Leadership in Healthcare

On reviewing Paul Borawski's writing about ideas for education, I looked for common themes--some high level principle that could apply to healthcare also.  I came away with leadership.  Every organization needs a strong leader--someone to point the way and inspire the troops to follow.  This is true for education, and it is also true for healthcare. 
Why?  What do leaders do, and how is that different from managers or supervisors? There is even a Journal of Leadership in Health Services.  Leaders should be visionary and determine the best direction for the organization.  Take charge and accept responsibility.  General George Patton is quoted as saying, "Tell the troops what you want done, but don't tell them how to do it.  They will amaze you with their ingenuity." 

Managers, by contrast, make it happen.  They marshal resources, assign tasks, monitor progress, etc.  Also needed, but a different focus.  supervisors make sure everyone comes to work and has the tools to perform their assigned tasks. 

So, what about healthcare? Taking the hospital as the prototypical example, healthcare organizations use a matrix organizational structure.  This works best in project oriented environments where a given employee may work on different projects sequentially and there is some advantage to sharing lessons learned with others in the same discipline or carry knowledge from one part of the organization to another.  The disadvantage with matrix structures is the confusion that comes with having multiple bosses and the fact that no one is ever in charge of anything.  I remember the chief of the surgery clinic at the University of MI saying one day, "I'm supposed to be in charge of this clinic, but no one here works for me." 

When no one is in charge, no one takes responsibility for what happens.  My wife and I were waitting in a pre-op area, when she noticed a nurse putting paper into a red-bag trash can.  She had heard me talk about the relative costs of red and white trash, so she knew this was wrong.  "Why is she doing that?"  The simple answer was that no one cared.  No one was responsible for that area.  No one's annual bonus depended on the efficient operation of day surgery.  So they put non-hazardous trash into the red bag and paid dollars per pound instead of putting it into the white bag that cost dollars per ton.

This is a major problem with healthcare today.  No one is in charge.  Institutions and sections within institutions are allowed to operate inefficiently, because there is no leader to stress efficiency and cost saving as a goal.  To some extent, the above examples could be explained by the lack of a profit motive in most large hospitals.  A moment's thought, however, will dispel that thought.  What's your favorite airline?  Least favorite?  Why?  Where do the employees of the best airline get their attitude?  Out their thumbs?  Are they born that way?  I was strolling up and down the corridors at Dulles airport recently, waiting for my flight, when I heard cheering and applause at a gate ahead of me.  I thought it must be some group charter, but as I got closer I could see that it was just a routine Southwest Airlines flight.  No one cheered at the Lufthansa gate.  Someone up the food chain set the tone for those employees.  That's leadership.

We recently returned from a cruise where a daily activity was getting people off the ship and on to buses on shore.  One group of employees assigned bus numbers for various tours.  The security group checked passengers off the ship.  Another group drove the tenders to the dock.  I'll let you imagine the chaos that ensued when these groups didn't talk to each other.  Leadership.  Someone needed to be in charge.  Responsible.

This is not to say that chaining the organizational structure of healthcare institutions and assigning leaders would solve all the problems.  Leaders don't always make wise decisions.  However, if we determined a new direction that would solve problems, we would have a mechanism for instituting those changes--a single, responsible individual in charge. 

Leadership in education, and leadership in healthcare.