I couldn't think of a better headline than borrowing from the provocative title of a new book, Patients Come Second by Paul Spiegelman, CEO of the Beryl Companies and Texas Health Presbyterian President Britt Berrett. The reason: We all know that in a new era of supposed accountability for hospitals and healthcare systems, the patient is supposed to be the first priority.
That should have been the case despite whatever financial methodology is being used, but, perverse incentives being what they are, maintaining volumes became more important than maintaining patients' health.
That's one reason the title, as healthcare embarks slowly, haltingly, into a new era, is so shocking.
But the two authors are being strategically provocative, to shed light on the fact that healthcare culture is often dysfunctional enough that in itself, it harms patient care. And that bothers them. Because culture is underappreciated in healthcare, they argue. Both Spiegelman and Berrett lead organizations considered by employees to be top places to work by a variety of measures.
"The irony is that the internal culture of hospitals is not very strong, especially since people have generally come to work there with a heart for service," says Spiegelman. "We have to understand that it's dominated by leaders who weren't really brought up in their silo of leadership school to know how to build a team, or play nice, or empower people to do their job."
Instead, healthcare has historically operated as a command-and-control environment, they both argue. Instead, leaders should adopt a philosophy of "trust and track," as Spiegelman says, which frees up leadership teams and those working in their area to improve care from the bottom up.
Berrett says the constant focus on the patient's well being, ironically, can lead to harm if the culture can't back up that focus.
"Too often we, as healthcare providers, are so focused on the patient, that we forget to take care of ourselves," says Berrett. "That can lead to burnout, bullying, and disharmony. It's pervasive. You can do that for awhile, but eventually people become disenchanted."
Moving from what Spiegelman and Berrett call transactional leadership to transformative leadership requires leaders to focus on the "why" of the new initiatives they're pursuing. These are diametrically opposed, incentive-wise, from what the rank and file, and even clinical leaders in the organization, are used to.
That includes explaining that the moves are for the greater good, not necessarily because doing so will pad the hospital or health system's financial coffers.
Berrett says many of his peers, at least when he first started speaking on the topic, would dismiss his focus on having fun in the workplace, team-building, and the big picture. They told him his leadership philosophies were "soft," and that they couldn't make much difference.
"Just the soft stuff?" Spiegelman retorts. "No, this is the hard stuff. There's nothing about productivity, financials, or performance in here."
Anyone can make decisions based on business fundamentals, they say. What's harder is building the culture that will sustain such initiatives.
Yet getting culture right can have a huge impact on those important areas.
"The fact is, we wouldn't be having this conversation if the economics of healthcare weren't changing," says Berrett. "Up to 7% of Medicare reimbursement will be at risk, and that puts most hospitals and health systems at risk for survival."
Culture should be most refined process in your organization, they argue. Yes, developing a culture of teamwork, purpose and fun is all common sense stuff, but leaders—at least in healthcare—haven't realized how important it is.
"All a bunch of new age crap?" Berrett asks. "No. You would think this is intuitive, but it's really not intuitive. The science is profound and research significant."
Leading like that also, much to leaders' surprise, says Berrett, requires less focus on bureaucracy.
"If we engage a team doing this with a purpose—a greater vision for the purpose behind what they're doing, the bureaucracy takes care of itself," Berrett says, equating internal bureaucracy to the creation of stifling rules to keep motorists safe from the worst drivers. "But if everyone's in alignment, you have [fewer] rules."
As part of their research, the two have created a website to measure an institution's "cultural IQ" through a series of questions. Once leaders see the results from their own team, it engages them in necessary conversations "that you might not have otherwise had," says Berrett.
Compiled together, they hope, the results can lead to even better techniques on developing a culture of inclusiveness and teamwork.
OK, you might say, I'm convinced. This culture development stuff is all much easier said than done. But the authors have little sympathy.
"This won't happen overnight," Spiegelman says. "The challenge is to find the leaders who get it. Some of that might be generational—and establish a long-term strategy. It takes three to five years to turn around culture."
As for that provocative title, Spiegelman is unapologetic and insists he means it.
"The title is something that came from the philosophy I have in my own business," he says. "If you focus on employees first, that drives customer loyalty and you can invest profit back in your people and the cycle continues. You hear patient, patient, patient, but there's a blind spot that our leaders have. Customer satisfaction comes from employee satisfaction."
Philip Betbeze is the senior leadership editor at HealthLeaders.