I have been in health care my entire working life. For the last 5-6 yrs I have traveled the USA as a free lance consultant for Performance Improvement, Clinical Resource Mgmt, UR, Risk Mgmt, Infection Control, Patient Relation programs and various other projects for primarily acute care facilities. Unfortunately, with the exception of perhaps two facilities, most either meet or surpass the prestated traits of a passive/agressive hospital.

These facilities are not safe for patients. Inlieu of correcting issues these facilities are very adept at doing RCA's that creat a papertrail and nothing more. Employees are penalized for "doing the right thing". Rocking the boat is the worst thing someone can do. Boards of Governors/Diretors remain negligent. I was recently in a quality Board of Governors meeting, (the whole Board did not want to waste its time listening to quality issues so it created a sub-committee), where I was told that they did not care about the operations of the hospital as that was only the concern of the CEO/President of the facility. There is no need for a Board that thinks the only reason they are there is to attend a social event. As long as this remains acceptable behavior by the people in charge patients remain in danger.
cby

I'm thrilled to report that this post was NOT about our hospital, but I absolutely agree with everything you said in your comments. Nick

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11/17/05
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2/04/04

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I want to also talk about my own experience with passive organizations in health care.

4 years ago, I began working with www.clinicalfocus.com. I act as their VP of Strategy on a part-time basis. We developed a technological tool and had signed letters of intent, we could present to angel investors on using this tool from a number of hospitals.

We got bogged down in the passive and mechanical practice and interference that emerges within hospitals that ties to legal talking to medical records, medical records feeling like they want included in the decision and more hub bub. I am not describing facts because on a people basis, everyone's intentions were excellent.

Similar to this experience when I returned to Boston in 1999 and began to talk to old colleagues from my former employer (the local HMO) I saw passivity in action I had never seen before.

I have become more active with Clinical Focus recently, because my ideas seem to be timely. We are now building cooperation with groups outside of hospitals that actually want to impact patient care. What is also key is how we engage in conversation. We simply no longer offer what we have (the big secret weapon for health care, I say with humor) to people who accept working in a mechanical way as the only way to work and are not people who want to innovate change in health care.

Its hard to do that when you are in a full time job. I would not want anyone including Nick to give up their paycheck. However, I keep asking myself how do people I respect like Nick and Tony fly with innovation in systems that are often passive and relying on technology and methods of practice they won't question or change?

That's my rant for today.

based on the "symptoms" listed above, it seems like it takes just a few passive aggressive leaders to turn the organization passive aggressive. All the more reason to hire the right people.

I agree with both the Mr. Jacobs and Ms. Young that many hospitals can be classified passive-aggressive (PA) organizations where more energy is put into thwarting change than starting it, but in the nicest way possible.

That PA label, by itself, is unfair for hospitals because of three systemic cultural norms that are dominant in hospitals:

1. RISK AVERSION: Their mission involves life and death decisions where the consequences of some errors can be catastrophic to the patient, the care providers and the hospital. In that environment, less effective managers and organizations prefer to 'bury their mistakes' as opposed to celebrate them or ‘to learn, to share, to achieve.'

2. SPECIALIZATION AND RATE OF CHANGE: For over half a century medicine has become increasingly specialized and the rate of knowledge aggregation has continued to accelerate. In that environment, each functional area or program becomes a knowledge silo where the person with the most degrees and years of experience tends to control process design and service delivery standards. If that person is not flexible and current, people below the leader ‘put forth only enough effort to look compliant.’ Further is that since people in one program area quickly learn that they do not understand the complexities of the jobs in other program areas, collegiality and mutual respect are encouraged while criticism or negative feedback is discouraged.

3. UNIQUE ROLE OF THE DOCTOR: Many observers expect that the most expensive resources in the hospital are the high cost assets such as the diagnostic imaging equipment – CAT scanners, MRIs – or the operating room. Experienced administrators and doctors both agree that the most expensive asset in the hospital is the doctor’s pen. What the doctor does or does not write for patient will determine if the patient stays two days or six days, if the patient will or will not have complications that could cost thousands of dollars to resolve, and even if the patient will require hospitalization at all. In no other industry is the person who determines 60 to 70% of the organization’s costs and resource utilization typically an outside contractor who is not paid by the organization or controlled by the CEO.

