Horizontals & Vertical - healthcare has to get it right

Medical/technical knowledge is vertical. Leadership knowledge is horizontal. Healthcare, especially doctors, need to understand this.


Clinical and medical knowledge i.e. technical knowledge – is vertical. It always starts with wide basic foundations and over time doctors knowledge becomes deeper and narrower. As a first year medical student you need to know about everything about a human body. But, say someone like a anal sphincter repair specialist or a paediatric neuro oncologist, who are very highly defined sub-specialists deliberately move away from their broad knowledge to knowing everything about their narrow scope of work. Such knowledge can mainly be learned from senior, mostly older more experienced persons, who have a higher technical knowledge. The process is pyramidal. Quite rightly so.


Leadership (and many aspects especially non-technical aspects of management) i.e. non-technical knowledge is horizontal. Leadership starts small and expands widely around us mostly in a flat transverse plane with amorphous blobby edges not necessarily circular. Leadership is where anyone and everyone has something to offer/teach/show anyone and everyone else irrespective of age, sex, colour, nationality, hierarchy, wealth, etc. The process is similar to an amoeboid motion expanding and ending up with varying end dimensions, yet no well defined end points for learning and development (though leaders themselves do have goals and aims).


Pilots learn flying (technical) mainly from other older, more experienced pilots – vertical; but crew resource management techniques (non-technical) is learned together with all staff who will be in an aircraft - horizontal.


What may be happening is that we are learning clinical, medical and technical stuff in multi-disciplinary, multi-professional combined learning atmosphere (some of the learning using this approach especially for procedural skills may be valid)


and


Leadership learning is being offered in situations and by organisations mainly or solely consisting of, designed for and responsible for doctors (such as deaneries, FMLM and many others).


I do not think there should be doctor leaders or nurse leaders which is what we find now; at least within organisations such as the NHS there should be leaders who happen to be doctors and leaders who happen to be nurses. Courses, teaching systems, learning atmospheres, pathways, about leadership in healthcare that are exclusive to any profession does a disservice to the whole cause by pre-defining a narrow mental perspective. The hierarchy in the professions are based on narrowing similarity (vertical) whereas leadership is based on broadening equality (horizontal).


It is possible that healthcare is now confused between horizontals and verticals. The quicker we resolve it the more successful we will be.

©M HEMADRI 

Follow me on twitter @HemadriTweets

'Nakamura invented the light bulb'

Would Nakamura invented the light bulb if he was working in the NHS?

Nakamura invented the light bulb, that is what we might probably say one day, that Nakamura invented the light bulb or to put it correctly that Nakamura re-invented the light bulb. Shuji Nakamura's inspiring story has been told before but here is an ultra-short version of it

Nakamura gets a masters from a relatively small university in a small city in Japan, goes off to work in a small company in a lab competes against the big companies, discovers many right things and makes products that would not sell.

Times get difficult, his department shrinks. He goes to his boss and wants to make a product that the big boys have tried to make and failed; with his record, he gets turned down. He goes to his boss's boss and gets some support to make it, despite his record of making nothing that sold, his company chairman gives him money, $2mil actually and he reinvents the light bulb. Well, he actually gets the blue component of the LED to work and the rest is history.

What is interesting is that Nakamura was a non-PhD working in the industry as a lab scientist who then gets a doctorate from his local university and within 5 years is head hunted by University of California and becomes a professor.

Nakamuras in NHS?

Let us imagine a scenario of a doctor who becomes a consultant in a DGH in the NHS and wants to do something that the big boys tried and failed.Then the DGH consultant fails as well, fails repeatedly - what are the chances that he will not be performance managed out of his/her activity and driven to the end of his wits.

What are the chances that the medical director or CD will be over-ruled by the CEO or Chairman and a doctor provided funding to carry on despite a record of 'failure'? What are the chances that even after this doctor discovered something interesting a big place will head hunt and make him/her an 'academic'? In fact he/she should be grateful if the GMC and the rest of the regulation did not land on him/her and crushed him/her out of existence.

Getting real

Now a lot of you are going to say that reinventing a light bulb while surely profound is unlikely to involve any damage to real human beings. You might say that any lurking Nakamuras in the NHS if supported could end up hurting patients. Good logical argument. Is that what is really hurting patients? Probably not. It is not any innovation by enthusiastic people that harms patients, it is the bureaucratic nay sayers who use the language of clinical governance and risk yet know very little about process capabilities, refuse to learn shared baselines, practice unimaginatively poor leadership who perpetuate harm in healthcare. They refuse to fix the system instead try to 'fix' the people in the system. Of course the medical profession does not do itself any favours by its ego, jealousy and macho attitude which will aim to shoot down anything that arises outside its hierarchical constraints by treating them as bad apples and recommending the use of evidence the origins of which  can probably attributed to the Abilene paradox.

In healthcare especially in the NHS it is pretty much impossible these days to take an extra breath without CD, CG, R&D, GCP, LREC, NREC, NICE, and every other alphabet in the soup wanting to spoil it for you, while claiming to support you. It is when people who are typically NHS managers and every other hierarchical bureaucrat stops behaving like researchers and most doctors who are not researchers begin to look at operational evidence as a valid method of creating a new practices, innovation and improvement that healthcare will be truly successful.

