Flatten the Hospitals

The opportunity, as I see it, is that front line health care workers, the folks in the trenches delivering care on a daily basis, haven’t been properly empowered.  There’s too much up there, top-down, ideas from on high management going on.  In hospitals the decision making process is largely centralized.  That is no good.  It won’t work in the long run.  The benefits of decentralized decision making (yes, I understand the concerns) are too important for the sustainability of our organizations to overlook.

Hospitals are amazingly hierarchical.  Talk to a health care worker and a major concern that arises is communication (especially with administration).  A serious holdup is the number of individuals a message has to go through before reaching the intended receiver.  By the time that message reaches a front line worker it has been stripped of reasoning, portraying management as heavy-handed (or disinterested, or out of touch, or etc.).  The solution is flatter organizations.

The definition of a flat organization depends on the source.  BNET’s definition is good because our flattening doesn’t need to be drastic, but a process of delayering: “a slimmed-down organization structure, with fewer levels between top and bottom than a traditional bureaucracy, that is supposedly more responsive and better able to cope with fast-moving change.”

Flat organizations encourage constant innovation.  And constant innovation is only possible through empowered employees.  Take this as an example from The New Yorker:

The answer has a lot to do with another distinctive element of Toyota’s approach: defining innovation as an incremental process, in which the goal is not to make huge, sudden leaps but, rather, to make things better on a daily basis. … And so it rejects the idea that innovation is the province of an elect few; instead, it’s taken to be an everyday task for which everyone is responsible. According to Matthew E. May, the author of a book about the company called “The Elegant Solution,” Toyota implements a million new ideas a year, and most of them come from ordinary workers. (Japanese companies get a hundred times as many suggestions from their workers as U.S. companies do.) Most of these ideas are small—making parts on a shelf easier to reach, say—and not all of them work. But cumulatively, every day, Toyota knows a little more, and does things a little better, than it did the day before.

Need a hospital example?  Check out this work on central line infections.

The transition will be difficult.  But change is necessary.  Nick Jacobs of Windber Research Institute and Windber Medical Center writes on the end of management:

The revolution quoted by Cloke and Goldsmith is one of “turning the inflexible, autocratic, static, coercive bureaucracies into agile, evolving, democratic, collaborative, self-managing webs of association.”  From our perspective, the object is to allow those butterflies the freedom to fly.

How do you manage a butterfly?  Work together on the goals and then get out of its way.  Provide it with just the very basic, fundamental needs and goals of your organization, and then trust it, love it, empower it, and encourage it.

If I could possibly find one example that would clearly embrace our success as an organization, it is that of doing everything possible to kill “parent to child management.”  It is not enough to move into the 21st century with our thinking; it is most important to identify those individuals who get it and then give them the space “to do it.”

Are they traditional?  Do they do everything the way you were taught in the “dark ages of the industrialized style of management?”  Nope.  Will it drive you crazy when you look for them, and discover that they are not on the flower where you expected to find them?  Sometimes.  Will they accomplish more than you have ever dreamed if you treat them with dignity, respect, love and freedom?  Oh, yeah.

You see, it is not about control.  Control is only necessary for those who are not trustworthy.  Better than trying to control a non trustworthy individual, simply help them find work somewhere else.  If they don’t get the mission, don’t understand the philosophy, and don’t work to their capacity, they shouldn’t be there.

On the other hand, if they are loyal, trustworthy, committed, and caring, back off and allow them to soar, and you will never see results of the kind they that they will deliver to you or your organization.

It would be foolish to think that we could flatten hospital structures by removing a few layers and believe that business would go on running smoothly.  No, we need to experiment with new ways of delivering care and that includes new approaches to administrative functions.  Self-directed teams, interdisciplinary teams, virtual teams—heck, maybe teams aren’t event the appropriate vehicle.  The point is that it is up to hospitals to find the best way to deliver care as part of the constant process of innovation.  And the best are already experimenting.

The more influence that patient satisfaction has on reimbursement levels and return visits, the more this will become a central issue for hospitals.  It is too bad that it takes those incentives to get it right: the patient deserves (and is beginning to demand) an enjoyable health care experience.  One that is possible only through employee empowerment.