THE TYRANNY OF THE STATUS QUO

Whenever organizations attempt change, it is important for success and sustainability to build participation and more importantly, ownership. 

That not only requires good communication, but reliable communication. And that communication campaign can raise issues of trust if it is quite differant than the typical leadership communication in that organization.

An informal "communication campaign" already exists; it is the present institution.  Daily work habits reinforce current operating structures and current beliefs of what is right and good.  Longstanding issues are often handled in the same dysfunctional way repeatedly while everyone knows and will state that it does not work well; or proudly proclaim that it has improved when all can see a significant problem still exists. 

The paradox of knowing something isn’t working right and doing it anyway, or excusing it as acceptable reflects the subjugation of common sense to the tyranny of the status quo.  As a result, employees must live for much of their waking life in a state of perceived helplessness, and thereby lose one of the hallmarks of being human - their individual ability to contribute. When they no longer believe in their ability to do so, the tyranny is complete.

The Communication Campaign competes with the status quo.  The underlying message of change must be a constant reminder.  As Charlie Chaplin aptly put it:

Don't confuse what you see around you with reality.

The status quo subjugates all employees to the "system."  Employees trust only in what currently works, view new ideas and efforts cynically, and learn to doubt their individual capacity to contribute.  Cynicism and doubt undermine the necessary drive to do what might be difficult and controversial, and to think anew.

An era can be said to end when its basic illusions are exhausted.

                                 ‑Arthur Miller, Playwright

PILLARS OF THE STATUS QUO

An organization may believe it is a learning organization, a creative organization, a positive, progressive place to work,  a continuous improvement organization. This may be their well-rehearsed script, and they selectively pick a few good changes, perhaps expensive ones, to reinforce the illusion that this is indeed their entire culture.

There are ways to test how deep and how real that goes, and to what extent the status quo has wrapped itself in the packaging of progress merely to defend no progress.

In an environment where tradition and innovation are functionally opposed, thought stated proudly as one and the same,  a belief system has developed to support the notion that any change is harmful.  But it isn't apparent upon discussion.  It comes out in reaction to any challenge to raise the bar.  And in that organization you will find very low, if any internal targets and deadlines for improvement. 

I'M NOT PUTTING MYSELF ON THE LINE

Refusing to set ambitious targets and deadlines is the first indicator that that organization is not run by any leaders at all, except the Tyranny of the Status Quo. 

The unwillingness for an executive to set ambitious targets and deadlines is defacto their inability to deal with the possibility of failure. It is their unwillingness to take the risk of bringing to light the shocks and tribulations that come from real and honest analysis. That avoidance of personal responsibility cascades instantly through the organization. Their improvement initiative has failed from the start.

In such an organization, any progress, even abysmal progress, triggers the flag of victory and the end of further movement. The Tyranny of the Status Quo has asserted its power effectively. The only changes such organizations can make are purchases and cuts, made from the top, requiring little or no actual teamwork or management development.  They may be wrapped in millions of dollars of staff training and workshops. But without that risk of ambitious deadlines and targets, little that does happen ever sustains.

Avoiding those targets and deadlines is avoiding failure even at the cost of actual progress. And who is avoiding that failure? The executive. That fear now travels like lightening. It is communicated even before the executive proudly announces the new "program."

Here are some comments reflecting belief in the status quo that reveal the true nature of an organization's culture. These are people's defensive responses when confronted with nothing more than the suggestion, the mere notion that they personally can do better...in particular your department, your own employees, you yourself can do better.....and that includes you, the CEO:

  1.      This isn't a factory.

  2.      We're already overworked.

  3.      You can't change it until you measure it.

  4.      We're professionals; you can't measure what we do.

  5.      We're as good as you can get.

  6.      They're always doing it to us. It's the community. I can't control that.

  7.      Productivity can't be improved without hurting quality.
7.a.     Real Quality can't be measured.

  8.      Whatever an outsider comes up with won't work.  They can't help us.  We can't be helped.

  9.      To do this someone must force the other departments/MD's to cooperate.

10.      We've always done it this way.

11.      We've never done it that way.

12.      It sounds good, but it isn't really new.  We're already doing it.

13.      We tried it, and it failed.
13.b.   We've made some (incremental) progress...therefore we have done all we can.

14.      This is different from what I expected; there must be something wrong with it.

15.      We've been through "improvement" before, nothing worthwhile comes from it.

16. We're already excellent.  Look at this single great metric. And all the other metrics are erroneous.

It is difficult to get a man to understand something when his salary depends upon his not understanding it.

