Leading a Revolution in American Health Care
Violent revolutions are rarely, if ever, led by people in power. The least likely person to lead a revolution in the American colonies was King George III. King Louis XVI was an improbable candidate to lead an overthrow of the French government.
But other kinds of revolutions can and should be provoked by the established leadership—the leader with a conscience who wants to begin the change at the top and who recognizes the following basic elements which are present in any revolution: (1) a present and pervasive injustice; (2) a large number of people who are aware of the injustice but feel powerless to accomplish change; and (3) a leader, or leaders, who must, at the minimum, understand the above, believe in themselves, believe in their mission, have a vision for how to accomplish that change, have a depth of commitment which is both passionate and persistent, and have an understanding that the revolution will only succeed if the vision is shared by the mass of people “on the front lines.”
The Problem
The single biggest obstacle to positive change in health care is, of course, inertia—inertia which comes from years of doing things the same way—inertia that is protected by the champions of the status quo who cover over mediocrity with arguments about tradition and who defend abuse of patients by claims like “everyone else does it this way.”
Is there a problem in American health care? Arguably, we have the finest hospital buildings, the best broadly available drugs, the best trained physicians, the best trained nurses, and the best broadly available medical technology of any health-care system in the world. Most American patients receive the “right” drugs, the “right” x-rays, the “right” lab tests, the “right” surgery, and the “right” medical therapies. Furthermore, the “right” health care is available to just about anyone.
If all of this is true, and I think that it is, then why ask questions? Not only are we no worse than anyone else but we may very well be “better.” But how would you like it if the motto of your hospital was, “Come to us; we’re no worse than anyone else.”
Let us go on an imaginary tour through the American general hospital. You are a seventy-year-old and you have just been involved in an automobile accident. You have sustained some cuts and bruises, are shaken and frightened by the accident, and feel some vague abdominal pain. A friend drives you to the hospital. You are able to walk to the front door of the emergency room. As you cross the threshold, what are your needs? Why did you come to this hospital? What do you actually expect? What do you have a right to expect?
One hundred percent of the patients who enter an emergency room are seeking the same thing, and it doesn’t take much insight to guess what that thing is—quick and competent medical treatment. Yet the first person you will meet in most emergency rooms is not a nurse or even a receptionist but a registration clerk. You as a patient want treatment. We in hospitals want to register you.
Unless your injuries are obviously severe, it is likely, in most emergency rooms, that you will begin to experience the process of being degraded. Step one in this process, a step that will be repeated throughout your stay in most American hospitals, is called WAITING. Unless you are President of the United States, YOU WILL WAIT. You are now under our control. Whether you are an assembly-line worker or president of a company, you have become our prisoner. You want your health back and we won’t give it to you unless you follow our orders. As long as this perception exists, you will do whatever we ask. After all, what is more important than your health—especially when you don’t have it?
A typical next step in the hospital treatment process is that we take your clothes away from you. Just like a convict you are asked to strip, and just like a convict, you are handed a degrading uniform commonly referred to as a “patient gown.” I have seen the strongest of personalities converted to the mentality of small children once they don one of those infamous patient gowns. Consider the following dichotomies between me as your doctor or nurse and you as a patient: I am healthy; you are not. I wear a uniform; you’re not even wearing your underwear—just a hospital gown. I am standing; you are sitting in a wheelchair or you are lying down. I know about medical treatment; you don’t know anything. I am confident; you are scared. I can probably give you your health back; you probably cannot get your health back without me. I am “young”; you are “old.”
The contrasts go on and on, but the single message is loud and clear: You are my hostage. You must obey.
A little bit like the interlocking pathologies of abusing husband and battered wife, I will only release you after I have given you “the punishment you deserve.” One big difference is that society not only condones this strange, decades-old relationship, it applauds it. If you are admitted to the hospital and stay for about six days, you will be repeatedly assaulted, physically and emotionally, by a team of thirty-five to forty different people day and night until we decide to release you. You will be poked and prodded and stabbed and fingered and exposed and x-rayed and drugged. In the midst of all this, if you attempt to sleep, the likelihood is that you will be awakened several times in the course of the night and day so that we can give you something to “help you sleep.” During your stay, it is likely that you will be placed in a room with a total stranger, sometimes separated from you by a curtain which blocks vision but none of the other senses.