Allowing and managing 'Nakamuras' in healthcare is not easy but will be rewarding; eliminating the healthcare 'Nakamuras' will allow the managers to sleep peacefully but might push true healthcare innovation into a coma.

If you know of any 'Nakamuras' in the NHS please let me know by leaving a comment below.

©M HEMADRI 

Follow me on twitter @HemadriTweets

Links & reference
The dream of the blue laser diode
http://engphys.mcmaster.ca/undergraduate/outlines/4e03/Nichia%20%27s%20Shuji%20Nakamura%20Dream%20of%20the%20Blue%20Laser%20Diode.htm
Time magazine short feature on Nakamura
http://www.time.com/time/magazine/article/0,9171,1604891,00.html

Servant Leaders in Healthcare - Stand up and make it count

Airline operational performance results for major carries in USA have come out and it shows that in general flying experience parameters are all getting better. The WSJ has a nice tabular column which explains it really well.

Southwest Airlines had the largest number of system wide emplanements (I take this to mean the highest number of passengers took Southwest flights) and they have the lowest rate of complaints per 100000 emplanements. Southwest had about 40% less complaints than the next best complained airline and the highest complained about airline had 14 times (1400%) more complaints than Southwest.

United had the highest complaints. The stats show that United had the highest rate of bumping (passengers denied boarding due to overbooking by airlines) and highest rate of lost baggage and understandably they had the highest complaints.

Then an interesting fact leaps out:

Out of 7 major USA airlines, Southwest had the second highest rate of bumping, third highest rate of late flights and was in the middle of the field for lost baggage but had the lowest rate of complaints. As I explained earlier it was not just lowest it was (at least for the month November 2011) had 14 times lower complaints than United.

There is nothing more that annoys passengers than bumping or flight delays or lost luggage. Why did Southwest have such a low rate of complaints? Why did Southwest customers not complain more? Looking at the data, one would expect many more complaints. How can we explain this?

Southwest Airlines practices Servant Leadership, which is pretty unusual at a whole organisation level. Servant Leadership seems to have led to employee empowerment which then leads to building ground level relationships with customers. All those lovely videos on youtube about Southwest are examples. Customers begin to see Southwest employees as 'friends' who are coping with difficulties that are common and typical of airlines; they do not want to add to the burden of their 'friends' by complaining.

Relationships trumps poor stats and bad stories. This is true of healthcare as well. Patients relationship with their doctors and their local hospitals are the ones that keep our NHS hospitals going; if that was not the case we would see a significant movement of patients away from high mortality hospitals every time the mortality results hit the press or a bad news story hit the press. That is not happening at a perceptible level.

However, some hospitals are finding an increase in complaints every time the mortality results are published and on the occasion when bad news stories are published. Complaints are a useful tool for feedback, problem detection and improvement but when an organisation is already on a well recognised path of validated development complaints on routine operational matters can also be a source of distraction, expense and negative publicity. Problems which were not or could not be prevented, as might happen in healthcare often, if identified, as soon as they happened and customer service methods were used to deal with them, could avoid complaints and its ill effects.

In an organisation that is clinically performing well, to ensure that the doctor-patient relationship and the hospital-patient relationship which clearly exists is translated into a low number of complaints would need empowered employees enabled by an organisation wide servant leadership approach.

Where are the servant leaders in healthcare? Which organisations follow servant leadership approach? I can recognise very few leaders but no organisation practising servant leadership.

The thoughts on servant leadership are quite old, ''Mark 9:35 Sitting down, Jesus called the Twelve and said, "If anyone wants to be first, he must be the very last, and the servant of all''; there are other religious and philosophical variations which are older and younger to that quote. However the management description of it was by Robert Greenleaf who wrote:

"The servant leader is servant first. It begins with the natural feeling that one wants to serve, to serve first. Then conscious choice brings one to aspire to lead."
"The difference manifests itself in the care taken by the servant-first to make sure that other people’s highest priorities are being served. The best test, and difficult to administer is: Do those served grow as persons? Do they, while being served, become healthier, wiser, freer, more autonomous, more likely themselves to become servant? And what is the effect on the least privileged in society; will they benefit, or at least not be further deprived?"
Robert Greenleaf: The Servant as Leader 1970. (http://www.greenleaf.org.uk/about.php)


One would have thought that the medical profession with its high altruistic calling of serving the ill would abound with servant leaders; it seems that may not be the case. The time has come for any true servant leaders in the NHS to stand up and be counted as this seems a good model for leadership development for our caring and noble profession.

©M HEMADRI 

Follow me on twitter @HemadriTweets

References

http://online.wsj.com/article/SB10001424127887324081704578231553159491828.html
http://www.dot.gov/sites/dot.dev/files/docs/2013JanuaryATCR.pdf

This blog was originally written for and posted at Faculty of Medical Leadership and Management  https://www.fmlm.ac.uk/blog/makani-hemadri/servant-leaders-nhs-%E2%80%93-stand-and-be-counted
Re-posted here 

Toyota for you doc

Toyota for you doc, what will it be for your patients?