                                                     ‑Upton Sinclair

  CHANGE, OWNERSHIP AND THE APPROPRIATE USE OF LANGUAGE

 Another assessment tool you can use during the project that forecasts quite accurately the success and sustainability of results is the level of active or passive ownership of the improvement effort.

                    ACTIVE                                               PASSIVE

    

    

     Our Improvement Project                             The Consultant’s Project / 
                                                                             The CEO's Project 

    

     Our Time Expectations                                 The Consultant’s Expectations

    

     Our Improvements                                       The Consultant’s Improvements

    

     Our Quality Program                                    The Consultant’s QA system

    

     Our Tools                                                   Their Tools

    

     Our System                                                 Their System

    

     Our Standard                                              Their Standard

    

     My Program                                                Their Program

    

     My New Strategy                                         Their Idea

And the best measure are the words that come out of the C suite's mouths. They teach active ownership or passive avoidance of responsibility in their own language. They either point the finger of blame for the cause of problems or simply say "This is my responsibility...it happened on my watch..but you know what? We move forward TOGETHER from here, right now..." That admission of personal responsibility is also the first step to giving the organization.....

AMNESTY FROM THE PAST

And that Amnesty is a minimum requirement for building ownership and sustainable results.

But Amnesty is quite paradoxical for many senior execs.  They don't see why it is so important, and thereby they are tepid in creating the environment necessary for real change. 

The exceptional executive lets folks off the hook for why the past has happened only to place full responsibility on themselves and their employees for getting it fixed post haste, today, right now. They build the incentive into action immediately, not by threat, but recognition. 

Threat is the motivation that causes people to hide and falsify data, basically surrounding the executive in a shroud of darkness. 

And that is the executive's fault for using threat in a healthcare environment.

So the exceptional executive takes all the blame instantly, completely, immediately as a means of turning the incentive positive. That isn't a feel good measure. It is a strategic step to getting clear data.

It is doing nothing more than stripping away the blinders their own people have placed around them.

That must take place in order for everyone to accept current conditions without blame, and the full responsibility to take the risk of fixing it.

Even the childish notion that we are good already but just becoming excellent has the seeds of its own self-destruction. Because every honest analysis will reveal instances of poor performance. So that step of taking full responsibility for the past must rest on the CEO.

This is why often only a new CEO can institute change.

But if they do so blaming the past and their predecessor, even couched in praise and obsequious flattery, they are actually instituting a culture of blame.

The Great new CEO finds and praises the things that are fabulous even in the midst of a performance, financial and quality nightmare. They publicly praise the past at all times. They are experts at finding talent in the rough in the middle of the night, in the depth of a raging storm. They are experts at finding strengths from the very people who participated in the problems. And they always set ambitious goals and deadlines as assignments, defending their goals with a smile; participating, taking responsibility. They listen, they adapt, while leading and pointing forward at all times.

And they find a way to assume full responsibility for the storm.  Great CEOs cannot afford to blame anyone, even the past, because blame is an act of avoiding personal responsibility. And what they do, not what they say, becomes the model for everyone's behavior. Whether you like it or not, in some ways, all employees inherit the genes, and are partial clones of the executive team.

 Only the Senior Executives can start this in the right way, can change that genotype from deleterious to healthy. And if they do it right, everyone follows their example.

We must look carefully at today, see it for what it is as a means of fixing it and making it better, and waste no time looking back or trying to assign blame. The blame always goes to the CEO.  But in an effective organization, the full credit for improvement goes to the workers alone. Not even to middle management. They follow the CEOs lead in giving all praise to their subordinates. A good CEO practices that communication with ninja discipline. They do it for one reason alone: The credit for progress is the fuel they need to drive more progress. If they give that credit to anyone else but the folks who do the work every day they cut their own power to drive and sustain change. The C suite's ability to acknowledge improvement and give away credit is their only real source of power to change the organization, and the behavior of all employees across all shifts and into the years ahead.


Every great CEO knows that handing out praise for real results is in fact, is defacto, laying personal responsibility for sustaining those results upon the shoulders of the front line employees (including the Nurses, Mid-Levels, Techs and Physicians who treat patients). And woe to the middle manager who gets in their way. Praising these front line workers alone aligns middle management to their supportive and coordinating functions. 