Periodically strangers will enter your room to clean it, deliver food, visit your fellow patient, fix the lights, or (and here comes one of the scary parts) come to “take you for treatment.” Even the most painless of procedures, a routine chest x-ray, will probably require you to sit in line and wait in your wonderful patient gown. There is no way you can advance your place in line while you are waiting, and it is very tough to get up and go to another hospital. Frankly, there would not be much point in leaving anyway because you would wait at the other hospital also.
Your family may come to visit you (if you have a family) but they will be required to leave after visiting hours (like most American prisons). When you are finally discharged, you or your insurance company will be billed several thousand dollars for your visit (not like American prisons). Will you have your health back? Maybe.
Is this what we expect from our health-care system? Is this what we have a right to expect? Although you know that everything that I have described above is essentially accurate, I suspect that it has not occurred to you that any of this is basically unjust. If it has struck you as unfair, it probably has not occurred to you that you should be the one to try to change things. So expected is the above treatment that many patients at the hospitals which I run, after undergoing the above experience, send me a note thanking me for the excellent care which they have received. Perhaps that is because we are not only no worse than anybody else—we are a bit better. But we are not different, yet. Something is wrong with American health care. The time for revolution has come.
It Is Time for a Revolution: Who Will Lead It and What Will They Do?
What I have said in the description above is that we have an American health-care system which gives great medical care and terrible human care. One highly attractive notion is that patients should be “partners” in their own health care. After all, each of us knows the unique aspects of our own bodies and we are the ones that will have to take the steps down the pathway back to wellness. We are the ones who choose what foods we eat, what conditions we live in, how we will deal with stress, and what advice we will follow. The doctor should be our partner, not our warden.
But the actual fact is that the human side of care in American hospitals is a crime and we who operate the hospitals in this country are the criminals. In an enlightened society, I would argue, the wisest approach to solving this problem is a process of rehabilitation rather than a concentration on punishment.
Where should the change begin?
Change on the Front Lines
Although the executives of our hospitals must take the lead, the real change will have to occur with the people who give care—nurses, technicians, doctors, social workers, and anyone else who interacts with patients and their families.
We must find a new pathway, because wrongs continue to be done along the old pathway. It is time to right those wrongs. I have never met a single doctor, nurse, or other medical professional who felt that they were intentionally degrading a single patient by their actions. One certain way to insure that things do not change would be to berate front-line staff. It is useful to note that a key element of every criminal act is intent; and this element is lacking in virtually every case of abuse in health care. Nevertheless, the wrongs continue because they have not been recognized.
The Change Agents
The change agents need to be everyone in the hospital, and the leaders of the hospital need to empower this change by: portraying the need for it; giving permission for that change to occur; supporting risk-taking; cheering for every success, whether big or small; actively participating in bringing about that change by working alongside the staff; and recognizing that there are two groups of people working in hospitals, the front-line caregivers and the people who support them (presidents and vice presidents are in the second group).
The Allegory of the Cave and the Pathway to Awareness
One of the most famous and instructive stories in all of literature is Plato’s allegory of the cave. As I remember this story, three men are tied together against a large stone facing towards the back wall of a cave. They are bound in such a way that they are not able to turn their heads and can only look straight in front of them. In the allegory, we are asked to accept that these men have lived this way all of their lives.
On the other side of the stone, a fire is built and people walk back and forth between the fire and the stone, casting shadows on the wall which the three prisoners can see. Everything these three prisoners know about life and about the shape of people is through the silhouettes which they see cast on the wall. At one point one of them is released by a guide who brings the person around to the other side of the stone. The freed man sees that there are three dimensions in the world. He sees the light of the fire, he feels its warmth, and he begins a journey with his guide up a pathway towards the mouth of the cave. As he proceeds along in his journey his awareness grows. As he passes out of the mouth of the cave he sees a world around him filled with trees, birds, clouds, animals, and all else in nature. He continues on in his journey of awareness until he reaches the moment when he experiences the highest state of awareness and knowledge. This state of awareness is symbolized by his ability to look directly into the sun wherein he sees all truth (and, in the story, suffers no eye damage). After this, he is taken back down into the cave where he is tied up again next to the other prisoners. He attempts to describe to them what he has seen, felt, smelled, tasted, and learned. Of course, they do not believe him. They conclude that he has lost his mind and they ridicule him.