With this type of ‘unclear lines as to where accountability lies’ for cost and quality outcomes, it is no wonder that hospital manager and staff often exhibit passive-aggressive behaviour.

The solution the original authors, three Booz, Allen Hamilton consultants, suggest is a little more comprehensive than a new sheriff and seven deputies as project managers.

We are making many of the mistakes in health care that we made with steel industry in the seventies; continued with electronics manufacturing in the eighties; repeated with airlines in the nineties; and continue today with automotive manufacturers. Mistakes don’t get any prettier the fourth and fifth time around. In these chronically ailing industries, less effective management teams tried to grow their way to greatness by merging (i.e., buying someone else’s customers or technology) and across-the-board cost cutting involving reduced customer service, staff complement, wages, benefits or outsourcing. The stresses of continual well-intentioned but poorly-executed reorganizations and cost cutting programs will eventual turn the most dedicated employees and managers into ‘deserters’ or passive-aggressive resistors of change.

The only organizations in these four terminally-ill industries who grew and prospered have done so with constant focus on the customer’s needs and wants (e.g., autos – Toyota; airlines - Southwest), constant innovation both in products and services or supply chain processes (e.g., steel – Nucor, electronics – Dell, RIM); having clear performance outcomes (e.g., British Airways or BA); sharing performance data with employees; and empowering their front line staff to own and change their processes to reduce waste, errors and delays.

When hospitals focus on the patient; empower staff to continually drive waste, errors and delay from the care pathways (not just the administrative support processes); and align patient / hospital and doctors goals there can be quantum leaps in quality, productivity, satisfaction and cost reductions.

Mr. Jacobs is correct that transforming the organization is not quick. While bringing in a new ‘sheriff’ or leader may be required, that solution is not without risk. More common and less risky is when senior management recognizes the current service delivery model, care pathways and strategies are no longer working effectively; and they lack the experience or resources to do the redesign and implementation. The change can be led by the existing management team if they get experienced help through consultants, selective recruiting and management development. The transformation of passive-aggressive organization involves many skills and disciplines: designing robust processes, clarifying roles, performance management systems that provide the transparent quality, cost and productivity data required, realigning rewards and recognition programs, etc. However in 12 to 36 months, anyone that has been through the successful transformation to a stronger ‘resilient’ organization will agree the investment was both critical to survival but one of the best investment decisions the organization ever made.

Hi Hospital Tony, you seem renewed in energy. The baby must be sleeping through the night now.

I beg to differ with you. I know many organizations that hire "the right people."

I think it really ties to what http://www.workecology.com is about as a thought leadership group when we ask the question, "Who really matters?" Which core group matters and who in the core group dictates what matters?

This is not simple now in the world of social network, free agents and the disparity of so many groups of professionals and how they organize to work with each other in health care.

Health care as a confusing sector (profit/non profit, et.c0 and hospitals as institutions have a very complex social network from which to draw talent, serve the patient and work with the limitations of the infrastructure that forces decisions in a direction that is not what people want.

I am starting to believe the best thing I can do now is to go out and teach Systems Thinking to groups of people cross practice, expertise and institution to learn how mechanical systemsfreeze the possibility of what the right people actually know what to do.

And in that regard then look at the financial issues and how to empower change within that structure.

Have a pleasant day all. If anyone would like to view a drawing of the systems at work and the cause and affect in practice, write me and I'll send you a diagram that I use to invite people into conversations from which to lead for change.

as always, very insightful comments, Lavinia. and thanks noticing my 2nd (err. probably 8th) wind on the blog here.

I guess I would agree with Jim Collins who says that it's more important to "get the right people on the bus" and THEN "figure out where to go" after that. With the right people, it's that much easier to model the right culture, think the right way (including systems thinking), and go the right way.