Structuring Leadership to Manage Change

By José Domingos

To state the obvious: Healthcare is complex. Even if we were to remove certain elements of our national system like distinct sets of federal and state regulations, multiple public and private payers, and systems for electronic record-keeping developed by competing vendors – we would still be left with complexity at the level of individual organizations and in the constant, dynamic evolution of medical knowledge and evidence-based practice.

Additionally, as organizations process the ongoing impact of a global pandemic, individuals in healthcare roles are questioning their professional choices as they weigh personal risk and stress with a commitment to the work of patient care.

During challenging times, leadership and management often come under scrutiny and reappraisal. A thoughtfully developed approach to leadership can address complexity at the individual, team, and organizational level while making a difference in operational stability, and, importantly, supporting individual fulfillment and personal satisfaction.

The Problem of Hierarchy

Despite generational changes in the composition of the workforce, a common career trajectory has people starting as individual contributors who follow the directives of a manager who reports to another manager, and so on, up to the top corporate leader. The assumption implicit in this structure is that moving up in the leadership hierarchy is the result of increasing levels of expertise and experience.

This traditional structure is a chain of command sometimes referred to as command and control. As one moves up the chain, the number of people at each level decreases and, in healthcare, the roles simultaneously become increasingly removed from the day-to-day delivery of care to patients and more concerned with issues of oversight, administration,  guidance, and compliance.

My own organization develops accreditation standards for healthcare settings and many are written assuming this structure. For every program, there are requirements that a governing body, CEO, administrator, or clinician assumes “ultimate leadership responsibility.” Standards reference individual responsibility for oversight of specific services or even systems.

The issue with a typical hierarchical structure is that it puts decision-makers a long way from those who will be affected by the decision. If our goal is patient-centered care, we have to consider whether a structure that moves decision-making farther from the patient is, in fact, the most efficient and effective approach. Bear in mind that addressing the expected is not the problem.  ”Escalation” generally happens only in unexpected situations. In healthcare, “unexpected” usually implies a level of urgency. And if it’s when things go awry that the hierarchy takes over, that distance between the problem and the authority to act can be a real impediment to a nimble response.

One familiar and obvious example – and one that goes back to the complications of U.S. healthcare as a whole – is pre-authorization requirements for insurance. There are a lot of layers between that decision and the person impacted by it. Those layers can lead to a lot of stress, anxiety, and potentially delayed or undelivered treatment.

What’s the solution? Complexity in healthcare is not going away. But we can manage complexity in organizations better than we do now and a change of perspective about who is considered a leader can open doors to better decision-making processes and greater personal satisfaction.

Alternative Leadership Structures

There are alternatives to the traditional chain of command hierarchy. One example is to formalize a flatter structure in which each individual manager has broader responsibility. This model removes as many middle managers as possible with the goal of shortening lines of communication, thereby shortening the time from decision to patient.

Studies have shown that flatter organizational structures lend themselves to fewer bureaucratic obstacles and greater team cohesion. Additional potential benefits are more supportive work environments and a greater culture of patient safety. This happens because individuals on cohesive teams connect their own contributions to the overall success of the group.

We have all seen examples in the recent past of medical errors and the damage that ensues from finger-pointing and blame. On cohesive teams, individuals understand how their work contributes to the overall success of the group. By focusing on team goals, there is less incentive to blame and more incentive for collaborative problem-solving. In this case, when a failure occurs, the immediate question is how the system allowed for that mistake and an analysis of the root cause rather than an effort to assign fault to an individual.

Nevertheless, abandoning a leadership structure that defines roles is simply unrealistic for most organizations. But it is possible to shift the perception of what it means to be a leader. This perceptual change gives everyone in the organization a leadership role regardless of where they sit in the defined hierarchy.

At my organization, we have adopted an approach based on the concept that everyone is an owner. This means that there is an expectation everyone is developing the ability to de-prioritize their own personal stake in a given decision in favor of a benefit to the organization. At its best, this approach should make it hard for someone from outside the organization to easily distinguish between those with senior leadership titles, managers, and individual contributors. It is an ongoing practice and we are seeing the results. Sometimes meetings are large due to the effort to include representation of every role with a stake in the topic being discussed. Partly this is to elicit input from multiple perspectives, and partly it is designed to develop leaders by giving team members the opportunity to stretch. By encouraging all team members to observe how departments and functions work together, and to speak up, we simultaneously discourage passive acceptance of the status quo.

Communicating for Change

One of the key elements of leadership is the ability to communicate a vision, which many understand as the responsibility of the CEO. But again, can we reframe the idea of “communicating a vision” more directly? A leader states the desired result.  Now, it becomes something that everyone can do. If we cede this responsibility solely to the top of a leadership hierarchy, to the “command and control” structure, we’re missing opportunities for incremental improvement throughout the organization.

An additional aspect of this – and one that can be practiced and developed – is communicating in a way that inspires others to pursue a described outcome with commitment and energy. This is what turns a “command” into a vision. Communicating a vision is not just about telling a good story. A true leadership vision must be rooted in organizational stewardship.

From a formal leader, like a CEO, the vision might address change through broad categories: growth of services, excellence of delivery, or focused specialization. From an individual leader seeking to implement a change, the “vision” to communicate might focus on addressing specific, incremental actions that are seen as easily achievable and then become milestones toward the intended outcome. By highlighting a team’s current and potential capabilities, that vision becomes a persuasive story to rally behind.

A second communications challenge is the ability to understand how decisions reverberate and plan for that ripple effect. For example, if a healthcare organization establishes a policy that the identity of all patients will be confirmed twice by every provider before rendering care, that policy must be communicated throughout the organization. What also must be considered is the patient’s perception when they are asked for their name and date of birth a fifth or sixth time. If that policy includes training on communications skills so that early in an encounter, patients are taught to understand that these questions are being asked for their protection and safety, then a rote activity evolves into a moment of connection that will positively impact patient experience.

Managing Change

Whether on websites, digital resources, or paper books, there is no shortage of ideas about how to deal with and manage change in healthcare settings. Leadership, in my opinion, is about managing change by moving people to act individually and in coordination while maintaining a sense of stewardship. This type of leadership happens at the organizational level, at the team level, and at the personal level. When practiced successfully, it creates a stable, high-performing organization.

Change challenges us and requires management, but a time when nothing is in flux is rare. The best time to think about intentional, thoughtful leadership is now.

José Domingos is President & CEO of the Accreditation Commission for Health Care (ACHC), a nonprofit healthcare accrediting organization with over 35 years of experience promoting safe, quality patient care. Reach Jose by email. Click for more information about ACHC, or call 855.937.2242.


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