When a leader has reached a high level of awareness and clear vision, how does he communicate that new vision to others? The three most common ways which people learn information are: to be told, to be shown, and to be involved.
Clearly the last of these options is the most effective. For example, I can tell you how something should be done and you may understand part of that. I can show you how it is done and that may tell you more. But only when I ask you to do the thing do both you and I know if you have fully understood the message. The principle of involvement is the single least understood aspect of communication. An understanding of the basic importance of involvement is critical to the leader’s ability to bring about change and to know that others will join him as he leads the way down the new path.
What Is the Current State of Leadership in Health Care and Who Is Not Likely to Lead?
Among my colleagues running the hospitals of America, I detect very few individuals who seem committed to fundamental change at a deep level.
In general I would describe many of my fellow hospital chief executive officers as a group of men (and a few women) who are pleased that they have made it to the top of their organization and who are interested in protecting their positions. Hospital presidents have always been a little bit like mayors of cities, balancing various political factions—board members, doctors, employees, community leaders, etc.—trying to keep things in balance. Recently there has been an increasingly competitive focus among hospitals, which has often had the effect of generating attitudes of suspicion, as well as a focus by CEOs on strategies that will give their organizations a “competitive edge.”
To the extent that this analysis is accurate, it is clearly not a portrayal of a setting that would support innovation and risk-taking. To suggest the word revolution to this group is to risk being branded as one who might better serve as a patient in the hospital than as the president.
Everything about hospital organizations militates in favor of the status quo and against change. Earlier I compared hospitals to prisons. Hospital-management organizations often look very much like the military. Just about everybody wears uniforms and the uniforms not only denote hierarchy and status but also suggest a rather clear chain of command.
One difference between the military and hospitals is that there are two lines of command in hospitals. One line of command flows out of who has control over care of the patient. The other line determines who has control over the people who have control over the patient.
In the first group the doctor continues to reign supreme. His or her uniform is the white coat; the baton is the stethoscope. In the old days (up through the 1950s) this command presence was so strong that when the physician entered the nurses’ station all the staff was required to stand in his presence. Today doctors complain that they can barely get nurses to answer them, much less stand up. In any case, the physician still maintains a position of high prestige, and the most important orders are not carried out without the doctor’s “order.”
Of course, people have noticed the power which the physician holds, and they have noticed what he looks like and how he dresses to achieve that power. Accordingly, just about every caregiver in a hospital tries to drape a stethoscope around his or her neck and wears a beeper in some prominent location. To the uninitiated many x-ray technicians, respiratory therapists, nurses aides, and housekeepers wearing scrub suits in surgery could all be taken for physicians, based upon their dress.
Registered nurses rarely wear caps anymore, yet nurses aides, unit clerks, and LPNs do their best to replicate the appearance of the RN, who is the individual who stands at the top of the nursing hierarchy.
Basically, orders for medical care continue to flow primarily from the physician to the nurse or technician or therapist who administers care to the patient. But the nurses and other front-line caregivers are not employed by the doctor. Instead, they are employed by the hospital and the hospital has its own hierarchy of managers clad in business suits, indistinguishable from their counterparts in industry.
In most hospital organizations—especially the large ones—there are incredible layers of management between the front-line staff nurse and the president of the hospital. Consider the following series, which is typical:
1. Nurse’s aide.
2. Licensed practical nurse (LPN).
3. Staff nurse.
4. Charge nurse.
5. Assistant nurse manager.
6. Nurse manager.
7. Assistant vice president for nursing (here we begin with business titles).
8. Vice president for patient care services.
9. Executive vice president and chief operating officer.
10. President and chief executive officer.
There are eight layers of management between me, the president, and the nurse’s aide, and six layers of management between me and the staff nurse on the floor. Meanwhile, I do not make any “command” decisions with respect to the direct care of any individual patient—those command decisions come from an independent contractor called a physician. (I do, however, retain the authority to fire anyone in this chain of command except for the doctor, unless he is employed by the hospital.)
There is one, and only one, circumstance that I can think of when the military chain of command is desirable in a hospital setting: when there is a crisis. At the moment a patient has a heart attack, a military chain of command is a marvelous thing to behold. Nurses and doctors shout orders, equipment is rolled into place, drugs are given with precision and professionalism, and patients’ lives are routinely saved by the efficiency of this process.
