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In this episode, we are joined by Robert Allan Bear, a physician and health care consultant, to explore the challenges of maintaining strong organizational cultures in health care systems. Robert delves into the impact of pre-pandemic stress and pandemic-induced erosion on health care organizations, and the critical need for strong leadership to rebuild faltering cultures. We discuss the actions successful health care leaders take, such as commanding attention, making meaning, meeting people where they are, picking the right fights, providing a home, and telling a better story. Tune in as we examine the importance of inspiring behaviors, addressing frustrations, and fostering hope for a brighter future in health care organizations amid turbulent times.
Robert Allan Bear is a physician and health care consultant.
He shares his story and discusses his KevinMD article, “The culture of my health care organization is broken. Is there hope?”
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Get CME for this episode by clicking on the CME link in the show notes. Today we welcome Robert Allan Bear. He’s a physician and health care consultant. His KevinMD article is titled “The culture of my health care organization is broken. Is there hope?” Robert, welcome to the show.
Robert Allan Bear: Thanks very much, Kevin. I appreciate your having me on your show. I’ll just provide a little background first of all, some personal background. In my professional life, I’ve had a collection of serial careers. I started out as an academic nephrologist and professor of medicine at two major Canadian academic health centers, moved on to be a medical administrator in each of those health centers, and over the last number of years have functioned as a health care consultant across Canada, a little bit in the United States, and in the Caribbean.
As a consultant, I’ve recently witnessed what I would consider to be a faltering organizational culture within many of the health care organizations I’ve been visiting. And I think, as we all recognize, organizational culture is a key contributor to the success of any organization. So I thought I would speak out about this issue. It’s a silent epidemic, in my opinion, and it deserves to be brought to the fore, and that’s what I intended to do by writing this article.
Kevin Pho: All right, your article is titled “The culture of my health care organization is broken. Is there hope?” So why don’t we get straight into that article? How did it come together, and tell us the key points.
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Robert Allan Bear: It all came together, actually, as a consequence of two readings that I happened upon. The first provided me with the Latin quote “Abyssus abyssum invocat,” which means “one hell calls forth another.” As I read that quote in its translation, I immediately thought of our health care system, and I thought of it in this way: In the United States, in Canada, in the U.K., and in other jurisdictions, the health care systems have been under incredible pressure as leaders tried to manage their organizations efficiently and effectively to provide services to the populations that they serve. Then, superimposed on these pressures, came the second hell, which was the pandemic, which created profound additional stresses on the system.
These stresses, particularly upon health care providers of all stripes, have ended up having a number of consequences: people feeling frustrated, angry, and demoralized. There have been many articles in your publication on physician burnout and nursing burnout. Many nurses and other health care professionals have chosen to leave their jobs and move on to others. There’s even been, in my experience in some of the organizations I visited, a disturbing rise in what I would characterize as unprofessional behavior, mediated by that anger and by that frustration.
As a consultant, I recognized that most of the leaders, medical and otherwise, I was encountering in their organizations were focusing on how best to manage change, as I’ve mentioned before, how best to ensure ever-increasing degrees of efficiency and effectiveness, and how to cope with some of the stresses that have resulted from the pandemic, and they haven’t necessarily paid enough attention, in my view, to the underlying organizational culture of the hospitals and health systems they serve.
This led me to my second reading, which was a New York Times article, actually, talking about how political leaders might respond to the stresses on democracies that exist today. When I looked at the five or six lessons for such leaders, it immediately struck me that the exact same lessons could be applied to health care leaders in our organizations today, if they feel that the organizational cultures in their institutions are faltering. The discussion of those steps really represents the body of my submission to your journal.
Kevin Pho: So tell us, what are some of those lessons that these organizations can learn from?
Robert Allan Bear: Well, the first lesson is entitled “command attention.” It’s really important for leaders to ensure that, around the change that is necessary, there is what John Kotter describes as a burning platform, creating a case for a really urgent change. As I write, it’s one of the opportunities for leadership to draw the troops together, to look them in the eye, and to say something like, “Enough is enough. This organization is not functioning as it should. Change is necessary. I’m going to be on it. We’re going to work as a team, and we’re going to make sure things end up in a much better place, and I really hope you’re with me. If you don’t want to be with me on this journey, then that’s a decision that you should take.” And really grab the attention of the organization.
That would be step one: Indicate that the leadership understands where the culture is, and indicate that the leadership is prepared to work with everyone to make sure that the culture is changed positively.
Kevin Pho: Now, in terms of some successes, can you tell us a story? Give us an example of an organization that made such a change for the better.
Robert Allan Bear: Well, I would speak in general terms to your question, Kevin. It’s been my experience, having been engaged in consulting work in over 120 hospitals in Canada, so I’ve been exposed to a lot of different organizations and their leadership, and my observation is that within half an hour of walking in the door, most people can understand the culture of that organization, what it’s like, and whether it’s a positive one or a negative one.
Kevin Pho: What do you use in the first 30 minutes? In that first 30 minutes, to assess the culture, what do you specifically look for?
Robert Allan Bear: I walk in the door, and I appreciate what the initial setting looks like. I appreciate how the staff have been trained to ensure that I’m welcomed. If I end up in an emergency room, I want to understand how triage works and whether it’s open, caring, compassionate, and concerned, with individuals expressing understanding and concern, or whether it’s an assembly line and I’m one widget in that line. By observing things like this, and simple things such as signage in the organization, such as organizations displaying their values, and then, as you walk through, even in those first few minutes, seeing people who have not only read about those values but also have learned how to express them, it’s pretty easy to determine an organization that’s highly functional from the culture point of view and one that needs some work in that area.
