others. I looked at the counter evidence and found that with this individual, it was unlikely that positive change would occur. The reinforcements for his harmful behavior were quite strong. It seemed that his behavior had a Milgram-like Authoritarian ripple effect. His subordinates modeled themselves after his sadistic behavior punching the Bobo-dolls that were beneath them.

My question to you, Kathryn, is a simple/complex one. How do we deal effectively with abuses of power?

Whistleblowers frequently get burned. I used learned optimism to make suggested changes and repeatly found myself severely punished by the Established Powers-That-Be. Also my own peers saw me as making waves, became afraid and many turned against me. I stood up to them for the most part, too.

How can LO promote solidarity and empowerment in a tough environment? Is it even advisable to keep hope high when in fact it would be much better to cut your losses and escape? I guess you’d have to be optimistic to escape, but that’s a secondary point.

PP is about creating solutions, right? What is a good solution for an employee at an authoritarian workplace? Employers have a lot of power to wield especially against the poor who are often burned out, need the money desperately and are eager to please to avoid getting fired.
The poor have a compound problem. They need cash desperately, get paid subsistence wages, don’t have healthcare and yet may have a very toxic boss who spews filth on them day in and out. Many times there are children involved so that it isn’t just a Take This Job and Shove It situation. Thinking about this situation evidentially might depress you, alternative thinking might be used to perpetuate the status quo, implications are likelwise a way to sugarcoat the situation. A plan of attack would help if that is a practical option.

What does PP have to inform economic justice?

Kathryn Britton 8 April 2007 - 6:38 pm


The thing that pops to the top of my mind is Jane Dutton’s chapter about dealing with corrosive connections in Energize Your Workplace: How to create and sustain high quality connections at work.

Here’s an interesting statement (p. 110): “Often, corrosive behavior may be an offshoot of a flexing of power and teh offending party may be oblivious to the damage that ensues. As I noted earlier, people in higher-status, highe-power positions simply do not pay as much attention to those below them as people in lower-status positions pay to those above them. Consequently, people in higher-power or status positions may find it difficult to see their causal role in creating corrosiveness, and they may be less motivated to remedy this destructive pattern. Por this reason, it is often the person with less power who must notice the corrosiveness of teh relationship and take action to deal with it.”

She has two examples of the spreading impact of corrosiveness that she calls “Spirals of Incivility” and “The Death Spiral: Turning Competent Performers into Basket Cases.” (P. 114)

Here are the titles of her strategies:
Naming the problem
Creating a sense of control
Bound and buffer
Buttress and strengthen
Target and transform

Then she has a section about putting the strategies to work.

Believe me, I have worked with people who create corrosive connections. I ran into a person of higher rank who was a marine at heart — listening pointed up, speaking pointed down. I agree with Jane Dutton’s statement, “It’s tempting to shrug off incivility and thoughtlessness as inconsequential, but such connections are not benign. Corrosive connections inflict multiple levels of damage on individuals and organizations that should not be ignored.” (p. 8) and “Moreover, corrosive connections can spark revenge, cheating, and other destructive behaviors.” (p. 10)

So I suggest you look at her work. Hey maybe I can get her to chime in on this discussion???

Jeff Dustin 9 April 2007 - 12:11 am


I really dig what you showed me about Jane Dutton’s work. Here’s a quickie story that illustrates the revenge aspect.
It was before a six month deployment and our sadistic boss had us moving furniture rather than making last minute preparations for the trip. After moving seven fifty plus pound desks my work crew took a five minute break. The sadistic fellow saw us taking a breather and screamed at us for ten minutes. (I watched the clock).

Well, for revenge one of the others took all the screws from the prefabricated desks, the ones that you need to rebuild these cheap office furnishings after moving, and put them in a little plastic bag. Also, the vengeful one took all the office keys and stuffed them into the bag. Then he walked outside and threw keys, screws and bag into the nearby creek. I asked him why he threw them away and he said, “because I hate that m—–f—-r”.

Obviously, low morale means low productivity or mediocre performance at best. So why does this negative leadership style exist and thrive even? Hopefully Jane Dutton will chime in, because I am fascinated with this topic.


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