Of course in actuality these crises occupy a fraction of one percent of any 24-hour period in the hospital. Yet this presence of potential emergency hangs over the hospital all of the time. Like the fire department or the army, we are always poised for the moment when the voice on the PA system calls a “Code E” or a “Code Blue.” We act as if we need the military approach all of the time when the actual fact is that this military command structure is incredibly damaging to the process of constructive change in the human care of patients. It is used endlessly as an excuse to explain away abusive treatment of patients. For example, the nurse tells the patient, “I can’t give you this medication because the doctor hasn’t ordered it yet and I can’t bother the doctor right now.” The implication is that the doctor is engaged in some lifesaving activity when there is a good likelihood that he is playing golf, talking to his stockbroker, or, more likely, talking to his lawyer.
The medical staff. Although doctors are well paid generally, they are also a terrifically hard-working group of professionals who are subjected to a barrage of interruptions from patients, fellow doctors, family members, stockbrokers, investment advisors, office staff, utilization-review coordinators, and insurance companies. Meanwhile, they practice medicine in a setting increasingly hostile to their best efforts and insensitive to rising malpractice insurance rates and decreasing respect for their credibility and dignity.
This group of physicians may be as ready now for change as they have been in the last fifty or sixty years.
Nevertheless, the hospital structure as described above presents enormous obstacles to revolution. To suggest change is to imply something which might risk a patient’s life or safety, jeopardize accreditation or licensure, increase the chance of a malpractice suit, or go against existing policies that have been built up over decades. In addition, there is always the sense that any significant change needs to be approved not only by the medical staff but by the board of directors.
The board of directors. The hospital board of directors is a well-meaning group of volunteers who visit the hospital for a few hours each month to attend meetings of an organization that is as foreign to them as it is to most other hospital visitors. Since the care of the patient is the domain of the doctor, hospital board members typically turn their attention to finances, something which they can not only influence and control but also more easily understand than the jargon of the medical profession.
The patient. Finally, the patient himself or herself could view radical change with the greatest skepticism. A key shibboleth in hospitals is cleanliness, which equates to sterility, which equates to safety. Linoleum floors, tile walls, and metal furniture may look cold and ugly but they seem to support the goddess of cleanliness. Accordingly, hospitals look, smell, and sound like some of the most unpleasant places anyone would want to be. Patients accept the unnecessarily sterile look of hospitals and some think that changes would shake their confidence.
It is an interesting job to be head of an organization which every person wants to leave and no person wants to come to. On a Saturday night when one of your friends says, “What shall we do for fun,” no one suggests that it would be great to check into the hospital.
Hospital employees know that the patient does not want to be there—they often do not want to be there themselves and are looking forward to the end of their eight-hour shift. This sets up a sad dynamic where the patient resents the x-ray technician and the x-ray technician resents the patient. The patient views the technician as necessary but bothersome, and the technician may view the patient as a body that needs to be x-rayed.
Of course none of these attitudes are things which we want to promote, but a blunt look at the daily and nightly operation of the American general hospital can often reveal a sullen crowd of patients who want to be home and a harried group of nurses who would like to get to the end of their shift.
In spite of the grim portrayal presented above, it is my view that almost every person who works in a hospital cares about the patients in that hospital. Every one of them would love it if the atmosphere changed and they felt permitted, encouraged, and empowered to reach out to their fellow human beings who look plaintively to them for solace.
How do I know this? I know it and you know it because we know that every being on earth shares a common emotion. We all have hope and we all seek meaning.
The existence of hope in the hearts of each of us and the search for something meaningful is enormously important in the health-care revolution that will one day come to America’s hospitals.
Solutions
In an extraordinary set of papers, Charles Kiefer and Peter Senge have described a process of change in organizations, and a way to bring about that change which is a powerful learning for any individual committed to leading a revolution.
Many writers from Peter Drucker to Tom Peters to Ron Zemke (Service America) to Warren Bennis (Leaders) to Charles Garfield (Peak Performance) have described the process of leadership and innovation and have outlined characteristics of the leading-edge organizations. However, Kiefer and Senge (1984) seem to have come up with a particularly good set of descriptions for the organization which we are trying to develop to revolutionize the way we give health care.
