U.S. hospitals mired in bureaucracy: 10 roadblocks to change. (Health Care Organizational Structure).

CHANGE IN ORGANIZATIONS is notoriously slow, (1) and nowhere is it slower than in that fascinating and unique organizational setting, the hospital.

Until a few years ago, we could smugly raise our palms in a "What can I do?" gesture, blaming slow change on traditionalthinking, passive-aggressive physicians. (2) But today, they are far outnumbered by forward-looking colleagues who blend a vision of the future with laudable determination to preserve professionalism. (3) The first generation of VPMAs in hospitals, their second and third generation successors and some clinically-oriented CEOs (4) deserve much credit for catalyzing this change.

At least ten factors delay needed change in U.S. hospitals--they are neither sophisticated nor academic. We don't need more complex technology or more brilliant leaders. Rather, as has been true for years in many organizations, commonly encountered roadblocks to change are primarily matters of human understanding and behavior.

This article examines the hospital, the most visible feature of a managed care organization or health care system. We may be focused on wellness, but the public seeks assurance that modern, dependable services will be provided on the scariest days of their lives, when illness or injury strikes. If this component cannot keep pace with change, our entire system is greatly diminished, or at a minimum is perceived to be weak.

The hospital's organizational model remains a complex, unique, and often obscure system of responsibility and authority. For example, the CEO is the primary decision-maker organizationally, but is not allowed to write on patients' "order sheets." Physicians' decisions, even pursuant to practice guidelines, impact goals established by the executive staff and board.

The challenge is to remove roadblocks that are under the leadership team's control, and to make the public aware of external obstructions. Positioned at the vertex of disparate organizational, interpersonal, and external forces, the VPMA is a natural choice to lead this organizational effort. The result should be that hospital leaders will not only think, but also act, "outside the box." The following ten roadblocks delaying change may be useful in deciding which, if any, actions should be taken, and how soon.

External factors

1. Too much regulation

Free competition is a myth. The reality is over-regulation. The hospital's leadership team must maintain institutional licensure from the state, renew JCAHO accreditation every three years, and comply with regulations of the Health Care Financing Administration (HCFA). And too often we find ourselves "fighting off rules like branches hitting us in the face, losing any sense of where we are supposed to be going..." (5)

Complaining about excessive regulation is not effective. Indeed, the public encourages regulation of our industry, to the point that politicians are proposing a protective Patients' Bill of Rights. (6) But there are two things we can do about oppressive regulation.

The first is, avoid the seductive trap of believing that "compliance" is our whole day's work. We need to look beyond compliance to truly substantive patient care-related activities.

Secondly, we must regain public and political support by showing that some pointed regulations are unnecessary because we choose to act ethically without them. In every way possible, we must demonstrate a connection between prominently posted mission and values statements and the ethic that predominates when the boardroom doors close.

2. Too many attorneys

One often hears the complaint, "Lawyers are in charge of everything!" However, attorneys are only in charge if hospital leaders abdicate their ultimate decision-making authority. My favorite board member said, "You will find that we ask our attorneys a lot of questions, but then we make our own decisions."

The more we depend on contracts, the slower we are to discover the satisfactions of mutual good faith efforts. The more details we try to cram into a document, the more we leave out, creating a fertile field for the wrong kind of attorney to encourage battles in which only he or she is a clear winner. A good tool for using attorneys more reasonably is the proper use of flexible professional guidelines, without trying to use every guideline as an absolute legal standard.

Check with your attorney. You may find that he or she agrees with the notion that we slow ourselves down unnecessarily by over-depending on legal advice.

3. Theatrical local TV newscasts TV ratings depend on the entertainment value and sensationalism of newscasts more than on solid objective reporting. Like a playwright, a successful news director must engage us with conflict, complications, and suspense. Local stories about everyday events could generate needed community support. But more "newsworthy" are horror stories from somewhere else, about a physician mistake or a hospital oversight.

