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Reducing Power Distance and Increasing Collaboration Can Reduce Errors and Improve Patient Care

Posted on Mon, Mar 13, 2017
Reducing Power Distance and Increasing Collaboration Can Reduce Errors and Improve Patient Care

By Adam Corley, MD, FACEP, FAAEM

Error reduction, quality improvement, patient safety and staff satisfaction are all impacted by a little-discussed concept known as power distance.

Traditionally in medicine, physicians were thought of as the “captains of the ship,” whose wisdom was unquestioned and whose instructions were to simply be followed. Doctors gave orders to nurses, allied health professionals and patients. Most members of the healthcare team went by their first names, but doctors still required a formal title.

This traditional hierarchy can be called a high power distance environment. Power distance is a term coined by Geert Hofstede, a Dutch social psychologist. In such systems, power relationships are autocratic, paternalistic and draconian. There is little premium put on collaboration, and subordinates are expected accept their lower positions. Authority and authorities (doctors, in this example) are rarely questioned, and their instructions are regarded as certain and inflexible.

In low power distance cultures, power is more evenly distributed, and there is a relatively small emotional distance between those in charge and others. Leaders and their teams are less concerned with status or title and more concerned with collaboration, communication, partnership and teamwork.

Luckily, medicine has begun transitioning from a high to low power distance environment, but we still have a long way to go. We have begun to shed titles between co-workers. We are encouraging all members of the healthcare team to share ideas and strategies with their colleagues. Nurses and allied healthcare workers are encouraged and empowered to challenge physicians if they notice errors or have concerns about the prescribed treatment plan. Physicians have begun to not only accept but to appreciate suggestions from their co-workers.

Medical specialists in fields like emergency medicine, anesthesia and surgery are developing team-based approaches to medicine. While the doctor is most often still at the helm, these highly functional team of RNs, advanced practice providers and other clinicians work collaboratively to deliver care. In most cases, these teams function in a very low power distance environment.

There still are elements of higher power distance that make sense in medicine and should remain. For example, emergent surgeries, CPR, code blue situations and trauma resuscitations still require a more rigid element of hierarchy, given the shortened timeframe for success and critical nature of the work.

Although it makes sense in medicine, a low power distance culture is not right for every field. The military is a classic example of an environment that works well with high power distance relationships. The features of a low power distance culture that make that hierarchy favorable in fields like medicine and aviation would not necessarily work well when fighting a war or keeping the peace.

A 2013 study published in the Journal of Patient Safety estimated that approximately 400,000 people die from preventable harm in medicine each year. We must continue to flatten our medical hierarchies, reduce our power distance and empower and encourage all members of the healthcare team to identify and report errors. Not only do patient’s benefit from the collaborative environment allowed for in a low power distance culture, but doctors and their nursing and allied health colleagues will be much happier practicing medicine this way.

Adam Corley, MD, FACEP, FAAEM, is an emergency physician with more than 10 years of clinical and leadership experience. Dr. Corley serves as Executive Vice President for EmCare’s West Division. He also serves as the medical director for several EMS services and the Anderson County Texas Sheriff’s Department. Dr. Corley lectures and writes on a variety of topics, including decision science and behavioral economics, management of disruptive behavior in healthcare, conflict resolution and healthcare leadership.

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Are the Best Hospitals Led by Physicians?

Posted on Mon, Feb 20, 2017
Are the Best Hospitals Led by Physicians?

Healthcare’s increasing complexity in this country and the growing emphasis on patient-centered care and efficiency in delivering clinical outcomes are forcing clinicians get better at balancing the competing imperatives of cost versus quality and technology versus humanity. Those challenges are preparing them to take on leadership roles—a good thing, say the authors of a recent op-ed published in the Harvard Business Review, who make a strong case that the best hospitals are led by physicians.

Many of the Top-Ranked Hospitals Are Led by Doctors

James K. Stoller, MD, a pulmonary/critical care physician at the Cleveland Clinic and chairman of the Education Institute; Amanda Goodall, PhD, senior lecturer in management at Cass Business School in London; and Agnes Baker, PhD, assistant professor at the University of Zurich, say there’s a correlation between physician-led hospitals and quality outcomes. Of the U.S. News and World Report (USNWR) 2016-17 Best Hospitals Honor Roll of this country’s top 20 hospitals, the five top-ranked hospitals—Mayo Clinic, Cleveland Clinic, Massachusetts General Hospital, Johns Hopkins Hospital and UCLA Medical Center— have physician CEOs and/or presidents. The authors also said the Mayo Clinic and Cleveland Clinic, ranked No. 1 and No. 2, respectively, have been physician-led since their inception about a century ago.

Dr. Goodall led a study published in 2011 that looked at CEOs of the USNWR’s 100 best hospitals in three key medical specialties: cancer, digestive disorders and cardiovascular care. The analysis found that hospital quality scores are approximately 25 percent higher in hospitals run by medically trained doctors than in hospitals run by professional managers who are not physicians. Research by Nick Bloom, Raffaella Sadun, and John Van Reenen published in 2014 found that hospitals with a higher percentage of clinically trained managers achieve higher quality scores.