Everyone, of course, would like to feel part of a team that is viewed with respect, wins when winning is important, and is composed of a group of talented and committed individuals. Kiefer and Senge describe the numerous examples we so often hear of groups of people who “have united under extreme pressure to achieve seemingly miraculous results.” They also contend that “these occurrences are much more frequent in American business than is commonly suspected.” Consider this paragraph from their paper on experiments in organizational innovation as they talk about the elements and the emotions of a peak performance:
There is a sense of sustained exhilaration, a moment of peacefulness in the midst of frantic activity when time seems to flow in slow motion. Maximum effort is extended; things come together effortlessly and in astonishingly effective ways that could never have been planned. A sense of predestination prevails; there is a feeling of unity with everything and everyone. Most who have been part of such an experience yearn to relive it and some find it so transforming that life becomes a search for duplicating it.
They go on to write that:
Organizations that cultivate this level of performance transform the way they operate in the world. They do not allow circumstances to constrain them, but look instead to creating the future and determining their own destinies. They are engaged in daring experiments in organizational innovation that fundamentally alter our understanding of how a group of people can work together.
The five elements which they describe as typical of a metanoic organization (an organization making a fundamental change) are: (1) purposefulness and vision; (2) alignment; (3) personal ability and mastery; (4) attention to organizational design, particularly in relation to how it performs as a system; and an element which is somewhat more complicated but no less crucial, (5) integration of intuition and rationality.
How is this transformation beginning to occur where I work, at Riverside Methodist Hospital in Columbus, Ohio, and how long does it take? I have a perhaps surprisingly specific answer to the second question. It takes five years in an organization our size (4,700 employees and 700 doctors and 23 board members). The answer to the first question is, of course, so complex that it can only be described through a sequence of examples and facts which may, ultimately, be the best teacher because, like a good story, they can serve as a basis from which you can draw your own set of conclusions.
In 1983, when I became president of Riverside Hospital, the organization had 3,800 employees, 550 doctors, revenues of $100 million, and made a “profit” of $6 million. Our funded depreciation (savings account) had $15 million in it and we had a debt of approximately $25 million. In addition to Riverside, we were managing one 60-bed hospital in northern Ohio (Riverside has 1,092 registered beds).
At the end of fiscal year 1987, Riverside was part of a holding company, which I also head, called U.S. Health Corporation. U.S. Health owns and operates seven hospitals with revenues of $300 million; a bottom line of $25 million; an employee group of over 6,000; 1,500 doctors; over 2,000 hospital beds; and a holding-company board of 10 people. By the end of 1987, U.S. Health Corporation had completed the acquisition of three additional hospitals and total revenues went up to over $400 million, while total beds increased to nearly 3,000. Debt at Riverside increased to $50 million in 1987, but funded depreciation (our savings account) increased to $56 million, meaning that in effect Riverside Hospital could have eliminated its entire debt and still had $6 million left in our “savings account.” Operating margins at Riverside were between eight and ten percent and are well above six percent throughout our system.
These cold statistics describe the successful accomplishment of one of our goals: growth. They say nothing about the second principal goal of our organization, the goal which I have been addressing in this paper—fundamental change in the quality of our service to patients. In that respect I would offer the following illustrations and examples.
Around Riverside Hospital there are a series of odd little signs. Next to a mirror in the hallway appears a sign which says “Karl’s Mirror”; next to a fan in the dietary department is a sign which says “Helen’s fan”; next to a time clock on the ground floor is a small sign which says “Jane’s time clock.” There are more signs like these and they represent our effort to recognize suggestions which have been offered by our employees. Change comes through a million small steps.
One week I changed out of my blue pin-striped suit into a dishwasher’s uniform and worked for several hours in the hospital dishroom. Earlier I had put on the uniform of a linen-services worker and worked for several hours in the hospital laundry. I have worked alongside three different x-ray technicians during the evening shift, and across two shifts as a patient escort, wheeling patients around the hospital. Some of my vice presidents have been doing this too. For years I have sent a personal note and a flower to every single employee who has been hospitalized at Riverside and have visited them when I could.
Every Wednesday and Thursday night during the local news a one-minute “advertisement” appears called the “Riverside Minute.” During this sixty seconds a Riverside doctor talks about an aspect of health care. About fifty of our doctors have done “Riverside Minutes.” Three other hospitals around the country have purchased this idea from us in the past several months.