Reporting only about conflicts delays, and misunderstandings, expected in any worthwhile change process, erodes support for our efforts. The coverage itself is an obstruction. The only effective defense is an indirect counterattack. Discover and collect the many good things you have to say about yourselves, about the difficulty of the change you are attempting, and about the anticipated positive impact on the community. Find audiences, anywhere you can. Tell your story.

Internal factors

4. A natural fear of change

We all fear change, to some degree. This fear of losing economic security, or power, or both, can make us ineffective agents of change.

Volumes have been written and thousands of seminars have been given on the subject of calming these natural fears. Opportunities for "input" must be given to all "stakeholders," avoiding surprises along the way unless they are welcome ones. Stakeholders need to be treated as fairly as possible without sacrificing goals and possible unwelcome results of the implemented change(s) need to be addressed so that those who wish to can flee the system.

We don't need more knowledge about dealing with the negative impact of change. We should not be surprised when fear of change obstructs our efforts. But often, we are. We need to better anticipate these fears, and take positive steps to relieve them.

5. Arguing when we do not really disagree

People arguing against change may or may not truly disagree with planned objectives. They may simply not understand exactly what the change agents are proposing. The remedy is precisely defining terms, up front. Some may view this as a delay in getting started. But experienced change agents know that developing buy-in is time spent productively indeed.

For example, when discussing proposed changes related to managed care, define it in the context of this particular debate. Some who support managed care as a delivery system in which flexible practice guidelines are used to eliminate needless variation might oppose it as a national financing system in which the stock market is depended upon to meet monthly hospital expenses. And some who oppose managed care as a system under the control of the politician/insurer complex might embrace it as an integrated system in which community members can obtain dependable and convenient health care services.

No factor impeding change is easier to overcome than the failure to provide clear definitions up front. And nothing is more often overlooked.

6. Cake Committee management mentality

The management groove we've been in for years in hospitals is to establish committees. Given the task of baking a cake, we might take the following steps: Appoint the Cake Committee, hire someone to staff the committee and give this person the title of Cake Coordinator, have the lawyer review the recipe, then meet monthly and develop minutes. And, of course, stay out of the kitchen!

One source of the Cake Committee management mentality is now-obsolete Joint Commission requirements (JCAHO also had a committee fetish). Another is a reluctance to exert leadership. Action (or inaction) by a committee is an effective way of sharing blame if a decision doesn't work out.

We need to examine how management tasks are performed and ensure that they are being executed in the most efficient and effective manner possible. When committees are needed, use them. But when layers of "approval steps" delay needed actions, then other approaches should be taken. Identify the individual(s) responsible for performing the task and offer assurances that exercising responsibility and authority is the key to career advancement. When errors in judgment are made, they should be used as an improvement opportunity, not as a cause for remonstration and "memos to the employee file."

This approach will lead to fewer group meetings, cultivate responsible individuals who feel that they have more time to accomplish what really needs to be done, and provide effective organizational support for those willing to exert genuine leadership.

7. Over-aggressive downsizing 

Downsizing has so thinned the ranks of hospital personnel that there is no time for creating change. In one hospital, management was bewildered by the high staff turnover rate, while in patient care areas nurses were justifiably chanting, "Two! Two! Two jobs in one!" People cannot move the organization forward if time to create change is not included in their job descriptions.

8. Natural conflict and choosing a health care ethic

Conflict is the norm in any organization. (7,8) But in hospitals, this natural conflict is deep-seated. There is plenty of room for reasonable disagreement about the very purpose of a hospital. And the battle lines are no longer clearly demarcated between physicians on one hand and executives on the other.

One group tends toward a utilitarian view of a hospital. These individuals believe that decisions regarding staffing, equipment, and space should be made based on the greatest good for the most people, even if the needs of an individual patient must, from time to time, be sacrificed. They view physicians as hospital advocates, distributing health care resources among their patients in a manner most favorable to the organization's objectives and capabilities.

Another group believes in preserving the traditional professional ethic in health care at all costs. These individuals reject the notion of physician as distributor and think that everything possible should be done for each patient--and the emphasis is on "everything" rather than on "possible."

