Leadership often is viewed as something emanating from the top and filtering downward. However, effective leadership is more about colleagues working together, buy-in and bottom-up implementation than anything else. For a leader to be effective, a culture of collegial buy-in must be present, and there must be reasons for followers to follow, to sustain a safety culture and to align their daily work efforts and patterns with clearly stated goals of the institution. Themes, goals and mission statements may emanate from the top, but their achievement depends on the efforts of subordinate levels of leadership and, ultimately, to those on the front-line.
In “closed” systems where members of staff are salaried employees, it may be easier to implement and sustain a culture of safety and to develop strategies to achieve institutional goals. In more “open” systems, where some doctors and nurses are employees and others are self-employed or working under contracts, especially agency staff, it may be more difficult for leadership to be effective. If leaders and front-line stakeholders are not aligned and working together to achieve the same outcomes, then safety and highest quality cannot be assured.
Contracts generally address the pragmatic aspects of work such as schedules, compensation and, for clinicians, professional privileges. Beyond contracts, one particularly effective management strategy for ensuring engagement with all stakeholders has been the development of “compacts”, which outline the obligations of an institution to staff and the obligations of staff to the institution. In healthcare this approach has achieved most notably through the efforts of Virginia Mason Medical Center in the USA, which has developed institutional compact relationships for leaders and for clinicians1.
Case Study:
A hospital recently has been encountering challenges in safety, including instances of surgical mishaps, healthcare infections and medication errors resulting in harm. Many clinicians are unhappy, they are not experiencing joy and meaning in their work and are considering leaving the hospital. In order to address these deficiencies, the hospital leadership has implemented a patient safety training program focused on standardizing processes, utilizing evidence-based checklists and holding team training to foster collegiality and shared decision making for diagnostic and therapeutic processes.
Even though front-line staff have been engaged in the formative discussions for these efforts several clinicians have expressed dissatisfaction with the requirements and have refused to participate in team training or to change their behavior, even when presented with evidence of the effectiveness of the new strategies. Furthermore, some prominent clinicians have been openly dismissive of these strategies, one stating, “If only the nurses would do what we tell them to do, this safety stuff would improve.” Needless to say, such attitudes have impaired implementation of new strategies and furthermore have confused subordinate clinical staff and degraded morale.
The hospital’s Chief Medical Officer met with the department heads for an evening roundtable discussion, in which the goals of the institution were discussed and the need for buy-in across the spectrum of hospital staff to improve safety and outcomes. He expressed disappointment and dismay that some clinicians, often highly respected and with great personal power, had refused to fully endorse these new efforts. He explained that these attitudes were not acceptable and that they were affecting subordinate staff negatively. He expressed the view that everyone agrees that patients come first: their safety, their perspectives on care and highest quality outcomes. Yet beyond this initial agreement, some clinicians’ acceptance and implementation of evidence-based improvement strategies did not align with these goals.
He encouraged those present to discuss their concerns and listened attentively. He expressed willingness to negotiate some aspects of the new programs but remained committed to the overall goals and strategies. He expressed his commitment to support the clinicians in their efforts and obligated the hospital to address and improve on deficiencies the clinicians identified. He promised to do this as part of a compact agreement with clinicians, who had initially been resistant to accepting the proposed changes that they would also bend with the “winds of change” and engage fully in implementing the new strategies.
Finally, he mentioned that individuals who continued to speak out against the new patient safety efforts or to participate in them ultimately would, if necessary, be disciplined. He tasked the department heads to manage their staff appropriately in the best interests of patients and for the good of the institution. He promised to maintain an open door for ongoing feedback and further discussions while remaining committed to the new strategies. His message was clear, concise, supportive, and firm in conviction.
Over the next several months, notable improvements were apparent in many areas, though two clinicians did receive reprimands and one was terminated.
“Sometimes, if you can’t get the people to change, then you may have to change the people2.”
* Reference:
1. Google for multiple representations of this.
2. I would like to attribute this to someone but do not know who first said this.