Thursday, August 13, 2015

Negotiating on Purpose

Over two years ago, the folks over at the athenahealth kindly invited me to submit columns to their Health Leadership Forum, and I have done so on an occasional basis since them. As I recently reviewed the columns, I realized that my own thoughts on the topics of leadership and coaching have evolved a bit, and I thought my readers over here at Not Running A Hospital might enjoy witnessing the transition. So for several days, I will be reprinting the posts from the Forum over here. Comments are welcome at the original site and here. Today's reprint is from a post dated September 25, 2013, "Negotiating on Purpose."

After her fifteen year-old son Lewis Blackman died from a series of preventable medical errors, Helen Haskell diagnosed the problems in the hospital by saying, “This was a system that was operating for its own benefit.”

What she meant was that each person in the hospital was unthinkingly engaged in a series of tasks that had become disconnected from the underlying purpose of the hospital. They were driven by their inclinations and imperatives rather than by the patient’s needs. Indeed, they were so trapped in that form of work that they could not notice the entreaties of a seriously concerned mother as her son deteriorated.

I once heard a Harvard business professor describe the financial imperatives of many hospitals in a less personalized, but analogous fashion. He called hospitals “business cost structures in search of revenue streams.”

What he meant was that the business strategies of the hospital had become detached from the humanistic purposes that had led to the creation of the hospital. There was thus a parallel to the individuals’ behavior noticed by Helen.

What a perversion of human endeavor when things reach this point! Activity for the sake of activity in the context of an organization that has lost its soul.

Lest we get distracted by the current debate about the incentives that might correspond to different payment models—fee for service, bundled, or capitated rates–is important to note that this kind of perverted personal and corporate behavior is not driven by rate design. The failure of Lewis Blackman’s doctors and nurses had nothing to do with financial incentives. No, the systemic forces at work that killed this young man were based on ego, fear, poorly functioning hierarchy, lack of communication, and cognitive errors.

Likewise, the corporate search for revenue for the entities that constitute our hospitals and health systems has not been driven by rate design. Under any payment regime, the underlying issue is that hospitals are huge fixed-cost enterprises, and the incentive to “feed the beast” often drives corporate strategy, driving out humanistic concerns. Indeed, it may be that a movement to provider risk-sharing will simply compound the problem in that it will require hospital systems to accumulate greater financial reserves to hedge the actuarial risks that are being transferred in their direction.

Let’s not lose the irony of this kind of situation. The people who have chosen to be in the health care field are, for the most part, the most well intentioned people in the world. They have devoted their lives to alleviating human suffering caused by disease. They are intelligent and thoughtful and highly trained.

Indeed, if each of us in health care were asked to state the purpose of our institution in our own words, I bet we would say something similar. In my former hospital it was codified as follows: “We hope to take care of patients in the manner we would want members of our own family cared for.”

People’s behavior in the moment, though, often is at variance with such purposes. Corporate imperatives likewise go awry.

It is at time like this that we search for leadership that will help steer the ship and those in it in a more humanistic direction. Surely the leader cannot be agnostic with regard to financial concerns, but he or she needs to act to help the organization put purpose above all. What can we expect and hope for from great leaders at this juncture in medicine’s crisis of purpose? The usual answer—inspiration—is not correct.

Professors often draw a distinction between management and leadership, noting that leaders have the ability to inspire people in an organization to a higher purpose. Yes, there is the kind of inspiration that occurs during a crisis, like that offered by Winston Churchill during World War II or Franklin Roosevelt during the Depression. But for most organizations involved in the day-to-day work of providing a service to the public, the professors’ description is off point, for the leader’s ability to inspire is not germane. The ability to inspire can provide a shot in the arm, but it seldom leads to sustained and mindful action on the part of people in an organization in support of its purpose.

My view is that inspiration comes from within and is tied to those ethical standards and good intentions that caused people to enter the health care professions in the first place. The leader’s job, then, is not to inspire. It is to use his or her influence to help create a supportive environment that permits the waiting reservoir of such intentions to be tapped.

Paul O’Neill, former Secretary of the Treasury and CEO of Alcoa Aluminum, has set forth a three-part test for an organization seeking to empower its staff to fulfill its mission:

1. Are my staff treated with dignity and respect by everyone, regardless of role or rank in the organization?

2. Are they given the knowledge, tools and support they need in order to make a contribution to our organization and that adds meaning to their life?

3. Are they recognized for their contribution?

The leader’s job is to carry out an ongoing negotiation with the various constituencies in a hospital to persuade them that it is in their interest to organize their work and behavior in such a manner as to permit these conditions to take hold. You might find it strange that I frame this responsibility as a negotiation, but that turns out to be a more apt description than others that might be used.

Hospitals are filled with highly trained professionals who want to spend their time doing the things they are trained to do. Those people are not generally trained in the kind of interpersonal skills and team behavior that is required to support Mr. O’Neill’s desired conditions. The leader has to persuade those individuals that their own role will be enhanced if they learn to behave in such a manner as will help develop O’Neill’s conditions. In negotiation parlance, they have to be made to feel that agreeing to such an approach is a better path than their alternative, i.e., not agreeing to it.

People who are likely to be the future leaders of health care institutions in America and abroad often come to me for career and training advice. My constant refrain is to learn the principles and framework of negotiation strategy. Negotiation can be defined as means of satisfying parties’ underlying interests by jointly decided action. You cannot be a leader if you do not know how to help a hospital’s constituencies understand that their interests are coincident with the purpose of your organization and if you cannot help them jointly decide on the actions needed to carry out that purpose.


Neville Sarkari MD, FACP said...

Thanks, you make some great points. I would also note that this applies to any healthcare organization. For example, I work in the large Hospice space, and although much is different from a hospital, much is also the same in terms of leadership and negotiation. Will be sharing. -Neville

Barry Carol said...

It’s great for a hospital CEO to try to drive the behavior of each employee and doctor with practice privileges in the direction you suggest. The real test, though, would be how the CEO reacts in the case of a high profile doctor, especially a surgeon, who generates a lot of revenue for the hospital but is arrogant, treats lower ranking (lower paid) employees badly and doesn’t countenance being questioned by nurses or techs. If the CEO is prepared to fire the rainmaker surgeon or withdraw his practice privileges, others will get the message that the expectation of a collegial and collaborative culture is for real. If he isn’t willing to, they won’t. At the same time, the CEO also needs to ensure that the hospital continues to survive and hopefully thrive financially. It’s a tough balancing act, especially for hospitals in a precarious financial condition.

Anonymous said...

I'd say Barry Carol has it on the head. I am thinking of the "monopoly" in the area that they let keep on trucking, when patients from that group have had problems they know about in writing and refuse to address the issue.