Thursday, April 30, 2015

Healing The Toxic Hospital

Part 1  Symptoms: Executive Nesting, Triangulation, and Eating Your Own Children  

In the world of organizational transformation, facilitators often deal with behaviors that are less than functional among their clients. The challenge is to raise the standard of personal and professional behavior by both facilitator and organization to support functional changes and improvements.

The Toxic Hospital is a hospital that poisons, eviscerates and eventually kills any number of good ideas. 

Turning that around requires a transformation process that starts with these steps:

1. First and foremost, Assessment. Then, 

2. Using that Assessment to design a Vision, Objective Outcomes, and a Change Process that will work as part of an Agreement with leaders. 
3. That Agreement must detail at least a few key behavioral requirements of leadership. 
4. Finally, transforming the Toxic Hospital requires facilitating an initial Client Commitment to that Agreement.

These are the initial steps before a formal project begins.

The facilitator has the most leverage before the Agreement is signed. 

That Agreement is not necessarily a contract with an outside firm. It may be a Project Agreement or Project Business Plan requiring the signature of the CEO and CMO, and possibly additional C-suite stakeholders. 

The organization's PI Leader can construct the Agreement and build the necessary support for it. 

The organization's leadership signs the document to place their personal responsibility up front, in writing, for the entire organization to see. In this way they build transparancy, visibility and public accountability for every participant. 

The Agreement represents leadership's actual commitment to the project, the work involved, and the outcomes. It is often the case that several key stakeholders, inlcuding the CMO, sign the document. All the dynamics to make that happen lay the roadwork for a smoother project with much better results.

If the Agreement has one or two basic management requirements of the organization's leadership, and at least a few promised objective, metric outcome results by the facilitator, the project has a chance of significant success. 

If the Agreement only promises outcomes without any management requirements of the organization, results will be limited, and sustainability unlikely.

This is the first of a short series of essays about these three key preparatory steps: Assessment, Designing the Project Plan, and working the Agreement through signature.


There are a few key identifiers for the level of organizational toxicity within a hospital.

The most telling criteria is the hospital's successful experience with past efforts at change. You can assess this by simple interview.

Some changes, like purchasing and installing new technology or new equipment; remodeling; changing the Charge Master; labor cuts or staffing additions do not actually require substantial behavior change. Buying or selling physician practices, another hospital, opening or closing outpatient clinics, building a new inpatient tower, these are all fairly demanding of leadership, negotiation, sales,  business finance and clinical skills. 

But these changes can all be done at least initially without significant management skills and teamwork. They don't require sustainable changes in daily behavior throughout the entire system. 

And that is often why such ventures do not succeed as expected. Yet even with modest results, these changes often are the organization's only perceived successes.

Getting compliance to a simple policy that requires a change in behavior and habit, a higher level of personal skill, every day, several times a day, among dozens or hundreds of different people, may actually be much more difficult. And that history reveals much about the level of Organizational Toxicity.

Looking at Patient Experience scores, patient throughput scores, CORE measures, SCIP measures, JCAHO survey results, employee and physician engagement scores, operating margin, efficiency and productivity benchmarks often yield a very mixed bag.

There are actual behaviors that reveal organizational Toxicity. And often, it boils down to the focus of key constituents.

Many professionals have established their careers by carefully dismantling the ideas and efforts of others. The focus of these professionals is generally what is wrong with any new idea that is not their own.

Such professionals are threatened by new ideas coming from the front line or from Physician staff, or community placement leaders. They want nothing to do with them. At best they are passive to these ideas, but not actively supportive of them.


1. Hear About It But Never Go and See It: Executive Nesting

Nowhere is this more evident then in the organization where executives do not visit the departments and speak to all levels of staff individually, especially front line staff, patients, and working physicians several times a week, as well as similar visits to community placements such as SNFs and Home Health agencies they depend upon.