Physician Leaders Have More Credibility With Other Clinicians

When asked why doctors make good hospital managers, Cleveland Clinic CEO Delos "Toby" Cosgrove, MD immediately answered, “peer-to-peer credibility.” Clinicians are more inclined to trust in a leader whose personal experience provides direct knowledge and insight into their challenges, motivations, and desire to put the needs of patients first. The authors assert that physician executives are more likely to have patient-focused strategies, and that if leaders understand based on firsthand experience “what is needed to complete a job to the highest standard, then they may be more likely to create the right work environment, set appropriate goals and accurately evaluate others’ contributions” and to “know what ‘good’ looks like when hiring other physicians.” Dr. Cosgrove also suggest that physician leaders are more likely to allow people to pursue innovative ideas and to tolerate “appropriate failure, which is a natural part of scientific endeavor and progress.”

Training Can Help Physicians Become Even Better Leaders

The authors argue that physicians traditionally have been trained in “command and control” environments as “heroic lone healers,” who are “collaboratively challenged.” But being an effective leader requires very different skills than those needed to be an effective doctor, including the ability to collaborate and to foster collaboration and teamwork among other clinicians. The op-ed mentions several examples of top-tier hospitals that engage physicians in leadership and management training, such as Yale Medicine and the Cleveland Clinic. Many healthcare institutions have in-house training developed by respected medical societies and business schools.
 

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Keeping Your Cool Amid the Chaos in the ED

Posted on Wed, Jun 29, 2016
Keeping Your Cool Amid the Chaos in the ED

By Ginger Wirth, RN

I’ve written about leading by example, and recently I had the opportunity to watch a fairly new leader do not only that but also lead from the front. I thought that I understood what that meant, but when I watched this medical director in action, it became even clearer to me.

I was observing processes in an emergency department and when I walked in at 10 a.m., things were clearly beyond the “norm.” I looked at the tracker and noted that names, numbers, different colors and flags filled the whole screen. There was nary a blank space to be seen. In the 24-bed department, the tracker told me that there were 18 patients waiting to be admitted and 11 of them were waiting for critical care beds. There also was a critical patient awaiting transfer. All of the other beds were filled with regular ED patients, and EMS was bringing more in the back door. I failed to mention that four of the critical care patients had been in the ED for more than 24 hours.

I saw the staff hurrying around the department, some looking more stressed than normal, while others maintained a smile despite the chaos. The medical director and I met in the ED at the same time. Without saying a word, she looked at me and I knew that she needed to fully assess the situation to determine the best way to help.

I watched her and was impressed. As many of us who have worked in emergency medicine know it’s frequently easiest to just grab the next chart and start seeing patients, go give the medication or provide the treatment. This medical director resisted that urge and she began making calls, activated the provider surge protocol, and assisted the facility and nursing leadership in implementing their capacity plan. The doctor remained in the middle of the nurses’ station directing the team, assisting advanced practice providers with reviewing discharges and turning over the low-acuity patients safely and rapidly. She also facilitated getting additional help for the hospitalists upstairs. They were able to get another hospitalist to come in and assist from the direction and notification from the ED SMD. She also made sure that the entire team was aware of the resources that were mobilized and what the plan was.

That entire scenario is exactly what I mean by “leading from the front.” Because of her leadership, providers and nursing staff were able to continue providing hands-on care to patients – and that’s exactly where we want them. The team felt comfortable knowing that the “administrative” stuff was being handled by the site medical director. By having the medical director there in the middle of the ED making calls, providing direction and supporting the staff, the team knew exactly what was happening and they were confident that relief was coming and beds would be found. While those calls could have been made in an office outside the ED, when action happens “outside” the chaos, many assume that nothing is happening. This frequently leads to dissatisfaction and low morale, and can have a negative impact on the care being provided.

On this day the team felt fully supported by the medical leadership in the ED. There was strong collaboration with nursing as well as the inpatient and administrative leaders. Frontline staff was able to focus on communicating with patients and their families about the delays and the plan going forward rather than making calls, assumptions and getting frustrated with the situation.

I know that this incident is nothing unique and there are EDs all over the country facing the same or similar days. I hope that they have nursing and physician leaders who can not only lead by example but also lead their departments and practices from the front.

Leadership requires collaboration, organization, planning and structure. It’s also important to be able to demonstrate the ability to stay calm in the face of stress, manage emotions – not only yours but at times the emotions of those around you – and to support and motivate the team. Be out there with your team, not only making sure that they believe you can do the things they are expected to do, but that you also are out there “in the trenches” with them.
 

“A true leader has the confidence to stand alone, the courage to make tough decisions, and the compassion to listen to the needs of others. He does not set out to be a leader, but becomes one by the equality of his actions and the integrity of his intent.”
-General Douglas MacArthur

Ginger Wirth

Ginger Wirth, RN, joined EmCare in 2013 as a Divisional Director of Clinical Services for the Alliance Group. Her goal is to make positive changes in healthcare by helping others focus on quality, excellence, and the overall patient experience. Wirth regards her role as Director of Clinical Services as the ideal opportunity to partner with nursing, physician and facility leaders to make positive changes to the entire patient care experience. Her 20-plus year nursing career has been dedicated to quality and excellence, promoting overall positive outcomes and safety for patients.
 

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