That psychology doesn't waste time blaming others, even a single employee. Because that just takes responsibility off the executives for the very environment they have contributed to.

The answer for full responsibility and dramatic improvement from employees is for the senior executive to assume full responsibility up front, in the communication campaign. Many executives are simply unable to take that kind of risk. And that is the first measure of the Tyranny of the Status Quo.

I AM SPARTACUS

But full responsibility for problems on the shoulders of the leaders is the only believable place from which they can assign full responsibility for vigilance, action and results.

The Senior Executive does this, however costly, to master and defeat the Tyranny of the Status Quo over their own life. And if they can do it first, then everyone who reports to them can take the same risk of assuming all responsibility for any adverse event in the Hospital.  When a patient falls in a room, and the dietary tech who delivered their tray an hour earlier says "That was my fault, because I didn't look at the patient to see if they were safely in their bed" then you know you have the right culture. 

Let's be clear: when a disaster happens, one that people have worked very hard to prevent, and everyone jumps in and says "I AM SPARTACUS", then you know the culture is right, and whatever caused that problem will be eradicated in the shortest time possible, and for all time to come, as long as leadership continues to take the ultimate blame for all problems and hand out all credit for progress.

And of coarse, that kind of responsibility drives all sorts of immediate vigilance and intervention.


Thus, you have indicators for the organization's true culture; the means to measure the prospects for long term success or failure of any change program;  And the guidelines for leadership behavior and communication that have proven themselves time and time again as the source of remarkable and lasting change.

Have you really seen me? The Power of Patient Observations

It is eye-opening to discover how much patients are not actually seen or understood in their stay in the Hospital. People are focused on their work, so in retrospect it makes sense. But if you stand outside of any particular job and just watch a patient for a couple of hours in the Emergency Department, or on an Inpatient Unit, or in a Clinic or Same-Day Surgery you will discover many things. Some very positive and affirming: people are healing patients all the time. And some of those things will be negative - opportunities for improvement.

When an executive spends the time to do observational work they are saying to the entire organization "It's better to open our eyes, even though we will discover some things aren't working, then to close our eyes and say conveniently, but untruthfully,  'mission accomplished'".

This chart is a simple method of illustrating a patient's experience during a period of two or three hours in any location in the Hospital. In the particular example here, this is a patient's three-hour stay in an Emergency Department. Each slice of color represents a period of time. The color coding is described at the bottom from left to right in the order in which it occurred. You can click on the chart for a larger full-size version easier to read or to print.

The patient walked in the door at nine AM. Without any delay at all, they were Triaged and registered. The Triage process was very fast, but the registration process took a little time.

The patient was taken to a room in back immediately after their registration (green) and began waiting in their treatment room. This first waiting period is illustrated as the first red block to the far left. Throughout the chart all patient waiting time is shown as red.

This patient had stomach pains, and did not require admission to the hospital. Most emergency departments would view a three hour length of stay as great. And in many ways it is. But not necessarily for an outpatient. 90 minutes is good for the outpatient.

There are several stages of work involved. Note the MD assessment in yellow. That actually took place in the last third of the visit. The patient spent nearly two-thirds of their visit just waiting. During that waiting time some work occurred - lab orders, MD / RN reviews and communication, phone calls, gathering materials / medications, etc.... However, the patient sat for just over an hour without anyone entering their room to keep them informed. From their perspective, this was all just waiting delay. This was during a very tense time for the patient, so that hour could well have been an eternity.

And much of that red time was delay for the staff as well: items waiting to be attended to, or not available when needed, etc....

We interviewed the patient at the close of their stay. They were very appreciative, but did mention that the delay was not a positive experience for them. They were worried and were unsure how serious their symptoms were. They became even more anxious, thinking the medical staff were trying to figure out what was wrong, and that maybe no one really knew. And no one could tell them until just near the very end of the stay, almost two hours into their visit.


As mentioned above, three hours is not long for an inpatient ED admission, but it is long for an outpatient. If you are in pain or worried, without proper care, teaching, attention, ten minutes can be a lifetime in hell. And nearly two hours waiting in back is not ideal care.

Here was a hospital that had already gone through a major lean initiative, and another Patient Satisfaction / Management Coaching initiative to 'hard-wire' improvement. The commitment to excellence was well established, so we heard.