Why do executives nest themselves high above and out of the operation? Outside of meetings with their direct reports, they are outside their element. And they are cautious and suspicious of any activity outside that circle.

Unfortunately, these are the key stakeholders whose visibility in the departments and the community, and whose positive leadership is necessary to develop, implement and sustain change. 

Efforts requiring the voluntary cooperation of physicians are especially sensitive to the lack of Executive Presence and dialogue in the departments where physicians and other staff work together.

The only means for executives to know what is happening in such an insulated environment is to depend very heavily on triangulation.

2. Talk About Them, Not With Them: Triangulation and Gossip

In the absence of active boots-on-the-ground supervision among senior executives for at least 15-20% of their time, management depends upon very poor channels of reporting for all their information. Hence interpretations become quite skewed, decisions based on those tend to err more often as a result, and many great ideas are tossed away. Naturally, employees who thought they were helping find themselves blindsided by the very leaders they were taking risks to help.

Light bulbs are thrown out in favor of candles daily in such an environment.

When two individuals discuss a third who is not present, this is triangulation. When two individuals share a story told by the third, but not witnessed by the two, that's gossip.

When an employee complains about a problem, it is the duty of management to investigate. Triangulation is a part of the job of management.  But in such an organization, the face to face, eyes on the operation investigation part doesn't happen. The executives share what the employee said with other employees and peers to ask for verification. They don't actually go to the place of work and inspect conditions directly, keeping the employee's remarks in confidence. The quality of the report never rises above gossip and popular opinion.

Sometimes, in incidents of misbehavior, this is necessary, because it isn't possible to catch another repeat incident of the behavior or to allow any possibility of  it happening again.

But using gossip and opinion polling as the main mechanism of executive decision-making relegates change to witch hunting, and fear spreads rather than passion for excellence. 

"Where there is fear, you get false numbers."

W. Edwards Demming

In this way they violate the confidentiality of the original dialogue, and punish the employee, rather than identify and fix the problem directly.

Some of this is necessary in management. All evaluations require some triangulation. But when triangulation becomes gossip, and the content of leadership discussions more than 50% of the time, then blame placing and exaggeration are inevitable.

The secret every good Facilitator knows is that when two executives are discussing a third individual they are actually always discussing themselves. The other person is just a metaphor for what, in mirror reflection, or in complementary fashion, are their own deficits and dysfunctions. Sometimes the other person must lose their job or assignment for what is really the skill deficit of the executive.

This is generally the case where triangulation is the major source of information reporting. It is the main avenue of a culture of personality, not results.

Helping executives see it, and re-focusing the dialogue on the two participants and how they can change themselves, actually focuses on something the executives can do, can succeed at in a way that immediately converts all the other folks they are talking about into more effective teammembers.

3. Good at Tearing Down, Not Building Up: The Spiders That Eat Their Own Children; the Children Who Eat Their Parents, Each Other, and then Themselves.

Even with good performance metrics showing initial improvement, the power of self-serving reporting among executives (who earned their place by their powers of charisma and effective criticism) can dismantle the support necessary for a good idea to become an active part of the organization's operation.

All new ideas require development, and suffer a higher learning curve to work through the bugs. A self-serving executive often uses this frustration to feather their own nest by triangulating against the individuals leading the change effort. They solidify their authority by dismantling employee-led change and letting participants off the hook for continued efffort.

Legitimate criticisms that could lead to refinement,  become personal attacks that destroy the project.

It is often unconscious. They do this as a reaction to discomfort, not as a planned strategy. And this becomes evident when, in their reaction and personal finger pointing, they dismantle the team they need to create the results they need.

"Well, the results were good for the first few weeks, but let's see what happens", said the executive who had no intention of helping support the effort. And the results weeks later? In the absence of their active, visible support? Initial results faded.

Imaging trying to teach a baby to walk without actually being in the room.

The Baby, naturally, will stand occasionally on their own, when they are ready, and then stumble and fall. 