Admissions to Riverside Hospital have been increasing steadily.
Although our occupancy remains approximately the same as it was in 1983 (slightly above 81 percent), we have approximately 1,000 more employees.
In 1986 the Ohio Kidney Stone Center opened on the campus of Riverside Hospital. The center is a nearly unique partnership between forty physicians and Riverside Hospital. It houses an extracorporeal shock-wave lithotripter (for treatment of kidney stone disease), and is physically no different from dozens of centers like it around the U.S. The equipment is the same. However, this center is the busiest in the U.S.
On the first floor of Riverside Hospital, at the end of a long corridor draped with streamers, is a door which says “Elizabeth Blackwell Center.” Elizabeth Blackwell was America’s first woman doctor. Five hundred Columbus-area women have offered their suggestions and thought up this center. It opened in 1985, and in its first two years over 15,000 women and their families had come in for help. The third and fourth floors of Riverside Methodist Hospital are called “The Elizabeth Blackwell Hospital.” All the floors in all the patient rooms contain carpeting and eighteenth-century furnishings. The beds have wooden head and footboards and are covered with real bedspreads.
Employee turnover is lower at Riverside than at any other hospital in central Ohio. Recently Hay and Associates conducted a survey of employee morale. Riverside employees ranked first in employee morale among all the hospitals which Hay has tested in the U.S. Yet Riverside ranks about third in a local wage-scale comparison.
Visitors and patients are constantly commenting about the way in which Riverside employees “smile so much.”
In the cafeteria is a large board which contains pictures of employees who are described as “Champions of Innovation.”
When you walk into the entrance of Riverside’s Emergency Room, the first person you see is a nurse who evaluates and sees that you are treated before you are registered. Heart patients who come to Riverside’s Emergency Room are admitted directly to the Heart Institute and do not wait in the emergency area.
Riverside has the largest group of volunteers of any hospital in the state of Ohio.
The average attendance at Riverside board meetings is 80 percent.
So many physicians have applied to join the staff at Riverside Hospital in recent years that a moratorium has been placed on staff privileges in the Heart Institute.
In 1987 ground was broken for the only freestanding hospice facility in central Ohio. The facility is being built entirely with contributions from the community. A quarter of a million dollars in gifts came from Riverside employees.
Riverside routinely ranks first (by a large margin) in community surveys as having the best reputation of any hospital in central Ohio.
In spite of the above steps forward, patients still wait too long to be treated. Patients’ families still have to wait too long for information about their family members. Nurses have not yet gained enough control over the management of patient care and still have to wait too long for doctors’ orders. Individual pain-management systems need to be improved. Too many patients are still spoken to as if they were six years old instead of sixty years old. Too many employee work areas are cramped, crowded, and not well lit or ventilated. There are not enough windows in the hospital. Lots of employees still watch the clock and wait for the end of their shift. Too many doctors still dodge their own patients. And we have got too many layers of hierarchy.
But we are going to change this. We are going to change because we know that it is the right thing to do and we know we can do it. And we are encouraged even by the small victories. For instance, we now have new “patient gowns.” These new gowns were designed not by a consultant, a designer, or me but by one of our nurse managers named Ann Stevens. They are not yet different enough, but they are better.
Bibliography
Kiefer, C. F., & Senge, P. M. (1984). Metanoic organizations. In J. D. Adams (Ed.), Transforming work. Alexandria, VA: Miles River Press.
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This paper was presented during Creativity Week X in 1987. Erie Chapman is still the president of Riverside Hospital and its parent holding company, U.S. Health Corporation. To visit with Erie in his hospital, you must be willing to run after him as you talk. He is constantly in motion visiting with the staff and the patients. You quickly learn that he really does understand the workings of Riverside from a firsthand perspective.
I’m reminded of the recent movie entitled The Doctor in which William Hurt plays a doctor who becomes a patient in his own hospital. He is then forced to experience his hospital from a new perspective—that of the powerless (and sometimes scared) patient. Erie has very effectively described this anxious state in this paper.
The paper also shows that bringing a new perspective to an old situation often results in innovation. Erie’s degree is in law—not hospital administration—and I wonder if this has proved to be an advantage in his restructuring the old, well-known situations at Riverside and in his establishing a process of continuous innovation. SSG.