These programs taught "continuous improvment" in their words. But in their structure of a single phase of discrete one-time process and management changes, they were actually teaching "one-time fix" behaviors.

Any interest at all in going back to observe patients or the flow again was the last thing on most folks' minds. They had been "improved" and didn't want to go back there. For them, continuous improvement was really a sign of failure.

Their words were "We believe in Continuous Improvement" but their actions were "We're already done with that. We won't be going back there again. Why would we?"

How well did these other improvement programs serve the hospital, if the culture, at the close of the project, was a culture of "we're done" "we're excellent enough" "we don't need to nor want to look anymore at that?" "Patient care? Mission Accomplished!"

Yet, the job was not done. The consultants were done, but the job wasn't really done, and certainly not 'hard-wired'.

Indeed, the notion of ''hard-wired' or 'made to last' speaks to the idea of the turn-key operation: That it can be done once and for all,  like buying a new car. But according to Tom Peters in Re-Imagine! this thinking is wrong: really exceptional performance must be built and re-built every day with great care and creativity,  and no one can proscribe exactly how it must look. Vigilance and observation do not end. They become part of everyone's personal practice, personal approach to seeking feedback; seeking to stay close to the patient's experience. And they use that constant flow of new information personally gathered to discuss, to brainstorm as they work, in the department, in real-time.


Peter Drucker wrote about this over fifty years ago in The Practice of Management. By the time  performance metrics are quantified into a nice report, they are obsolete. They can only confirm that you have managed well, but cannot guide you. For that, you must gather your own handful of information every day directly, and that in collaboration with the people you work with.

You cannot "hard-wire" living systems, and if you really try to, it becomes a barrier, an impediment to true excellence. That is why nobody wanted to look again. They thought it was now "hard-wired". However, because excellence is a flow of energy, ideas, teamwork and creativity, a process of self-examination and observation, a human process of collaboration and change, a living process, it cannot be nailed down into something fixed, or done, so that others feel it is "mission accomplished" and can turn away to other things.

There is something uncomfortably open-ended about real excellence. But many thrive on the adventure.

 "Systems" become obsolete very quickly in a truly exceptional operation. New methods and philosophies are developed all the time because no matter how good it was, people want to do better. It is a 'hard wired' realization to see that there is no standing still. You cannot maintain. You can move forward, and if not, the hospital slips backward.


"Maintaining" the number one position requires continuous effort. It doesn't end. It must be made, constructed, built every day again. And that is because in a Hospital, excellence is care, and care is human performance.

It won't look the same every day, or for every patient. To reach and live a core set of  values means, paradoxically, not doing it the same way. Customization, adjusting for the patient. Listening. It is always new. That is the difference between life and death to an organization or a human being.

Rather than "hard-wire" why not think about "liberation" of the organization? Rather than think of the Hospital as some giant machine, why not think of it as a living entity always poised to take the next step in personal growth? Why not?

But a living being needs nurturing and feeding, and sometimes they don't turn out just as you might like.

Innovation is far more powerful than any machine.

Nowhere is this distinction between living in the flow of excellence and living in a retrospective hard-wired "system" most in evidence than with 'rounding'. When we have watched folks "round" after having earned a "black belt" in rounding, we see they are hitting the points on their checklist, but missing obvious things staring them in the face. They talk to the patient but stop noticing that the nurse hasn't washed her or his hands or used the hand sanitizer. They ask the patient questions, but do not stop to watch a nurse and a patient interact with each other, nor to give good praise or feedback when such interactions happen to take place in front of them. They don't ask the nurse "How are YOU doing today? How is the work flow for you?" They don't stop and brainstorm for a solution right there. And many a tired nurse has been simply overlooked by the exec doing rounding. They are trying to get through their "rounding" responsibilities. And that is what they are doing - going through the motions. But they aren't actually rounding.

Try telling an Olympic Athlete that your training exercises to help them swim, or run, or jump are so good they will not actually need to swim, jump, or run again! That is the chimera of "lean" and "hard-wiring" promises. Once you "hard-wire" anything, people stop thinking about what they should be doing; people stop looking around to see what is going on; people rely upon the "system" now because it has already been built, in the past tense; and so in the 'present tense' they just go through the motions of that "system" just like they did the last system. No Olympic Athlete could get away with that.