In a recent Medscape survey it was found that doctors’ choice of cars were as follows: Toyota (16.73%), Honda (14.8%), Lexus (8.3%), BMW (7.5%), and Mercedes-Benz (5.32%). Ford came in a very close sixth at 5.24%, and Chevrolet came in eighth at 4.13%.

It is apparent that 25% of doctors chose Toyota directly (since Lexus is manufactured by Toyota) and 31.53% come from the the lean methodology (since Honda also follows similar methods) constituting the top two car choices of American doctors. If other Japanese manufacturers were included it would be much more. It is a 2012 survey that means the doctors were probably aware of Toyota’s problems from 2010.

Why would doctor’s chose cars manufactured with lean methodology despite Toyota's recent problems? It is possible that the doctors feel those cars are still highly reliable despite the odd headline problems. The doctors are perhaps really impressed with the degree of honesty with which Toyota has recalled to rectify problems and the degree of humility shown in offering a public world wide apology. It may be the case that Toyota, Honda and those who share their lean philosophy still offer great value for money – doctors also do look for value for money.

What is fascinating is that the majority of doctors, the same doctors who like Toyota lean methodology despite its problems, do not follow the healthcare adaptations of lean methodology despite undeniably proven examples within America. Virginia Mason is a small scale system and Intermountain is a large scale system that has excellent versions of clinical lean (there are others too). There is huge resistance to even begin to look at the methodology.

Human beings and healthcare, are not cars and car manufacturing, so I do understand if we did not want industry people directly applying their methods to healthcare. Clinical lean and healthcare delivery lean is specific and different (as practised at a few places in the world), the translation and adaptation has already been done and fine tuned for nearly a quarter of a century. Clinicians need to show the relevant leadership to make it work in their patch where ever they are in the world.

It is not too much to ask is it, to deliver value to your patient; the same or more value that you expect from your car? I know patients are not cars and healthcare is godzillion times more complex that the automotive industry. That is why I talk about value creation and the application of healthcare specific lean (not other industry lean) from proven systems. Clinicians only have to learn and apply clinical lean in healthcare – if you can learn and practice medicine with all its complexity, applying clinical lean where possible, with its eventual elegant simplicity is a piece of cake. Or is it?

©M HEMADRI

Taste the sampler menu of clinical lean by attending the Clinical Quality Improvement Course

Find some of the high level the outlining principles HERE

Hand Washing compliance 100%

Hand hygiene 100% compliance at Ellis Hospitals. How did they do that?

Mary Ellen Crittenden, Vice President of Quality at Ellis told us that their board had a 'zero tolerance policy' for non-compliance.

They had a huge focus on clinician buy in and cultural issues developed over many months. They had 'secret shoppers' watching people and built it up the tempo gradually to a stage where they then announced a 'three strikes and you are out' policy.

If some one did not wash their hands:

first time - they were sent home with pay
second time - they were sent home without pay
third time - they were sent home and asked not to come back i.e. sacked

As an aside they had the same policy for their employed and visiting doctors, apparently they did not have to sack any of their more than 1000 doctors

Of course not all their deployments to improve quality were this harshly enforced.
Based on similar attitudes and healthcare lean methodology they have also achieved

495 continuous days without a single central line infection
0 - ZERO infections for hip surgery in whole of 2010 and till April 2011

They are looking forward to many other low or zeros soon (colonic surgery, caesarean sections, etc)

Ellis Hospital system in New York (http://www.ellismedicine.org/Home.aspx) is not exactly Mayo or Johns Hopkins but they have achieved great results.

When will we see this here at our work place? Most of us sooner or later are likely to end up as a patient in our local hospitals; well, it could happen tomorrow. We have to get it sorted before we occupy one of these beds!

The proven methods are available; we can do it if we want.

HEMADRI

PS: As recalled from what was heard at a conference in 2011

Clinical Leadership 'Development' - have we got it right?

Development has two components; in order, first is technical skills (hard) and second is personal (so called soft).

Technical skills in my view has two steps core professional skills (how to do the best) and core generic skills (how to do the best for everyone, every time, everyday). Many of us are good at our core professional technical skills (eg surgery, finance, radiology, facilities, HR, cardiology, etc) but it is very well known that in healthcare many of us are unaware of core generic technical skills (evidence, shared baselines, operational data analysis and data tracking, data based decision making).

The NHS is and has been focused for a while on 'leadership', 'social movements', 'change' and such similar things.

My problem with this is profound. I believe that core generic technical development should precede personal development. Personal development methodology is very profound and is designed to promote self-awareness and self-belief. The risk is when the personal development comes before the technical development, people become so convinced about themselves and what they are doing that they feel that technical development is a non-essential trivial distraction.

What is also interesting is the technical skills are easier to teach/learn, assess and practice though most people would think it is difficult and personal development is far more difficult to achieve and demonstrate though most people would think that they have 'got it' after a few sessions.

I have huge concerns that at a local level the deaneries and SHAs do not do this and at a national level personal development happens at a fantastic level to NHS persons who mostly do not have the technical development. 

The fundamental message here is, one must know what/how to do it before they begin to believe they can do it.