Progress and change are impossible as long as hospital leaders insist that these are the only two alternatives. The key is to frame and adopt a new ethic that combines a flexible utilitarian approach with reasonable concern for meeting needs of patients with difficult and complex medical problems. (9,10)

9. The past

There was a time when management and physicians were considered to be natural enemies. Bitter feelings remain from battles long since fought and lost or won that interfere with new cooperative efforts. The more recent past encompasses the first phase of managed care. Takeovers, threats of physician strikes, and gag orders do not make the best foundation stones on which to build a future.

The key to overcoming the past is well known, but seldom used: Committed and effective leadership by individuals who help us separate the issues. However disgruntled we may feel about some event, discussions about new issues and fresh opportunities must begin at a clear and clean square one.

10. Lack of trust

Lack of trust is by far the largest roadblock delaying effective change. That's as true in hospitals as it is in any other organization. There can be no forward movement until there is genuine trust between members of the executive team, the management team, and frontline health care professionals.

Trust can be defined as, "the acceptance of vulnerability to harm that others could inflict, but which we judge that they will not, in fact, inflict." (11) As countless experienced executives have discovered, once trust is betrayed it is extremely hard to re-establish. Plus, there is no statute of limitations on acts that betray someone's trust.

Two key ingredients of a trusting relationship are (1) that false expectations are not created and (2) reasonable expectations are not disappointed. (11) To keep the trust, don't promise the impossible and keep your promises. Being trustworthy sells very well, because it has become such a rare commodity!

What steps must be taken to develop this necessary degree of trust? No external resource can be expected to offer an off-the-shelf plan that will work for all organizations. Developing trust requires a joint effort between all the parties involved and is the key factor in change management--without it, attempts to remove the other roadblocks will be an exercise in futility.

References

(1.) DeChemey, Stephen G., MD, MPH. Accelerating Acceptance. The Physician Executive. 25:6, November/December, 1999. p. 32.

(2.) Thompson, Richard E., MD. Physicians and Hospitals: Easing Adversary Relationships. Chicago, Illinois: Pluribus Press, 1984.

(3.) Thompson, Richard B., MD. So You've Been Integrated, Now What? Opportunities for Physicians Practicing in Managed Care Organizations. Tampa, Florida: ACPE, 1998.

(4.) Klint, Robert B., MD. A Dance in Anger: Physician Responses to changes in Practice. The Physician Executive. 25:2 March/April, 1999. p. 18.

(5.) Howard, Philip K. The Death of Common Sense, New York, New York: Warner Books. 1994. p. 177.

(6.) studdert, David M., LLB, ScD, MPH, and Brennan, Troyen A., MD, JD, MPH. The Problems with Punitive Damages in Lawsuits against Managed care Organizations. New England Journal of Medicine. 342:4, January 27, 2000. pp. 289-283.

(7.) Toffler, Alvin. Future Shock. New York, New York: Bantam Books, 1971. p. 146.

(8.) Neuhauser, Peg C. Tribal Warfare in Organizations. New York, New York: Harper Business Books, 1988.

(9.) Kassirer, Jerome P., MD. Managing Care: should we Adopt a New Ethic? New England Journal of Medicine. 339:6, August 6, 1998. p. 397.

(10.) Shortell, Stephen M. et al. Physicians as Double Agents: Maintaining Trust in an Era of Multiple Accountabilities. Journal of the American Medical Association, 280:12, September 23/30, 1998. p. 1102.

(11.) Baler, Annette. cited in Food Biotechnology In Ethical Perspective, by Paul B. Thompson. New York, New York: Blackie Academic and Professional Books, 1997. p. 219.

Richard E. Thompson, MD, is a member of the American College of Physician Executives living in Dunedin, Florida, and author of Health Care Reform as Social Change (ACPE, 1993), So You've Been Integrated, Now What? (ACPE, 1996), and Keys to Winning Physician Support 2nd Edition: Real Winners Don't Gag the Good Guys (ACPE, 1998). He can be reached by calling 727/789-4635 or via email at [e-mail].