But they can't go much further without their parent(s) there encouraging them. And when they fall alone, repeatedly, it becomes a habit for them. Now teaching them to stay standing, and to take a step forward, will take a lot more careful parental encouragement.

The thing that, under the right conditions, is the basis of joy, shared joy among mom, dad and baby, now becomes trauma, hardened into habit.

Imagine if parents used the thinking of such executives:

"Every effort so far has resulted in a fall. Standing is a bad idea for Junior! We no longer encourage it!"

It's a principle of human behavior that, as social creatures, we require our leader with us, our coach, to help us do even the smallest things that are entirely new and different.

But when managers, staff and providers are exposed to the above focus on dysfunctional criticism, the last thing they want is the executive nosing about. The entire organization adopts the same dysfunctional behavioral repertoire of their leaders.

Then they become the dysfunction their leaders accused them of being. And that becomes a self-fulfilling prophecy that executives, managers, providers and employees use to justify their isolation from each other and even their own patients.

Now you have employees criticizing any new idea, even one they came up with, along with their leaders, at the moment of even mild discomfort; at the moment when nothing more than brainstorming would take them to the next level; while their leaders do the same to employees and each other.

It becomes a blind response, a knee-jerk reaction, a comfort-zone reaction when any discomfort arises.

The skills of critical thinking, which are powerful and important, when used as the sole platform for management, fueled by the discomforts of change, lead to disastrous results.

What is missing is Vision, positive vision, vision so powerful, so visible, so ingrained in the mission of the hospital, and so embedded into the heart of the executive, physician and employee that neither the executive, physician nor the employee thinks about blame. That vision guides criticism into the realm of constructive criticism.

They are always thinking about how to take each person's strengths and work to them. How to help the Other perform better, not compete against them, in the interests of everyone's patients. They are always thinking about how to modify the new change so it works better, not how to dismantle the change  and go back into the caves: The caves where comfort is measured by darkness. 

That vision helps participants set aside their addiction to focusing on the weaknesses of others, including themselves, and work to their strengths. They are always thinking about how better to listen, to look, to lend a hand, and then guide.

And that is teamwork. That is also coaching. Teamwork and coaching require Vision Setting, Task Management, Supervision and Positive Feedback.

You must have a destination. It gives all that effort purpose.

"You cannot move forward looking sideways".

If people are afraid of the negative and withering criticism of their peers and their leaders, not only do they avoid stepping forward with change, but resent anyone else who does so, and then they join in the mob with their own destructive criticism. In the Toxic Hospital, any effort towards real change is seen as an insult to everyone else.

4. Good Supervision IS coaching.

But the skills of Vision Setting and Coaching aren't always in the Executive's, Manager's or the Employee's repertoire, hence the necessity of training as a crucual first step in any significant effort towards change: Vision, Training, Metrics, Pilots and Supervision.

Training can help participants put aside their own personal fears, personal concerns and take risks. It is easier to help participants understand the dynamic and power of Vision in helping overcome the dynamic and power of fear, than to try to explain individually how an executive's own dysfunctional behavior was the result of fear and the absence of vision.

And when it is necessary to provide that feedback, if training has taken place first, then the personal feedback will be received well, as simply a symptom of the past organizational dynamic, and not a personal remark. Indeed, with good training, executives are often the first to spot their old dysfunctional repertoires and are ready to risk responding differently.

Then the feedback is focused on new behavior, not old; part of progress, not destruction. It is a source of help, presented in a helpful, private way.

Training can help participants honor and respect the other person's idea, and even to help their peers succeed in piloting it. Training can help replace concerns for personal image and reputation, with the Vision of a Better Organization...a Healthy Hospital.

And most importantly, Training can lay the groundwork for the individual coaching to come.

Therefore, all good programs targeting significant and sustained organizational change contain a very strong element of formal Training, followed by an equally robust element of individual management coaching.

NEXT: Building the Agreement