Kevin Pho: Among health care organizations with, let’s say, a failing culture, what are some of the common themes that you’ve observed that connect these organizations?
Robert Allan Bear: Well, the most common theme, and I try to address this in some of the steps that I mentioned in my post, is isolated management: management whose words do not connect with their actions, management who are working as hard as they know how in their offices but are somewhat isolated from the staff, from the physicians, and from the patients. These are individuals who aren’t managing by walking around, who don’t have a presence in the organization, and who aren’t hearing and listening carefully about how people are feeling, what they’re experiencing, what their issues are, and why they’re frustrated around issues that could easily be corrected and that have been long-standing issues. Those are the things that I observe in organizations where, in my opinion, the organizational culture needs some work.
Kevin Pho: Now, there is a notion that there’s a little bit of tension in a lot of organizations between the clinical staff and the administrative staff, and perhaps one reason is that their goals are a little bit different, because sometimes what’s best for patients isn’t necessarily what’s best for the financial bottom line. How can organizations manage that tension?
Robert Allan Bear: I think that’s a great question, Kevin, and I thank you for asking it. In different jurisdictions, in different countries, and for different reasons, it’s not uncommon for tensions to exist between the medical staff and the administrative staff. Again, I’ll speak to this at a high level and emphasize that the best approach to resolving those types of tensions is through genuine, strategic engagement of physicians. In my experience, physician engagement does not happen organically. There needs to be a strategy, underpinned by specific and concrete actions, so that physicians, first and foremost, feel valued, feel like they actually are being listened to, feel that they have a role in decision-making, and feel that their work, when it’s exemplary, is recognized and honored, and all these things. And I state emphatically that this kind of approach never happens organically. It really needs some thought: How can we engage with our medical staff, who, along with other health care professionals, are such central parts of the organization and any success it’s going to have?
Kevin Pho: So you mentioned that physician engagement isn’t organic. On a more granular level, what are some specific examples of how administration can engage physicians?
Robert Allan Bear: Well, I think it starts with the medical organizational structure of organizations. Who are the physicians who are in positions of influence and, potentially, leadership? How are they selected? How are they performing? How is their performance assessed? How are they doing in developing a team-oriented approach among the physician population? And then, at a distinctly granular level, I always like to see how physicians are recognized in the organization at milestones, and physicians whose performance goes beyond the pale. I’m always interested in looking at the medical organizational structure and seeing how physicians have meaningful input into decision-making processes.
In my article, I talk about the importance of picking fights, and it’s just amazing to me how so many organizations’ administrators pick meaningless fights with their physician population that do nothing but destroy morale, undermine culture, and lead to a negative impact in the organization.
Kevin Pho: So what is an example of such a meaningless fight that they pick?
Robert Allan Bear: Well, in a hospital at which I was working recently, and these things seem small, but they’re not so small, I heard about the physicians’ concerns about a new physician dictating system for final notes, consultation notes, etc., that was just being imposed upon them without consultation. Consultation would have been such an easy thing to do, and yet it was ignored, and the final solution was presented to the physicians, prompting outrage and undermining the relationship between the physicians and the administration. This is a small example, but in organizations that behave like this, it’s emblematic of a broader set of issues.
Kevin Pho: Why is it that some administrators don’t include physicians in the decision-making process? Because obviously, we’re physicians, and it seems like common sense to include physicians in the decision-making process, but obviously that’s not universal. Tell us about the mindset of the administrator who doesn’t see it that way. How did it become that way?
Robert Allan Bear: Well, again, in my opinion, a lot of it relates to bias and to what I would refer to as mythical information. Some of the myths out there are, “Yeah, well, physicians are always going to be physicians,” and, “Physicians are always going to look after themselves,” and, “Physicians never care about the other health care workers,” and, “Physicians put themselves ahead of the patient too often to make sure their own needs are met.” I describe all of these as mythical. In organizations with highly functional organizational cultures, physicians portray none of those attributes.
And yet, if an administrator ends up believing those myths, which are widespread, then there will be a natural antipathy toward wanting to reach out to involve and engage physicians. So I think that’s a barrier that must be overcome. Highly successful hospital and health system administrators, as we all know, do a great job of working in partnership with their medical organizational structures, with their formal leaders, and with their professional staff organizations.
Kevin Pho: We’re talking to Robert Allan Bear. He’s a physician and health care consultant. His KevinMD article is titled “The culture of my health care organization is broken. Is there hope?” Robert, tell us some of the take-home messages that you want to leave with the KevinMD audience.
Robert Allan Bear: The take-home message that I would leave would be, first of all, that there are things that leadership can do in hospitals and health care organizations to make sure that the culture is optimized. And from the physician point of view, too many look to their formal administrative leaders to carry the load on this. I think it’s important to recognize the power and the influence that both formal and informal physician leaders can have in an organization.
And I would say the steps that I mentioned in my article are these: Create a burning platform for change. Make sure people understand what you’re really striving for in terms of team-based care and patient-centered care. Manage by walking around, physicians and others. Engage people where they work, understand what their frustrations and concerns are, and try to commit to dealing with them. Pick your fights. Make a workplace feel like a home, where people can be listened to, where people are treated with respect, and where people feel safe. Tell a better story, and this doesn’t apply just to the administrative leadership but to the physician leadership at large, formal and informal. What’s the history of this organization? What should its future be? What’s the story? Do you want to be part of it? Tell that better story; storytelling is an extraordinarily powerful motivator of change.
So those would be my take-home messages, and it should be a team-oriented effort to ensure that the organization in which one works has an organizational culture that’s extremely positive.
Kevin Pho: Robert, thank you so much for sharing your time and insight, and thanks again for being on the show.
Robert Allan Bear: I appreciate the opportunity.
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